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The Rural Surgeon: Critical staff ‘wearing many hats’
In my recent travels to ACS state chapter gatherings and in my meeting with rural surgeons in a variety of settings, I have heard on many occasions a particular theme of concern: the lack of resources, in particular, personnel resources available in rural hospitals. A shortage of nurses, assistants, and support staff of all kinds has emerged as a serious, continuing challenge for surgeons who work in small communities.
Rural surgery still “gets it done” in spite of resource challenges. Actually, rural surgeons perform more procedures per year with more variety in procedure types than did their urban peers, in spite of limited resources (J. Am. Coll. Surg. 2005;201:732-6).
Resource shortage for rural practices is a common subject on the rural surgery Listserv. Rural surgeons might exclaim, “We have done so much with so little for so long that we are now expected to do everything with nothing forever!” Nursing and support personnel are key resources that can be in short supply.
The rural surgery Listserv has hosted a contest inviting rural surgeons to complete the following statement: “You know you are a rural surgeon if … (YKYAARSI).” At a recent rural surgery dinner at a scientific meeting, we had a little fun amidst all of the serious topics. The winner surgeon read his winning entry: “You know you are a rural surgeon if your first OR assistant is also the OR director, the director of nursing, the DRG coordinator, the director of QA for the ER, the coordinator of emergency preparedness, the committee coordinator for the annual hospital Christmas party, the chairwoman of the committee for quality measures, the best enema nurse, and the best interpreter of the local jargon, such as ‘casophagus’ (esophagus), ‘whistle’ (penis), ‘physic’ (enema), ‘hepmotoma’ (hematoma ), and ‘toodinitis’ (vaginal infection).” Laughter and cheers followed.
Is this hyperbole? The winning YKYAARSI entry is likely closer to reality for many rural surgeons than might be supposed by those who practice in institutions with abundant personnel resources. In small community hospitals, one dedicated staff nurse can have many roles and many jobs.
Early in my career, I practiced with a true team. Individuals had specific roles. My physician assistants assisted me during operations and on rounds. The OR head nurse “ran the board.” The director of surgical services coordinated all functions of the OR from an office. The emergency room was under the management of a veteran emergency nurse. Patients received outstanding bedside nursing care on the surgical floors and in the ICU. IV teams developed and provided valuable services. Skilled lab techs drew blood. An administrative assistant coordinated social events and fund raising. Clearly, trained individuals focused on their areas of expertise.
Gradually, this structure changed. Individuals had to assume many different roles and fill positions that were otherwise unfamiliar to them. The nursing and support personnel resources available for surgery started to diminish significantly.
Today, the concept of team is reduced to single individuals “wearing many hats.” They have all accepted the additional roles to support their hospitals and then made sincere efforts to perform well. The added responsibilities have stressed these well-intentioned nurses, technicians, and assistants both physically and emotionally. Frequently circumstances prevented them from being resources for surgery, straining surgical performance and patient care. I have experienced such situations firsthand, and I have no doubt many readers have as well.
The YKYAARSI winning entry came to life at my critical access hospital. The OR charge nurse became the director for surgical services, ob.gyn., and the emergency department. Previously, this capable nurse would either circulate my cases or be the first assistant. She also took call. She had the greatest skill starting IVs. With the additional duties outside of the OR, this “resource” nearly disappeared, depriving the practice of her abilities and experience. Providing overall quality care became even more challenging. The new “director of almost everything” also led efforts to raise funds for the hospital building campaign. In addition, she developed and coordinated a half-marathon to lift spirits and get pledges for the hospital. In spite of being encouraged to the contrary by hospital administration, even this smart, determined nurse fell behind, and was no longer a resource for surgery.
Like other rural surgeons in similar circumstances, I persisted and adapted to working with less, but I recognize that this situation is not ideal, and perhaps in the long run, not sustainable.
The root of the problem of limited personnel resources for rural surgery is multifactorial and the topic for another column. If you have experienced a personnel shortage or a situation of critical staff “wearing many hats” and would like to contribute to this discussion, please feel free to e-mail me.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
In my recent travels to ACS state chapter gatherings and in my meeting with rural surgeons in a variety of settings, I have heard on many occasions a particular theme of concern: the lack of resources, in particular, personnel resources available in rural hospitals. A shortage of nurses, assistants, and support staff of all kinds has emerged as a serious, continuing challenge for surgeons who work in small communities.
Rural surgery still “gets it done” in spite of resource challenges. Actually, rural surgeons perform more procedures per year with more variety in procedure types than did their urban peers, in spite of limited resources (J. Am. Coll. Surg. 2005;201:732-6).
Resource shortage for rural practices is a common subject on the rural surgery Listserv. Rural surgeons might exclaim, “We have done so much with so little for so long that we are now expected to do everything with nothing forever!” Nursing and support personnel are key resources that can be in short supply.
The rural surgery Listserv has hosted a contest inviting rural surgeons to complete the following statement: “You know you are a rural surgeon if … (YKYAARSI).” At a recent rural surgery dinner at a scientific meeting, we had a little fun amidst all of the serious topics. The winner surgeon read his winning entry: “You know you are a rural surgeon if your first OR assistant is also the OR director, the director of nursing, the DRG coordinator, the director of QA for the ER, the coordinator of emergency preparedness, the committee coordinator for the annual hospital Christmas party, the chairwoman of the committee for quality measures, the best enema nurse, and the best interpreter of the local jargon, such as ‘casophagus’ (esophagus), ‘whistle’ (penis), ‘physic’ (enema), ‘hepmotoma’ (hematoma ), and ‘toodinitis’ (vaginal infection).” Laughter and cheers followed.
Is this hyperbole? The winning YKYAARSI entry is likely closer to reality for many rural surgeons than might be supposed by those who practice in institutions with abundant personnel resources. In small community hospitals, one dedicated staff nurse can have many roles and many jobs.
Early in my career, I practiced with a true team. Individuals had specific roles. My physician assistants assisted me during operations and on rounds. The OR head nurse “ran the board.” The director of surgical services coordinated all functions of the OR from an office. The emergency room was under the management of a veteran emergency nurse. Patients received outstanding bedside nursing care on the surgical floors and in the ICU. IV teams developed and provided valuable services. Skilled lab techs drew blood. An administrative assistant coordinated social events and fund raising. Clearly, trained individuals focused on their areas of expertise.
Gradually, this structure changed. Individuals had to assume many different roles and fill positions that were otherwise unfamiliar to them. The nursing and support personnel resources available for surgery started to diminish significantly.
Today, the concept of team is reduced to single individuals “wearing many hats.” They have all accepted the additional roles to support their hospitals and then made sincere efforts to perform well. The added responsibilities have stressed these well-intentioned nurses, technicians, and assistants both physically and emotionally. Frequently circumstances prevented them from being resources for surgery, straining surgical performance and patient care. I have experienced such situations firsthand, and I have no doubt many readers have as well.
The YKYAARSI winning entry came to life at my critical access hospital. The OR charge nurse became the director for surgical services, ob.gyn., and the emergency department. Previously, this capable nurse would either circulate my cases or be the first assistant. She also took call. She had the greatest skill starting IVs. With the additional duties outside of the OR, this “resource” nearly disappeared, depriving the practice of her abilities and experience. Providing overall quality care became even more challenging. The new “director of almost everything” also led efforts to raise funds for the hospital building campaign. In addition, she developed and coordinated a half-marathon to lift spirits and get pledges for the hospital. In spite of being encouraged to the contrary by hospital administration, even this smart, determined nurse fell behind, and was no longer a resource for surgery.
Like other rural surgeons in similar circumstances, I persisted and adapted to working with less, but I recognize that this situation is not ideal, and perhaps in the long run, not sustainable.
The root of the problem of limited personnel resources for rural surgery is multifactorial and the topic for another column. If you have experienced a personnel shortage or a situation of critical staff “wearing many hats” and would like to contribute to this discussion, please feel free to e-mail me.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
In my recent travels to ACS state chapter gatherings and in my meeting with rural surgeons in a variety of settings, I have heard on many occasions a particular theme of concern: the lack of resources, in particular, personnel resources available in rural hospitals. A shortage of nurses, assistants, and support staff of all kinds has emerged as a serious, continuing challenge for surgeons who work in small communities.
Rural surgery still “gets it done” in spite of resource challenges. Actually, rural surgeons perform more procedures per year with more variety in procedure types than did their urban peers, in spite of limited resources (J. Am. Coll. Surg. 2005;201:732-6).
Resource shortage for rural practices is a common subject on the rural surgery Listserv. Rural surgeons might exclaim, “We have done so much with so little for so long that we are now expected to do everything with nothing forever!” Nursing and support personnel are key resources that can be in short supply.
The rural surgery Listserv has hosted a contest inviting rural surgeons to complete the following statement: “You know you are a rural surgeon if … (YKYAARSI).” At a recent rural surgery dinner at a scientific meeting, we had a little fun amidst all of the serious topics. The winner surgeon read his winning entry: “You know you are a rural surgeon if your first OR assistant is also the OR director, the director of nursing, the DRG coordinator, the director of QA for the ER, the coordinator of emergency preparedness, the committee coordinator for the annual hospital Christmas party, the chairwoman of the committee for quality measures, the best enema nurse, and the best interpreter of the local jargon, such as ‘casophagus’ (esophagus), ‘whistle’ (penis), ‘physic’ (enema), ‘hepmotoma’ (hematoma ), and ‘toodinitis’ (vaginal infection).” Laughter and cheers followed.
Is this hyperbole? The winning YKYAARSI entry is likely closer to reality for many rural surgeons than might be supposed by those who practice in institutions with abundant personnel resources. In small community hospitals, one dedicated staff nurse can have many roles and many jobs.
Early in my career, I practiced with a true team. Individuals had specific roles. My physician assistants assisted me during operations and on rounds. The OR head nurse “ran the board.” The director of surgical services coordinated all functions of the OR from an office. The emergency room was under the management of a veteran emergency nurse. Patients received outstanding bedside nursing care on the surgical floors and in the ICU. IV teams developed and provided valuable services. Skilled lab techs drew blood. An administrative assistant coordinated social events and fund raising. Clearly, trained individuals focused on their areas of expertise.
Gradually, this structure changed. Individuals had to assume many different roles and fill positions that were otherwise unfamiliar to them. The nursing and support personnel resources available for surgery started to diminish significantly.
Today, the concept of team is reduced to single individuals “wearing many hats.” They have all accepted the additional roles to support their hospitals and then made sincere efforts to perform well. The added responsibilities have stressed these well-intentioned nurses, technicians, and assistants both physically and emotionally. Frequently circumstances prevented them from being resources for surgery, straining surgical performance and patient care. I have experienced such situations firsthand, and I have no doubt many readers have as well.
