Click here to view some basic information about seizure first aid.

Click here to view some basic information about seizure first aid.

Click here to view some basic information about seizure first aid.

The American College of Surgeons (ACS) submitted a comment letter June 27 on the Centers for Medicare & Medicaid Services (CMS) proposed rule on implementation of certain provisions of MACRA. Specifically, the CMS set forth proposals on the two pathways by which MACRA replaces the sustainable growth rate (SGR) formula: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Among other issues, the ACS comments address the four components of MIPS: 1. quality, 2. resource use, 3. advancing care information, and 4. clinical practice improvement activities. The comments also address the criteria necessary for an APM model to be considered an “Advanced” APM, specifically: 1. use of certified electronic health records technology, 2. inclusion of quality measures comparable to MIPS, and 3. taking on more than nominal financial risk. Participation in an Advanced APM would exclude the clinician from participation in MIPS. For more information on the proposed rule or the comment letter, contact [email protected].

The American College of Surgeons (ACS) submitted a comment letter June 27 on the Centers for Medicare & Medicaid Services (CMS) proposed rule on implementation of certain provisions of MACRA. Specifically, the CMS set forth proposals on the two pathways by which MACRA replaces the sustainable growth rate (SGR) formula: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Among other issues, the ACS comments address the four components of MIPS: 1. quality, 2. resource use, 3. advancing care information, and 4. clinical practice improvement activities. The comments also address the criteria necessary for an APM model to be considered an “Advanced” APM, specifically: 1. use of certified electronic health records technology, 2. inclusion of quality measures comparable to MIPS, and 3. taking on more than nominal financial risk. Participation in an Advanced APM would exclude the clinician from participation in MIPS. For more information on the proposed rule or the comment letter, contact [email protected].

The American College of Surgeons (ACS) submitted a comment letter June 27 on the Centers for Medicare & Medicaid Services (CMS) proposed rule on implementation of certain provisions of MACRA. Specifically, the CMS set forth proposals on the two pathways by which MACRA replaces the sustainable growth rate (SGR) formula: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Among other issues, the ACS comments address the four components of MIPS: 1. quality, 2. resource use, 3. advancing care information, and 4. clinical practice improvement activities. The comments also address the criteria necessary for an APM model to be considered an “Advanced” APM, specifically: 1. use of certified electronic health records technology, 2. inclusion of quality measures comparable to MIPS, and 3. taking on more than nominal financial risk. Participation in an Advanced APM would exclude the clinician from participation in MIPS. For more information on the proposed rule or the comment letter, contact [email protected].

The American College of Surgeons (ACS) regulatory staff submitted a comment letter to the Centers for Medicare & Medicaid Services (CMS) on June 16 regarding the 2017 Inpatient Prospective Payment System (IPPS) proposed rule. Learn more about the proposed rule here.. The notice and comment period, which began with the proposed rule’s release April 27, enables individuals and organizations to provide input on the changes the CMS plans to make. The CMS takes these comments into consideration as it crafts the final rule.

The IPPS outlines coverage criteria for Medicare Part A inpatient hospital claims. Because a large portion of surgical care is provided in the inpatient setting, the rule both directly and indirectly affects surgeons. The ACS comment letter included feedback on the CMS’s proposed changes to the Hospital Value-Based Purchasing Program and the Hospital Acquired Conditions Reduction Program, both pay-for-performance programs, and the Hospital Inpatient Quality Reporting Program, a pay-for-reporting program. For more information about the IPPS proposed rule, see the CMS fact sheet.

The American College of Surgeons (ACS) regulatory staff submitted a comment letter to the Centers for Medicare & Medicaid Services (CMS) on June 16 regarding the 2017 Inpatient Prospective Payment System (IPPS) proposed rule. Learn more about the proposed rule here.. The notice and comment period, which began with the proposed rule’s release April 27, enables individuals and organizations to provide input on the changes the CMS plans to make. The CMS takes these comments into consideration as it crafts the final rule.

The IPPS outlines coverage criteria for Medicare Part A inpatient hospital claims. Because a large portion of surgical care is provided in the inpatient setting, the rule both directly and indirectly affects surgeons. The ACS comment letter included feedback on the CMS’s proposed changes to the Hospital Value-Based Purchasing Program and the Hospital Acquired Conditions Reduction Program, both pay-for-performance programs, and the Hospital Inpatient Quality Reporting Program, a pay-for-reporting program. For more information about the IPPS proposed rule, see the CMS fact sheet.

The American College of Surgeons (ACS) regulatory staff submitted a comment letter to the Centers for Medicare & Medicaid Services (CMS) on June 16 regarding the 2017 Inpatient Prospective Payment System (IPPS) proposed rule. Learn more about the proposed rule here.. The notice and comment period, which began with the proposed rule’s release April 27, enables individuals and organizations to provide input on the changes the CMS plans to make. The CMS takes these comments into consideration as it crafts the final rule.

The IPPS outlines coverage criteria for Medicare Part A inpatient hospital claims. Because a large portion of surgical care is provided in the inpatient setting, the rule both directly and indirectly affects surgeons. The ACS comment letter included feedback on the CMS’s proposed changes to the Hospital Value-Based Purchasing Program and the Hospital Acquired Conditions Reduction Program, both pay-for-performance programs, and the Hospital Inpatient Quality Reporting Program, a pay-for-reporting program. For more information about the IPPS proposed rule, see the CMS fact sheet.

The scientific program, online registration, travel and housing reservation links, and previews of other planned events for the American College of Surgeons (ACS) Clinical Congress 2016, October 16-20 in Washington, DC, are now available online. The Walter E. Washington Convention Center will be the host site for the scientific sessions, courses, and scientific posters and technical exhibits; the Marriott Marquis Washington, DC, will serve as the headquarters hotel for the meeting.

The theme for Clinical Congress 2016 is Challenges for the Second Century, as the ACS pursues its next 100 years of improving quality of care for surgical patients. Clinical Congress provides outstanding education and training opportunities for ACS Fellows, Associate Fellows, Resident Members, Medical Student Members, and other surgical team members. Attendees will find leading-edge surgical research presentations, a new lineup of Didactic/Experiential Postgraduate Courses, Surgical Skills Postgraduate Courses, timely discussions of relevant surgical topics, member engagement events, and unparalleled access to peers. You can earn up to 47.5 AMA PRA Category 1 Credits™ while attending premier educational sessions and courses.

Register by August 22 to take advantage of early-bird pricing. Various hotel options are available, so make your housing reservations and travel plans now to receive reduced Clinical Congress rates.

The scientific program, online registration, travel and housing reservation links, and previews of other planned events for the American College of Surgeons (ACS) Clinical Congress 2016, October 16-20 in Washington, DC, are now available online. The Walter E. Washington Convention Center will be the host site for the scientific sessions, courses, and scientific posters and technical exhibits; the Marriott Marquis Washington, DC, will serve as the headquarters hotel for the meeting.

The theme for Clinical Congress 2016 is Challenges for the Second Century, as the ACS pursues its next 100 years of improving quality of care for surgical patients. Clinical Congress provides outstanding education and training opportunities for ACS Fellows, Associate Fellows, Resident Members, Medical Student Members, and other surgical team members. Attendees will find leading-edge surgical research presentations, a new lineup of Didactic/Experiential Postgraduate Courses, Surgical Skills Postgraduate Courses, timely discussions of relevant surgical topics, member engagement events, and unparalleled access to peers. You can earn up to 47.5 AMA PRA Category 1 Credits™ while attending premier educational sessions and courses.

Register by August 22 to take advantage of early-bird pricing. Various hotel options are available, so make your housing reservations and travel plans now to receive reduced Clinical Congress rates.

The scientific program, online registration, travel and housing reservation links, and previews of other planned events for the American College of Surgeons (ACS) Clinical Congress 2016, October 16-20 in Washington, DC, are now available online. The Walter E. Washington Convention Center will be the host site for the scientific sessions, courses, and scientific posters and technical exhibits; the Marriott Marquis Washington, DC, will serve as the headquarters hotel for the meeting.

The theme for Clinical Congress 2016 is Challenges for the Second Century, as the ACS pursues its next 100 years of improving quality of care for surgical patients. Clinical Congress provides outstanding education and training opportunities for ACS Fellows, Associate Fellows, Resident Members, Medical Student Members, and other surgical team members. Attendees will find leading-edge surgical research presentations, a new lineup of Didactic/Experiential Postgraduate Courses, Surgical Skills Postgraduate Courses, timely discussions of relevant surgical topics, member engagement events, and unparalleled access to peers. You can earn up to 47.5 AMA PRA Category 1 Credits™ while attending premier educational sessions and courses.

Register by August 22 to take advantage of early-bird pricing. Various hotel options are available, so make your housing reservations and travel plans now to receive reduced Clinical Congress rates.

