ACS Surgery News

Despite the federal government shutdown, the Affordable Care Act’s insurance marketplaces opened for enrollment on Oct. 1.

The online health marketplaces were up and running for just a few hours when complaints starting circulating about glitches. Consumers got error messages and had trouble logging in. And when they did get in, the websites for the various state and federal exchanges ran slowly.

A large part of the problem was the high volume of traffic to the websites, federal officials said.

As of late afternoon on Oct. 1, about 2.8 million visits were logged to healthcare.gov, the clearinghouse that serves the federally run marketplaces and links consumers to the state-run online marketplaces. That’s about seven times more users than Medicare.gov has ever had at any one time, Marilyn Tavenner, the administrator of the Centers for Medicare and Medicaid Services, said during a news conference.

Additionally, the Health and Human Services department received more than 80,000 calls to its help line and more than 60,000 requests for online chats to help enroll in health plans.

HHS would not release figures on how many Americans had enrolled in health plans through the federal and state marketplaces. Ms. Tavenner said that data would be released later, but that consumers were successfully enrolling.

States also reported heavy web traffic. Officials in New York reported that their state exchanges website had 2 million visits in the first 2 hours of operation. Due to the high volume, they posted a notice to consumers to come back later if they had trouble logging in.

"This gives you a sense of how important this is to millions of Americans," President Obama said during a news conference in the Rose Garden.

The president admitted that there have been "glitches" with the enrollment process, but vowed that they would be fixed.

Ms. Tavenner said federal officials had been working throughout the day to correct problems, including adding capacity to healthcare.gov. They also made adjustments to resolve problems that consumers had creating accounts. Some states, including Maryland and Hawaii, had some technical problems that kept consumers from enrolling in health plans on Oct. 1, HHS officials said.

Individuals will have until March 31, 2014, to enroll in a health plan through the marketplaces. However, they must enroll by Dec. 15 to have their coverage begin on Jan. 1, 2014.

[email protected]

Despite the federal government shutdown, the Affordable Care Act’s insurance marketplaces opened for enrollment on Oct. 1.

The online health marketplaces were up and running for just a few hours when complaints starting circulating about glitches. Consumers got error messages and had trouble logging in. And when they did get in, the websites for the various state and federal exchanges ran slowly.

A large part of the problem was the high volume of traffic to the websites, federal officials said.

As of late afternoon on Oct. 1, about 2.8 million visits were logged to healthcare.gov, the clearinghouse that serves the federally run marketplaces and links consumers to the state-run online marketplaces. That’s about seven times more users than Medicare.gov has ever had at any one time, Marilyn Tavenner, the administrator of the Centers for Medicare and Medicaid Services, said during a news conference.

Additionally, the Health and Human Services department received more than 80,000 calls to its help line and more than 60,000 requests for online chats to help enroll in health plans.

HHS would not release figures on how many Americans had enrolled in health plans through the federal and state marketplaces. Ms. Tavenner said that data would be released later, but that consumers were successfully enrolling.

States also reported heavy web traffic. Officials in New York reported that their state exchanges website had 2 million visits in the first 2 hours of operation. Due to the high volume, they posted a notice to consumers to come back later if they had trouble logging in.

"This gives you a sense of how important this is to millions of Americans," President Obama said during a news conference in the Rose Garden.

The president admitted that there have been "glitches" with the enrollment process, but vowed that they would be fixed.

Ms. Tavenner said federal officials had been working throughout the day to correct problems, including adding capacity to healthcare.gov. They also made adjustments to resolve problems that consumers had creating accounts. Some states, including Maryland and Hawaii, had some technical problems that kept consumers from enrolling in health plans on Oct. 1, HHS officials said.

Individuals will have until March 31, 2014, to enroll in a health plan through the marketplaces. However, they must enroll by Dec. 15 to have their coverage begin on Jan. 1, 2014.

[email protected]

Despite the federal government shutdown, the Affordable Care Act’s insurance marketplaces opened for enrollment on Oct. 1.

The online health marketplaces were up and running for just a few hours when complaints starting circulating about glitches. Consumers got error messages and had trouble logging in. And when they did get in, the websites for the various state and federal exchanges ran slowly.

A large part of the problem was the high volume of traffic to the websites, federal officials said.

As of late afternoon on Oct. 1, about 2.8 million visits were logged to healthcare.gov, the clearinghouse that serves the federally run marketplaces and links consumers to the state-run online marketplaces. That’s about seven times more users than Medicare.gov has ever had at any one time, Marilyn Tavenner, the administrator of the Centers for Medicare and Medicaid Services, said during a news conference.

Additionally, the Health and Human Services department received more than 80,000 calls to its help line and more than 60,000 requests for online chats to help enroll in health plans.

HHS would not release figures on how many Americans had enrolled in health plans through the federal and state marketplaces. Ms. Tavenner said that data would be released later, but that consumers were successfully enrolling.

States also reported heavy web traffic. Officials in New York reported that their state exchanges website had 2 million visits in the first 2 hours of operation. Due to the high volume, they posted a notice to consumers to come back later if they had trouble logging in.

"This gives you a sense of how important this is to millions of Americans," President Obama said during a news conference in the Rose Garden.

The president admitted that there have been "glitches" with the enrollment process, but vowed that they would be fixed.

Ms. Tavenner said federal officials had been working throughout the day to correct problems, including adding capacity to healthcare.gov. They also made adjustments to resolve problems that consumers had creating accounts. Some states, including Maryland and Hawaii, had some technical problems that kept consumers from enrolling in health plans on Oct. 1, HHS officials said.

Individuals will have until March 31, 2014, to enroll in a health plan through the marketplaces. However, they must enroll by Dec. 15 to have their coverage begin on Jan. 1, 2014.

[email protected]

With lawmakers unable to make a deal on how to fund the government, federal agencies began a partial shutdown on Oct. 1.

The government closure should not hit doctors in the pocketbook. Medicare is expected to continue "largely without disruption" in the short term, according to the Health and Human Services department contingency plan for operating during a shutdown. Payments for Medicaid and the Children’s Health Insurance Program should also be unaffected, since federal monies for that program were previously set aside.

But the shutdown will impact many of the day-to-day functions at federal health agencies, from grant making to disease surveillance.

Doctors and other health care providers at the National Institutes of Health continue to care for current patients but are now unable to admit new patients unless it is deemed medically necessary by the NIH director. The agency is providing only minimal support for ongoing research protocols and has halted approval of new grant applications.

Some staffers at the Centers for Disease Control and Prevention are on duty to respond to disease outbreaks and other emergencies; however, seasonal influenza monitoring is on hold, as is technical support to states for infectious disease surveillance.

The Vaccines for Children program, mandated by law, continues despite the shutdown.

Graduate medical training at children’s hospitals is on hold since the Health Resources and Services Administration cannot make payments to the Children’s Hospitals Graduate Medical Education Payment Program during the shutdown.

Health care advocacy groups began sounding off Oct. 1 on the shutdown’s impact on public health.

"We encourage policymakers to consider the dramatic impact that funding cuts to medical research and doctor training will have on the health of the country and the millions of patients who depend on the lifesaving research conducted at, and critical health care services provided by, the nation’s medical schools and teaching hospitals," said Dr. Darrell G. Kirch, president and CEO of the Association of American Medical Colleges.

In the meantime, despite the government shutdown, enrollment in the Affordable Care Act’s health exchanges began as scheduled.

[email protected]

With lawmakers unable to make a deal on how to fund the government, federal agencies began a partial shutdown on Oct. 1.

The government closure should not hit doctors in the pocketbook. Medicare is expected to continue "largely without disruption" in the short term, according to the Health and Human Services department contingency plan for operating during a shutdown. Payments for Medicaid and the Children’s Health Insurance Program should also be unaffected, since federal monies for that program were previously set aside.

But the shutdown will impact many of the day-to-day functions at federal health agencies, from grant making to disease surveillance.

Doctors and other health care providers at the National Institutes of Health continue to care for current patients but are now unable to admit new patients unless it is deemed medically necessary by the NIH director. The agency is providing only minimal support for ongoing research protocols and has halted approval of new grant applications.

Some staffers at the Centers for Disease Control and Prevention are on duty to respond to disease outbreaks and other emergencies; however, seasonal influenza monitoring is on hold, as is technical support to states for infectious disease surveillance.

The Vaccines for Children program, mandated by law, continues despite the shutdown.

Graduate medical training at children’s hospitals is on hold since the Health Resources and Services Administration cannot make payments to the Children’s Hospitals Graduate Medical Education Payment Program during the shutdown.

Health care advocacy groups began sounding off Oct. 1 on the shutdown’s impact on public health.

"We encourage policymakers to consider the dramatic impact that funding cuts to medical research and doctor training will have on the health of the country and the millions of patients who depend on the lifesaving research conducted at, and critical health care services provided by, the nation’s medical schools and teaching hospitals," said Dr. Darrell G. Kirch, president and CEO of the Association of American Medical Colleges.

In the meantime, despite the government shutdown, enrollment in the Affordable Care Act’s health exchanges began as scheduled.

[email protected]

With lawmakers unable to make a deal on how to fund the government, federal agencies began a partial shutdown on Oct. 1.

The government closure should not hit doctors in the pocketbook. Medicare is expected to continue "largely without disruption" in the short term, according to the Health and Human Services department contingency plan for operating during a shutdown. Payments for Medicaid and the Children’s Health Insurance Program should also be unaffected, since federal monies for that program were previously set aside.

But the shutdown will impact many of the day-to-day functions at federal health agencies, from grant making to disease surveillance.

Doctors and other health care providers at the National Institutes of Health continue to care for current patients but are now unable to admit new patients unless it is deemed medically necessary by the NIH director. The agency is providing only minimal support for ongoing research protocols and has halted approval of new grant applications.

Some staffers at the Centers for Disease Control and Prevention are on duty to respond to disease outbreaks and other emergencies; however, seasonal influenza monitoring is on hold, as is technical support to states for infectious disease surveillance.

The Vaccines for Children program, mandated by law, continues despite the shutdown.

Graduate medical training at children’s hospitals is on hold since the Health Resources and Services Administration cannot make payments to the Children’s Hospitals Graduate Medical Education Payment Program during the shutdown.

Health care advocacy groups began sounding off Oct. 1 on the shutdown’s impact on public health.

"We encourage policymakers to consider the dramatic impact that funding cuts to medical research and doctor training will have on the health of the country and the millions of patients who depend on the lifesaving research conducted at, and critical health care services provided by, the nation’s medical schools and teaching hospitals," said Dr. Darrell G. Kirch, president and CEO of the Association of American Medical Colleges.