The YKYAARSI winning entry came to life at my critical access hospital. The OR charge nurse became the director for surgical services, ob.gyn., and the emergency department. Previously, this capable nurse would either circulate my cases or be the first assistant. She also took call. She had the greatest skill starting IVs. With the additional duties outside of the OR, this “resource” nearly disappeared, depriving the practice of her abilities and experience. Providing overall quality care became even more challenging. The new “director of almost everything” also led efforts to raise funds for the hospital building campaign. In addition, she developed and coordinated a half-marathon to lift spirits and get pledges for the hospital. In spite of being encouraged to the contrary by hospital administration, even this smart, determined nurse fell behind, and was no longer a resource for surgery.
Like other rural surgeons in similar circumstances, I persisted and adapted to working with less, but I recognize that this situation is not ideal, and perhaps in the long run, not sustainable.
The root of the problem of limited personnel resources for rural surgery is multifactorial and the topic for another column. If you have experienced a personnel shortage or a situation of critical staff “wearing many hats” and would like to contribute to this discussion, please feel free to e-mail me.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
The Rural Surgeon: Thanksgiving
Thanksgiving will soon be here and celebrated joyfully with food, friends, and family in many homes around the country. Football, as well, has become a big part of this tradition on the fourth Thursday of November, an official holiday proclaimed by Abraham Lincoln in 1863. The first Thanksgiving was at Plymouth Plantation in 1621. It is unknown if any rural surgeons were present then. During this holiday, many rural surgeons will be giving thanks for more than food, friends, family, and football.
Twenty-five percent of the population is rural and fewer than 10% of surgeons practice in rural locations. This fact is complicated by the advanced age of the surgeons (~55 y/o) with more than 60% of them planning to retire in less than 10 years. The changes to all aspects of health care today, such as the Affordable Care Act, ACOs, and EMRs, affect the rural health care environment more profoundly and actually promote the deterioration of rural surgical practices. In recent years, rural surgeons have had few reasons to give thanks for the trajectory of their professional situation and fewer yet for the degree of acknowledgment of their challenges by the profession as a whole.
In the past 2 years, thanks to the tireless efforts of a few activists and enlightened leadership in the College, the ACS is now reaching out to rural surgeons, to recognize and to represent them. An important first step was the establishment of the Advisory Council on Rural Surgery, with its pillars for member services, education, quality, advocacy, as well as communication. The Council is chaired by Dr. Tyler Hughes.
Some critics might conclude that this council is just another group of surgeons more concerned about appearances and prominent positions than making an impact on the professional lives of rural surgeons. But such a conclusion would be wrong. Since its inception, the ACRS has worked relentlessly to identify and address the needs of rural surgeons. Efforts of all the pillars have involved education, along with local and national engagement of rural surgeons with emphasis on training, recruitment, and retention. The ACRS has stressed and promoted the value and quality found in rural surgical practices. Members of the Council have generously given their time and enthusiasm to advance these goals.
One of the major roles played by ACRS members has been contributing articles on the realities of a rural practice for the ACS Bulletin’s regular column, “Dispatches from rural surgeons.” Member services chair Dr. Mike Sarap wrote the initial article “The value of chapter membership: The rural surgeon’s perspective,” detailing chapter membership benefits. It concluded that patient care would benefit from a united, networked surgical community. Local ACS chapters can be a foundation of community and professional support among rural surgeons.
Dr. Mark Savarise, advocacy chair, wrote the feature article, “CPT 2012 brings with it new codes and code changes,” that provided invaluable information to rural surgeons, who otherwise would have struggled to secure it. Recently, Dr. Savarise wrote “ACS intervenes to resolve questions about the 96-hour rule” on an issue of great concern to rural surgeons. These efforts to raise awareness, articulate concerns, advocate for change, and inform members about issues are among the most important tasks of the ACRS.
The ACRS also emphasizes continuing education for rural surgeons. Rural surgery symposiums and skills courses over the years attest to that fact and acknowledge the ACRS connection with the Mithoefer Center, Cooperstown, NY, and the Nora Institute in Chicago, IL. ACRS council member, Dr. David Borgstrom, “Rural surgical practice requires a new training model, offers great opportunities” in another Bulletin rural surgery dispatch. The article describes the existing and emerging training programs, ranging from rural surgery rotations and dedicated rural surgery tracks to immersion and fellowship opportunities. The ACS has hosted a series of regional meetings such as the ACS Surgical Healthcare Quality Forum Iowa in June 2014 to engage the surgical community to share ideas on training and workforce needs, maintenance of quality care, and staff retention. In addition, ACS has introduced the Transition to Practice Program in General Surgery, which has been established in several institutions to help residents move into rural surgical practice. This program offers clinical training but also practice management training tailored to rural surgery.
ACRS quality chair, Dr. Don Nakayama, professor and chair at West Virginia University, Morgantown, has collected standards criteria for rural surgery centers of excellence and is composing a verification document for rural surgical practices. This document will assist rural surgeons and be instrumental in maintaining resources and quality in their practices. Once implemented by the ACS, the verification process for rural surgery, like the well-established program for trauma, will enable the highest standards required for the inspiring quality and for better outcomes. This new verification process and its standards give the rural surgeon a basis for the best practice.
The College has stepped up its advocacy efforts to have an impact on policy and legislation to support all surgeons. The ACS Washington office is vital and Dr. Pat Bailey, ACS medical director of advocacy, has worked with the ACRS to make sure the concerns of rural surgeons are incorporated into the advocacy strategy.
One of the four pillars of the ACRS is communication. The rural surgeons listserv was developed in by the ACRS in 2012 and has been a great success. With more than 1,000 members, and several million emails exchanged, the listserv has become meeting place for the community of rural surgeons. During the numerous rural listserv discussions and threads, many of the emails expressed thanks and appreciation. One rural surgeon volunteered, “This is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.” The conversation continued with this sentiment, “I am terrifically gratified to find that the guilt I have suffered all these years (30+) is misplaced.” As the thread continued, the word thanks appeared multiple times. The communication mission of the ACRS will continue with the development of the ACS Communities platform.
The ACS support for rural surgeons came at an ideal time. And for many in the community, this support is a cause for thankfulness.
In participating in the listserv, rural surgeons identified many topics of interest and some actual concerns to them. Call and locum tenens coverage were the most prominent potential issues. The ACS leadership is aware of both subjects and is currently investigating each one. These matters are vital to rural surgeons, and this publication, ACS Surgery News, invites rural surgeons (or any reader) to respond with any additional information. A productive dialogue could follow and be useful to the ACS. Regardless, the ACS will continue without interruption the process of support rural surgeons.
By its actions, the ACS gives living proof to its motto – “inspiring quality, highest standards, better outcomes” – which now have improved chances for surgeons to continue their work in rural communities. Rural surgeons have experienced the true meaning of ACS Fellowship. Indeed, during this Thanksgiving, rural surgeons will be giving thanks for food, friends, family, and the calling to the surgical profession. Rural surgeons will also be grateful for their College and its personal support of their profession and their practices. Thank you and Happy Thanksgiving to everyone.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
Thanksgiving will soon be here and celebrated joyfully with food, friends, and family in many homes around the country. Football, as well, has become a big part of this tradition on the fourth Thursday of November, an official holiday proclaimed by Abraham Lincoln in 1863. The first Thanksgiving was at Plymouth Plantation in 1621. It is unknown if any rural surgeons were present then. During this holiday, many rural surgeons will be giving thanks for more than food, friends, family, and football.
Twenty-five percent of the population is rural and fewer than 10% of surgeons practice in rural locations. This fact is complicated by the advanced age of the surgeons (~55 y/o) with more than 60% of them planning to retire in less than 10 years. The changes to all aspects of health care today, such as the Affordable Care Act, ACOs, and EMRs, affect the rural health care environment more profoundly and actually promote the deterioration of rural surgical practices. In recent years, rural surgeons have had few reasons to give thanks for the trajectory of their professional situation and fewer yet for the degree of acknowledgment of their challenges by the profession as a whole.
In the past 2 years, thanks to the tireless efforts of a few activists and enlightened leadership in the College, the ACS is now reaching out to rural surgeons, to recognize and to represent them. An important first step was the establishment of the Advisory Council on Rural Surgery, with its pillars for member services, education, quality, advocacy, as well as communication. The Council is chaired by Dr. Tyler Hughes.
Some critics might conclude that this council is just another group of surgeons more concerned about appearances and prominent positions than making an impact on the professional lives of rural surgeons. But such a conclusion would be wrong. Since its inception, the ACRS has worked relentlessly to identify and address the needs of rural surgeons. Efforts of all the pillars have involved education, along with local and national engagement of rural surgeons with emphasis on training, recruitment, and retention. The ACRS has stressed and promoted the value and quality found in rural surgical practices. Members of the Council have generously given their time and enthusiasm to advance these goals.
One of the major roles played by ACRS members has been contributing articles on the realities of a rural practice for the ACS Bulletin’s regular column, “Dispatches from rural surgeons.” Member services chair Dr. Mike Sarap wrote the initial article “The value of chapter membership: The rural surgeon’s perspective,” detailing chapter membership benefits. It concluded that patient care would benefit from a united, networked surgical community. Local ACS chapters can be a foundation of community and professional support among rural surgeons.
Dr. Mark Savarise, advocacy chair, wrote the feature article, “CPT 2012 brings with it new codes and code changes,” that provided invaluable information to rural surgeons, who otherwise would have struggled to secure it. Recently, Dr. Savarise wrote “ACS intervenes to resolve questions about the 96-hour rule” on an issue of great concern to rural surgeons. These efforts to raise awareness, articulate concerns, advocate for change, and inform members about issues are among the most important tasks of the ACRS.
The ACRS also emphasizes continuing education for rural surgeons. Rural surgery symposiums and skills courses over the years attest to that fact and acknowledge the ACRS connection with the Mithoefer Center, Cooperstown, NY, and the Nora Institute in Chicago, IL. ACRS council member, Dr. David Borgstrom, “Rural surgical practice requires a new training model, offers great opportunities” in another Bulletin rural surgery dispatch. The article describes the existing and emerging training programs, ranging from rural surgery rotations and dedicated rural surgery tracks to immersion and fellowship opportunities. The ACS has hosted a series of regional meetings such as the ACS Surgical Healthcare Quality Forum Iowa in June 2014 to engage the surgical community to share ideas on training and workforce needs, maintenance of quality care, and staff retention. In addition, ACS has introduced the Transition to Practice Program in General Surgery, which has been established in several institutions to help residents move into rural surgical practice. This program offers clinical training but also practice management training tailored to rural surgery.