Clinicians outside of the surgical specialties may consider surgeons primarily providers of technical services, but those of us who provide surgical care fully appreciate that communicating with patients and families is a large component of routine surgical practice. Typical communications in surgical practice include obtaining a history of present illness, which is a key element in the ultimate decision to offer a surgical intervention, or not; discussing the risks, benefits, and alternatives of any operation being considered; and the numerous discussions held following any surgical procedure. What many surgeons may not fully appreciate, however, is how these routine communication events can fall under the general category of advance care planning (ACP).

ACP is defined as a process in which physicians (and other health care providers) discuss a patient’s goals, values, and beliefs and determine how these inform a patient’s desire for current or future medical care. Hickman et al. (Hastings Center Report Special Report 35, no. 6 (2005):S26-S30) note that ACP should focus on defining “good” care for each patient. Furthermore, changes in a patient’s medical condition represent an opportune time to revisit a patient’s hopes and goals. Consideration of surgical intervention often represents a major change in a patient’s medical condition and therefore is an excellent opportunity to engage a patient in an ACP discussion.

Given that ACP discussions are likely occurring in surgical practices on a regular basis, surgeons need to be aware of a recent change in the Physician Fee Schedule that took effect Jan. 1, 2016. Effective this date, Current Procedural Terminology (CPT) codes 99497 and 99498 now allow for billing for ACP services. CPT code 99497 includes ACP “including the explanation and discussion of advance directives such as standard forms (with the completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with patient, family member(s) and/or surrogate.” CPT code 99498 is used for each additional 30 minutes spent in such face-to-face ACP counseling.

The nuts and bolts of how these ACP CPT codes work:

How many times can these code(s) be used? There are no limits on the number of times ACP can be reported for a given beneficiary in a given time period. For example, if an ACP discussion was held with a patient and/or family member and/or surrogate prior to a major elective procedure and again in the postoperative period, the above CPT codes could be used twice. In each instance, the ACP discussion must be documented, along with any relevant change in the patient’s clinical status that prompted another ACP discussion.

Can a patient or their family member/surrogate refuse ACP services? ACP services are voluntary; therefore, a patient or their family member/surrogate can refuse ACP services. These CPT codes only can be used if a patient or family member/surrogate consents for ACP services.

What must be documented in ACP services? Physicians should consult their Medicare Administrative Contractors for documentation requirements. Examples of elements to be included in the documentation are a brief description of the discussion with the patient or family/surrogate regarding the voluntary nature of ACP services, an explanation of advance directives and documentation if an advance directive is completed, who was present during the discussion, and time spent in the face-to-face encounter.

Does an advance directive have to be completed to bill the service? No. If an advance directive is completed, this should be documented (see above), but completion of the directive is not a requirement for billing the service.

Can ACP be reported in addition to an evaluation and management (E/M) service (such as an office visit)? Yes. CPT codes 99497 and 99498 may be billed on the same day or a different day as most other E/M services. They may be billed within the global surgical period.

Is a specific diagnosis required to use the ACP CPT codes? No, a specific diagnosis is not required for the ACP codes to be billed.

According to the 2016 Medicare Physician Fee Schedule, the reimbursement is $85.99 for CPT 99497 and $74.88 for CPT 99498. For comparison, the reimbursement for E/M CPT 99203 (30-minute initial evaluation) = $108.85, CPT 99204 (45-minute initial evaluation) = $166.13, and CPT 99205 (60-minute initial evaluation) = $208.38. Far more important than the financial remuneration for these discussions, however, is the critical need for surgeons to have and document their ACP discussions with their patients and/or their family member/surrogate. As surgeons, we are often called to see patients when they are facing a significant change in their health – whether that is a new diagnosis of cancer or after a traumatic injury. Understanding a patient’s values, hopes, and concerns is an essential component to ensuring that our patients receive the best care, as defined by them.

Dr. Fahy is associate professor of surgery and internal medicine at the University of New Mexico, Albuquerque. She is a surgical oncologist who is also board certified in hospice and palliative medicine. Dr. Fahy does not have any relevant conflicts of interest to disclose.

Clinicians outside of the surgical specialties may consider surgeons primarily providers of technical services, but those of us who provide surgical care fully appreciate that communicating with patients and families is a large component of routine surgical practice. Typical communications in surgical practice include obtaining a history of present illness, which is a key element in the ultimate decision to offer a surgical intervention, or not; discussing the risks, benefits, and alternatives of any operation being considered; and the numerous discussions held following any surgical procedure. What many surgeons may not fully appreciate, however, is how these routine communication events can fall under the general category of advance care planning (ACP).

ACP is defined as a process in which physicians (and other health care providers) discuss a patient’s goals, values, and beliefs and determine how these inform a patient’s desire for current or future medical care. Hickman et al. (Hastings Center Report Special Report 35, no. 6 (2005):S26-S30) note that ACP should focus on defining “good” care for each patient. Furthermore, changes in a patient’s medical condition represent an opportune time to revisit a patient’s hopes and goals. Consideration of surgical intervention often represents a major change in a patient’s medical condition and therefore is an excellent opportunity to engage a patient in an ACP discussion.

Given that ACP discussions are likely occurring in surgical practices on a regular basis, surgeons need to be aware of a recent change in the Physician Fee Schedule that took effect Jan. 1, 2016. Effective this date, Current Procedural Terminology (CPT) codes 99497 and 99498 now allow for billing for ACP services. CPT code 99497 includes ACP “including the explanation and discussion of advance directives such as standard forms (with the completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with patient, family member(s) and/or surrogate.” CPT code 99498 is used for each additional 30 minutes spent in such face-to-face ACP counseling.

The nuts and bolts of how these ACP CPT codes work:

How many times can these code(s) be used? There are no limits on the number of times ACP can be reported for a given beneficiary in a given time period. For example, if an ACP discussion was held with a patient and/or family member and/or surrogate prior to a major elective procedure and again in the postoperative period, the above CPT codes could be used twice. In each instance, the ACP discussion must be documented, along with any relevant change in the patient’s clinical status that prompted another ACP discussion.

Can a patient or their family member/surrogate refuse ACP services? ACP services are voluntary; therefore, a patient or their family member/surrogate can refuse ACP services. These CPT codes only can be used if a patient or family member/surrogate consents for ACP services.

What must be documented in ACP services? Physicians should consult their Medicare Administrative Contractors for documentation requirements. Examples of elements to be included in the documentation are a brief description of the discussion with the patient or family/surrogate regarding the voluntary nature of ACP services, an explanation of advance directives and documentation if an advance directive is completed, who was present during the discussion, and time spent in the face-to-face encounter.

Does an advance directive have to be completed to bill the service? No. If an advance directive is completed, this should be documented (see above), but completion of the directive is not a requirement for billing the service.

Can ACP be reported in addition to an evaluation and management (E/M) service (such as an office visit)? Yes. CPT codes 99497 and 99498 may be billed on the same day or a different day as most other E/M services. They may be billed within the global surgical period.

Is a specific diagnosis required to use the ACP CPT codes? No, a specific diagnosis is not required for the ACP codes to be billed.

According to the 2016 Medicare Physician Fee Schedule, the reimbursement is $85.99 for CPT 99497 and $74.88 for CPT 99498. For comparison, the reimbursement for E/M CPT 99203 (30-minute initial evaluation) = $108.85, CPT 99204 (45-minute initial evaluation) = $166.13, and CPT 99205 (60-minute initial evaluation) = $208.38. Far more important than the financial remuneration for these discussions, however, is the critical need for surgeons to have and document their ACP discussions with their patients and/or their family member/surrogate. As surgeons, we are often called to see patients when they are facing a significant change in their health – whether that is a new diagnosis of cancer or after a traumatic injury. Understanding a patient’s values, hopes, and concerns is an essential component to ensuring that our patients receive the best care, as defined by them.

Dr. Fahy is associate professor of surgery and internal medicine at the University of New Mexico, Albuquerque. She is a surgical oncologist who is also board certified in hospice and palliative medicine. Dr. Fahy does not have any relevant conflicts of interest to disclose.

Clinicians outside of the surgical specialties may consider surgeons primarily providers of technical services, but those of us who provide surgical care fully appreciate that communicating with patients and families is a large component of routine surgical practice. Typical communications in surgical practice include obtaining a history of present illness, which is a key element in the ultimate decision to offer a surgical intervention, or not; discussing the risks, benefits, and alternatives of any operation being considered; and the numerous discussions held following any surgical procedure. What many surgeons may not fully appreciate, however, is how these routine communication events can fall under the general category of advance care planning (ACP).

ACP is defined as a process in which physicians (and other health care providers) discuss a patient’s goals, values, and beliefs and determine how these inform a patient’s desire for current or future medical care. Hickman et al. (Hastings Center Report Special Report 35, no. 6 (2005):S26-S30) note that ACP should focus on defining “good” care for each patient. Furthermore, changes in a patient’s medical condition represent an opportune time to revisit a patient’s hopes and goals. Consideration of surgical intervention often represents a major change in a patient’s medical condition and therefore is an excellent opportunity to engage a patient in an ACP discussion.