In the meantime, despite the government shutdown, enrollment in the Affordable Care Act’s health exchanges began as scheduled.

[email protected]

Whether we agree or not with the validity of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or the penalties of high 30-day readmissions, it would be challenging to find a hospitalist group where these measures are not popping up on the dashboard reports. We argue that advance care planning can aid in bending these metrics in a favorable direction.

Approximately 30% of Medicare dollars are spent on the 5% of beneficiaries who die each year (Health Serv. Res. 2004;39:363-75). The last month of life for those Medicare benefits account for one-third of the expenditures. A longitudinal, multi-institutional study looked at whether having a discussion about end-of-life preferences made a difference in quality or cost of care (Arch. Intern. Med. 2009;169:480-8).

Patients were asked "Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?" For those who answered yes, costs were lower by over 35%, quality of care was rated higher, and people were more likely to spend their final days at home (53.8% vs. 37.8%).

Perhaps the most tested, sophisticated, and celebrated model for advance care planning is practiced throughout the Gunderson Health System in La Crosse, Wis.

In its model, certified advance care planning facilitators (most of whom are nurses) see patients in all venues, from the home to the hospital. They craft disease-specific advance directives with patients and families, the results of which are shared with the patient’s entire community including providers, family members, and others within the community.

Their results, which have been reproduced by other systems using the Gunderson methods, are quite staggering. If we consider the percentage of patients with advanced illnesses who have completed advance directives, the percentage of physicians who are aware of those advance directives, and then have consistency between the directives and which treatments are actually delivered, then we find that national data show us hitting below the 50% mark on all three of these issues (J. Am. Geriatr. Soc. 2010;58:1249-55).

Using Gunderson’s advance care planning program, these metrics all skyrocket to 95% or higher.

The Dartmouth Atlas Study data from 2007 comparing the number of days spent in the hospital and cost of care over the last 2 years of life show the Gunderson numbers are better. Patients spend less than 14 days in the hospital and their cost of care is less than $19,000 over those 2 years. For similar patient populations in other medical centers, the days spent in the hospital are 40-55 and costs exceed $60,000.

In our quest to build the better system, let’s highlight the role of advance care planning and resource it appropriately.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Whether we agree or not with the validity of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or the penalties of high 30-day readmissions, it would be challenging to find a hospitalist group where these measures are not popping up on the dashboard reports. We argue that advance care planning can aid in bending these metrics in a favorable direction.

Approximately 30% of Medicare dollars are spent on the 5% of beneficiaries who die each year (Health Serv. Res. 2004;39:363-75). The last month of life for those Medicare benefits account for one-third of the expenditures. A longitudinal, multi-institutional study looked at whether having a discussion about end-of-life preferences made a difference in quality or cost of care (Arch. Intern. Med. 2009;169:480-8).

Patients were asked "Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?" For those who answered yes, costs were lower by over 35%, quality of care was rated higher, and people were more likely to spend their final days at home (53.8% vs. 37.8%).

Perhaps the most tested, sophisticated, and celebrated model for advance care planning is practiced throughout the Gunderson Health System in La Crosse, Wis.

In its model, certified advance care planning facilitators (most of whom are nurses) see patients in all venues, from the home to the hospital. They craft disease-specific advance directives with patients and families, the results of which are shared with the patient’s entire community including providers, family members, and others within the community.

Their results, which have been reproduced by other systems using the Gunderson methods, are quite staggering. If we consider the percentage of patients with advanced illnesses who have completed advance directives, the percentage of physicians who are aware of those advance directives, and then have consistency between the directives and which treatments are actually delivered, then we find that national data show us hitting below the 50% mark on all three of these issues (J. Am. Geriatr. Soc. 2010;58:1249-55).

Using Gunderson’s advance care planning program, these metrics all skyrocket to 95% or higher.

The Dartmouth Atlas Study data from 2007 comparing the number of days spent in the hospital and cost of care over the last 2 years of life show the Gunderson numbers are better. Patients spend less than 14 days in the hospital and their cost of care is less than $19,000 over those 2 years. For similar patient populations in other medical centers, the days spent in the hospital are 40-55 and costs exceed $60,000.

In our quest to build the better system, let’s highlight the role of advance care planning and resource it appropriately.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Whether we agree or not with the validity of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) or the penalties of high 30-day readmissions, it would be challenging to find a hospitalist group where these measures are not popping up on the dashboard reports. We argue that advance care planning can aid in bending these metrics in a favorable direction.

Approximately 30% of Medicare dollars are spent on the 5% of beneficiaries who die each year (Health Serv. Res. 2004;39:363-75). The last month of life for those Medicare benefits account for one-third of the expenditures. A longitudinal, multi-institutional study looked at whether having a discussion about end-of-life preferences made a difference in quality or cost of care (Arch. Intern. Med. 2009;169:480-8).

Patients were asked "Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying?" For those who answered yes, costs were lower by over 35%, quality of care was rated higher, and people were more likely to spend their final days at home (53.8% vs. 37.8%).

Perhaps the most tested, sophisticated, and celebrated model for advance care planning is practiced throughout the Gunderson Health System in La Crosse, Wis.

In its model, certified advance care planning facilitators (most of whom are nurses) see patients in all venues, from the home to the hospital. They craft disease-specific advance directives with patients and families, the results of which are shared with the patient’s entire community including providers, family members, and others within the community.

Their results, which have been reproduced by other systems using the Gunderson methods, are quite staggering. If we consider the percentage of patients with advanced illnesses who have completed advance directives, the percentage of physicians who are aware of those advance directives, and then have consistency between the directives and which treatments are actually delivered, then we find that national data show us hitting below the 50% mark on all three of these issues (J. Am. Geriatr. Soc. 2010;58:1249-55).

Using Gunderson’s advance care planning program, these metrics all skyrocket to 95% or higher.

The Dartmouth Atlas Study data from 2007 comparing the number of days spent in the hospital and cost of care over the last 2 years of life show the Gunderson numbers are better. Patients spend less than 14 days in the hospital and their cost of care is less than $19,000 over those 2 years. For similar patient populations in other medical centers, the days spent in the hospital are 40-55 and costs exceed $60,000.

In our quest to build the better system, let’s highlight the role of advance care planning and resource it appropriately.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

As the American College of Surgeons celebrates its 100-year anniversary, we find ourselves confronted with challenges that threaten the quality and delivery of surgical care in this country. Two of the more pressing issues that imperil the future of our art are perceived deficiencies in surgical training and the lack of clarity and consensus regarding future surgical manpower needs. These two issues are linked and will require a reasoned and active resolution if we are going to provide competent surgeons in a more balanced manner by both geography and specialty to our ever-changing American demographic.

Training

There is now a general agreement among many members of the surgery profession that the current training paradigms are inadequate and in need of immediate reform. Examples include the increasing Board exam failure rates, escalation of subspecialization, increasing need for postresidency mentoring and finishing fellowships, reports of perceived undertraining by our newly minted residents and fellows, uneven competence in the performance of basic surgical procedures noted in the first year of fellowship, and reported difficulties in independent functioning in the early years of surgical practice.

Many forces have aligned to diminish the quality of training including work-hour restrictions, therapeutic trends that have markedly reduced the need for open surgery, the laparoscopic revolution, and the expansion of competing nonsurgical interventional specialties. Other factors include shifts in graduate medical funding with the resultant RVU (Relative Value Unit) pressures on the surgical faculty, generational shifts that emphasize work/life balance, and restrictive training regulations that have led to a reduction in the resident autonomous operative experience.

Despite these developments, many of which are truly intractable, we cannot accept de facto a lower standard of excellence in training for surgeons in this country. We bear a historic responsibility to the talented and dedicated young men and women who depend on us to adequately train them for the rigors of surgical practice. Therefore, we must gain the collective resolve to work among ourselves and within the system to reach out to all members of the house of surgery as well as the involved regulatory agencies. We must dedicate ourselves to an intense study of the problem and ultimately reach a consensus on implementable practical reforms that will result in the needed sea change in surgical training. Preliminary suggestions include providing more autonomy at the senior resident level; limiting the numbers of subspecialties, particularly as they compete with resident training; increasing the efficiencies of training, particularly at the junior levels; and embracing training technologies such as simulators. In addition, surgical faculty should be drawn less from RVU-driven groups and more from a cadre of educators who are remunerated for their educational time and expertise. We should also be looking to the development of specific, nationally required resident performance benchmarks. This is but the beginning of the national dialogue, but with the right resolve, I am confidant we will create the needed corrective recipe.

Manpower

Currently American surgical delivery is suffering from a maldistribution of surgical talent by both geography and specialty. Futuristic medical manpower studies have been limited by historic biases, poorly designed metrics, and entrenched interests resulting in inaccuracy. The old head-count method of trying to match medical school class size with projected population demographics is overly simplistic and a recipe for failure. To borrow an idea from military planners, we in the surgical profession are always preparing for the last war. To paraphrase a frequently made statement by Dr. Tom Russell, FACS, the essential consideration of any successful manpower study should begin with the question: "What will the future work be and where will it be done and by whom?" The evolution of medical therapeutics, pharmacology, and genomics; improvement and expansion of public health services; the explosion of new technologies; continuing public demand for more minimally invasive as well as nonoperative therapies; and the expansion of competing invasive non-surgical specialties are all trends that will shape future surgical manpower needs. Proliferation and acceptance of physician extenders and nurse practitioners as well as the continued investment in clinical effectiveness studies and clinical guidelines will markedly transform the type and volume of surgical work done in this country.

In addition to understanding the effects of the above forces, it is going to be equally important to consider possible shifts in demographics. A recent and insightful look into possible future scenarios is presented in the book "The Next Hundred Million: America in 2050," by Joel Kotkin (New York: Penguin, 2010). In this futuristic study of American demographics, the author predicts an outmigration from urban America, a resurgence of rural America, and a revitalization of many of America’s so called "fly-over zones." This transformation would be driven by telecommunications, decentralization of American commerce, the recent energy revolution, and the search for lifestyle quality heretofore not realized in urban America. Such an evolution would have tremendous implications for the future of rural surgery and the consequent need for well-trained general surgeons, and would call into question the overcentralization of surgical care.

As the population grows and longevity rates increase, the future cost of health care is going to be one of society’s dominant concerns. The current overproduction of surgical subspecialists as well as the overconcentration of redundant and competing tertiary-care services, often within blocks of each other, will certainly come under increasing scrutiny. As health care planners start to address the questions of future surgical care delivery and the implications of bearable cost, hopefully a rebalancing as to specialty and geography will occur.