ACRS quality chair, Dr. Don Nakayama, professor and chair at West Virginia University, Morgantown, has collected standards criteria for rural surgery centers of excellence and is composing a verification document for rural surgical practices. This document will assist rural surgeons and be instrumental in maintaining resources and quality in their practices. Once implemented by the ACS, the verification process for rural surgery, like the well-established program for trauma, will enable the highest standards required for the inspiring quality and for better outcomes. This new verification process and its standards give the rural surgeon a basis for the best practice.
The College has stepped up its advocacy efforts to have an impact on policy and legislation to support all surgeons. The ACS Washington office is vital and Dr. Pat Bailey, ACS medical director of advocacy, has worked with the ACRS to make sure the concerns of rural surgeons are incorporated into the advocacy strategy.
One of the four pillars of the ACRS is communication. The rural surgeons listserv was developed in by the ACRS in 2012 and has been a great success. With more than 1,000 members, and several million emails exchanged, the listserv has become meeting place for the community of rural surgeons. During the numerous rural listserv discussions and threads, many of the emails expressed thanks and appreciation. One rural surgeon volunteered, “This is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.” The conversation continued with this sentiment, “I am terrifically gratified to find that the guilt I have suffered all these years (30+) is misplaced.” As the thread continued, the word thanks appeared multiple times. The communication mission of the ACRS will continue with the development of the ACS Communities platform.
The ACS support for rural surgeons came at an ideal time. And for many in the community, this support is a cause for thankfulness.
In participating in the listserv, rural surgeons identified many topics of interest and some actual concerns to them. Call and locum tenens coverage were the most prominent potential issues. The ACS leadership is aware of both subjects and is currently investigating each one. These matters are vital to rural surgeons, and this publication, ACS Surgery News, invites rural surgeons (or any reader) to respond with any additional information. A productive dialogue could follow and be useful to the ACS. Regardless, the ACS will continue without interruption the process of support rural surgeons.
By its actions, the ACS gives living proof to its motto – “inspiring quality, highest standards, better outcomes” – which now have improved chances for surgeons to continue their work in rural communities. Rural surgeons have experienced the true meaning of ACS Fellowship. Indeed, during this Thanksgiving, rural surgeons will be giving thanks for food, friends, family, and the calling to the surgical profession. Rural surgeons will also be grateful for their College and its personal support of their profession and their practices. Thank you and Happy Thanksgiving to everyone.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
Thanksgiving will soon be here and celebrated joyfully with food, friends, and family in many homes around the country. Football, as well, has become a big part of this tradition on the fourth Thursday of November, an official holiday proclaimed by Abraham Lincoln in 1863. The first Thanksgiving was at Plymouth Plantation in 1621. It is unknown if any rural surgeons were present then. During this holiday, many rural surgeons will be giving thanks for more than food, friends, family, and football.
Twenty-five percent of the population is rural and fewer than 10% of surgeons practice in rural locations. This fact is complicated by the advanced age of the surgeons (~55 y/o) with more than 60% of them planning to retire in less than 10 years. The changes to all aspects of health care today, such as the Affordable Care Act, ACOs, and EMRs, affect the rural health care environment more profoundly and actually promote the deterioration of rural surgical practices. In recent years, rural surgeons have had few reasons to give thanks for the trajectory of their professional situation and fewer yet for the degree of acknowledgment of their challenges by the profession as a whole.
In the past 2 years, thanks to the tireless efforts of a few activists and enlightened leadership in the College, the ACS is now reaching out to rural surgeons, to recognize and to represent them. An important first step was the establishment of the Advisory Council on Rural Surgery, with its pillars for member services, education, quality, advocacy, as well as communication. The Council is chaired by Dr. Tyler Hughes.
Some critics might conclude that this council is just another group of surgeons more concerned about appearances and prominent positions than making an impact on the professional lives of rural surgeons. But such a conclusion would be wrong. Since its inception, the ACRS has worked relentlessly to identify and address the needs of rural surgeons. Efforts of all the pillars have involved education, along with local and national engagement of rural surgeons with emphasis on training, recruitment, and retention. The ACRS has stressed and promoted the value and quality found in rural surgical practices. Members of the Council have generously given their time and enthusiasm to advance these goals.
One of the major roles played by ACRS members has been contributing articles on the realities of a rural practice for the ACS Bulletin’s regular column, “Dispatches from rural surgeons.” Member services chair Dr. Mike Sarap wrote the initial article “The value of chapter membership: The rural surgeon’s perspective,” detailing chapter membership benefits. It concluded that patient care would benefit from a united, networked surgical community. Local ACS chapters can be a foundation of community and professional support among rural surgeons.
Dr. Mark Savarise, advocacy chair, wrote the feature article, “CPT 2012 brings with it new codes and code changes,” that provided invaluable information to rural surgeons, who otherwise would have struggled to secure it. Recently, Dr. Savarise wrote “ACS intervenes to resolve questions about the 96-hour rule” on an issue of great concern to rural surgeons. These efforts to raise awareness, articulate concerns, advocate for change, and inform members about issues are among the most important tasks of the ACRS.
The ACRS also emphasizes continuing education for rural surgeons. Rural surgery symposiums and skills courses over the years attest to that fact and acknowledge the ACRS connection with the Mithoefer Center, Cooperstown, NY, and the Nora Institute in Chicago, IL. ACRS council member, Dr. David Borgstrom, “Rural surgical practice requires a new training model, offers great opportunities” in another Bulletin rural surgery dispatch. The article describes the existing and emerging training programs, ranging from rural surgery rotations and dedicated rural surgery tracks to immersion and fellowship opportunities. The ACS has hosted a series of regional meetings such as the ACS Surgical Healthcare Quality Forum Iowa in June 2014 to engage the surgical community to share ideas on training and workforce needs, maintenance of quality care, and staff retention. In addition, ACS has introduced the Transition to Practice Program in General Surgery, which has been established in several institutions to help residents move into rural surgical practice. This program offers clinical training but also practice management training tailored to rural surgery.
ACRS quality chair, Dr. Don Nakayama, professor and chair at West Virginia University, Morgantown, has collected standards criteria for rural surgery centers of excellence and is composing a verification document for rural surgical practices. This document will assist rural surgeons and be instrumental in maintaining resources and quality in their practices. Once implemented by the ACS, the verification process for rural surgery, like the well-established program for trauma, will enable the highest standards required for the inspiring quality and for better outcomes. This new verification process and its standards give the rural surgeon a basis for the best practice.
The College has stepped up its advocacy efforts to have an impact on policy and legislation to support all surgeons. The ACS Washington office is vital and Dr. Pat Bailey, ACS medical director of advocacy, has worked with the ACRS to make sure the concerns of rural surgeons are incorporated into the advocacy strategy.
One of the four pillars of the ACRS is communication. The rural surgeons listserv was developed in by the ACRS in 2012 and has been a great success. With more than 1,000 members, and several million emails exchanged, the listserv has become meeting place for the community of rural surgeons. During the numerous rural listserv discussions and threads, many of the emails expressed thanks and appreciation. One rural surgeon volunteered, “This is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.” The conversation continued with this sentiment, “I am terrifically gratified to find that the guilt I have suffered all these years (30+) is misplaced.” As the thread continued, the word thanks appeared multiple times. The communication mission of the ACRS will continue with the development of the ACS Communities platform.
The ACS support for rural surgeons came at an ideal time. And for many in the community, this support is a cause for thankfulness.
In participating in the listserv, rural surgeons identified many topics of interest and some actual concerns to them. Call and locum tenens coverage were the most prominent potential issues. The ACS leadership is aware of both subjects and is currently investigating each one. These matters are vital to rural surgeons, and this publication, ACS Surgery News, invites rural surgeons (or any reader) to respond with any additional information. A productive dialogue could follow and be useful to the ACS. Regardless, the ACS will continue without interruption the process of support rural surgeons.
By its actions, the ACS gives living proof to its motto – “inspiring quality, highest standards, better outcomes” – which now have improved chances for surgeons to continue their work in rural communities. Rural surgeons have experienced the true meaning of ACS Fellowship. Indeed, during this Thanksgiving, rural surgeons will be giving thanks for food, friends, family, and the calling to the surgical profession. Rural surgeons will also be grateful for their College and its personal support of their profession and their practices. Thank you and Happy Thanksgiving to everyone.
Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.
ACS loans ancient Irish deer antlers to exhibit at Art Institute of Chicago
The American College of Surgeons (ACS) is loaning one of its treasures to a major exhibition at the Art Institute of Chicago – Ireland: Art on a World Stage, 1690-1840. The College’s Ancient Irish Deer Antlers from Ballybetagh will be on display at the exhibit which will open on St. Patrick’s Day 2015 and run through June 7. According to ACS Archivist Adam Carey, the massive skull and antlers of an extinct, Irish Elk displayed in the reception area of the College’s Chicago headquarters office was a diplomatic gift to the College from the Royal College of Surgeons in 1921.
Mr. Carey gives all due credit for the Art Institute’s pursuit of the antlers to Dan Steinke, ACS Office Services Manager. Mr. Steinke oversaw the construction of the current display case, with staff from the Field Museum of Natural History, in Chicago, providing assistance on proper mounting. “It was that connection that prompted the Art Institute to contact us for the loan,” Mr. Carey said.
The antlers are steeped in history. The College received the antlers at the height of Ireland’s “troubles” in the 1920s. The “troubles” refer to the decades of violence between elements of Northern Ireland’s Irish nationalist community, who are mostly Catholics, and its unionist community, mainly self-identified as British and/or Protestant. Ancient elk or deer antlers served as prominent symbols in Irish country homes. Thousands of years old and preserved in Ireland’s bogs, antlers displayed in an entrance hall signified a family’s roots and claims to Irish land.
Douglas Druick, president and Eloise W. Martin Director of the Art Institute, in a letter expressed deep gratitude to the College for loaning this vital artifact to the exhibit.
Mr. Druick explained that the agricultural depression in the British Isles in the 1880s resulted in the delivery of many extraordinary objects from Ireland to the U.S. and Canada and are now scattered from Honolulu, HI, to Portland, ME, Ottawa, Canada, and San Antonio, TX. “Through this exhibition and the accompanying catalogue published by the Art Institute of Chicago in association with Yale University Press, these often little-known objects will be shown together for the first time,” Mr. Druick explained.
The exhibition will present 300 objects drawn from public and private collections across North America. Arranged thematically throughout six galleries, the exhibit’s paintings, sculpture, and architecture as well as book bindings, ceramics, glass, furniture, metalwork, and textiles will celebrate the Irish as artists, collectors, and patrons. Chicago will be the only venue for the exhibit.