Given that ACP discussions are likely occurring in surgical practices on a regular basis, surgeons need to be aware of a recent change in the Physician Fee Schedule that took effect Jan. 1, 2016. Effective this date, Current Procedural Terminology (CPT) codes 99497 and 99498 now allow for billing for ACP services. CPT code 99497 includes ACP “including the explanation and discussion of advance directives such as standard forms (with the completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with patient, family member(s) and/or surrogate.” CPT code 99498 is used for each additional 30 minutes spent in such face-to-face ACP counseling.

The nuts and bolts of how these ACP CPT codes work:

How many times can these code(s) be used? There are no limits on the number of times ACP can be reported for a given beneficiary in a given time period. For example, if an ACP discussion was held with a patient and/or family member and/or surrogate prior to a major elective procedure and again in the postoperative period, the above CPT codes could be used twice. In each instance, the ACP discussion must be documented, along with any relevant change in the patient’s clinical status that prompted another ACP discussion.

Can a patient or their family member/surrogate refuse ACP services? ACP services are voluntary; therefore, a patient or their family member/surrogate can refuse ACP services. These CPT codes only can be used if a patient or family member/surrogate consents for ACP services.

What must be documented in ACP services? Physicians should consult their Medicare Administrative Contractors for documentation requirements. Examples of elements to be included in the documentation are a brief description of the discussion with the patient or family/surrogate regarding the voluntary nature of ACP services, an explanation of advance directives and documentation if an advance directive is completed, who was present during the discussion, and time spent in the face-to-face encounter.

Does an advance directive have to be completed to bill the service? No. If an advance directive is completed, this should be documented (see above), but completion of the directive is not a requirement for billing the service.

Can ACP be reported in addition to an evaluation and management (E/M) service (such as an office visit)? Yes. CPT codes 99497 and 99498 may be billed on the same day or a different day as most other E/M services. They may be billed within the global surgical period.

Is a specific diagnosis required to use the ACP CPT codes? No, a specific diagnosis is not required for the ACP codes to be billed.

According to the 2016 Medicare Physician Fee Schedule, the reimbursement is $85.99 for CPT 99497 and $74.88 for CPT 99498. For comparison, the reimbursement for E/M CPT 99203 (30-minute initial evaluation) = $108.85, CPT 99204 (45-minute initial evaluation) = $166.13, and CPT 99205 (60-minute initial evaluation) = $208.38. Far more important than the financial remuneration for these discussions, however, is the critical need for surgeons to have and document their ACP discussions with their patients and/or their family member/surrogate. As surgeons, we are often called to see patients when they are facing a significant change in their health – whether that is a new diagnosis of cancer or after a traumatic injury. Understanding a patient’s values, hopes, and concerns is an essential component to ensuring that our patients receive the best care, as defined by them.

Dr. Fahy is associate professor of surgery and internal medicine at the University of New Mexico, Albuquerque. She is a surgical oncologist who is also board certified in hospice and palliative medicine. Dr. Fahy does not have any relevant conflicts of interest to disclose.

I feel honored to join Tyler G. Hughes as co-Editor of the ACS Surgery News and I am excited to work with its Managing Editor, Therese Borden, to bring to its readers breaking information on a broad range of subjects of interest and importance to practicing surgeons. Although we have a great challenge to fill the giant shoes of our immediate predecessor, Layton “Bing” Rikkers, we will do our best to address the vexing clinical, economic, social, and administrative challenges that continue to confront us no matter what our practice type and setting.

I could not ask for a more accomplished and versatile co-Editor than Tyler Hughes. As a general surgeon practicing in the truly rural setting of McPherson, Kan., since 1995, he became an articulate spokesman for rural surgeons across the country during his tenure on the ACS Board of Governors as Kansas’ at-large member. As the crisis in access to general surgical care for rural Americans became increasingly evident, Tyler was asked to speak to the Board of Regents in February 2012, and the first new Advisory Council in 50 years was formed: the Advisory Council for Rural Surgery (ACRS), of which Tyler was named the first Chair. In 4 short years, the ACRS has become a force to promote better communication among rural surgeons and to call attention to the needs of them and their patients.

Tyler’s communication skills have also been put to great use in his role as Editor of the ACS Web Portal and as the inaugural Editor-in-Chief of the ACS Communities, an activity that has met with incredible success in promoting communication among the far-flung individual surgeons who constitute the ACS membership. Along the way, he has also served as an Associate Editor of “Selected Readings in General Surgery” and a member of the steering committee of Evidence Based Reviews in Surgery.

He currently serves as a Director of the American Board of Surgery (ABS). He is therefore familiar with all of the issues of surgical training, certification, and re-certification. He is similarly well versed in the complexities surrounding the implementation of Maintenance of Certification, which remains a “work in progress” that his experience as a practicing, small-town general surgeon will certainly inform.

Tyler has distinguished himself in other leadership positions throughout his more than 30 years as a surgeon, including as President of his 600-member physician group when he initially practiced in Dallas. He has been a Fellow in the ACS for his entire surgical career and holds a deep respect, affection, and loyalty to the College. He possesses mainstream values, true to his upbringing and his long residence in America’s heartland; yet, he understands and respects the divergent views of surgeons across our country. He is also not afraid to tackle challenging problems, which is why I know that our tenure as co-Editors of ACS Surgery News is not likely to become boring.

I feel honored to join Tyler G. Hughes as co-Editor of the ACS Surgery News and I am excited to work with its Managing Editor, Therese Borden, to bring to its readers breaking information on a broad range of subjects of interest and importance to practicing surgeons. Although we have a great challenge to fill the giant shoes of our immediate predecessor, Layton “Bing” Rikkers, we will do our best to address the vexing clinical, economic, social, and administrative challenges that continue to confront us no matter what our practice type and setting.

I could not ask for a more accomplished and versatile co-Editor than Tyler Hughes. As a general surgeon practicing in the truly rural setting of McPherson, Kan., since 1995, he became an articulate spokesman for rural surgeons across the country during his tenure on the ACS Board of Governors as Kansas’ at-large member. As the crisis in access to general surgical care for rural Americans became increasingly evident, Tyler was asked to speak to the Board of Regents in February 2012, and the first new Advisory Council in 50 years was formed: the Advisory Council for Rural Surgery (ACRS), of which Tyler was named the first Chair. In 4 short years, the ACRS has become a force to promote better communication among rural surgeons and to call attention to the needs of them and their patients.

Tyler’s communication skills have also been put to great use in his role as Editor of the ACS Web Portal and as the inaugural Editor-in-Chief of the ACS Communities, an activity that has met with incredible success in promoting communication among the far-flung individual surgeons who constitute the ACS membership. Along the way, he has also served as an Associate Editor of “Selected Readings in General Surgery” and a member of the steering committee of Evidence Based Reviews in Surgery.

He currently serves as a Director of the American Board of Surgery (ABS). He is therefore familiar with all of the issues of surgical training, certification, and re-certification. He is similarly well versed in the complexities surrounding the implementation of Maintenance of Certification, which remains a “work in progress” that his experience as a practicing, small-town general surgeon will certainly inform.

Tyler has distinguished himself in other leadership positions throughout his more than 30 years as a surgeon, including as President of his 600-member physician group when he initially practiced in Dallas. He has been a Fellow in the ACS for his entire surgical career and holds a deep respect, affection, and loyalty to the College. He possesses mainstream values, true to his upbringing and his long residence in America’s heartland; yet, he understands and respects the divergent views of surgeons across our country. He is also not afraid to tackle challenging problems, which is why I know that our tenure as co-Editors of ACS Surgery News is not likely to become boring.

I feel honored to join Tyler G. Hughes as co-Editor of the ACS Surgery News and I am excited to work with its Managing Editor, Therese Borden, to bring to its readers breaking information on a broad range of subjects of interest and importance to practicing surgeons. Although we have a great challenge to fill the giant shoes of our immediate predecessor, Layton “Bing” Rikkers, we will do our best to address the vexing clinical, economic, social, and administrative challenges that continue to confront us no matter what our practice type and setting.

I could not ask for a more accomplished and versatile co-Editor than Tyler Hughes. As a general surgeon practicing in the truly rural setting of McPherson, Kan., since 1995, he became an articulate spokesman for rural surgeons across the country during his tenure on the ACS Board of Governors as Kansas’ at-large member. As the crisis in access to general surgical care for rural Americans became increasingly evident, Tyler was asked to speak to the Board of Regents in February 2012, and the first new Advisory Council in 50 years was formed: the Advisory Council for Rural Surgery (ACRS), of which Tyler was named the first Chair. In 4 short years, the ACRS has become a force to promote better communication among rural surgeons and to call attention to the needs of them and their patients.

Tyler’s communication skills have also been put to great use in his role as Editor of the ACS Web Portal and as the inaugural Editor-in-Chief of the ACS Communities, an activity that has met with incredible success in promoting communication among the far-flung individual surgeons who constitute the ACS membership. Along the way, he has also served as an Associate Editor of “Selected Readings in General Surgery” and a member of the steering committee of Evidence Based Reviews in Surgery.