The Challenge

The American College of Surgeons was founded in 1913 in large measure to address many of the issues stated above as they stood a century ago. As a result of these early leaders’ resolve and enlightened work, surgery flourished because of excellent training based on the broadly competent general surgeon with a commitment to provide excellent care across our broad and diverse land. Now, 100 years later, we face crises of deficient training, inefficient delivery systems, and unsophisticated manpower planning. The needed resolutions and corrective measures will require insightful thought and bold action, some of which will no doubt threaten the status quo as well as many bastions of self-interest. However, inaction is not an option because training and manpower shortcomings will threaten the future quality of surgery as well as have markedly negative implications for the American economy.

Fortunately, the American College of Surgeons is engaged and responding to these critical issues. Under the leadership of Dr. David Hoyt, FACS, Executive Director of the ACS, and Dr. Julie Frieschlag, FACS, Chair of the Board of Regents, a Blue Ribbon Committee has been formed to respond to these concerns. I can think of no better way to celebrate our Centennial as well as begin our next 100 years of work than to once again commit ourselves to the affordability, availability, and quality of American surgery.

Dr. Elsey is a general and vascular surgeon in private practice in Atlanta and a member of the ACS Board of Regents.

As the American College of Surgeons celebrates its 100-year anniversary, we find ourselves confronted with challenges that threaten the quality and delivery of surgical care in this country. Two of the more pressing issues that imperil the future of our art are perceived deficiencies in surgical training and the lack of clarity and consensus regarding future surgical manpower needs. These two issues are linked and will require a reasoned and active resolution if we are going to provide competent surgeons in a more balanced manner by both geography and specialty to our ever-changing American demographic.

Training

There is now a general agreement among many members of the surgery profession that the current training paradigms are inadequate and in need of immediate reform. Examples include the increasing Board exam failure rates, escalation of subspecialization, increasing need for postresidency mentoring and finishing fellowships, reports of perceived undertraining by our newly minted residents and fellows, uneven competence in the performance of basic surgical procedures noted in the first year of fellowship, and reported difficulties in independent functioning in the early years of surgical practice.

Many forces have aligned to diminish the quality of training including work-hour restrictions, therapeutic trends that have markedly reduced the need for open surgery, the laparoscopic revolution, and the expansion of competing nonsurgical interventional specialties. Other factors include shifts in graduate medical funding with the resultant RVU (Relative Value Unit) pressures on the surgical faculty, generational shifts that emphasize work/life balance, and restrictive training regulations that have led to a reduction in the resident autonomous operative experience.

Despite these developments, many of which are truly intractable, we cannot accept de facto a lower standard of excellence in training for surgeons in this country. We bear a historic responsibility to the talented and dedicated young men and women who depend on us to adequately train them for the rigors of surgical practice. Therefore, we must gain the collective resolve to work among ourselves and within the system to reach out to all members of the house of surgery as well as the involved regulatory agencies. We must dedicate ourselves to an intense study of the problem and ultimately reach a consensus on implementable practical reforms that will result in the needed sea change in surgical training. Preliminary suggestions include providing more autonomy at the senior resident level; limiting the numbers of subspecialties, particularly as they compete with resident training; increasing the efficiencies of training, particularly at the junior levels; and embracing training technologies such as simulators. In addition, surgical faculty should be drawn less from RVU-driven groups and more from a cadre of educators who are remunerated for their educational time and expertise. We should also be looking to the development of specific, nationally required resident performance benchmarks. This is but the beginning of the national dialogue, but with the right resolve, I am confidant we will create the needed corrective recipe.

Manpower

Currently American surgical delivery is suffering from a maldistribution of surgical talent by both geography and specialty. Futuristic medical manpower studies have been limited by historic biases, poorly designed metrics, and entrenched interests resulting in inaccuracy. The old head-count method of trying to match medical school class size with projected population demographics is overly simplistic and a recipe for failure. To borrow an idea from military planners, we in the surgical profession are always preparing for the last war. To paraphrase a frequently made statement by Dr. Tom Russell, FACS, the essential consideration of any successful manpower study should begin with the question: "What will the future work be and where will it be done and by whom?" The evolution of medical therapeutics, pharmacology, and genomics; improvement and expansion of public health services; the explosion of new technologies; continuing public demand for more minimally invasive as well as nonoperative therapies; and the expansion of competing invasive non-surgical specialties are all trends that will shape future surgical manpower needs. Proliferation and acceptance of physician extenders and nurse practitioners as well as the continued investment in clinical effectiveness studies and clinical guidelines will markedly transform the type and volume of surgical work done in this country.

In addition to understanding the effects of the above forces, it is going to be equally important to consider possible shifts in demographics. A recent and insightful look into possible future scenarios is presented in the book "The Next Hundred Million: America in 2050," by Joel Kotkin (New York: Penguin, 2010). In this futuristic study of American demographics, the author predicts an outmigration from urban America, a resurgence of rural America, and a revitalization of many of America’s so called "fly-over zones." This transformation would be driven by telecommunications, decentralization of American commerce, the recent energy revolution, and the search for lifestyle quality heretofore not realized in urban America. Such an evolution would have tremendous implications for the future of rural surgery and the consequent need for well-trained general surgeons, and would call into question the overcentralization of surgical care.

As the population grows and longevity rates increase, the future cost of health care is going to be one of society’s dominant concerns. The current overproduction of surgical subspecialists as well as the overconcentration of redundant and competing tertiary-care services, often within blocks of each other, will certainly come under increasing scrutiny. As health care planners start to address the questions of future surgical care delivery and the implications of bearable cost, hopefully a rebalancing as to specialty and geography will occur.

The Challenge

The American College of Surgeons was founded in 1913 in large measure to address many of the issues stated above as they stood a century ago. As a result of these early leaders’ resolve and enlightened work, surgery flourished because of excellent training based on the broadly competent general surgeon with a commitment to provide excellent care across our broad and diverse land. Now, 100 years later, we face crises of deficient training, inefficient delivery systems, and unsophisticated manpower planning. The needed resolutions and corrective measures will require insightful thought and bold action, some of which will no doubt threaten the status quo as well as many bastions of self-interest. However, inaction is not an option because training and manpower shortcomings will threaten the future quality of surgery as well as have markedly negative implications for the American economy.

Fortunately, the American College of Surgeons is engaged and responding to these critical issues. Under the leadership of Dr. David Hoyt, FACS, Executive Director of the ACS, and Dr. Julie Frieschlag, FACS, Chair of the Board of Regents, a Blue Ribbon Committee has been formed to respond to these concerns. I can think of no better way to celebrate our Centennial as well as begin our next 100 years of work than to once again commit ourselves to the affordability, availability, and quality of American surgery.

Dr. Elsey is a general and vascular surgeon in private practice in Atlanta and a member of the ACS Board of Regents.

As the American College of Surgeons celebrates its 100-year anniversary, we find ourselves confronted with challenges that threaten the quality and delivery of surgical care in this country. Two of the more pressing issues that imperil the future of our art are perceived deficiencies in surgical training and the lack of clarity and consensus regarding future surgical manpower needs. These two issues are linked and will require a reasoned and active resolution if we are going to provide competent surgeons in a more balanced manner by both geography and specialty to our ever-changing American demographic.

Training

There is now a general agreement among many members of the surgery profession that the current training paradigms are inadequate and in need of immediate reform. Examples include the increasing Board exam failure rates, escalation of subspecialization, increasing need for postresidency mentoring and finishing fellowships, reports of perceived undertraining by our newly minted residents and fellows, uneven competence in the performance of basic surgical procedures noted in the first year of fellowship, and reported difficulties in independent functioning in the early years of surgical practice.

Many forces have aligned to diminish the quality of training including work-hour restrictions, therapeutic trends that have markedly reduced the need for open surgery, the laparoscopic revolution, and the expansion of competing nonsurgical interventional specialties. Other factors include shifts in graduate medical funding with the resultant RVU (Relative Value Unit) pressures on the surgical faculty, generational shifts that emphasize work/life balance, and restrictive training regulations that have led to a reduction in the resident autonomous operative experience.

Despite these developments, many of which are truly intractable, we cannot accept de facto a lower standard of excellence in training for surgeons in this country. We bear a historic responsibility to the talented and dedicated young men and women who depend on us to adequately train them for the rigors of surgical practice. Therefore, we must gain the collective resolve to work among ourselves and within the system to reach out to all members of the house of surgery as well as the involved regulatory agencies. We must dedicate ourselves to an intense study of the problem and ultimately reach a consensus on implementable practical reforms that will result in the needed sea change in surgical training. Preliminary suggestions include providing more autonomy at the senior resident level; limiting the numbers of subspecialties, particularly as they compete with resident training; increasing the efficiencies of training, particularly at the junior levels; and embracing training technologies such as simulators. In addition, surgical faculty should be drawn less from RVU-driven groups and more from a cadre of educators who are remunerated for their educational time and expertise. We should also be looking to the development of specific, nationally required resident performance benchmarks. This is but the beginning of the national dialogue, but with the right resolve, I am confidant we will create the needed corrective recipe.

Manpower

Currently American surgical delivery is suffering from a maldistribution of surgical talent by both geography and specialty. Futuristic medical manpower studies have been limited by historic biases, poorly designed metrics, and entrenched interests resulting in inaccuracy. The old head-count method of trying to match medical school class size with projected population demographics is overly simplistic and a recipe for failure. To borrow an idea from military planners, we in the surgical profession are always preparing for the last war. To paraphrase a frequently made statement by Dr. Tom Russell, FACS, the essential consideration of any successful manpower study should begin with the question: "What will the future work be and where will it be done and by whom?" The evolution of medical therapeutics, pharmacology, and genomics; improvement and expansion of public health services; the explosion of new technologies; continuing public demand for more minimally invasive as well as nonoperative therapies; and the expansion of competing invasive non-surgical specialties are all trends that will shape future surgical manpower needs. Proliferation and acceptance of physician extenders and nurse practitioners as well as the continued investment in clinical effectiveness studies and clinical guidelines will markedly transform the type and volume of surgical work done in this country.

In addition to understanding the effects of the above forces, it is going to be equally important to consider possible shifts in demographics. A recent and insightful look into possible future scenarios is presented in the book "The Next Hundred Million: America in 2050," by Joel Kotkin (New York: Penguin, 2010). In this futuristic study of American demographics, the author predicts an outmigration from urban America, a resurgence of rural America, and a revitalization of many of America’s so called "fly-over zones." This transformation would be driven by telecommunications, decentralization of American commerce, the recent energy revolution, and the search for lifestyle quality heretofore not realized in urban America. Such an evolution would have tremendous implications for the future of rural surgery and the consequent need for well-trained general surgeons, and would call into question the overcentralization of surgical care.