The American College of Surgeons (ACS) is loaning one of its treasures to a major exhibition at the Art Institute of Chicago – Ireland: Art on a World Stage, 1690-1840. The College’s Ancient Irish Deer Antlers from Ballybetagh will be on display at the exhibit which will open on St. Patrick’s Day 2015 and run through June 7. According to ACS Archivist Adam Carey, the massive skull and antlers of an extinct, Irish Elk displayed in the reception area of the College’s Chicago headquarters office was a diplomatic gift to the College from the Royal College of Surgeons in 1921.
Mr. Carey gives all due credit for the Art Institute’s pursuit of the antlers to Dan Steinke, ACS Office Services Manager. Mr. Steinke oversaw the construction of the current display case, with staff from the Field Museum of Natural History, in Chicago, providing assistance on proper mounting. “It was that connection that prompted the Art Institute to contact us for the loan,” Mr. Carey said.
The antlers are steeped in history. The College received the antlers at the height of Ireland’s “troubles” in the 1920s. The “troubles” refer to the decades of violence between elements of Northern Ireland’s Irish nationalist community, who are mostly Catholics, and its unionist community, mainly self-identified as British and/or Protestant. Ancient elk or deer antlers served as prominent symbols in Irish country homes. Thousands of years old and preserved in Ireland’s bogs, antlers displayed in an entrance hall signified a family’s roots and claims to Irish land.
Douglas Druick, president and Eloise W. Martin Director of the Art Institute, in a letter expressed deep gratitude to the College for loaning this vital artifact to the exhibit.
Mr. Druick explained that the agricultural depression in the British Isles in the 1880s resulted in the delivery of many extraordinary objects from Ireland to the U.S. and Canada and are now scattered from Honolulu, HI, to Portland, ME, Ottawa, Canada, and San Antonio, TX. “Through this exhibition and the accompanying catalogue published by the Art Institute of Chicago in association with Yale University Press, these often little-known objects will be shown together for the first time,” Mr. Druick explained.
The exhibition will present 300 objects drawn from public and private collections across North America. Arranged thematically throughout six galleries, the exhibit’s paintings, sculpture, and architecture as well as book bindings, ceramics, glass, furniture, metalwork, and textiles will celebrate the Irish as artists, collectors, and patrons. Chicago will be the only venue for the exhibit.
The American College of Surgeons (ACS) is loaning one of its treasures to a major exhibition at the Art Institute of Chicago – Ireland: Art on a World Stage, 1690-1840. The College’s Ancient Irish Deer Antlers from Ballybetagh will be on display at the exhibit which will open on St. Patrick’s Day 2015 and run through June 7. According to ACS Archivist Adam Carey, the massive skull and antlers of an extinct, Irish Elk displayed in the reception area of the College’s Chicago headquarters office was a diplomatic gift to the College from the Royal College of Surgeons in 1921.
Mr. Carey gives all due credit for the Art Institute’s pursuit of the antlers to Dan Steinke, ACS Office Services Manager. Mr. Steinke oversaw the construction of the current display case, with staff from the Field Museum of Natural History, in Chicago, providing assistance on proper mounting. “It was that connection that prompted the Art Institute to contact us for the loan,” Mr. Carey said.
The antlers are steeped in history. The College received the antlers at the height of Ireland’s “troubles” in the 1920s. The “troubles” refer to the decades of violence between elements of Northern Ireland’s Irish nationalist community, who are mostly Catholics, and its unionist community, mainly self-identified as British and/or Protestant. Ancient elk or deer antlers served as prominent symbols in Irish country homes. Thousands of years old and preserved in Ireland’s bogs, antlers displayed in an entrance hall signified a family’s roots and claims to Irish land.
Douglas Druick, president and Eloise W. Martin Director of the Art Institute, in a letter expressed deep gratitude to the College for loaning this vital artifact to the exhibit.
Mr. Druick explained that the agricultural depression in the British Isles in the 1880s resulted in the delivery of many extraordinary objects from Ireland to the U.S. and Canada and are now scattered from Honolulu, HI, to Portland, ME, Ottawa, Canada, and San Antonio, TX. “Through this exhibition and the accompanying catalogue published by the Art Institute of Chicago in association with Yale University Press, these often little-known objects will be shown together for the first time,” Mr. Druick explained.
The exhibition will present 300 objects drawn from public and private collections across North America. Arranged thematically throughout six galleries, the exhibit’s paintings, sculpture, and architecture as well as book bindings, ceramics, glass, furniture, metalwork, and textiles will celebrate the Irish as artists, collectors, and patrons. Chicago will be the only venue for the exhibit.
Is your practice administering the CAHPS survey?
The American College of Surgeons (ACS), in partnership with other surgical and anesthesia organizations and the Agency for Healthcare Research and Quality’s (AHRQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Consortium, developed the Surgical Care survey.
The survey assesses surgical pati- ents’ experiences before, during, and after surgical procedures as a means of identifying opportunities to improve quality of care, surgical outcomes, and patient experiences of care, as well as for public reporting.
The CAHPS Surgical Care survey is a standardized patient survey that produces clear and usable comparative information for consumers and health care providers.
The survey captures information for which patients are the best source of information or information only patients can answer.
The CAHPS Surgical Care Survey has been available to the public since 2010 and is the only National Quality Forum–endorsed measure designed to assess surgical quality from the patient’s perspective.
ACS is currently collecting information on the survey use in order to maintain its National Quality Forum endorsement. If you have experience in administering the survey, please contact Jill Sage, ACS Quality Affairs Manager, at [email protected] or 202-672-1507. Access the survey and survey instructions online at https://www. facs.org/advocacy/quality/cahps].
The American College of Surgeons (ACS), in partnership with other surgical and anesthesia organizations and the Agency for Healthcare Research and Quality’s (AHRQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Consortium, developed the Surgical Care survey.
The survey assesses surgical pati- ents’ experiences before, during, and after surgical procedures as a means of identifying opportunities to improve quality of care, surgical outcomes, and patient experiences of care, as well as for public reporting.
The CAHPS Surgical Care survey is a standardized patient survey that produces clear and usable comparative information for consumers and health care providers.
The survey captures information for which patients are the best source of information or information only patients can answer.
The CAHPS Surgical Care Survey has been available to the public since 2010 and is the only National Quality Forum–endorsed measure designed to assess surgical quality from the patient’s perspective.
ACS is currently collecting information on the survey use in order to maintain its National Quality Forum endorsement. If you have experience in administering the survey, please contact Jill Sage, ACS Quality Affairs Manager, at [email protected] or 202-672-1507. Access the survey and survey instructions online at https://www. facs.org/advocacy/quality/cahps].
The American College of Surgeons (ACS), in partnership with other surgical and anesthesia organizations and the Agency for Healthcare Research and Quality’s (AHRQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Consortium, developed the Surgical Care survey.
The survey assesses surgical pati- ents’ experiences before, during, and after surgical procedures as a means of identifying opportunities to improve quality of care, surgical outcomes, and patient experiences of care, as well as for public reporting.
The CAHPS Surgical Care survey is a standardized patient survey that produces clear and usable comparative information for consumers and health care providers.
The survey captures information for which patients are the best source of information or information only patients can answer.
The CAHPS Surgical Care Survey has been available to the public since 2010 and is the only National Quality Forum–endorsed measure designed to assess surgical quality from the patient’s perspective.
ACS is currently collecting information on the survey use in order to maintain its National Quality Forum endorsement. If you have experience in administering the survey, please contact Jill Sage, ACS Quality Affairs Manager, at [email protected] or 202-672-1507. Access the survey and survey instructions online at https://www. facs.org/advocacy/quality/cahps].
ACS Foundation 1913 Legacy Campaign nearing $2.5 million
The American College of Surgeons (ACS) Board of Directors recently announced this week that with the addition of nearly $100,000 in gifts made at the ACS Clinical Congress 2014, the 1913 Legacy Campaign is nearing the $2.5 million milestone. The fundraising effort, led by the 1913 Legacy Campaign National Steering Committee, continues to secure gifts to advance programming that is critical to the College’s mission. At the annual Fellows Leadership Society (FLS) luncheon as well as at other Clinical Congress events, the Foundation honored the more than 260 donors who have contributed to the campaign. New campaign donors received a “Great Mace” lapel pin, designed especially for the 1913 Campaign. Philanthropic investments within three priority campaign initiatives will benefit the Surgeon, the Profession, and the Societal Good.
At the FLS luncheon, Amilu Stewart, MD, FACS, Chair of the ACS Foundation, also honored the 2014 Distinguished Philanthropist Award recipients, Past-President W. Gerald Austen, MD, FACS, and Patricia R. Austen, RN, who encouraged the guests to follow their lead and contribute to the 1913 Legacy Campaign.For more information on the ACS Foundation or to participate in the campaign, which is now in its public phase, contact the ACS Foundation at 312-202-5338, or visit the Foundation website at www.facs.org/1913Campaign.
The American College of Surgeons (ACS) Board of Directors recently announced this week that with the addition of nearly $100,000 in gifts made at the ACS Clinical Congress 2014, the 1913 Legacy Campaign is nearing the $2.5 million milestone. The fundraising effort, led by the 1913 Legacy Campaign National Steering Committee, continues to secure gifts to advance programming that is critical to the College’s mission. At the annual Fellows Leadership Society (FLS) luncheon as well as at other Clinical Congress events, the Foundation honored the more than 260 donors who have contributed to the campaign. New campaign donors received a “Great Mace” lapel pin, designed especially for the 1913 Campaign. Philanthropic investments within three priority campaign initiatives will benefit the Surgeon, the Profession, and the Societal Good.
At the FLS luncheon, Amilu Stewart, MD, FACS, Chair of the ACS Foundation, also honored the 2014 Distinguished Philanthropist Award recipients, Past-President W. Gerald Austen, MD, FACS, and Patricia R. Austen, RN, who encouraged the guests to follow their lead and contribute to the 1913 Legacy Campaign.For more information on the ACS Foundation or to participate in the campaign, which is now in its public phase, contact the ACS Foundation at 312-202-5338, or visit the Foundation website at www.facs.org/1913Campaign.
The American College of Surgeons (ACS) Board of Directors recently announced this week that with the addition of nearly $100,000 in gifts made at the ACS Clinical Congress 2014, the 1913 Legacy Campaign is nearing the $2.5 million milestone. The fundraising effort, led by the 1913 Legacy Campaign National Steering Committee, continues to secure gifts to advance programming that is critical to the College’s mission. At the annual Fellows Leadership Society (FLS) luncheon as well as at other Clinical Congress events, the Foundation honored the more than 260 donors who have contributed to the campaign. New campaign donors received a “Great Mace” lapel pin, designed especially for the 1913 Campaign. Philanthropic investments within three priority campaign initiatives will benefit the Surgeon, the Profession, and the Societal Good.