He currently serves as a Director of the American Board of Surgery (ABS). He is therefore familiar with all of the issues of surgical training, certification, and re-certification. He is similarly well versed in the complexities surrounding the implementation of Maintenance of Certification, which remains a “work in progress” that his experience as a practicing, small-town general surgeon will certainly inform.

Tyler has distinguished himself in other leadership positions throughout his more than 30 years as a surgeon, including as President of his 600-member physician group when he initially practiced in Dallas. He has been a Fellow in the ACS for his entire surgical career and holds a deep respect, affection, and loyalty to the College. He possesses mainstream values, true to his upbringing and his long residence in America’s heartland; yet, he understands and respects the divergent views of surgeons across our country. He is also not afraid to tackle challenging problems, which is why I know that our tenure as co-Editors of ACS Surgery News is not likely to become boring.

As Layton “Bing” Rikkers leaves his post as Editor of ACS Surgery News, it has fallen to Karen Deveney and me to shepherd the paper forward as co-Editors. Dr. Rikkers felt that a combination approach of an academic surgeon and a community surgeon would bring balance to ACS Surgery News that would be representative of the nature of the American College of Surgeons (ACS).

In Karen Deveney we have an accomplished academic surgeon who has wide ranging interests in and out of surgery. Karen was raised in rural Oregon, went to Stanford for undergraduate education, and did her medical school and residency at University of California, San Francisco. Among her cohort in those times of training and her early academic career were Donald Trunkey, George Sheldon, and Brent Eastman, all of whom, like Karen, went on to have a major impact in the world of surgery.

After a stint in the military serving in Germany with her surgeon husband Cliff, Karen eventually landed at Oregon Health and Science University where she went on to serve as Program Director for 20 years at one of the best general surgery training programs in the country. She served as Second Vice-President of the ACS and is the immediate past-President of the Pacific Coast Surgical Association.

Her CV reflects varied academic interests and activities. So, Karen’s contributions to academic surgery are outstanding. But in Karen we also get a person who is alive to the needs of the population beyond the walls of her major medical center. Karen has been a leader in the march to save surgical access for rural populations. She is a founding member of the ACS Advisory Council for Rural Surgery, serving as the Education Pillar Chair of that Council. In her own institution, Karen is a pioneer in developing a model rural surgery track for general surgery residents – first in Grants Pass, Ore. and then in Coos Bay, Ore.

She has been a hardworking general and colorectal surgeon for over 30 years. And, like almost all dedicated surgical educators, she has taken call – enduring the long call schedule of her residents throughout her career.

Karen and I hope to make a good team in this new effort. We are different in many ways, but very much the same in others. We plan a synergy that will unflinchingly recognize the challenges in surgery and facilitate positive discussion and reporting of the solutions for those challenges. Among those challenges are the changing economic structure of surgery, the facilitation of useful quality efforts, and most importantly, the rapid dissemination of significant clinical and scientific information vital to surgeons everywhere.

Dr. Hughes is an ACS Fellow with the department of general surgery, McPherson Hospital, McPherson, Kan., and is the Editor in Chief of ACS Communities. He is also Associate Editor for ACS Surgery News.

As Layton “Bing” Rikkers leaves his post as Editor of ACS Surgery News, it has fallen to Karen Deveney and me to shepherd the paper forward as co-Editors. Dr. Rikkers felt that a combination approach of an academic surgeon and a community surgeon would bring balance to ACS Surgery News that would be representative of the nature of the American College of Surgeons (ACS).

In Karen Deveney we have an accomplished academic surgeon who has wide ranging interests in and out of surgery. Karen was raised in rural Oregon, went to Stanford for undergraduate education, and did her medical school and residency at University of California, San Francisco. Among her cohort in those times of training and her early academic career were Donald Trunkey, George Sheldon, and Brent Eastman, all of whom, like Karen, went on to have a major impact in the world of surgery.

After a stint in the military serving in Germany with her surgeon husband Cliff, Karen eventually landed at Oregon Health and Science University where she went on to serve as Program Director for 20 years at one of the best general surgery training programs in the country. She served as Second Vice-President of the ACS and is the immediate past-President of the Pacific Coast Surgical Association.

Her CV reflects varied academic interests and activities. So, Karen’s contributions to academic surgery are outstanding. But in Karen we also get a person who is alive to the needs of the population beyond the walls of her major medical center. Karen has been a leader in the march to save surgical access for rural populations. She is a founding member of the ACS Advisory Council for Rural Surgery, serving as the Education Pillar Chair of that Council. In her own institution, Karen is a pioneer in developing a model rural surgery track for general surgery residents – first in Grants Pass, Ore. and then in Coos Bay, Ore.

She has been a hardworking general and colorectal surgeon for over 30 years. And, like almost all dedicated surgical educators, she has taken call – enduring the long call schedule of her residents throughout her career.

Karen and I hope to make a good team in this new effort. We are different in many ways, but very much the same in others. We plan a synergy that will unflinchingly recognize the challenges in surgery and facilitate positive discussion and reporting of the solutions for those challenges. Among those challenges are the changing economic structure of surgery, the facilitation of useful quality efforts, and most importantly, the rapid dissemination of significant clinical and scientific information vital to surgeons everywhere.

Dr. Hughes is an ACS Fellow with the department of general surgery, McPherson Hospital, McPherson, Kan., and is the Editor in Chief of ACS Communities. He is also Associate Editor for ACS Surgery News.

As Layton “Bing” Rikkers leaves his post as Editor of ACS Surgery News, it has fallen to Karen Deveney and me to shepherd the paper forward as co-Editors. Dr. Rikkers felt that a combination approach of an academic surgeon and a community surgeon would bring balance to ACS Surgery News that would be representative of the nature of the American College of Surgeons (ACS).

In Karen Deveney we have an accomplished academic surgeon who has wide ranging interests in and out of surgery. Karen was raised in rural Oregon, went to Stanford for undergraduate education, and did her medical school and residency at University of California, San Francisco. Among her cohort in those times of training and her early academic career were Donald Trunkey, George Sheldon, and Brent Eastman, all of whom, like Karen, went on to have a major impact in the world of surgery.

After a stint in the military serving in Germany with her surgeon husband Cliff, Karen eventually landed at Oregon Health and Science University where she went on to serve as Program Director for 20 years at one of the best general surgery training programs in the country. She served as Second Vice-President of the ACS and is the immediate past-President of the Pacific Coast Surgical Association.

Her CV reflects varied academic interests and activities. So, Karen’s contributions to academic surgery are outstanding. But in Karen we also get a person who is alive to the needs of the population beyond the walls of her major medical center. Karen has been a leader in the march to save surgical access for rural populations. She is a founding member of the ACS Advisory Council for Rural Surgery, serving as the Education Pillar Chair of that Council. In her own institution, Karen is a pioneer in developing a model rural surgery track for general surgery residents – first in Grants Pass, Ore. and then in Coos Bay, Ore.

She has been a hardworking general and colorectal surgeon for over 30 years. And, like almost all dedicated surgical educators, she has taken call – enduring the long call schedule of her residents throughout her career.

Karen and I hope to make a good team in this new effort. We are different in many ways, but very much the same in others. We plan a synergy that will unflinchingly recognize the challenges in surgery and facilitate positive discussion and reporting of the solutions for those challenges. Among those challenges are the changing economic structure of surgery, the facilitation of useful quality efforts, and most importantly, the rapid dissemination of significant clinical and scientific information vital to surgeons everywhere.

Dr. Hughes is an ACS Fellow with the department of general surgery, McPherson Hospital, McPherson, Kan., and is the Editor in Chief of ACS Communities. He is also Associate Editor for ACS Surgery News.

Following the National Lung Screening Trial (NLST), which showed at-risk patients screened with CT scans had reduced lung cancer-specific mortality, many institutions have incorporated lung cancer screening protocols into clinical practice (Aberle et al. N Engl J Med. 2011;365[5]:395). These protocols, along with new generation, high resolution multidetector CT scans, have increased the number of detected peripheral lung nodules, many smaller in size. It is estimated that over 150,000 solitary nodules are diagnosed each year in the United States (Herth et al. Expert Rev Respir Med. 2016; 0[8]:901) and, in keeping with the NLST, greater than 25% of subjects screened have lung nodules suspicious for lung cancer. As a result, many leading health practices have created specific lung nodule programs to handle the volume in an effort to deliver timely care in the evaluation of lung cancer.