As the population grows and longevity rates increase, the future cost of health care is going to be one of society’s dominant concerns. The current overproduction of surgical subspecialists as well as the overconcentration of redundant and competing tertiary-care services, often within blocks of each other, will certainly come under increasing scrutiny. As health care planners start to address the questions of future surgical care delivery and the implications of bearable cost, hopefully a rebalancing as to specialty and geography will occur.

The Challenge

The American College of Surgeons was founded in 1913 in large measure to address many of the issues stated above as they stood a century ago. As a result of these early leaders’ resolve and enlightened work, surgery flourished because of excellent training based on the broadly competent general surgeon with a commitment to provide excellent care across our broad and diverse land. Now, 100 years later, we face crises of deficient training, inefficient delivery systems, and unsophisticated manpower planning. The needed resolutions and corrective measures will require insightful thought and bold action, some of which will no doubt threaten the status quo as well as many bastions of self-interest. However, inaction is not an option because training and manpower shortcomings will threaten the future quality of surgery as well as have markedly negative implications for the American economy.

Fortunately, the American College of Surgeons is engaged and responding to these critical issues. Under the leadership of Dr. David Hoyt, FACS, Executive Director of the ACS, and Dr. Julie Frieschlag, FACS, Chair of the Board of Regents, a Blue Ribbon Committee has been formed to respond to these concerns. I can think of no better way to celebrate our Centennial as well as begin our next 100 years of work than to once again commit ourselves to the affordability, availability, and quality of American surgery.

Dr. Elsey is a general and vascular surgeon in private practice in Atlanta and a member of the ACS Board of Regents.

The annual meeting of the American Medical Association (AMA) House of Delegates (HOD) took place June 15-19 in Chicago, IL. More than 550 delegates as well as alternate delegates converged on the Windy City to consider and adopt policy for the AMA. Issues such as health care policy were discussed, educational sessions were presented, and elections took place.

Reports and resolutions

The HOD reviewed more than 160 resolutions and 65 reports, including the following centered on issues of relevance to surgeons:

Invasive procedures: As originally submitted to the HOD, this report from the AMA Board of Trustees called for revising the current AMA, definition of surgery and guidelines on invasive procedures for the treatment of chronic pain, including procedures using fluoroscopy. Efforts to bridge the definitions for surgery and procedures fell short. A revised report was adopted that retained the current AMA definition of surgery but focused only on invasive pain management procedures.

Recognition of obesity as a disease: The ACS and 10 other medical/specialty societies cosponsored this resolution, which called on the AMA to recognize obesity as a disease with multiple pathophysiological aspects requiring a range of interventions to advance treatment and prevention. Evidence presented demonstrated that obesity is a metabolic disease that occurs as a result of unhealthy behaviors related to food and beverage consumption; lack of sufficient physical activity; and work, school, and messaging environments. The resolution further noted that obesity leads to chronic diseases, such as hypertension, heart disease, diabetes, and arthritis. The ACS delegation emphasized that metabolic (bariatric) surgeons are on the front lines of treating severe obesity with life-improving and lifesaving results. The resolution passed with a 60 percent majority of the delegates.

Payment variations across outpatient sites of service: Cost transparency across sites of service was a major point of discussion, which received positive comments in reference committee testimony. In addition to adopting recommendations from the AMA Council on Medical Service to reaffirm some existing AMA policies related to Medicare payments across outpatient settings, the HOD adopted a recommendation that the AMA work with states to advocate for third party payors to:

• Assess equal or lower facility coinsurance for lower-cost sites of service (hospital outpatient department, ambulatory surgical center, or office-based facility);

• Publish and routinely update pertinent information related to patient cost-sharing; and

• Allow their plan’s participating physicians to perform outpatient procedures at an appropriate site of service as chosen by the physician and the patient.

AMA support for states in their development of legislation to support physician-led, team-based care: With a focus on physician-led, team-based care, this resolution was adopted and directed the AMA to assist state medical societies and specialty organizations with seeking passage of legislation that would define the valued role of mid-level and other health care professionals within a physician-led team that promotes optimal quality patient care and patient safety. The resolution also called on the AMA to actively oppose health care teams that are led by nonphysician health care practitioners.

An update on Maintenance of Certification (MOC), Osteopathic Continuous Certification (OCC), and Maintenance of Licensure (MOL): A major topic of discussion was MOC, OCC, and MOL requirements. Many resolutions introduced reflected concerns regarding the implementation, cost, and additional exam burdens on physicians that these requirements pose. These resolutions largely recommended that the Council on Medical Education continue to monitor the requirements and engage in ongoing dialogues with medical and licensing boards.

Government interference in the practice of medicine and the patient-physician relationship: The AMA HOD passed several resolutions that led to the adoption of a Statement of Principles concerning the roles of federal and state governments in health care and the patient-physician relationship. These principles include:

• Physicians should not be prohibited by law or regulation from discussing with or asking their patients about risk factors or disclosing information to patients, including proprietary information on exposure to potentially dangerous chemicals or biological agents that may affect their health or the health of their families, sexual partners, and other individuals with whom they have been in contact.

• All parties involved in the provision of health care, including government, are responsible for acknowledging and supporting the intimacy and importance of the patient-physician relationship and the ethical obligations of the physician to put the patient first.

• The fundamental ethical principles of beneficence, honesty, confidentiality, privacy, and advocacy are central to the delivery of evidence-based, individualized care and must be respected by all parties.

• Laws and regulations should not mandate the provision of care that, in the physician’s clinical judgment and based on clinical evidence and the norms of the profession, is either unnecessary or ill-suited for a particular patient at the time services are rendered.

In addition, the AMA will oppose any government regulation or legislative action on the content of the individual clinical encounter between a patient and physician without a compelling and evidence-based benefit to the patient, a substantial public health justification, or both.

For a complete list of HOD actions, go to http://www.ama-assn.org/ams/pub/meeting/index.shtml.

Elections

AMA officers, trustees, and council members are elected during the annual meeting. This year, three members of the College were elected to serve on AMA councils and in other leadership positions. Maya Babu, MD, a neurosurgery resident at the Mayo Clinic, Rochester, MN, was elected to serve in the resident/fellow trustee position on the AMA Board of Trustees; Andrew Gurman, MD, FACS, a hand surgeon who practices in Altoona, PA, was re-elected as speaker of the HOD; and Liana Puscas, MD, FACS, an otolaryngologist and assistant professor of surgery, Duke University Medical School, in Durham, NC, was elected to the AMA Council on Medical Education. 

Ardis Dee Hoven, MD, assumed the presidency of the AMA. An internal medicine and infectious disease specialist from Lexington, KY, she is the 168th president of the organization and only the third woman to hold this office.

Other officers elected are as follows:

President-elect – Robert M. Wah, MD, reproductive endocrinologist from Bethesda, MD.

Board of Trustees – Gerald E. Harmon, MD, a family physician from Pawleys Island, SC; and David O. Barbe, MD, re-elected, a family physician in Mountain Grove, MO.

Vice-speaker of the HOD – Susan R. Bailey, MD, re-elected, an allergist in Fort Worth, TX.

Surgical Caucus

The Surgical Caucus of the AMA brings together surgeons, anesthesiologists, and emergency physicians for focused discussions regarding relevant AMA resolutions that affect surgical interventions. The Caucus held a one-hour program titled "Visiting the Surgical Home." Speakers provided a description of the concept of the surgical home, discussed how the surgical home improves coordination of patient care and relates to other models of coordinated care, and reviewed some of the benefits of implementing the surgical home.

ACS Delegation

The College was well represented by five delegates. New to the delegation was Leigh Neumayer, MD, FACS, a general surgeon from Salt Lake City, UT, and a member of the ACS Board of Regents. She joined four seasoned veterans of the HOD, including: John H. Armstrong, MD, FACS, trauma surgeon, chair of the delegation, and Surgeon General/Secretary of Health for the State of Florida; Jacob Moalem, MD, FACS, an endocrine surgeon from Rochester, NY; Richard Reiling, MD, FACS, a general surgeon from Charlotte, NC; and Patricia L. Turner, MD, FACS, a general surgeon and Director of the ACS Division of Member Services.

In addition, the College Delegation was assisted by Timothy Kresowik, MD, FACS, a vascular surgeon from Iowa City, IA. and an alternate delegate from the Society for Vascular Surgery, and Kenneth Louis, MD, FACS, a neurosurgeon from Tampa, FL, and an alternate delegate for the Florida Medical Association.

The delegation is open to comments and feedback on issues before the HOD as well as suggestions for resolutions. The November Interim HOD meeting will take place November 16-19 in National Harbor, MD. For those surgeons who would like to become familiar with pending issues and policies, items of business will be posted in early November on the AMA website at http://www.ama-assn.org/ama/pub/about-ama/our-people/house-delegates.page. Fellows who follow this activity and have thoughts, comments, or questions may contact the ACS Delegation at [email protected].

Dr. Armstrong is Surgeon General and Secretary, Florida Department of Health, Tallahassee, FL. He serves on the ACS Board of Governors and the ACS Health Policy and Advocacy Group.

Mr. Sutton is Manager of State Affairs, ACS Division of Advocacy and Health Policy, Washington, DC.

The annual meeting of the American Medical Association (AMA) House of Delegates (HOD) took place June 15-19 in Chicago, IL. More than 550 delegates as well as alternate delegates converged on the Windy City to consider and adopt policy for the AMA. Issues such as health care policy were discussed, educational sessions were presented, and elections took place.

Reports and resolutions

The HOD reviewed more than 160 resolutions and 65 reports, including the following centered on issues of relevance to surgeons:

Invasive procedures: As originally submitted to the HOD, this report from the AMA Board of Trustees called for revising the current AMA, definition of surgery and guidelines on invasive procedures for the treatment of chronic pain, including procedures using fluoroscopy. Efforts to bridge the definitions for surgery and procedures fell short. A revised report was adopted that retained the current AMA definition of surgery but focused only on invasive pain management procedures.

Recognition of obesity as a disease: The ACS and 10 other medical/specialty societies cosponsored this resolution, which called on the AMA to recognize obesity as a disease with multiple pathophysiological aspects requiring a range of interventions to advance treatment and prevention. Evidence presented demonstrated that obesity is a metabolic disease that occurs as a result of unhealthy behaviors related to food and beverage consumption; lack of sufficient physical activity; and work, school, and messaging environments. The resolution further noted that obesity leads to chronic diseases, such as hypertension, heart disease, diabetes, and arthritis. The ACS delegation emphasized that metabolic (bariatric) surgeons are on the front lines of treating severe obesity with life-improving and lifesaving results. The resolution passed with a 60 percent majority of the delegates.