At the FLS luncheon, Amilu Stewart, MD, FACS, Chair of the ACS Foundation, also honored the 2014 Distinguished Philanthropist Award recipients, Past-President W. Gerald Austen, MD, FACS, and Patricia R. Austen, RN, who encouraged the guests to follow their lead and contribute to the 1913 Legacy Campaign.For more information on the ACS Foundation or to participate in the campaign, which is now in its public phase, contact the ACS Foundation at 312-202-5338, or visit the Foundation website at www.facs.org/1913Campaign.
Lifetime Achievement Award presented posthumously to Dr. Russell
Carlos A. Pellegrini, MD, FACS, Immediate Past-President of the American College of Surgeons (ACS), presented the ACS Lifetime Achievement Award to Thomas R. Russell, MD, FACS, former Executive Director of the College, during the Convocation, October 26, at Clinical Congress 2014 in San Francisco, CA. The award was presented posthumously, and daughters, Jackie and Katie, and wife Nona, accepted it on his behalf.
Following is an edited text of Dr. Pellegrini’s remarks:
It is my great honor to present the Lifetime Achievement Award of the American College of Surgeons. This award is presented to an extraordinary individual for a lifetime of contributions to the art of medicine and surgery, and service to the ACS. Not surprisingly, this is only the third time that our College has conferred this award in its 100-year history. In choosing Dr. Thomas R. Russell, the College is not only recognizing his contributions and service to the organization’s mission, but also is recognizing a dedicated leader, a compassionate humanitarian, and a man who touched many lives in ways that left us all better people for having known him.
A committed physician
Dr. Russell spent his youth in California and had the unique experience as a teenager of working as a wrangler at a dude ranch, a job that would have a profound influence in his life. After earning his bachelor of arts degree at the University of California, Berkeley, and his medical degree from Creighton University Medical School, Omaha, NE, Tom returned to the Bay Area for his surgical residency training at the University of California, San Francisco. His training was interrupted by service in the Vietnam War from 1968 to 1970, during which he served as a Lieutenant Commander and flight surgeon in the U.S. Navy. In 1975, he joined a practice in San Francisco and began what would become 25 years as a practicing general and colon and rectal surgeon.
Tom became a Fellow of the ACS in 1979. He was Secretary and later President of the Northern California Chapter of the College. He was elected to the Board of Governors in 1990 and served in that role until 1993, when he was elected to the Board of Regents. His roles in the ACS as a Regent are too numerous to name, but included chairing the Nominating Committee and serving on the Member Services Liaison Committee and the Advisory Council for Colon and Rectal Surgery.
Insightful leadership
In 1999, the Board of Regents, facing unprecedented challenges, asked Tom to take the difficult job of Executive Director of the College. Our College was in need of thoughtful and compassionate leadership, and Tom was the right person for the job. He had a reputation as a bright, kind, high-energy individual who was willing to weigh all sides of an issue.
Soon after assuming the position of Executive Director, he initiated a strategic planning process, which revealed his innovative and insightful leadership. The College structure was reorganized. Education programs were expanded to offer new and innovative courses. He directed the establishment of the ACS Foundation in 2005 to better support the ACS’ scholarship programs.
A mission statement was developed to guide the work of staff and volunteers alike: “The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.” These articulately presented ideals continue to guide us.
Dr. Russell encouraged the College to take a proactive stance in the politically charged atmosphere of the early 2000s to protect patients’ access to quality care. Under his leadership, our presence in Washington, DC, grew, and a new building was erected near Capitol Hill to house our Division of Advocacy and Health Policy.
One of Dr. Russell’s most significant accomplishments as ACS Executive Director was bringing the Veterans Affairs (VA) National Surgical Quality Improvement Program into the private sector under the College’s aegis as ACS NSQIP®, which launched in 2004. Nearly 600 hospitals have since become participants in ACS NSQIP and have used the program’s risk-adjusted, evidence-based outcomes data to significantly reduce complications, limit error, and save countless lives and millions of dollars.
Kind, fair, and honorable
I count it among one of the great blessings of my life that I am able to call Tom a friend. He was insightful, generous, personable, compassionate, and above all, kind, fair, and honorable. His spirit lives on in the lives of his partner and wife, Nona, and his daughters, Katie and Jackie, the three “stars” of his life. His gentle humor and enduring optimism always brought out the best in people. His imprint will permanently remain on the College and the countless lives he touched while living every day by his motto, “Take the stairs, be nice to the janitor, and the patient comes first.”
Carlos A. Pellegrini, MD, FACS, Immediate Past-President of the American College of Surgeons (ACS), presented the ACS Lifetime Achievement Award to Thomas R. Russell, MD, FACS, former Executive Director of the College, during the Convocation, October 26, at Clinical Congress 2014 in San Francisco, CA. The award was presented posthumously, and daughters, Jackie and Katie, and wife Nona, accepted it on his behalf.
Following is an edited text of Dr. Pellegrini’s remarks:
It is my great honor to present the Lifetime Achievement Award of the American College of Surgeons. This award is presented to an extraordinary individual for a lifetime of contributions to the art of medicine and surgery, and service to the ACS. Not surprisingly, this is only the third time that our College has conferred this award in its 100-year history. In choosing Dr. Thomas R. Russell, the College is not only recognizing his contributions and service to the organization’s mission, but also is recognizing a dedicated leader, a compassionate humanitarian, and a man who touched many lives in ways that left us all better people for having known him.
A committed physician
Dr. Russell spent his youth in California and had the unique experience as a teenager of working as a wrangler at a dude ranch, a job that would have a profound influence in his life. After earning his bachelor of arts degree at the University of California, Berkeley, and his medical degree from Creighton University Medical School, Omaha, NE, Tom returned to the Bay Area for his surgical residency training at the University of California, San Francisco. His training was interrupted by service in the Vietnam War from 1968 to 1970, during which he served as a Lieutenant Commander and flight surgeon in the U.S. Navy. In 1975, he joined a practice in San Francisco and began what would become 25 years as a practicing general and colon and rectal surgeon.
Tom became a Fellow of the ACS in 1979. He was Secretary and later President of the Northern California Chapter of the College. He was elected to the Board of Governors in 1990 and served in that role until 1993, when he was elected to the Board of Regents. His roles in the ACS as a Regent are too numerous to name, but included chairing the Nominating Committee and serving on the Member Services Liaison Committee and the Advisory Council for Colon and Rectal Surgery.
Insightful leadership
In 1999, the Board of Regents, facing unprecedented challenges, asked Tom to take the difficult job of Executive Director of the College. Our College was in need of thoughtful and compassionate leadership, and Tom was the right person for the job. He had a reputation as a bright, kind, high-energy individual who was willing to weigh all sides of an issue.
Soon after assuming the position of Executive Director, he initiated a strategic planning process, which revealed his innovative and insightful leadership. The College structure was reorganized. Education programs were expanded to offer new and innovative courses. He directed the establishment of the ACS Foundation in 2005 to better support the ACS’ scholarship programs.
A mission statement was developed to guide the work of staff and volunteers alike: “The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.” These articulately presented ideals continue to guide us.
Dr. Russell encouraged the College to take a proactive stance in the politically charged atmosphere of the early 2000s to protect patients’ access to quality care. Under his leadership, our presence in Washington, DC, grew, and a new building was erected near Capitol Hill to house our Division of Advocacy and Health Policy.
One of Dr. Russell’s most significant accomplishments as ACS Executive Director was bringing the Veterans Affairs (VA) National Surgical Quality Improvement Program into the private sector under the College’s aegis as ACS NSQIP®, which launched in 2004. Nearly 600 hospitals have since become participants in ACS NSQIP and have used the program’s risk-adjusted, evidence-based outcomes data to significantly reduce complications, limit error, and save countless lives and millions of dollars.
Kind, fair, and honorable
I count it among one of the great blessings of my life that I am able to call Tom a friend. He was insightful, generous, personable, compassionate, and above all, kind, fair, and honorable. His spirit lives on in the lives of his partner and wife, Nona, and his daughters, Katie and Jackie, the three “stars” of his life. His gentle humor and enduring optimism always brought out the best in people. His imprint will permanently remain on the College and the countless lives he touched while living every day by his motto, “Take the stairs, be nice to the janitor, and the patient comes first.”
Carlos A. Pellegrini, MD, FACS, Immediate Past-President of the American College of Surgeons (ACS), presented the ACS Lifetime Achievement Award to Thomas R. Russell, MD, FACS, former Executive Director of the College, during the Convocation, October 26, at Clinical Congress 2014 in San Francisco, CA. The award was presented posthumously, and daughters, Jackie and Katie, and wife Nona, accepted it on his behalf.
Following is an edited text of Dr. Pellegrini’s remarks:
It is my great honor to present the Lifetime Achievement Award of the American College of Surgeons. This award is presented to an extraordinary individual for a lifetime of contributions to the art of medicine and surgery, and service to the ACS. Not surprisingly, this is only the third time that our College has conferred this award in its 100-year history. In choosing Dr. Thomas R. Russell, the College is not only recognizing his contributions and service to the organization’s mission, but also is recognizing a dedicated leader, a compassionate humanitarian, and a man who touched many lives in ways that left us all better people for having known him.
A committed physician
Dr. Russell spent his youth in California and had the unique experience as a teenager of working as a wrangler at a dude ranch, a job that would have a profound influence in his life. After earning his bachelor of arts degree at the University of California, Berkeley, and his medical degree from Creighton University Medical School, Omaha, NE, Tom returned to the Bay Area for his surgical residency training at the University of California, San Francisco. His training was interrupted by service in the Vietnam War from 1968 to 1970, during which he served as a Lieutenant Commander and flight surgeon in the U.S. Navy. In 1975, he joined a practice in San Francisco and began what would become 25 years as a practicing general and colon and rectal surgeon.
Tom became a Fellow of the ACS in 1979. He was Secretary and later President of the Northern California Chapter of the College. He was elected to the Board of Governors in 1990 and served in that role until 1993, when he was elected to the Board of Regents. His roles in the ACS as a Regent are too numerous to name, but included chairing the Nominating Committee and serving on the Member Services Liaison Committee and the Advisory Council for Colon and Rectal Surgery.
Insightful leadership
In 1999, the Board of Regents, facing unprecedented challenges, asked Tom to take the difficult job of Executive Director of the College. Our College was in need of thoughtful and compassionate leadership, and Tom was the right person for the job. He had a reputation as a bright, kind, high-energy individual who was willing to weigh all sides of an issue.