Pulmonary specialists managing patients with lung nodules are faced with the difficult challenge of deciding if a patient with a nodule is a candidate for serial surveillance, tissue biopsy (transthoracic needle aspiration [TTNA] vs. bronchoscopic biopsy [TBX]), or surgical resection. Calculation of the probability of a nodule being malignant is most helpful in making these decisions for patients with low and high malignancy risk factors, as surveillance and resection are appropriate steps, respectively. However, for those with an intermediate (5%-65%) probability of having a malignant nodule, the diagnostic procedure risks, yields, and timing have to be considered because delayed sampling or false-negative results may negatively impact survival. Kanashiki et al (Oncol Rep. 2003;10[3]:649) showed that worse survival is associated with patients with imaging-to-diagnosis times of greater than 4 months. Over the past decade, image-guided bronchoscopy has been used to improve the yield for tissue sampling of smaller peripheral nodules in a timely fashion. The most common method of image-guided bronchoscopy today is electromagnetic navigation bronchoscopy (ENB).

Courtesy Eric L. Flenaugh, FCCP

Electromagnetic navigation bronchoscopy has shown promise for increasing diagnostic yields for peripheral nodules (PN) over conventional bronchoscopy. Over time, the improved yields have plateaued as ENB use in clinical practice increased and limitations of the early generation technology became apparent. Earlier ENB technology uses a single inspiratory CT scan of the chest to reconstruct a 3D virtual model of the airways and parenchyma. A tracked sensor is then used to navigate through the imaging reconstructed airways toward the targeted lesion, the sensor is then removed, and through a dedicated catheter instruments are used to obtain samples from the lesion. In a meta-analysis using this technology, lesions greater than 2 cm had a diagnostic yield ranging from 66.7% to 94.7%. However, as the PN size decreased to less than or equal to 2 cm, the diagnostic yield range dropped significantly with some yields reported as low as 18.2% (van ‘t Westeinde et al. Chest. 2012;142(2):377). More recently, Ost and colleagues performed a multicenter study of consecutive patients undergoing bronchoscopic sampling of PN (Ost et al. Am J Respir Crit Care Med. 2016;193[1]:68). Although it was not a randomized trial and each bronchoscopist influenced the selection of the sampling technique, the authors reported that the diagnostic yields for navigation-guided bronchoscopy were lower than conventional bronchoscopy, 38.5% and 63.7%, respectively. Taken on face value alone, one might conclude that ENB not be used to biopsy PNs. However, deeper analysis of the data showed that 97% of the ENB procedures were performed using the earlier technology described above, suggesting that the single inspiratory imaging CT scan and navigation procedure technique, which differs significantly from conventional bronchoscopy, may have some influence on the lower than expected yields.

Courtesy Eric L. Flenaugh, FCCP

Despite increasing use and experience with ENB, diagnostic yields remain static. Chen and colleagues hypothesized that using a single inspiratory CT scan may not allow the endoscopist to make adjustments for PN movement as the lung moves during the respiratory cycle. Using different imaging protocol, the investigators assessed movement of 85 lung nodules during the respiratory cycle with paired-full inspiration and tidal-volume expiration, thin sliced (0.5-1.0 mm) CT scans. They found that the average motion of all lesions during respiration was 17.6 mm, 12.2 mm in the right-upper lobe, 10.6 mm in the left-upper lobe, and 25.3 mm and 23.8 mm in the right- and left- lower lobes, respectively (Chen et al. Chest. 2015;147[5];1275) (Fig. 1). They concluded that the location of targeted lesions on a single inspiration planning CT scan alone does not accurately represent the position of the lesion during bronchoscopy.

Although being able to correct for nodule movement throughout the respiratory cycle during the procedure is a significant improvement, it doesn’t guarantee that the tissue sample is obtained from the targeted lesion. To accomplish that, the system would have to be able to determine when the instrument being used to sample is in the target. The earlier ENB systems allowed for navigation to the target with a separate sensor through a steerable catheter. However, when the target was reached, the sensor had to be removed so that sampling instruments could be introduced into the catheter. Since the instruments are not tracked and the movement of the nodule is occurring, there is no guarantee that the instrument is in the target at the time of sampling. Advanced technology now allows for the tracking sensor to be placed in the tip of standard bronchoscopy instruments, making them “tip-tracked” and able to be used with standard bronchoscopes and equipment; thus, making the new ENB procedure similar to conventional bronchoscopy that was shown to have higher diagnostic yields (Figs. 2 and 3).

Courtesy Eric L. Flenaugh, FCCP

Our institution incorporated this technology (Veran Medical, St. Louis) into our advanced diagnostic and interventional pulmonary program for lung nodules and published our initial experience and results. During the initial 8 months of screening for lung cancer, we performed procedures on 44 patients with PNs suspicious for lung cancer. The rate for successful target sampling was 90.2% with a cancer diagnosis rate of 39%, which is similar to that found in the NLST. Those patients who had nonmalignant but abnormal pathologic findings (inflammation, granuloma, fibrosis, and so on) were monitored for a minimum of 12 months. Most of the lesions either remained stable or disappeared on follow-up imaging (Flenaugh et al. The Internet Journal of Pulmonary Medicine. 2016;18[1]). We concluded that (1) the combination of paired inspiratory and expiratory CT scan imaging accounts for nodule movement and (2) using tip-tracked conventional instruments to enter into the lesion at the time of biopsy contributes to improved yields.

Newer ENB technology is not limited to transbronchial sampling. For PNs less than 2 cm and deep in the lung periphery, current recommendations prefer TTNA over bronchoscopic biopsy because of yield rates of 90% (Chest. 2007; 132(suppl 3):131S). Using the same paired CT scanning and tip-tracking method on transthoracic needles, the new systems allow pulmonologists to perform electromagnetic transthoracic needle aspiration (ETTNA) of PNs using the same basic equipment and during the same procedure visit (Fig. 4). This “one stop shopping” approach of bronchoscopy with the option of converting to ETTNA if the PN is not reachable endoscopically has proven to be cost efficient and allows for timely diagnosis and focused care (Yarmis et al. J Thorac Dis. 2016;8(1):186). In a prospective study designed specifically to assess feasibility, safety, and diagnostic yield of ETTNA in a single procedure, Yarmis and colleagues enrolled 24 patients to undergo endobronchial ultrasound for lung cancer staging followed by ENB and ETTNA. Ninety-six percent of the patients were candidates for ETTNA. The authors reported the yield for ETTNA was 83%, ETTNA plus ENB 87%, and ETTNA plus ENB plus endobronchial ultrasound for complete staging was 92%. Five pneumothoraces were reported; however, only two (8%) required a drainage intervention. This protocol is unique because it makes use of several advanced diagnostic procedures, including tip-tracked navigation technology, to localize, sample, diagnose, and stage during one patient procedure visit.

Courtesy Eric L. Flenaugh, FCCP

As lung cancer screening becomes commonplace in clinical practice and imaging technology improves, pulmonary specialists can expect to encounter and manage a greater number of pulmonary nodules. Advancements in technology now offer options for improving diagnostic accuracy while providing timely, safe, and cost effective care. While not all new technology will prove beneficial in disease management, those that improve the deficiencies of earlier technology offer us the best chance to improve practice. This perspective highlights such technology.

Dr. Flenaugh is Associate Professor, Director of Advanced Diagnostic & Interventional Pulmonary Service,Morehouse School of Medicine and Grady Hospital, Atlanta; Dr. Foreman is Professor of Medicine, Associate Chair for Research, Pulmonary & Critical Care Medicine, Morehouse School of Medicine.

Following the National Lung Screening Trial (NLST), which showed at-risk patients screened with CT scans had reduced lung cancer-specific mortality, many institutions have incorporated lung cancer screening protocols into clinical practice (Aberle et al. N Engl J Med. 2011;365[5]:395). These protocols, along with new generation, high resolution multidetector CT scans, have increased the number of detected peripheral lung nodules, many smaller in size. It is estimated that over 150,000 solitary nodules are diagnosed each year in the United States (Herth et al. Expert Rev Respir Med. 2016; 0[8]:901) and, in keeping with the NLST, greater than 25% of subjects screened have lung nodules suspicious for lung cancer. As a result, many leading health practices have created specific lung nodule programs to handle the volume in an effort to deliver timely care in the evaluation of lung cancer.

Pulmonary specialists managing patients with lung nodules are faced with the difficult challenge of deciding if a patient with a nodule is a candidate for serial surveillance, tissue biopsy (transthoracic needle aspiration [TTNA] vs. bronchoscopic biopsy [TBX]), or surgical resection. Calculation of the probability of a nodule being malignant is most helpful in making these decisions for patients with low and high malignancy risk factors, as surveillance and resection are appropriate steps, respectively. However, for those with an intermediate (5%-65%) probability of having a malignant nodule, the diagnostic procedure risks, yields, and timing have to be considered because delayed sampling or false-negative results may negatively impact survival. Kanashiki et al (Oncol Rep. 2003;10[3]:649) showed that worse survival is associated with patients with imaging-to-diagnosis times of greater than 4 months. Over the past decade, image-guided bronchoscopy has been used to improve the yield for tissue sampling of smaller peripheral nodules in a timely fashion. The most common method of image-guided bronchoscopy today is electromagnetic navigation bronchoscopy (ENB).