Payment variations across outpatient sites of service: Cost transparency across sites of service was a major point of discussion, which received positive comments in reference committee testimony. In addition to adopting recommendations from the AMA Council on Medical Service to reaffirm some existing AMA policies related to Medicare payments across outpatient settings, the HOD adopted a recommendation that the AMA work with states to advocate for third party payors to:

• Assess equal or lower facility coinsurance for lower-cost sites of service (hospital outpatient department, ambulatory surgical center, or office-based facility);

• Publish and routinely update pertinent information related to patient cost-sharing; and

• Allow their plan’s participating physicians to perform outpatient procedures at an appropriate site of service as chosen by the physician and the patient.

AMA support for states in their development of legislation to support physician-led, team-based care: With a focus on physician-led, team-based care, this resolution was adopted and directed the AMA to assist state medical societies and specialty organizations with seeking passage of legislation that would define the valued role of mid-level and other health care professionals within a physician-led team that promotes optimal quality patient care and patient safety. The resolution also called on the AMA to actively oppose health care teams that are led by nonphysician health care practitioners.

An update on Maintenance of Certification (MOC), Osteopathic Continuous Certification (OCC), and Maintenance of Licensure (MOL): A major topic of discussion was MOC, OCC, and MOL requirements. Many resolutions introduced reflected concerns regarding the implementation, cost, and additional exam burdens on physicians that these requirements pose. These resolutions largely recommended that the Council on Medical Education continue to monitor the requirements and engage in ongoing dialogues with medical and licensing boards.

Government interference in the practice of medicine and the patient-physician relationship: The AMA HOD passed several resolutions that led to the adoption of a Statement of Principles concerning the roles of federal and state governments in health care and the patient-physician relationship. These principles include:

• Physicians should not be prohibited by law or regulation from discussing with or asking their patients about risk factors or disclosing information to patients, including proprietary information on exposure to potentially dangerous chemicals or biological agents that may affect their health or the health of their families, sexual partners, and other individuals with whom they have been in contact.

• All parties involved in the provision of health care, including government, are responsible for acknowledging and supporting the intimacy and importance of the patient-physician relationship and the ethical obligations of the physician to put the patient first.

• The fundamental ethical principles of beneficence, honesty, confidentiality, privacy, and advocacy are central to the delivery of evidence-based, individualized care and must be respected by all parties.

• Laws and regulations should not mandate the provision of care that, in the physician’s clinical judgment and based on clinical evidence and the norms of the profession, is either unnecessary or ill-suited for a particular patient at the time services are rendered.

In addition, the AMA will oppose any government regulation or legislative action on the content of the individual clinical encounter between a patient and physician without a compelling and evidence-based benefit to the patient, a substantial public health justification, or both.

For a complete list of HOD actions, go to http://www.ama-assn.org/ams/pub/meeting/index.shtml.

Elections

AMA officers, trustees, and council members are elected during the annual meeting. This year, three members of the College were elected to serve on AMA councils and in other leadership positions. Maya Babu, MD, a neurosurgery resident at the Mayo Clinic, Rochester, MN, was elected to serve in the resident/fellow trustee position on the AMA Board of Trustees; Andrew Gurman, MD, FACS, a hand surgeon who practices in Altoona, PA, was re-elected as speaker of the HOD; and Liana Puscas, MD, FACS, an otolaryngologist and assistant professor of surgery, Duke University Medical School, in Durham, NC, was elected to the AMA Council on Medical Education. 

Ardis Dee Hoven, MD, assumed the presidency of the AMA. An internal medicine and infectious disease specialist from Lexington, KY, she is the 168th president of the organization and only the third woman to hold this office.

Other officers elected are as follows:

President-elect – Robert M. Wah, MD, reproductive endocrinologist from Bethesda, MD.

Board of Trustees – Gerald E. Harmon, MD, a family physician from Pawleys Island, SC; and David O. Barbe, MD, re-elected, a family physician in Mountain Grove, MO.

Vice-speaker of the HOD – Susan R. Bailey, MD, re-elected, an allergist in Fort Worth, TX.

Surgical Caucus

The Surgical Caucus of the AMA brings together surgeons, anesthesiologists, and emergency physicians for focused discussions regarding relevant AMA resolutions that affect surgical interventions. The Caucus held a one-hour program titled "Visiting the Surgical Home." Speakers provided a description of the concept of the surgical home, discussed how the surgical home improves coordination of patient care and relates to other models of coordinated care, and reviewed some of the benefits of implementing the surgical home.

ACS Delegation

The College was well represented by five delegates. New to the delegation was Leigh Neumayer, MD, FACS, a general surgeon from Salt Lake City, UT, and a member of the ACS Board of Regents. She joined four seasoned veterans of the HOD, including: John H. Armstrong, MD, FACS, trauma surgeon, chair of the delegation, and Surgeon General/Secretary of Health for the State of Florida; Jacob Moalem, MD, FACS, an endocrine surgeon from Rochester, NY; Richard Reiling, MD, FACS, a general surgeon from Charlotte, NC; and Patricia L. Turner, MD, FACS, a general surgeon and Director of the ACS Division of Member Services.

In addition, the College Delegation was assisted by Timothy Kresowik, MD, FACS, a vascular surgeon from Iowa City, IA. and an alternate delegate from the Society for Vascular Surgery, and Kenneth Louis, MD, FACS, a neurosurgeon from Tampa, FL, and an alternate delegate for the Florida Medical Association.

The delegation is open to comments and feedback on issues before the HOD as well as suggestions for resolutions. The November Interim HOD meeting will take place November 16-19 in National Harbor, MD. For those surgeons who would like to become familiar with pending issues and policies, items of business will be posted in early November on the AMA website at http://www.ama-assn.org/ama/pub/about-ama/our-people/house-delegates.page. Fellows who follow this activity and have thoughts, comments, or questions may contact the ACS Delegation at [email protected].

Dr. Armstrong is Surgeon General and Secretary, Florida Department of Health, Tallahassee, FL. He serves on the ACS Board of Governors and the ACS Health Policy and Advocacy Group.

Mr. Sutton is Manager of State Affairs, ACS Division of Advocacy and Health Policy, Washington, DC.

The annual meeting of the American Medical Association (AMA) House of Delegates (HOD) took place June 15-19 in Chicago, IL. More than 550 delegates as well as alternate delegates converged on the Windy City to consider and adopt policy for the AMA. Issues such as health care policy were discussed, educational sessions were presented, and elections took place.

Reports and resolutions

The HOD reviewed more than 160 resolutions and 65 reports, including the following centered on issues of relevance to surgeons:

Invasive procedures: As originally submitted to the HOD, this report from the AMA Board of Trustees called for revising the current AMA, definition of surgery and guidelines on invasive procedures for the treatment of chronic pain, including procedures using fluoroscopy. Efforts to bridge the definitions for surgery and procedures fell short. A revised report was adopted that retained the current AMA definition of surgery but focused only on invasive pain management procedures.

Recognition of obesity as a disease: The ACS and 10 other medical/specialty societies cosponsored this resolution, which called on the AMA to recognize obesity as a disease with multiple pathophysiological aspects requiring a range of interventions to advance treatment and prevention. Evidence presented demonstrated that obesity is a metabolic disease that occurs as a result of unhealthy behaviors related to food and beverage consumption; lack of sufficient physical activity; and work, school, and messaging environments. The resolution further noted that obesity leads to chronic diseases, such as hypertension, heart disease, diabetes, and arthritis. The ACS delegation emphasized that metabolic (bariatric) surgeons are on the front lines of treating severe obesity with life-improving and lifesaving results. The resolution passed with a 60 percent majority of the delegates.

Payment variations across outpatient sites of service: Cost transparency across sites of service was a major point of discussion, which received positive comments in reference committee testimony. In addition to adopting recommendations from the AMA Council on Medical Service to reaffirm some existing AMA policies related to Medicare payments across outpatient settings, the HOD adopted a recommendation that the AMA work with states to advocate for third party payors to:

• Assess equal or lower facility coinsurance for lower-cost sites of service (hospital outpatient department, ambulatory surgical center, or office-based facility);

• Publish and routinely update pertinent information related to patient cost-sharing; and

• Allow their plan’s participating physicians to perform outpatient procedures at an appropriate site of service as chosen by the physician and the patient.

AMA support for states in their development of legislation to support physician-led, team-based care: With a focus on physician-led, team-based care, this resolution was adopted and directed the AMA to assist state medical societies and specialty organizations with seeking passage of legislation that would define the valued role of mid-level and other health care professionals within a physician-led team that promotes optimal quality patient care and patient safety. The resolution also called on the AMA to actively oppose health care teams that are led by nonphysician health care practitioners.

An update on Maintenance of Certification (MOC), Osteopathic Continuous Certification (OCC), and Maintenance of Licensure (MOL): A major topic of discussion was MOC, OCC, and MOL requirements. Many resolutions introduced reflected concerns regarding the implementation, cost, and additional exam burdens on physicians that these requirements pose. These resolutions largely recommended that the Council on Medical Education continue to monitor the requirements and engage in ongoing dialogues with medical and licensing boards.

Government interference in the practice of medicine and the patient-physician relationship: The AMA HOD passed several resolutions that led to the adoption of a Statement of Principles concerning the roles of federal and state governments in health care and the patient-physician relationship. These principles include:

• Physicians should not be prohibited by law or regulation from discussing with or asking their patients about risk factors or disclosing information to patients, including proprietary information on exposure to potentially dangerous chemicals or biological agents that may affect their health or the health of their families, sexual partners, and other individuals with whom they have been in contact.

• All parties involved in the provision of health care, including government, are responsible for acknowledging and supporting the intimacy and importance of the patient-physician relationship and the ethical obligations of the physician to put the patient first.

• The fundamental ethical principles of beneficence, honesty, confidentiality, privacy, and advocacy are central to the delivery of evidence-based, individualized care and must be respected by all parties.

• Laws and regulations should not mandate the provision of care that, in the physician’s clinical judgment and based on clinical evidence and the norms of the profession, is either unnecessary or ill-suited for a particular patient at the time services are rendered.

In addition, the AMA will oppose any government regulation or legislative action on the content of the individual clinical encounter between a patient and physician without a compelling and evidence-based benefit to the patient, a substantial public health justification, or both.

For a complete list of HOD actions, go to http://www.ama-assn.org/ams/pub/meeting/index.shtml.

Elections

AMA officers, trustees, and council members are elected during the annual meeting. This year, three members of the College were elected to serve on AMA councils and in other leadership positions. Maya Babu, MD, a neurosurgery resident at the Mayo Clinic, Rochester, MN, was elected to serve in the resident/fellow trustee position on the AMA Board of Trustees; Andrew Gurman, MD, FACS, a hand surgeon who practices in Altoona, PA, was re-elected as speaker of the HOD; and Liana Puscas, MD, FACS, an otolaryngologist and assistant professor of surgery, Duke University Medical School, in Durham, NC, was elected to the AMA Council on Medical Education. 