Soon after assuming the position of Executive Director, he initiated a strategic planning process, which revealed his innovative and insightful leadership. The College structure was reorganized. Education programs were expanded to offer new and innovative courses. He directed the establishment of the ACS Foundation in 2005 to better support the ACS’ scholarship programs.
A mission statement was developed to guide the work of staff and volunteers alike: “The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.” These articulately presented ideals continue to guide us.
Dr. Russell encouraged the College to take a proactive stance in the politically charged atmosphere of the early 2000s to protect patients’ access to quality care. Under his leadership, our presence in Washington, DC, grew, and a new building was erected near Capitol Hill to house our Division of Advocacy and Health Policy.
One of Dr. Russell’s most significant accomplishments as ACS Executive Director was bringing the Veterans Affairs (VA) National Surgical Quality Improvement Program into the private sector under the College’s aegis as ACS NSQIP®, which launched in 2004. Nearly 600 hospitals have since become participants in ACS NSQIP and have used the program’s risk-adjusted, evidence-based outcomes data to significantly reduce complications, limit error, and save countless lives and millions of dollars.
Kind, fair, and honorable
I count it among one of the great blessings of my life that I am able to call Tom a friend. He was insightful, generous, personable, compassionate, and above all, kind, fair, and honorable. His spirit lives on in the lives of his partner and wife, Nona, and his daughters, Katie and Jackie, the three “stars” of his life. His gentle humor and enduring optimism always brought out the best in people. His imprint will permanently remain on the College and the countless lives he touched while living every day by his motto, “Take the stairs, be nice to the janitor, and the patient comes first.”
EHRs: Incentives spurred adoption
Financial incentives and potential penalties were the major influencers on most physicians’ decision to adopt electronic health records, according to a new report from the Office of the National Coordinator for Health IT.
Almost two-thirds (62%) of physicians cited the incentives/penalties established by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 as the major influence for adoption of EHRs.
“We have seen a significant increase in the adoption and use of health IT systems among providers and the new data show the importance of incentives in building an interoperable health IT system,” Dr. Karen DeSalvo, Acting Assistant Secretary of Health and National Coordinator for Health IT, said in a statement.
Two other big factors for adoption, according to the report: Thirty-nine percent said because it was a requirement for board certification, and 37% said because trusted colleagues were using EHRs.
The vast majority of physicians (81%) said they currently were using an EHR or planned to adopt one. Doctors in large or multispecialty practices had the highest rates of adoption and the lowest numbers of those who said they would never have an EHR.
Solo practice physicians (44%) and surgical specialists (32%) were those most likely to have not adopted an EHR and to have no plans to do so.
The biggest reasons for not having an EHR were a lack of money, time, or staff, along with privacy concerns.
Of physicians who were not currently using EHRs, 51% said that incentive payments or financial penalties would be a major driver for adoption, 46% said technical assistance with adoption would be a motivator, and 44% said that having EHRs as a requirement for board certification would fuel adoption.
“It’s no surprise that incentives have helped drive adoption of health information technology,” said Dr. Robert Wergin, president of the American Academy of Family Physicians.
Dr. Wergin noted that physicians can’t pass on infrastructure costs to patients, so “incentives to help defray the cost of that infrastructure helped make health information technology adoption possible.”
The report is based on the 2011-2013 Physician Workflow Survey, a component of the National Ambulatory Medical Care Survey, conducted by the Centers for Disease Control and Prevention.
On Twitter @aliciaault
Financial incentives and potential penalties were the major influencers on most physicians’ decision to adopt electronic health records, according to a new report from the Office of the National Coordinator for Health IT.
Almost two-thirds (62%) of physicians cited the incentives/penalties established by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 as the major influence for adoption of EHRs.
“We have seen a significant increase in the adoption and use of health IT systems among providers and the new data show the importance of incentives in building an interoperable health IT system,” Dr. Karen DeSalvo, Acting Assistant Secretary of Health and National Coordinator for Health IT, said in a statement.
Two other big factors for adoption, according to the report: Thirty-nine percent said because it was a requirement for board certification, and 37% said because trusted colleagues were using EHRs.
The vast majority of physicians (81%) said they currently were using an EHR or planned to adopt one. Doctors in large or multispecialty practices had the highest rates of adoption and the lowest numbers of those who said they would never have an EHR.
Solo practice physicians (44%) and surgical specialists (32%) were those most likely to have not adopted an EHR and to have no plans to do so.
The biggest reasons for not having an EHR were a lack of money, time, or staff, along with privacy concerns.
Of physicians who were not currently using EHRs, 51% said that incentive payments or financial penalties would be a major driver for adoption, 46% said technical assistance with adoption would be a motivator, and 44% said that having EHRs as a requirement for board certification would fuel adoption.
“It’s no surprise that incentives have helped drive adoption of health information technology,” said Dr. Robert Wergin, president of the American Academy of Family Physicians.
Dr. Wergin noted that physicians can’t pass on infrastructure costs to patients, so “incentives to help defray the cost of that infrastructure helped make health information technology adoption possible.”
The report is based on the 2011-2013 Physician Workflow Survey, a component of the National Ambulatory Medical Care Survey, conducted by the Centers for Disease Control and Prevention.
On Twitter @aliciaault
Financial incentives and potential penalties were the major influencers on most physicians’ decision to adopt electronic health records, according to a new report from the Office of the National Coordinator for Health IT.
Almost two-thirds (62%) of physicians cited the incentives/penalties established by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 as the major influence for adoption of EHRs.
“We have seen a significant increase in the adoption and use of health IT systems among providers and the new data show the importance of incentives in building an interoperable health IT system,” Dr. Karen DeSalvo, Acting Assistant Secretary of Health and National Coordinator for Health IT, said in a statement.
Two other big factors for adoption, according to the report: Thirty-nine percent said because it was a requirement for board certification, and 37% said because trusted colleagues were using EHRs.
The vast majority of physicians (81%) said they currently were using an EHR or planned to adopt one. Doctors in large or multispecialty practices had the highest rates of adoption and the lowest numbers of those who said they would never have an EHR.
Solo practice physicians (44%) and surgical specialists (32%) were those most likely to have not adopted an EHR and to have no plans to do so.
The biggest reasons for not having an EHR were a lack of money, time, or staff, along with privacy concerns.
Of physicians who were not currently using EHRs, 51% said that incentive payments or financial penalties would be a major driver for adoption, 46% said technical assistance with adoption would be a motivator, and 44% said that having EHRs as a requirement for board certification would fuel adoption.
“It’s no surprise that incentives have helped drive adoption of health information technology,” said Dr. Robert Wergin, president of the American Academy of Family Physicians.
Dr. Wergin noted that physicians can’t pass on infrastructure costs to patients, so “incentives to help defray the cost of that infrastructure helped make health information technology adoption possible.”
The report is based on the 2011-2013 Physician Workflow Survey, a component of the National Ambulatory Medical Care Survey, conducted by the Centers for Disease Control and Prevention.
On Twitter @aliciaault
ICD lead extraction complication rates warrant surgical backup
CHICAGO– Transvenous lead extraction was associated with a significant risk of urgent cardiac surgery and mortality in a real-world cohort of patients undergoing procedures across a wide spectrum of centers and operators.
Among the 11,304 extractions, the major complication rate was 2.3% and mortality rate 0.9%.
While the complication rate was in line with previously published single-center registry data, the mortality rate was more than twice that reported in recent single-center studies from high-volume centers (0.9% vs. 0.4%), Dr. Nitesh Sood reported at the American Heart Association annual scientific sessions.
Of the 98 perioperative deaths, 18 occurred during the lead extraction procedure.
Another 41 patients (16%) required urgent cardiac surgery, of whom 14 (34%) died during or in the immediate postoperative period after surgery.
“Thus, while overall rate of major complications remains low, there exists a significant risk of urgent cardiac surgery and mortality during transvenous lead extractions [TLE] performed in the ‘real world.’ Appropriate training of all personnel involved and optimal cardiothoracic surgical back-up at centers performing TLE is imperative,” Dr. Sood of the Southcoast Health System, Fall River, Mass., concluded.
The analysis is the largest real-world cohort of TLE involving 11,304 patients with an implantable cardioverter defibrillator (ICD) in the American College of Cardiology Foundation’s National Cardiovascular Data Registry (NCDR) ICD Registry with lead extraction data submitted between April 2010 and July 2012. Major complication was a combined endpoint of major operative complications, postoperative or in-hospital mortality, as defined by the NCDR ICD Registry.
The 258 complications included 62 cardiac arrests, 55 pericardial tamponades, 47 pneumothoraces, and 40 cardiac perforations.
In multivariate analysis, significant predictors of any complication were female sex (adjusted odds ratio, 1.46), heart failure admission vs. lead extraction admission (OR, 2.6), noncardiac admission vs. lead extraction admission (OR, 2.4), lead-only procedure vs. extraction during generator change/upgrade (OR, 1.76), age of lead (OR, 1.08), and clinical status requiring lead replacement (OR, 2.2). Dr. Sood reported.
Among lead characteristics, multivariate predictors of major perioperative complications included at least three concurrent leads extracted (OR, 2.13), longer implant duration (OR, 1.13), flat coil design vs. round (OR, 2.68), greater proximal coil surface area (OR, 1.04), and dislodgement of other leads during extraction (OR, 3.97), he noted.
CHICAGO– Transvenous lead extraction was associated with a significant risk of urgent cardiac surgery and mortality in a real-world cohort of patients undergoing procedures across a wide spectrum of centers and operators.
Among the 11,304 extractions, the major complication rate was 2.3% and mortality rate 0.9%.
While the complication rate was in line with previously published single-center registry data, the mortality rate was more than twice that reported in recent single-center studies from high-volume centers (0.9% vs. 0.4%), Dr. Nitesh Sood reported at the American Heart Association annual scientific sessions.
Of the 98 perioperative deaths, 18 occurred during the lead extraction procedure.
Another 41 patients (16%) required urgent cardiac surgery, of whom 14 (34%) died during or in the immediate postoperative period after surgery.
“Thus, while overall rate of major complications remains low, there exists a significant risk of urgent cardiac surgery and mortality during transvenous lead extractions [TLE] performed in the ‘real world.’ Appropriate training of all personnel involved and optimal cardiothoracic surgical back-up at centers performing TLE is imperative,” Dr. Sood of the Southcoast Health System, Fall River, Mass., concluded.