Courtesy Eric L. Flenaugh, FCCP

Electromagnetic navigation bronchoscopy has shown promise for increasing diagnostic yields for peripheral nodules (PN) over conventional bronchoscopy. Over time, the improved yields have plateaued as ENB use in clinical practice increased and limitations of the early generation technology became apparent. Earlier ENB technology uses a single inspiratory CT scan of the chest to reconstruct a 3D virtual model of the airways and parenchyma. A tracked sensor is then used to navigate through the imaging reconstructed airways toward the targeted lesion, the sensor is then removed, and through a dedicated catheter instruments are used to obtain samples from the lesion. In a meta-analysis using this technology, lesions greater than 2 cm had a diagnostic yield ranging from 66.7% to 94.7%. However, as the PN size decreased to less than or equal to 2 cm, the diagnostic yield range dropped significantly with some yields reported as low as 18.2% (van ‘t Westeinde et al. Chest. 2012;142(2):377). More recently, Ost and colleagues performed a multicenter study of consecutive patients undergoing bronchoscopic sampling of PN (Ost et al. Am J Respir Crit Care Med. 2016;193[1]:68). Although it was not a randomized trial and each bronchoscopist influenced the selection of the sampling technique, the authors reported that the diagnostic yields for navigation-guided bronchoscopy were lower than conventional bronchoscopy, 38.5% and 63.7%, respectively. Taken on face value alone, one might conclude that ENB not be used to biopsy PNs. However, deeper analysis of the data showed that 97% of the ENB procedures were performed using the earlier technology described above, suggesting that the single inspiratory imaging CT scan and navigation procedure technique, which differs significantly from conventional bronchoscopy, may have some influence on the lower than expected yields.

Courtesy Eric L. Flenaugh, FCCP

Despite increasing use and experience with ENB, diagnostic yields remain static. Chen and colleagues hypothesized that using a single inspiratory CT scan may not allow the endoscopist to make adjustments for PN movement as the lung moves during the respiratory cycle. Using different imaging protocol, the investigators assessed movement of 85 lung nodules during the respiratory cycle with paired-full inspiration and tidal-volume expiration, thin sliced (0.5-1.0 mm) CT scans. They found that the average motion of all lesions during respiration was 17.6 mm, 12.2 mm in the right-upper lobe, 10.6 mm in the left-upper lobe, and 25.3 mm and 23.8 mm in the right- and left- lower lobes, respectively (Chen et al. Chest. 2015;147[5];1275) (Fig. 1). They concluded that the location of targeted lesions on a single inspiration planning CT scan alone does not accurately represent the position of the lesion during bronchoscopy.

Although being able to correct for nodule movement throughout the respiratory cycle during the procedure is a significant improvement, it doesn’t guarantee that the tissue sample is obtained from the targeted lesion. To accomplish that, the system would have to be able to determine when the instrument being used to sample is in the target. The earlier ENB systems allowed for navigation to the target with a separate sensor through a steerable catheter. However, when the target was reached, the sensor had to be removed so that sampling instruments could be introduced into the catheter. Since the instruments are not tracked and the movement of the nodule is occurring, there is no guarantee that the instrument is in the target at the time of sampling. Advanced technology now allows for the tracking sensor to be placed in the tip of standard bronchoscopy instruments, making them “tip-tracked” and able to be used with standard bronchoscopes and equipment; thus, making the new ENB procedure similar to conventional bronchoscopy that was shown to have higher diagnostic yields (Figs. 2 and 3).

Courtesy Eric L. Flenaugh, FCCP

Our institution incorporated this technology (Veran Medical, St. Louis) into our advanced diagnostic and interventional pulmonary program for lung nodules and published our initial experience and results. During the initial 8 months of screening for lung cancer, we performed procedures on 44 patients with PNs suspicious for lung cancer. The rate for successful target sampling was 90.2% with a cancer diagnosis rate of 39%, which is similar to that found in the NLST. Those patients who had nonmalignant but abnormal pathologic findings (inflammation, granuloma, fibrosis, and so on) were monitored for a minimum of 12 months. Most of the lesions either remained stable or disappeared on follow-up imaging (Flenaugh et al. The Internet Journal of Pulmonary Medicine. 2016;18[1]). We concluded that (1) the combination of paired inspiratory and expiratory CT scan imaging accounts for nodule movement and (2) using tip-tracked conventional instruments to enter into the lesion at the time of biopsy contributes to improved yields.

Newer ENB technology is not limited to transbronchial sampling. For PNs less than 2 cm and deep in the lung periphery, current recommendations prefer TTNA over bronchoscopic biopsy because of yield rates of 90% (Chest. 2007; 132(suppl 3):131S). Using the same paired CT scanning and tip-tracking method on transthoracic needles, the new systems allow pulmonologists to perform electromagnetic transthoracic needle aspiration (ETTNA) of PNs using the same basic equipment and during the same procedure visit (Fig. 4). This “one stop shopping” approach of bronchoscopy with the option of converting to ETTNA if the PN is not reachable endoscopically has proven to be cost efficient and allows for timely diagnosis and focused care (Yarmis et al. J Thorac Dis. 2016;8(1):186). In a prospective study designed specifically to assess feasibility, safety, and diagnostic yield of ETTNA in a single procedure, Yarmis and colleagues enrolled 24 patients to undergo endobronchial ultrasound for lung cancer staging followed by ENB and ETTNA. Ninety-six percent of the patients were candidates for ETTNA. The authors reported the yield for ETTNA was 83%, ETTNA plus ENB 87%, and ETTNA plus ENB plus endobronchial ultrasound for complete staging was 92%. Five pneumothoraces were reported; however, only two (8%) required a drainage intervention. This protocol is unique because it makes use of several advanced diagnostic procedures, including tip-tracked navigation technology, to localize, sample, diagnose, and stage during one patient procedure visit.

Courtesy Eric L. Flenaugh, FCCP

As lung cancer screening becomes commonplace in clinical practice and imaging technology improves, pulmonary specialists can expect to encounter and manage a greater number of pulmonary nodules. Advancements in technology now offer options for improving diagnostic accuracy while providing timely, safe, and cost effective care. While not all new technology will prove beneficial in disease management, those that improve the deficiencies of earlier technology offer us the best chance to improve practice. This perspective highlights such technology.

Dr. Flenaugh is Associate Professor, Director of Advanced Diagnostic & Interventional Pulmonary Service,Morehouse School of Medicine and Grady Hospital, Atlanta; Dr. Foreman is Professor of Medicine, Associate Chair for Research, Pulmonary & Critical Care Medicine, Morehouse School of Medicine.

Following the National Lung Screening Trial (NLST), which showed at-risk patients screened with CT scans had reduced lung cancer-specific mortality, many institutions have incorporated lung cancer screening protocols into clinical practice (Aberle et al. N Engl J Med. 2011;365[5]:395). These protocols, along with new generation, high resolution multidetector CT scans, have increased the number of detected peripheral lung nodules, many smaller in size. It is estimated that over 150,000 solitary nodules are diagnosed each year in the United States (Herth et al. Expert Rev Respir Med. 2016; 0[8]:901) and, in keeping with the NLST, greater than 25% of subjects screened have lung nodules suspicious for lung cancer. As a result, many leading health practices have created specific lung nodule programs to handle the volume in an effort to deliver timely care in the evaluation of lung cancer.

Pulmonary specialists managing patients with lung nodules are faced with the difficult challenge of deciding if a patient with a nodule is a candidate for serial surveillance, tissue biopsy (transthoracic needle aspiration [TTNA] vs. bronchoscopic biopsy [TBX]), or surgical resection. Calculation of the probability of a nodule being malignant is most helpful in making these decisions for patients with low and high malignancy risk factors, as surveillance and resection are appropriate steps, respectively. However, for those with an intermediate (5%-65%) probability of having a malignant nodule, the diagnostic procedure risks, yields, and timing have to be considered because delayed sampling or false-negative results may negatively impact survival. Kanashiki et al (Oncol Rep. 2003;10[3]:649) showed that worse survival is associated with patients with imaging-to-diagnosis times of greater than 4 months. Over the past decade, image-guided bronchoscopy has been used to improve the yield for tissue sampling of smaller peripheral nodules in a timely fashion. The most common method of image-guided bronchoscopy today is electromagnetic navigation bronchoscopy (ENB).