Ardis Dee Hoven, MD, assumed the presidency of the AMA. An internal medicine and infectious disease specialist from Lexington, KY, she is the 168th president of the organization and only the third woman to hold this office.

Other officers elected are as follows:

President-elect – Robert M. Wah, MD, reproductive endocrinologist from Bethesda, MD.

Board of Trustees – Gerald E. Harmon, MD, a family physician from Pawleys Island, SC; and David O. Barbe, MD, re-elected, a family physician in Mountain Grove, MO.

Vice-speaker of the HOD – Susan R. Bailey, MD, re-elected, an allergist in Fort Worth, TX.

Surgical Caucus

The Surgical Caucus of the AMA brings together surgeons, anesthesiologists, and emergency physicians for focused discussions regarding relevant AMA resolutions that affect surgical interventions. The Caucus held a one-hour program titled "Visiting the Surgical Home." Speakers provided a description of the concept of the surgical home, discussed how the surgical home improves coordination of patient care and relates to other models of coordinated care, and reviewed some of the benefits of implementing the surgical home.

ACS Delegation

The College was well represented by five delegates. New to the delegation was Leigh Neumayer, MD, FACS, a general surgeon from Salt Lake City, UT, and a member of the ACS Board of Regents. She joined four seasoned veterans of the HOD, including: John H. Armstrong, MD, FACS, trauma surgeon, chair of the delegation, and Surgeon General/Secretary of Health for the State of Florida; Jacob Moalem, MD, FACS, an endocrine surgeon from Rochester, NY; Richard Reiling, MD, FACS, a general surgeon from Charlotte, NC; and Patricia L. Turner, MD, FACS, a general surgeon and Director of the ACS Division of Member Services.

In addition, the College Delegation was assisted by Timothy Kresowik, MD, FACS, a vascular surgeon from Iowa City, IA. and an alternate delegate from the Society for Vascular Surgery, and Kenneth Louis, MD, FACS, a neurosurgeon from Tampa, FL, and an alternate delegate for the Florida Medical Association.

The delegation is open to comments and feedback on issues before the HOD as well as suggestions for resolutions. The November Interim HOD meeting will take place November 16-19 in National Harbor, MD. For those surgeons who would like to become familiar with pending issues and policies, items of business will be posted in early November on the AMA website at http://www.ama-assn.org/ama/pub/about-ama/our-people/house-delegates.page. Fellows who follow this activity and have thoughts, comments, or questions may contact the ACS Delegation at [email protected].

Dr. Armstrong is Surgeon General and Secretary, Florida Department of Health, Tallahassee, FL. He serves on the ACS Board of Governors and the ACS Health Policy and Advocacy Group.

Mr. Sutton is Manager of State Affairs, ACS Division of Advocacy and Health Policy, Washington, DC.

The Executive Committee of the Commission on Cancer (CoC) approved the formation of a full Committee on Advocacy to address legislative and regulatory issues that impact cancer care. The CoC Executive Committee will approve the slate of Committee leaders at its meeting on Oct. 6. Active members of the Member Organization Steering Committee’s Advocacy Subcommittee will continue their ongoing work as full Advocacy Committee members.

During the American College of Surgeons Clinical Congress in Washington, DC, the CoC will host a legislative briefing, Commission on Cancer: Ensuring High-Quality, Patient-Centered Cancer Care, Wednesday, Oct. 9, from 3:00-4:30 pm, at 2325 Rayburn House Office Building, A reception will follow at 5:00-6:30 pm. Space is limited. For more information and to reserve a place at the briefing, contact Kristin McDonald at 202-337-2701 or [email protected].

The Executive Committee of the Commission on Cancer (CoC) approved the formation of a full Committee on Advocacy to address legislative and regulatory issues that impact cancer care. The CoC Executive Committee will approve the slate of Committee leaders at its meeting on Oct. 6. Active members of the Member Organization Steering Committee’s Advocacy Subcommittee will continue their ongoing work as full Advocacy Committee members.

During the American College of Surgeons Clinical Congress in Washington, DC, the CoC will host a legislative briefing, Commission on Cancer: Ensuring High-Quality, Patient-Centered Cancer Care, Wednesday, Oct. 9, from 3:00-4:30 pm, at 2325 Rayburn House Office Building, A reception will follow at 5:00-6:30 pm. Space is limited. For more information and to reserve a place at the briefing, contact Kristin McDonald at 202-337-2701 or [email protected].

The Executive Committee of the Commission on Cancer (CoC) approved the formation of a full Committee on Advocacy to address legislative and regulatory issues that impact cancer care. The CoC Executive Committee will approve the slate of Committee leaders at its meeting on Oct. 6. Active members of the Member Organization Steering Committee’s Advocacy Subcommittee will continue their ongoing work as full Advocacy Committee members.

During the American College of Surgeons Clinical Congress in Washington, DC, the CoC will host a legislative briefing, Commission on Cancer: Ensuring High-Quality, Patient-Centered Cancer Care, Wednesday, Oct. 9, from 3:00-4:30 pm, at 2325 Rayburn House Office Building, A reception will follow at 5:00-6:30 pm. Space is limited. For more information and to reserve a place at the briefing, contact Kristin McDonald at 202-337-2701 or [email protected].

Members of the Steering Committee for the American College of Surgeons (ACS) Transition to Practice (TTP) Program in General Surgery will participate in a Town Hall Meeting on Wednesday, October 9, at 7:00 am in Room 206 of the Walter E. Washington Convention Center during the 2013 Clinical Congress. J. David Richardson, MD, FACS, a general thoracic and vascular surgeon, Louisville, KY, professor of surgery and vice chair of the department of surgery, University of Louisville School of Medicine, and Former Chair, ACS Board of Regents; and R. Phillip Burns, MD, FACS, a general surgeon, chairman and professor of surgery, department of surgery, University of Tennessee College of Medicine, Chattanooga, and First Vice-President, ACS Board of Regents, will co-moderate this interactive Town Hall Meeting. ACS leadership and TTP pilot program chiefs will answer questions and provide specific details to surgeons interested in bringing the TTP program to their institution or applying as a TTP associate.

The ACS Division of Education launched the TTP program earlier in 2013 in response to an identified need for additional surgical training for general surgeons coming out of residency. The program is intended to bridge the gap between residency and independent practice as well as to provide a pathway for those wishing to move into general surgery practice. TTP associates will experience increasing autonomy throughout the year in a broad-based clinical setting, build their competence and confidence in general surgery, develop practice management skills, and gain practical experience for the next phase of their careers.

For additional information, contact the Division of Education at 312-202-5491, [email protected] or visit the website at www.facs.org/ttp.

Members of the Steering Committee for the American College of Surgeons (ACS) Transition to Practice (TTP) Program in General Surgery will participate in a Town Hall Meeting on Wednesday, October 9, at 7:00 am in Room 206 of the Walter E. Washington Convention Center during the 2013 Clinical Congress. J. David Richardson, MD, FACS, a general thoracic and vascular surgeon, Louisville, KY, professor of surgery and vice chair of the department of surgery, University of Louisville School of Medicine, and Former Chair, ACS Board of Regents; and R. Phillip Burns, MD, FACS, a general surgeon, chairman and professor of surgery, department of surgery, University of Tennessee College of Medicine, Chattanooga, and First Vice-President, ACS Board of Regents, will co-moderate this interactive Town Hall Meeting. ACS leadership and TTP pilot program chiefs will answer questions and provide specific details to surgeons interested in bringing the TTP program to their institution or applying as a TTP associate.

The ACS Division of Education launched the TTP program earlier in 2013 in response to an identified need for additional surgical training for general surgeons coming out of residency. The program is intended to bridge the gap between residency and independent practice as well as to provide a pathway for those wishing to move into general surgery practice. TTP associates will experience increasing autonomy throughout the year in a broad-based clinical setting, build their competence and confidence in general surgery, develop practice management skills, and gain practical experience for the next phase of their careers.

For additional information, contact the Division of Education at 312-202-5491, [email protected] or visit the website at www.facs.org/ttp.

Members of the Steering Committee for the American College of Surgeons (ACS) Transition to Practice (TTP) Program in General Surgery will participate in a Town Hall Meeting on Wednesday, October 9, at 7:00 am in Room 206 of the Walter E. Washington Convention Center during the 2013 Clinical Congress. J. David Richardson, MD, FACS, a general thoracic and vascular surgeon, Louisville, KY, professor of surgery and vice chair of the department of surgery, University of Louisville School of Medicine, and Former Chair, ACS Board of Regents; and R. Phillip Burns, MD, FACS, a general surgeon, chairman and professor of surgery, department of surgery, University of Tennessee College of Medicine, Chattanooga, and First Vice-President, ACS Board of Regents, will co-moderate this interactive Town Hall Meeting. ACS leadership and TTP pilot program chiefs will answer questions and provide specific details to surgeons interested in bringing the TTP program to their institution or applying as a TTP associate.

The ACS Division of Education launched the TTP program earlier in 2013 in response to an identified need for additional surgical training for general surgeons coming out of residency. The program is intended to bridge the gap between residency and independent practice as well as to provide a pathway for those wishing to move into general surgery practice. TTP associates will experience increasing autonomy throughout the year in a broad-based clinical setting, build their competence and confidence in general surgery, develop practice management skills, and gain practical experience for the next phase of their careers.

For additional information, contact the Division of Education at 312-202-5491, [email protected] or visit the website at www.facs.org/ttp.

The American College of Surgeons (ACS), the American Society for Metabolic and Bariatric Surgery (ASMBS), and other medical societies recently sent a letter to the Centers for Medicare & Medicaid Services (CMS) opposing the agency’s plan to reverse its certification requirement for bariatric surgery facilities. The organizations maintain that removing the certification requirement could place Medicare patients at risk and is based on an incomplete review and analysis of the evidence.

"Substantial gains have been made in the quality of bariatric surgery because of certified and accredited programs," said ACS Executive Director David B. Hoyt, MD, FACS. "This proposed decision by CMS could be a setback, particularly for the Medicare beneficiaries, who have a higher risk of morbidity and mortality than the general bariatric surgery population."

In its proposed decision memo, CMS wrote, "There is little evidence that the requirement for facility certification/COE (center of excellence) designation for coverage of approved bariatric surgery procedures impacts outcomes for Medicare beneficiaries." However, several studies point to the positive effects of facility certification. In fact, a new study conducted by researchers at the University of California-Irvine indicates that the in-hospital mortality rate at non-accredited bariatric centers is more than three times higher than at accredited centers (0.22% vs. 0.06%).