The analysis is the largest real-world cohort of TLE involving 11,304 patients with an implantable cardioverter defibrillator (ICD) in the American College of Cardiology Foundation’s National Cardiovascular Data Registry (NCDR) ICD Registry with lead extraction data submitted between April 2010 and July 2012. Major complication was a combined endpoint of major operative complications, postoperative or in-hospital mortality, as defined by the NCDR ICD Registry.
The 258 complications included 62 cardiac arrests, 55 pericardial tamponades, 47 pneumothoraces, and 40 cardiac perforations.
In multivariate analysis, significant predictors of any complication were female sex (adjusted odds ratio, 1.46), heart failure admission vs. lead extraction admission (OR, 2.6), noncardiac admission vs. lead extraction admission (OR, 2.4), lead-only procedure vs. extraction during generator change/upgrade (OR, 1.76), age of lead (OR, 1.08), and clinical status requiring lead replacement (OR, 2.2). Dr. Sood reported.
Among lead characteristics, multivariate predictors of major perioperative complications included at least three concurrent leads extracted (OR, 2.13), longer implant duration (OR, 1.13), flat coil design vs. round (OR, 2.68), greater proximal coil surface area (OR, 1.04), and dislodgement of other leads during extraction (OR, 3.97), he noted.
CHICAGO– Transvenous lead extraction was associated with a significant risk of urgent cardiac surgery and mortality in a real-world cohort of patients undergoing procedures across a wide spectrum of centers and operators.
Among the 11,304 extractions, the major complication rate was 2.3% and mortality rate 0.9%.
While the complication rate was in line with previously published single-center registry data, the mortality rate was more than twice that reported in recent single-center studies from high-volume centers (0.9% vs. 0.4%), Dr. Nitesh Sood reported at the American Heart Association annual scientific sessions.
Of the 98 perioperative deaths, 18 occurred during the lead extraction procedure.
Another 41 patients (16%) required urgent cardiac surgery, of whom 14 (34%) died during or in the immediate postoperative period after surgery.
“Thus, while overall rate of major complications remains low, there exists a significant risk of urgent cardiac surgery and mortality during transvenous lead extractions [TLE] performed in the ‘real world.’ Appropriate training of all personnel involved and optimal cardiothoracic surgical back-up at centers performing TLE is imperative,” Dr. Sood of the Southcoast Health System, Fall River, Mass., concluded.
The analysis is the largest real-world cohort of TLE involving 11,304 patients with an implantable cardioverter defibrillator (ICD) in the American College of Cardiology Foundation’s National Cardiovascular Data Registry (NCDR) ICD Registry with lead extraction data submitted between April 2010 and July 2012. Major complication was a combined endpoint of major operative complications, postoperative or in-hospital mortality, as defined by the NCDR ICD Registry.
The 258 complications included 62 cardiac arrests, 55 pericardial tamponades, 47 pneumothoraces, and 40 cardiac perforations.
In multivariate analysis, significant predictors of any complication were female sex (adjusted odds ratio, 1.46), heart failure admission vs. lead extraction admission (OR, 2.6), noncardiac admission vs. lead extraction admission (OR, 2.4), lead-only procedure vs. extraction during generator change/upgrade (OR, 1.76), age of lead (OR, 1.08), and clinical status requiring lead replacement (OR, 2.2). Dr. Sood reported.
Among lead characteristics, multivariate predictors of major perioperative complications included at least three concurrent leads extracted (OR, 2.13), longer implant duration (OR, 1.13), flat coil design vs. round (OR, 2.68), greater proximal coil surface area (OR, 1.04), and dislodgement of other leads during extraction (OR, 3.97), he noted.
AT THE AHA SCIENTIFIC SESSIONS
Key clinical point: Appropriate training and optimal cardiothoracic surgical backup is necessary at all centers performing lead extractions, because of a significant risk of urgent cardiac surgery and death.
Major finding: The major complication rate was 2.3% and mortality rate 0.9%.
Data source: Retrospective analysis of 11,304 patients with transvenous lead extraction in the NCDR ICD Registry.
Disclosures: The study was supported by the American College of Cardiology Foundation’s National Cardiovascular Data Registry. Dr. Sood reported having no financial disclosures. Three coauthors reported relationships with device makers.
Autoantibodies not predictive of surgery for Graves’ disease
CORONADO, CALIF.– Measurement of thyroid antibodies had no impact on the clinical features of Graves’ disease best treated with surgery, results from a single-center retrospective study showed.
The findings are part of a larger study meant to develop ways to help patients decide between surgery and radioactive iodine for their Graves’ disease. “We know that certain clinical features make patients lean toward surgery instead of radioactive iodine, including severe ophthalmopathy and young women who have concerns about family planning,” Dr. Dawn M. Elfenbein said in an interview during the annual meeting of the American Thyroid Association. “In the long-term picture, I think that a lot of provider preferences go into this decision, but we’d like to move this to being more of a patient-centered decision. So we’re trying to see if there are biochemical factors about patients that can help us recommend one treatment versus the other.”
Dr. Elfenbein of the section of endocrine surgery in the department of surgery at the University of Wisconsin, Madison, and her associates reviewed the records of 469 patients treated with radioactive iodine (RAI) or surgery for Graves’ disease at the institution during August 2008-September 2013. They excluded patients with contraindications to RAI or those with other indications for surgery or who previously failed either treatment.
Of the 469 patients, 78% were women, and their mean age was 40 years. Most (71%) underwent RAI while 29% underwent surgery. The percentage of patients who opted for surgery increased each year of the study, from 14% in the first year to 52% in the final year.
More than half of the patients (52%) had thyroid peroxidase (TPO) measured prior to treatment, while 44% had thyroglobulin antibodies (TgAb) and 45% had either thyroid simulating immunoglobulin (TSIg) or thyrotropin receptor antibody (TRAb) measured.
Dr. Elfenbein and her associates found that clinical features such as ophthalmopathy or a compressive goiter appeared to influence a patient’s decision to choose surgery over RAI. On bivariate analysis, patients with a positive TSIg or TRAb were significantly more likely to have ophthalmopathy (41% vs. 25%) while patients with positive TgAb were significantly more likely to have goiter (71% vs. 55%). On multivariate analysis, however, antibody positivity was not predictive of ophthalmopathy or goiter.
“Surgery became the primary definitive treatment of choice over RAI for Graves’ disease at our institution over the study period, particularly for younger women,” the researchers wrote in their abstract. The concluded that measurement of thyroid-specific antibodies “does not independently predict those clinical features best treated with surgery. Clinical features and patient preferences should be considered independently from autoantibody levels.”
Dr. Elfenbein acknowledged certain limitations of the study, including its retrospective design and that fact that autoantibody levels were not measured after treatment. “What would be more helpful is to measure antibodies in everyone before they undergo treatment and measure those same antibodies after treatment to see what happens; to see if there are any differences in recurrence rates with higher antibodies,” she said. “We can be more deliberate moving forward.” She reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF.– Measurement of thyroid antibodies had no impact on the clinical features of Graves’ disease best treated with surgery, results from a single-center retrospective study showed.
The findings are part of a larger study meant to develop ways to help patients decide between surgery and radioactive iodine for their Graves’ disease. “We know that certain clinical features make patients lean toward surgery instead of radioactive iodine, including severe ophthalmopathy and young women who have concerns about family planning,” Dr. Dawn M. Elfenbein said in an interview during the annual meeting of the American Thyroid Association. “In the long-term picture, I think that a lot of provider preferences go into this decision, but we’d like to move this to being more of a patient-centered decision. So we’re trying to see if there are biochemical factors about patients that can help us recommend one treatment versus the other.”
Dr. Elfenbein of the section of endocrine surgery in the department of surgery at the University of Wisconsin, Madison, and her associates reviewed the records of 469 patients treated with radioactive iodine (RAI) or surgery for Graves’ disease at the institution during August 2008-September 2013. They excluded patients with contraindications to RAI or those with other indications for surgery or who previously failed either treatment.
Of the 469 patients, 78% were women, and their mean age was 40 years. Most (71%) underwent RAI while 29% underwent surgery. The percentage of patients who opted for surgery increased each year of the study, from 14% in the first year to 52% in the final year.
More than half of the patients (52%) had thyroid peroxidase (TPO) measured prior to treatment, while 44% had thyroglobulin antibodies (TgAb) and 45% had either thyroid simulating immunoglobulin (TSIg) or thyrotropin receptor antibody (TRAb) measured.
Dr. Elfenbein and her associates found that clinical features such as ophthalmopathy or a compressive goiter appeared to influence a patient’s decision to choose surgery over RAI. On bivariate analysis, patients with a positive TSIg or TRAb were significantly more likely to have ophthalmopathy (41% vs. 25%) while patients with positive TgAb were significantly more likely to have goiter (71% vs. 55%). On multivariate analysis, however, antibody positivity was not predictive of ophthalmopathy or goiter.
“Surgery became the primary definitive treatment of choice over RAI for Graves’ disease at our institution over the study period, particularly for younger women,” the researchers wrote in their abstract. The concluded that measurement of thyroid-specific antibodies “does not independently predict those clinical features best treated with surgery. Clinical features and patient preferences should be considered independently from autoantibody levels.”
Dr. Elfenbein acknowledged certain limitations of the study, including its retrospective design and that fact that autoantibody levels were not measured after treatment. “What would be more helpful is to measure antibodies in everyone before they undergo treatment and measure those same antibodies after treatment to see what happens; to see if there are any differences in recurrence rates with higher antibodies,” she said. “We can be more deliberate moving forward.” She reported having no financial disclosures.
On Twitter @dougbrunk
CORONADO, CALIF.– Measurement of thyroid antibodies had no impact on the clinical features of Graves’ disease best treated with surgery, results from a single-center retrospective study showed.
The findings are part of a larger study meant to develop ways to help patients decide between surgery and radioactive iodine for their Graves’ disease. “We know that certain clinical features make patients lean toward surgery instead of radioactive iodine, including severe ophthalmopathy and young women who have concerns about family planning,” Dr. Dawn M. Elfenbein said in an interview during the annual meeting of the American Thyroid Association. “In the long-term picture, I think that a lot of provider preferences go into this decision, but we’d like to move this to being more of a patient-centered decision. So we’re trying to see if there are biochemical factors about patients that can help us recommend one treatment versus the other.”
Dr. Elfenbein of the section of endocrine surgery in the department of surgery at the University of Wisconsin, Madison, and her associates reviewed the records of 469 patients treated with radioactive iodine (RAI) or surgery for Graves’ disease at the institution during August 2008-September 2013. They excluded patients with contraindications to RAI or those with other indications for surgery or who previously failed either treatment.
Of the 469 patients, 78% were women, and their mean age was 40 years. Most (71%) underwent RAI while 29% underwent surgery. The percentage of patients who opted for surgery increased each year of the study, from 14% in the first year to 52% in the final year.