Courtesy Eric L. Flenaugh, FCCP

Electromagnetic navigation bronchoscopy has shown promise for increasing diagnostic yields for peripheral nodules (PN) over conventional bronchoscopy. Over time, the improved yields have plateaued as ENB use in clinical practice increased and limitations of the early generation technology became apparent. Earlier ENB technology uses a single inspiratory CT scan of the chest to reconstruct a 3D virtual model of the airways and parenchyma. A tracked sensor is then used to navigate through the imaging reconstructed airways toward the targeted lesion, the sensor is then removed, and through a dedicated catheter instruments are used to obtain samples from the lesion. In a meta-analysis using this technology, lesions greater than 2 cm had a diagnostic yield ranging from 66.7% to 94.7%. However, as the PN size decreased to less than or equal to 2 cm, the diagnostic yield range dropped significantly with some yields reported as low as 18.2% (van ‘t Westeinde et al. Chest. 2012;142(2):377). More recently, Ost and colleagues performed a multicenter study of consecutive patients undergoing bronchoscopic sampling of PN (Ost et al. Am J Respir Crit Care Med. 2016;193[1]:68). Although it was not a randomized trial and each bronchoscopist influenced the selection of the sampling technique, the authors reported that the diagnostic yields for navigation-guided bronchoscopy were lower than conventional bronchoscopy, 38.5% and 63.7%, respectively. Taken on face value alone, one might conclude that ENB not be used to biopsy PNs. However, deeper analysis of the data showed that 97% of the ENB procedures were performed using the earlier technology described above, suggesting that the single inspiratory imaging CT scan and navigation procedure technique, which differs significantly from conventional bronchoscopy, may have some influence on the lower than expected yields.

Courtesy Eric L. Flenaugh, FCCP

Despite increasing use and experience with ENB, diagnostic yields remain static. Chen and colleagues hypothesized that using a single inspiratory CT scan may not allow the endoscopist to make adjustments for PN movement as the lung moves during the respiratory cycle. Using different imaging protocol, the investigators assessed movement of 85 lung nodules during the respiratory cycle with paired-full inspiration and tidal-volume expiration, thin sliced (0.5-1.0 mm) CT scans. They found that the average motion of all lesions during respiration was 17.6 mm, 12.2 mm in the right-upper lobe, 10.6 mm in the left-upper lobe, and 25.3 mm and 23.8 mm in the right- and left- lower lobes, respectively (Chen et al. Chest. 2015;147[5];1275) (Fig. 1). They concluded that the location of targeted lesions on a single inspiration planning CT scan alone does not accurately represent the position of the lesion during bronchoscopy.

Although being able to correct for nodule movement throughout the respiratory cycle during the procedure is a significant improvement, it doesn’t guarantee that the tissue sample is obtained from the targeted lesion. To accomplish that, the system would have to be able to determine when the instrument being used to sample is in the target. The earlier ENB systems allowed for navigation to the target with a separate sensor through a steerable catheter. However, when the target was reached, the sensor had to be removed so that sampling instruments could be introduced into the catheter. Since the instruments are not tracked and the movement of the nodule is occurring, there is no guarantee that the instrument is in the target at the time of sampling. Advanced technology now allows for the tracking sensor to be placed in the tip of standard bronchoscopy instruments, making them “tip-tracked” and able to be used with standard bronchoscopes and equipment; thus, making the new ENB procedure similar to conventional bronchoscopy that was shown to have higher diagnostic yields (Figs. 2 and 3).

Courtesy Eric L. Flenaugh, FCCP

Our institution incorporated this technology (Veran Medical, St. Louis) into our advanced diagnostic and interventional pulmonary program for lung nodules and published our initial experience and results. During the initial 8 months of screening for lung cancer, we performed procedures on 44 patients with PNs suspicious for lung cancer. The rate for successful target sampling was 90.2% with a cancer diagnosis rate of 39%, which is similar to that found in the NLST. Those patients who had nonmalignant but abnormal pathologic findings (inflammation, granuloma, fibrosis, and so on) were monitored for a minimum of 12 months. Most of the lesions either remained stable or disappeared on follow-up imaging (Flenaugh et al. The Internet Journal of Pulmonary Medicine. 2016;18[1]). We concluded that (1) the combination of paired inspiratory and expiratory CT scan imaging accounts for nodule movement and (2) using tip-tracked conventional instruments to enter into the lesion at the time of biopsy contributes to improved yields.

Newer ENB technology is not limited to transbronchial sampling. For PNs less than 2 cm and deep in the lung periphery, current recommendations prefer TTNA over bronchoscopic biopsy because of yield rates of 90% (Chest. 2007; 132(suppl 3):131S). Using the same paired CT scanning and tip-tracking method on transthoracic needles, the new systems allow pulmonologists to perform electromagnetic transthoracic needle aspiration (ETTNA) of PNs using the same basic equipment and during the same procedure visit (Fig. 4). This “one stop shopping” approach of bronchoscopy with the option of converting to ETTNA if the PN is not reachable endoscopically has proven to be cost efficient and allows for timely diagnosis and focused care (Yarmis et al. J Thorac Dis. 2016;8(1):186). In a prospective study designed specifically to assess feasibility, safety, and diagnostic yield of ETTNA in a single procedure, Yarmis and colleagues enrolled 24 patients to undergo endobronchial ultrasound for lung cancer staging followed by ENB and ETTNA. Ninety-six percent of the patients were candidates for ETTNA. The authors reported the yield for ETTNA was 83%, ETTNA plus ENB 87%, and ETTNA plus ENB plus endobronchial ultrasound for complete staging was 92%. Five pneumothoraces were reported; however, only two (8%) required a drainage intervention. This protocol is unique because it makes use of several advanced diagnostic procedures, including tip-tracked navigation technology, to localize, sample, diagnose, and stage during one patient procedure visit.

Courtesy Eric L. Flenaugh, FCCP

As lung cancer screening becomes commonplace in clinical practice and imaging technology improves, pulmonary specialists can expect to encounter and manage a greater number of pulmonary nodules. Advancements in technology now offer options for improving diagnostic accuracy while providing timely, safe, and cost effective care. While not all new technology will prove beneficial in disease management, those that improve the deficiencies of earlier technology offer us the best chance to improve practice. This perspective highlights such technology.

Dr. Flenaugh is Associate Professor, Director of Advanced Diagnostic & Interventional Pulmonary Service,Morehouse School of Medicine and Grady Hospital, Atlanta; Dr. Foreman is Professor of Medicine, Associate Chair for Research, Pulmonary & Critical Care Medicine, Morehouse School of Medicine.

Regular readers of this column may remember the March 2015 edition devoted to the topic of the CMS’s proposal to transition all 10-day and 90-day global codes to 0-day global codes in 2017 and 2018, respectively. As a result of a coordinated advocacy effort of the American College of Surgeons and a coalition of 24 other surgical and medical groups including the American Medical Association, the American Academy of Dermatology, and the American College of Cardiology, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) included a provision that required that the Centers for Medicare & Medicaid Services (CMS) instead collect data from a representative sample of providers to facilitate the accurate valuation of surgical services before proposing any changes to the global payment structure.

Fast forward to July 7, 2016, and the release of the 2017 Physician Fee Schedule (PFS) proposed rule. In that proposed rule, the CMS disregards the specific legislative language from Congress and proposes to collect data from all physicians who provide 10- and 90-day global services. This would obviously create yet another huge administrative burden AND also coincide with the time physicians and practices are engaged in efforts to implement the changes required by the new Quality Payment Program (QPP) mandated by MACRA. Specifically, if the proposed PFS rule is finalized, all surgeons would be required to submit data in 10-minute increments for all 10- and 90-day global code services.

Obviously, this is in direct conflict with the language in MACRA that directs the CMS to collect these data from a “representative sample” of practitioners.

Upon discovering the CMS’s plan in the proposed rule, the legislative team in ACS’s Division of Advocacy and Health Policy contacted the congressional sponsors of the original effort directed at the global codes, Rep. Larry Bucshon, MD, FACS (R-IN), and Rep. Ami Bera, MD (D-CA). Dr. Bucshon and Dr. Bera began circulating a letter, addressed to Health and Human Services Secretary Sylvia Burwell and CMS Acting Administrator Andrew Slavitt, urging the CMS to abandon the proposed policy outlined in the 2017 PFS proposed rule regarding the arduous data collection requirements for global codes.

In the week leading up to the summer congressional recess, the ACS sent the letter to all 435 offices in the House of Representatives urging other members to sign on to the letter. The ACS lobbyists and those from the coalition of groups previously involved in the efforts relative to global codes are currently engaged in individual follow-up with offices as well. The goal is to make a strong showing to the CMS with a large number of signatures from members of Congress in the hope that the CMS will modify the final rule in accordance with the legislative language found in MACRA.

This is where we need your help!

By the time you receive this issue of ACS Surgery News, all Fellows will have received an email requesting that they respond by contacting their individual members of Congress to urge them to sign on to the letter. This may be accomplished either by placing a call or by sending an email communication.

Those choosing to call may use the ACS Legislative Hotline at 877-996-4464. Follow the instructions to be connected to the office of your member of Congress. Once connected, please inform them that you are a constituent, and then deliver the following message:

“As a surgeon and a constituent, I urge Rep. _____ to join Rep Dr. Larry Bucshon and Rep. Dr. Ami Bera in supporting the bipartisan sign-on letter to the CMS in order to stop the administratively burdensome data entry changes proposed by the CMS relative to 10- and 90-day global codes.

“The proposed changes would mandate that all practitioners who perform global code services enter data in 10-minute intervals for every patient billed under global codes rather than adhering to the direction of Congress to obtain the necessary information from a ‘representative sample’ as was mandated in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).”