Other groups that signed the joint letter include The Obesity Society, the American Society of Bariatric Physicians, and the Society of American Gastrointestinal Endoscopic Surgeons. View the press release announcing the joint letter at http://www.facs.org/news/2013/medicare0813.html.

The American College of Surgeons (ACS), the American Society for Metabolic and Bariatric Surgery (ASMBS), and other medical societies recently sent a letter to the Centers for Medicare & Medicaid Services (CMS) opposing the agency’s plan to reverse its certification requirement for bariatric surgery facilities. The organizations maintain that removing the certification requirement could place Medicare patients at risk and is based on an incomplete review and analysis of the evidence.

"Substantial gains have been made in the quality of bariatric surgery because of certified and accredited programs," said ACS Executive Director David B. Hoyt, MD, FACS. "This proposed decision by CMS could be a setback, particularly for the Medicare beneficiaries, who have a higher risk of morbidity and mortality than the general bariatric surgery population."

In its proposed decision memo, CMS wrote, "There is little evidence that the requirement for facility certification/COE (center of excellence) designation for coverage of approved bariatric surgery procedures impacts outcomes for Medicare beneficiaries." However, several studies point to the positive effects of facility certification. In fact, a new study conducted by researchers at the University of California-Irvine indicates that the in-hospital mortality rate at non-accredited bariatric centers is more than three times higher than at accredited centers (0.22% vs. 0.06%).

Other groups that signed the joint letter include The Obesity Society, the American Society of Bariatric Physicians, and the Society of American Gastrointestinal Endoscopic Surgeons. View the press release announcing the joint letter at http://www.facs.org/news/2013/medicare0813.html.

The American College of Surgeons (ACS), the American Society for Metabolic and Bariatric Surgery (ASMBS), and other medical societies recently sent a letter to the Centers for Medicare & Medicaid Services (CMS) opposing the agency’s plan to reverse its certification requirement for bariatric surgery facilities. The organizations maintain that removing the certification requirement could place Medicare patients at risk and is based on an incomplete review and analysis of the evidence.

"Substantial gains have been made in the quality of bariatric surgery because of certified and accredited programs," said ACS Executive Director David B. Hoyt, MD, FACS. "This proposed decision by CMS could be a setback, particularly for the Medicare beneficiaries, who have a higher risk of morbidity and mortality than the general bariatric surgery population."

In its proposed decision memo, CMS wrote, "There is little evidence that the requirement for facility certification/COE (center of excellence) designation for coverage of approved bariatric surgery procedures impacts outcomes for Medicare beneficiaries." However, several studies point to the positive effects of facility certification. In fact, a new study conducted by researchers at the University of California-Irvine indicates that the in-hospital mortality rate at non-accredited bariatric centers is more than three times higher than at accredited centers (0.22% vs. 0.06%).

Other groups that signed the joint letter include The Obesity Society, the American Society of Bariatric Physicians, and the Society of American Gastrointestinal Endoscopic Surgeons. View the press release announcing the joint letter at http://www.facs.org/news/2013/medicare0813.html.

To the outside observer, the process of carrying out a well-orchestrated operation, no matter how complex, can appear routine almost to the point of boredom. Well-trained members of the team do their jobs, and, with the possible exception of a few moments that are more tense or difficult than others, things go smoothly.

When a crisis erupts, a different set of procedures comes into play. Well-prepared teams usually deal with surgical crises in the operating room (OR) just as effectively. Nevertheless, such teams may be unavailable under certain circumstances, and even the best teams may not be well-drilled in how to handle every crisis.

To ensure that surgical teams are capable of effectively responding to emergency situations, the American College of Surgeons (ACS), through its membership on the Council on Surgical and Perioperative Safety (CSPS), is participating in a campaign to introduce and implement crisis checklists in the OR and perioperative arena. 

The value of checklists

The use of checklists has migrated from the flight line to the operating room, but the surgical profession has only begun to appreciate the potential benefits and applications of this instrument. The purpose of checklists in the OR is to ensure that critical steps in preparing for and performing operations are taken and not left to memory. Situations most vulnerable to oversight are those that are, or are perceived to be, routine and those that arise during crises. Checklists provide a parachute.

Simulation laboratories have proliferated as a means of improving surgical training and as a way of testing and improving process in the OR. A number of simulation trials have tested the applicability and utility of crisis checklists. Clinicians who used them in simulated crises expressed a strong desire to have crisis checklists available, not just for training, but in the clinical setting. Initial implementation projects have been initiated at the Brigham and Women’s Hospital, Boston, MA; Stanford University, CA; and Cooper University Health System based in Camden, NJ.

The concept is hardly new. Educational programs, such as the Advanced Trauma Life Support® and Advanced Cardiac Life Support programs and the military Combat Casualty Care Course, have used checklists as an instructional expedient for many years.

The CSPS campaign

The CSPS, which the ACS was instrumental in establishing, has partnered with Ariadne Labs at the Harvard School of Public Health to launch and support a coordinated campaign to stimulate the availability and the implementation of crisis checklists. The CSPS is a unique collaborative of seven organizations representing health care professionals who are involved in perioperative care: the ACS, the American Association of Nurse Anesthetists, the American Association of Surgical Physician Assistants, the Association of PeriOperative Registered Nurses, the American Society of Anesthesiologists, the American Society of PeriAnesthesia Nurses, and the Association of Surgical Technologists. The combined membership exceeds 250,000, and the total number of individuals in the seven professions exceeds 2 million.

The CSPS intends to launch a campaign to inform its membership and the surgical community at large of the importance and effectiveness of crisis checklists and of strategies for introducing them into practice. Early experience points to the critical role of a local champion and a multidisciplinary implementation team dedicated to promoting checklist customization and adoption. Ideally, training in the use of crisis checklists would take place in a simulated operating room environment, with or without a formal simulation laboratory. Multidisciplinary staff involvement is an essential component, and so is recognition of local resources, needs, and circumstances.

The CSPS plans to expose all members of the perioperative team to the concept of crisis checklists through advocacy and education on a national level. The idea is to create a framework to implement a multidisciplinary, multi-institutional collaboration. A coordinated message from the seven organizations that comprise the CSPS will support efforts both nationally and locally.

The surgical community has the opportunity to lead in the development, adoption, and implementation of crisis checklists in collaboration with other professionals in the operating room and perioperative area. Checklists offer additional ways to improve patient care and surgical outcomes using a familiar tool. More information will be made available over the next few months.

Web resources for the implementation team are available at www.projectcheck.org and at http://emergencymanual.stanford.edu, or on the CSPS website at http://www.cspsteam.org.

Dr. Dagi is Distinguished Scholar and Professor, The School of Medicine, Dentistry Biomedical Sciences, Queen\'s University Belfast, Northern Ireland; and lecturer, department of global health and social medicine, Harvard Medical School, Boston, MA; Chair, ACS Committee on Perioperative Care; and member, CSPS Board of Directors.

Dr. Healy is Emeritus Gerald B. Healy Chair in Otolaryngology, Children\'s Hospital, Boston; professor of otology and laryngology, Harvard Medical School; ACS Past-President and Past-Chair of the Board of Regents; and member, CSPS Board of Directors.

To the outside observer, the process of carrying out a well-orchestrated operation, no matter how complex, can appear routine almost to the point of boredom. Well-trained members of the team do their jobs, and, with the possible exception of a few moments that are more tense or difficult than others, things go smoothly.

When a crisis erupts, a different set of procedures comes into play. Well-prepared teams usually deal with surgical crises in the operating room (OR) just as effectively. Nevertheless, such teams may be unavailable under certain circumstances, and even the best teams may not be well-drilled in how to handle every crisis.

To ensure that surgical teams are capable of effectively responding to emergency situations, the American College of Surgeons (ACS), through its membership on the Council on Surgical and Perioperative Safety (CSPS), is participating in a campaign to introduce and implement crisis checklists in the OR and perioperative arena. 

The value of checklists

The use of checklists has migrated from the flight line to the operating room, but the surgical profession has only begun to appreciate the potential benefits and applications of this instrument. The purpose of checklists in the OR is to ensure that critical steps in preparing for and performing operations are taken and not left to memory. Situations most vulnerable to oversight are those that are, or are perceived to be, routine and those that arise during crises. Checklists provide a parachute.

Simulation laboratories have proliferated as a means of improving surgical training and as a way of testing and improving process in the OR. A number of simulation trials have tested the applicability and utility of crisis checklists. Clinicians who used them in simulated crises expressed a strong desire to have crisis checklists available, not just for training, but in the clinical setting. Initial implementation projects have been initiated at the Brigham and Women’s Hospital, Boston, MA; Stanford University, CA; and Cooper University Health System based in Camden, NJ.

The concept is hardly new. Educational programs, such as the Advanced Trauma Life Support® and Advanced Cardiac Life Support programs and the military Combat Casualty Care Course, have used checklists as an instructional expedient for many years.

The CSPS campaign

The CSPS, which the ACS was instrumental in establishing, has partnered with Ariadne Labs at the Harvard School of Public Health to launch and support a coordinated campaign to stimulate the availability and the implementation of crisis checklists. The CSPS is a unique collaborative of seven organizations representing health care professionals who are involved in perioperative care: the ACS, the American Association of Nurse Anesthetists, the American Association of Surgical Physician Assistants, the Association of PeriOperative Registered Nurses, the American Society of Anesthesiologists, the American Society of PeriAnesthesia Nurses, and the Association of Surgical Technologists. The combined membership exceeds 250,000, and the total number of individuals in the seven professions exceeds 2 million.

The CSPS intends to launch a campaign to inform its membership and the surgical community at large of the importance and effectiveness of crisis checklists and of strategies for introducing them into practice. Early experience points to the critical role of a local champion and a multidisciplinary implementation team dedicated to promoting checklist customization and adoption. Ideally, training in the use of crisis checklists would take place in a simulated operating room environment, with or without a formal simulation laboratory. Multidisciplinary staff involvement is an essential component, and so is recognition of local resources, needs, and circumstances.

The CSPS plans to expose all members of the perioperative team to the concept of crisis checklists through advocacy and education on a national level. The idea is to create a framework to implement a multidisciplinary, multi-institutional collaboration. A coordinated message from the seven organizations that comprise the CSPS will support efforts both nationally and locally.

The surgical community has the opportunity to lead in the development, adoption, and implementation of crisis checklists in collaboration with other professionals in the operating room and perioperative area. Checklists offer additional ways to improve patient care and surgical outcomes using a familiar tool. More information will be made available over the next few months.