More than half of the patients (52%) had thyroid peroxidase (TPO) measured prior to treatment, while 44% had thyroglobulin antibodies (TgAb) and 45% had either thyroid simulating immunoglobulin (TSIg) or thyrotropin receptor antibody (TRAb) measured.
Dr. Elfenbein and her associates found that clinical features such as ophthalmopathy or a compressive goiter appeared to influence a patient’s decision to choose surgery over RAI. On bivariate analysis, patients with a positive TSIg or TRAb were significantly more likely to have ophthalmopathy (41% vs. 25%) while patients with positive TgAb were significantly more likely to have goiter (71% vs. 55%). On multivariate analysis, however, antibody positivity was not predictive of ophthalmopathy or goiter.
“Surgery became the primary definitive treatment of choice over RAI for Graves’ disease at our institution over the study period, particularly for younger women,” the researchers wrote in their abstract. The concluded that measurement of thyroid-specific antibodies “does not independently predict those clinical features best treated with surgery. Clinical features and patient preferences should be considered independently from autoantibody levels.”
Dr. Elfenbein acknowledged certain limitations of the study, including its retrospective design and that fact that autoantibody levels were not measured after treatment. “What would be more helpful is to measure antibodies in everyone before they undergo treatment and measure those same antibodies after treatment to see what happens; to see if there are any differences in recurrence rates with higher antibodies,” she said. “We can be more deliberate moving forward.” She reported having no financial disclosures.
On Twitter @dougbrunk
AT THE ATA ANNUAL MEETING
Key clinical point: Measuring thyroid antibodies adds no value in predicting clinical features of Graves’ disease best treated with surgery.
Major finding: On bivariate analysis, patients with a positive TSIg or TRAb were more likely to have ophthalmopathy (41% vs. 25%; P = .04) while patients with positive TgAb were more likely to have goiter (71% vs. 55%; P = .03). On multivariate analysis, however, antibody positivity was not predictive of ophthalmopathy or goiter.
Data source: A retrospective analysis of 469 patients treated with radioactive iodine (RAI) or surgery for Graves’ disease at the University of Wisconsin, Madison, during August 2008-September 2013.
Disclosures:Dr. Elfenbein reported having no financial disclosures.
Hopkins protocol aims to limit sarcoma morcellation risk
VANCOUVER– To minimize the risk of spreading occult malignancy, Johns Hopkins University in Baltimore no longer uses uterine morcellation for fibroids or hysterectomies in women over age 50 years.
Morcellation is also contraindicated under the Hopkins protocol if women have other risk factors for gynecologic cancer, including tamoxifen use, pelvic radiation, hereditary cancer syndromes, and BRCA mutations.
For women who qualify, morcellation can be performed only by high-volume surgeons who isolate their targets within an endoscopy bag to catch spills. Case peer-review, endometrial sampling, and imaging – including an MRI for fibroids – are required beforehand to rule out occult malignancy, and women must be warned of the risk of occult malignancy before opting for morcellation.
“Given the review of our institutional data and recent national debate surrounding power morcellation, our institution developed the protocol to enhance safety for women [undergoing] minimally invasive surgery for benign indications,” said Dr. Stephanie Ricci, a gynecologic oncology fellow at Hopkins.
She explained the protocol just days before the Food and Drug Administration released similar guidance, contraindicating power morcellation in peri- or postmenopausal women, and when tissue can be removed en bloc either vaginally or by mini-laparotomy, which is the case in the majority of hysterectomies and myomectomies. Women must also be warned of the risk of occult malignancy before morcellation, the agency said Nov. 24.
Taken together, the Hopkins’ protocol and the FDA’s guidance could help define the narrow pool of women for whom morcellation might still be an option, be it to preserve fertility or for some other reason.
“It’s possible that a higher rate of peer-review and preop imaging and endometrial sampling counter the risk of occult malignancy,” Dr. Ricci said at a meeting sponsored by AAGL.
Hopkins developed its rules in part based on a review led by Dr. Ricci of 424 morcellation cases there from 2005 to 2014. Two occult cancers were identified in women who underwent power morcellation, giving an incidence of 0.47%.
One case was a 55-year-old woman who presented with pain and hematometra. Her preoperative endometrial biopsy was negative, and she had a preop CT. She was morcellized with endoscopy bag containment and found to have invasive cervical adenocarcinoma. The second case was a 56-year-old women morcellized in 2009 for fibroids with no preoperative imaging, biopsy, or containment bag. She was found to have a uterine sarcoma. Both patients underwent chemotherapy and are currently without evidence of disease.
Almost 90% of the morcellation cases in the series were under age 50 years, 93% had preop uterine imaging, and almost half had preoperative biopsy.
“The one thing our institution has always done, and it speaks to the low rate of sarcoma we found in our study, is that all patients are [reviewed] in a preop gynecological oncology conference, even if they are being taken to the OR for benign indications,” Dr. Ricci said.
Dr. Ricci reported having no financial disclosures.
VANCOUVER– To minimize the risk of spreading occult malignancy, Johns Hopkins University in Baltimore no longer uses uterine morcellation for fibroids or hysterectomies in women over age 50 years.
Morcellation is also contraindicated under the Hopkins protocol if women have other risk factors for gynecologic cancer, including tamoxifen use, pelvic radiation, hereditary cancer syndromes, and BRCA mutations.
For women who qualify, morcellation can be performed only by high-volume surgeons who isolate their targets within an endoscopy bag to catch spills. Case peer-review, endometrial sampling, and imaging – including an MRI for fibroids – are required beforehand to rule out occult malignancy, and women must be warned of the risk of occult malignancy before opting for morcellation.
“Given the review of our institutional data and recent national debate surrounding power morcellation, our institution developed the protocol to enhance safety for women [undergoing] minimally invasive surgery for benign indications,” said Dr. Stephanie Ricci, a gynecologic oncology fellow at Hopkins.
She explained the protocol just days before the Food and Drug Administration released similar guidance, contraindicating power morcellation in peri- or postmenopausal women, and when tissue can be removed en bloc either vaginally or by mini-laparotomy, which is the case in the majority of hysterectomies and myomectomies. Women must also be warned of the risk of occult malignancy before morcellation, the agency said Nov. 24.
Taken together, the Hopkins’ protocol and the FDA’s guidance could help define the narrow pool of women for whom morcellation might still be an option, be it to preserve fertility or for some other reason.
“It’s possible that a higher rate of peer-review and preop imaging and endometrial sampling counter the risk of occult malignancy,” Dr. Ricci said at a meeting sponsored by AAGL.
Hopkins developed its rules in part based on a review led by Dr. Ricci of 424 morcellation cases there from 2005 to 2014. Two occult cancers were identified in women who underwent power morcellation, giving an incidence of 0.47%.
One case was a 55-year-old woman who presented with pain and hematometra. Her preoperative endometrial biopsy was negative, and she had a preop CT. She was morcellized with endoscopy bag containment and found to have invasive cervical adenocarcinoma. The second case was a 56-year-old women morcellized in 2009 for fibroids with no preoperative imaging, biopsy, or containment bag. She was found to have a uterine sarcoma. Both patients underwent chemotherapy and are currently without evidence of disease.
Almost 90% of the morcellation cases in the series were under age 50 years, 93% had preop uterine imaging, and almost half had preoperative biopsy.
“The one thing our institution has always done, and it speaks to the low rate of sarcoma we found in our study, is that all patients are [reviewed] in a preop gynecological oncology conference, even if they are being taken to the OR for benign indications,” Dr. Ricci said.
Dr. Ricci reported having no financial disclosures.
VANCOUVER– To minimize the risk of spreading occult malignancy, Johns Hopkins University in Baltimore no longer uses uterine morcellation for fibroids or hysterectomies in women over age 50 years.
Morcellation is also contraindicated under the Hopkins protocol if women have other risk factors for gynecologic cancer, including tamoxifen use, pelvic radiation, hereditary cancer syndromes, and BRCA mutations.
For women who qualify, morcellation can be performed only by high-volume surgeons who isolate their targets within an endoscopy bag to catch spills. Case peer-review, endometrial sampling, and imaging – including an MRI for fibroids – are required beforehand to rule out occult malignancy, and women must be warned of the risk of occult malignancy before opting for morcellation.
“Given the review of our institutional data and recent national debate surrounding power morcellation, our institution developed the protocol to enhance safety for women [undergoing] minimally invasive surgery for benign indications,” said Dr. Stephanie Ricci, a gynecologic oncology fellow at Hopkins.
She explained the protocol just days before the Food and Drug Administration released similar guidance, contraindicating power morcellation in peri- or postmenopausal women, and when tissue can be removed en bloc either vaginally or by mini-laparotomy, which is the case in the majority of hysterectomies and myomectomies. Women must also be warned of the risk of occult malignancy before morcellation, the agency said Nov. 24.
Taken together, the Hopkins’ protocol and the FDA’s guidance could help define the narrow pool of women for whom morcellation might still be an option, be it to preserve fertility or for some other reason.
“It’s possible that a higher rate of peer-review and preop imaging and endometrial sampling counter the risk of occult malignancy,” Dr. Ricci said at a meeting sponsored by AAGL.
Hopkins developed its rules in part based on a review led by Dr. Ricci of 424 morcellation cases there from 2005 to 2014. Two occult cancers were identified in women who underwent power morcellation, giving an incidence of 0.47%.
One case was a 55-year-old woman who presented with pain and hematometra. Her preoperative endometrial biopsy was negative, and she had a preop CT. She was morcellized with endoscopy bag containment and found to have invasive cervical adenocarcinoma. The second case was a 56-year-old women morcellized in 2009 for fibroids with no preoperative imaging, biopsy, or containment bag. She was found to have a uterine sarcoma. Both patients underwent chemotherapy and are currently without evidence of disease.
Almost 90% of the morcellation cases in the series were under age 50 years, 93% had preop uterine imaging, and almost half had preoperative biopsy.
“The one thing our institution has always done, and it speaks to the low rate of sarcoma we found in our study, is that all patients are [reviewed] in a preop gynecological oncology conference, even if they are being taken to the OR for benign indications,” Dr. Ricci said.
Dr. Ricci reported having no financial disclosures.
AT THE AAGL GLOBAL CONFERENCE
Key clinical point: In addition to the FDA’s recent morcellation contraindications, the procedure shouldn’t be done in women who have uterine sarcoma risk factors.
Major finding: There were two occult malignancies in a series of 424 morcellation cases at Johns Hopkins University, both in women over 50 years old.
Data source: A review of morcellation cases over 9 years.
Disclosures: The lead investigator reported having no financial disclosures.