Web resources for the implementation team are available at www.projectcheck.org and at http://emergencymanual.stanford.edu, or on the CSPS website at http://www.cspsteam.org.

Dr. Dagi is Distinguished Scholar and Professor, The School of Medicine, Dentistry Biomedical Sciences, Queen\'s University Belfast, Northern Ireland; and lecturer, department of global health and social medicine, Harvard Medical School, Boston, MA; Chair, ACS Committee on Perioperative Care; and member, CSPS Board of Directors.

Dr. Healy is Emeritus Gerald B. Healy Chair in Otolaryngology, Children\'s Hospital, Boston; professor of otology and laryngology, Harvard Medical School; ACS Past-President and Past-Chair of the Board of Regents; and member, CSPS Board of Directors.

To the outside observer, the process of carrying out a well-orchestrated operation, no matter how complex, can appear routine almost to the point of boredom. Well-trained members of the team do their jobs, and, with the possible exception of a few moments that are more tense or difficult than others, things go smoothly.

When a crisis erupts, a different set of procedures comes into play. Well-prepared teams usually deal with surgical crises in the operating room (OR) just as effectively. Nevertheless, such teams may be unavailable under certain circumstances, and even the best teams may not be well-drilled in how to handle every crisis.

To ensure that surgical teams are capable of effectively responding to emergency situations, the American College of Surgeons (ACS), through its membership on the Council on Surgical and Perioperative Safety (CSPS), is participating in a campaign to introduce and implement crisis checklists in the OR and perioperative arena. 

The value of checklists

The use of checklists has migrated from the flight line to the operating room, but the surgical profession has only begun to appreciate the potential benefits and applications of this instrument. The purpose of checklists in the OR is to ensure that critical steps in preparing for and performing operations are taken and not left to memory. Situations most vulnerable to oversight are those that are, or are perceived to be, routine and those that arise during crises. Checklists provide a parachute.

Simulation laboratories have proliferated as a means of improving surgical training and as a way of testing and improving process in the OR. A number of simulation trials have tested the applicability and utility of crisis checklists. Clinicians who used them in simulated crises expressed a strong desire to have crisis checklists available, not just for training, but in the clinical setting. Initial implementation projects have been initiated at the Brigham and Women’s Hospital, Boston, MA; Stanford University, CA; and Cooper University Health System based in Camden, NJ.

The concept is hardly new. Educational programs, such as the Advanced Trauma Life Support® and Advanced Cardiac Life Support programs and the military Combat Casualty Care Course, have used checklists as an instructional expedient for many years.

The CSPS campaign

The CSPS, which the ACS was instrumental in establishing, has partnered with Ariadne Labs at the Harvard School of Public Health to launch and support a coordinated campaign to stimulate the availability and the implementation of crisis checklists. The CSPS is a unique collaborative of seven organizations representing health care professionals who are involved in perioperative care: the ACS, the American Association of Nurse Anesthetists, the American Association of Surgical Physician Assistants, the Association of PeriOperative Registered Nurses, the American Society of Anesthesiologists, the American Society of PeriAnesthesia Nurses, and the Association of Surgical Technologists. The combined membership exceeds 250,000, and the total number of individuals in the seven professions exceeds 2 million.

The CSPS intends to launch a campaign to inform its membership and the surgical community at large of the importance and effectiveness of crisis checklists and of strategies for introducing them into practice. Early experience points to the critical role of a local champion and a multidisciplinary implementation team dedicated to promoting checklist customization and adoption. Ideally, training in the use of crisis checklists would take place in a simulated operating room environment, with or without a formal simulation laboratory. Multidisciplinary staff involvement is an essential component, and so is recognition of local resources, needs, and circumstances.

The CSPS plans to expose all members of the perioperative team to the concept of crisis checklists through advocacy and education on a national level. The idea is to create a framework to implement a multidisciplinary, multi-institutional collaboration. A coordinated message from the seven organizations that comprise the CSPS will support efforts both nationally and locally.

The surgical community has the opportunity to lead in the development, adoption, and implementation of crisis checklists in collaboration with other professionals in the operating room and perioperative area. Checklists offer additional ways to improve patient care and surgical outcomes using a familiar tool. More information will be made available over the next few months.

Web resources for the implementation team are available at www.projectcheck.org and at http://emergencymanual.stanford.edu, or on the CSPS website at http://www.cspsteam.org.

Dr. Dagi is Distinguished Scholar and Professor, The School of Medicine, Dentistry Biomedical Sciences, Queen\'s University Belfast, Northern Ireland; and lecturer, department of global health and social medicine, Harvard Medical School, Boston, MA; Chair, ACS Committee on Perioperative Care; and member, CSPS Board of Directors.

Dr. Healy is Emeritus Gerald B. Healy Chair in Otolaryngology, Children\'s Hospital, Boston; professor of otology and laryngology, Harvard Medical School; ACS Past-President and Past-Chair of the Board of Regents; and member, CSPS Board of Directors.

The American College of Surgeons (ACS) and Commission on Cancer (CoC) on September 4 released separate lists of commonly ordered but not always necessary tests or procedures as part of the Choosing Wisely® campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation.  The list from each of the 30 specialty society Choosing Wisely partners identifies five targeted, evidence-based recommendations for potentially unnecessary and sometimes harmful tests and procedures and that call for conversations between patients and physicians regarding essential care.

The American College of Surgeons’ list set forth the following five recommendations:

Don’t perform axillary lymph node dissection for clinical stages I and II breast cancer with clinically negative lymph nodes without attempting sentinel node biopsy.

Avoid the routine use of "whole-body" diagnostic computed tomography (CT) scanning in patients with minor or single system trauma.

Avoid colorectal cancer screening tests on asymptomatic patients with a life expectancy of less than ten years and no family or personal history of colorectal neoplasia.

Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam.

Don’t do computed tomography for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

"These recommendations will help to enhance the patient-surgeon relationship and heighten the quality of care surgical patients receive, which is one of our highest priorities," said David B. Hoyt, MD, FACS, ACS Executive Director.

The Commission on Cancer established the following five recommendations:

Don’t perform surgery to remove a breast lump for suspicious findings unless needle biopsy cannot be done.

Don’t initiate surveillance testing after cancer treatment without providing the patient a survivorship care plan.

Don’t use surgery as the initial treatment without considering presurgical (neoadjuvant) systemic and/or radiation for cancer types and stage where it is effective at improving local cancer control, quality of life, or survival.

Don’t perform major abdominal surgery or thoracic surgery without a pathway or standard protocol for post-operative pain control and pneumonia prevention.

Don’t initiate cancer treatment without defining the extent of the cancer (through clinical staging) and discussing with the patient the intent of treatment.

"This initiative will help provide cancer patients with a highly credible resource to obtain reliable information when discussing certain aspects of their care with their physicians," said David P. Winchester, MD, FACS, Medical Director, ACS Cancer Programs.

The American College of Surgeons (ACS) and Commission on Cancer (CoC) on September 4 released separate lists of commonly ordered but not always necessary tests or procedures as part of the Choosing Wisely® campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation.  The list from each of the 30 specialty society Choosing Wisely partners identifies five targeted, evidence-based recommendations for potentially unnecessary and sometimes harmful tests and procedures and that call for conversations between patients and physicians regarding essential care.

The American College of Surgeons’ list set forth the following five recommendations:

Don’t perform axillary lymph node dissection for clinical stages I and II breast cancer with clinically negative lymph nodes without attempting sentinel node biopsy.

Avoid the routine use of "whole-body" diagnostic computed tomography (CT) scanning in patients with minor or single system trauma.

Avoid colorectal cancer screening tests on asymptomatic patients with a life expectancy of less than ten years and no family or personal history of colorectal neoplasia.

Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam.

Don’t do computed tomography for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

"These recommendations will help to enhance the patient-surgeon relationship and heighten the quality of care surgical patients receive, which is one of our highest priorities," said David B. Hoyt, MD, FACS, ACS Executive Director.

The Commission on Cancer established the following five recommendations:

Don’t perform surgery to remove a breast lump for suspicious findings unless needle biopsy cannot be done.

Don’t initiate surveillance testing after cancer treatment without providing the patient a survivorship care plan.

Don’t use surgery as the initial treatment without considering presurgical (neoadjuvant) systemic and/or radiation for cancer types and stage where it is effective at improving local cancer control, quality of life, or survival.

Don’t perform major abdominal surgery or thoracic surgery without a pathway or standard protocol for post-operative pain control and pneumonia prevention.

Don’t initiate cancer treatment without defining the extent of the cancer (through clinical staging) and discussing with the patient the intent of treatment.

"This initiative will help provide cancer patients with a highly credible resource to obtain reliable information when discussing certain aspects of their care with their physicians," said David P. Winchester, MD, FACS, Medical Director, ACS Cancer Programs.

The American College of Surgeons (ACS) and Commission on Cancer (CoC) on September 4 released separate lists of commonly ordered but not always necessary tests or procedures as part of the Choosing Wisely® campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation.  The list from each of the 30 specialty society Choosing Wisely partners identifies five targeted, evidence-based recommendations for potentially unnecessary and sometimes harmful tests and procedures and that call for conversations between patients and physicians regarding essential care.

The American College of Surgeons’ list set forth the following five recommendations:

Don’t perform axillary lymph node dissection for clinical stages I and II breast cancer with clinically negative lymph nodes without attempting sentinel node biopsy.

Avoid the routine use of "whole-body" diagnostic computed tomography (CT) scanning in patients with minor or single system trauma.

Avoid colorectal cancer screening tests on asymptomatic patients with a life expectancy of less than ten years and no family or personal history of colorectal neoplasia.

Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam.

Don’t do computed tomography for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

"These recommendations will help to enhance the patient-surgeon relationship and heighten the quality of care surgical patients receive, which is one of our highest priorities," said David B. Hoyt, MD, FACS, ACS Executive Director.

The Commission on Cancer established the following five recommendations:

Don’t perform surgery to remove a breast lump for suspicious findings unless needle biopsy cannot be done.

Don’t initiate surveillance testing after cancer treatment without providing the patient a survivorship care plan.

Don’t use surgery as the initial treatment without considering presurgical (neoadjuvant) systemic and/or radiation for cancer types and stage where it is effective at improving local cancer control, quality of life, or survival.

Don’t perform major abdominal surgery or thoracic surgery without a pathway or standard protocol for post-operative pain control and pneumonia prevention.

Don’t initiate cancer treatment without defining the extent of the cancer (through clinical staging) and discussing with the patient the intent of treatment.

"This initiative will help provide cancer patients with a highly credible resource to obtain reliable information when discussing certain aspects of their care with their physicians," said David P. Winchester, MD, FACS, Medical Director, ACS Cancer Programs.