For those wishing further information on this matter or for those who would prefer to contact their representative by email, an ACTION Alert can be found on the SurgeonsVoice website (www.surgeonsvoice.com – click on the Take Action tab on the right side of the page). The alert addressing the global codes issue is at the top of the list and includes a fact sheet that outlines the issue and provides background information along with a link to facilitate transmittal of your message urging your representative to sign on to the Bucshon-Bera letter. Because Congress has adjourned for their summer recess and will not return until Sept. 6, 2016, we have ample time to gather the overwhelming support we need to initiate action precluding the inclusion of this flawed proposal in the final rule, which is expected to be released the first week of November 2016.

I respectfully request that ALL Fellows do their part and contact their member of Congress via one of the two methods provided. There can be no argument that the minimal time required to invest in our collective advocacy efforts relative to this matter pales in comparison to the time required to comply with the proposed CMS policy we seek to prevent being published in the final PFS rule.

Until next month …

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

Regular readers of this column may remember the March 2015 edition devoted to the topic of the CMS’s proposal to transition all 10-day and 90-day global codes to 0-day global codes in 2017 and 2018, respectively. As a result of a coordinated advocacy effort of the American College of Surgeons and a coalition of 24 other surgical and medical groups including the American Medical Association, the American Academy of Dermatology, and the American College of Cardiology, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) included a provision that required that the Centers for Medicare & Medicaid Services (CMS) instead collect data from a representative sample of providers to facilitate the accurate valuation of surgical services before proposing any changes to the global payment structure.

Fast forward to July 7, 2016, and the release of the 2017 Physician Fee Schedule (PFS) proposed rule. In that proposed rule, the CMS disregards the specific legislative language from Congress and proposes to collect data from all physicians who provide 10- and 90-day global services. This would obviously create yet another huge administrative burden AND also coincide with the time physicians and practices are engaged in efforts to implement the changes required by the new Quality Payment Program (QPP) mandated by MACRA. Specifically, if the proposed PFS rule is finalized, all surgeons would be required to submit data in 10-minute increments for all 10- and 90-day global code services.

Obviously, this is in direct conflict with the language in MACRA that directs the CMS to collect these data from a “representative sample” of practitioners.

Upon discovering the CMS’s plan in the proposed rule, the legislative team in ACS’s Division of Advocacy and Health Policy contacted the congressional sponsors of the original effort directed at the global codes, Rep. Larry Bucshon, MD, FACS (R-IN), and Rep. Ami Bera, MD (D-CA). Dr. Bucshon and Dr. Bera began circulating a letter, addressed to Health and Human Services Secretary Sylvia Burwell and CMS Acting Administrator Andrew Slavitt, urging the CMS to abandon the proposed policy outlined in the 2017 PFS proposed rule regarding the arduous data collection requirements for global codes.

In the week leading up to the summer congressional recess, the ACS sent the letter to all 435 offices in the House of Representatives urging other members to sign on to the letter. The ACS lobbyists and those from the coalition of groups previously involved in the efforts relative to global codes are currently engaged in individual follow-up with offices as well. The goal is to make a strong showing to the CMS with a large number of signatures from members of Congress in the hope that the CMS will modify the final rule in accordance with the legislative language found in MACRA.

This is where we need your help!

By the time you receive this issue of ACS Surgery News, all Fellows will have received an email requesting that they respond by contacting their individual members of Congress to urge them to sign on to the letter. This may be accomplished either by placing a call or by sending an email communication.

Those choosing to call may use the ACS Legislative Hotline at 877-996-4464. Follow the instructions to be connected to the office of your member of Congress. Once connected, please inform them that you are a constituent, and then deliver the following message:

“As a surgeon and a constituent, I urge Rep. _____ to join Rep Dr. Larry Bucshon and Rep. Dr. Ami Bera in supporting the bipartisan sign-on letter to the CMS in order to stop the administratively burdensome data entry changes proposed by the CMS relative to 10- and 90-day global codes.

“The proposed changes would mandate that all practitioners who perform global code services enter data in 10-minute intervals for every patient billed under global codes rather than adhering to the direction of Congress to obtain the necessary information from a ‘representative sample’ as was mandated in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).”

For those wishing further information on this matter or for those who would prefer to contact their representative by email, an ACTION Alert can be found on the SurgeonsVoice website (www.surgeonsvoice.com – click on the Take Action tab on the right side of the page). The alert addressing the global codes issue is at the top of the list and includes a fact sheet that outlines the issue and provides background information along with a link to facilitate transmittal of your message urging your representative to sign on to the Bucshon-Bera letter. Because Congress has adjourned for their summer recess and will not return until Sept. 6, 2016, we have ample time to gather the overwhelming support we need to initiate action precluding the inclusion of this flawed proposal in the final rule, which is expected to be released the first week of November 2016.

I respectfully request that ALL Fellows do their part and contact their member of Congress via one of the two methods provided. There can be no argument that the minimal time required to invest in our collective advocacy efforts relative to this matter pales in comparison to the time required to comply with the proposed CMS policy we seek to prevent being published in the final PFS rule.

Until next month …

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

Regular readers of this column may remember the March 2015 edition devoted to the topic of the CMS’s proposal to transition all 10-day and 90-day global codes to 0-day global codes in 2017 and 2018, respectively. As a result of a coordinated advocacy effort of the American College of Surgeons and a coalition of 24 other surgical and medical groups including the American Medical Association, the American Academy of Dermatology, and the American College of Cardiology, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) included a provision that required that the Centers for Medicare & Medicaid Services (CMS) instead collect data from a representative sample of providers to facilitate the accurate valuation of surgical services before proposing any changes to the global payment structure.

Fast forward to July 7, 2016, and the release of the 2017 Physician Fee Schedule (PFS) proposed rule. In that proposed rule, the CMS disregards the specific legislative language from Congress and proposes to collect data from all physicians who provide 10- and 90-day global services. This would obviously create yet another huge administrative burden AND also coincide with the time physicians and practices are engaged in efforts to implement the changes required by the new Quality Payment Program (QPP) mandated by MACRA. Specifically, if the proposed PFS rule is finalized, all surgeons would be required to submit data in 10-minute increments for all 10- and 90-day global code services.

Obviously, this is in direct conflict with the language in MACRA that directs the CMS to collect these data from a “representative sample” of practitioners.

Upon discovering the CMS’s plan in the proposed rule, the legislative team in ACS’s Division of Advocacy and Health Policy contacted the congressional sponsors of the original effort directed at the global codes, Rep. Larry Bucshon, MD, FACS (R-IN), and Rep. Ami Bera, MD (D-CA). Dr. Bucshon and Dr. Bera began circulating a letter, addressed to Health and Human Services Secretary Sylvia Burwell and CMS Acting Administrator Andrew Slavitt, urging the CMS to abandon the proposed policy outlined in the 2017 PFS proposed rule regarding the arduous data collection requirements for global codes.

In the week leading up to the summer congressional recess, the ACS sent the letter to all 435 offices in the House of Representatives urging other members to sign on to the letter. The ACS lobbyists and those from the coalition of groups previously involved in the efforts relative to global codes are currently engaged in individual follow-up with offices as well. The goal is to make a strong showing to the CMS with a large number of signatures from members of Congress in the hope that the CMS will modify the final rule in accordance with the legislative language found in MACRA.

This is where we need your help!

By the time you receive this issue of ACS Surgery News, all Fellows will have received an email requesting that they respond by contacting their individual members of Congress to urge them to sign on to the letter. This may be accomplished either by placing a call or by sending an email communication.

Those choosing to call may use the ACS Legislative Hotline at 877-996-4464. Follow the instructions to be connected to the office of your member of Congress. Once connected, please inform them that you are a constituent, and then deliver the following message:

“As a surgeon and a constituent, I urge Rep. _____ to join Rep Dr. Larry Bucshon and Rep. Dr. Ami Bera in supporting the bipartisan sign-on letter to the CMS in order to stop the administratively burdensome data entry changes proposed by the CMS relative to 10- and 90-day global codes.

“The proposed changes would mandate that all practitioners who perform global code services enter data in 10-minute intervals for every patient billed under global codes rather than adhering to the direction of Congress to obtain the necessary information from a ‘representative sample’ as was mandated in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).”

For those wishing further information on this matter or for those who would prefer to contact their representative by email, an ACTION Alert can be found on the SurgeonsVoice website (www.surgeonsvoice.com – click on the Take Action tab on the right side of the page). The alert addressing the global codes issue is at the top of the list and includes a fact sheet that outlines the issue and provides background information along with a link to facilitate transmittal of your message urging your representative to sign on to the Bucshon-Bera letter. Because Congress has adjourned for their summer recess and will not return until Sept. 6, 2016, we have ample time to gather the overwhelming support we need to initiate action precluding the inclusion of this flawed proposal in the final rule, which is expected to be released the first week of November 2016.

I respectfully request that ALL Fellows do their part and contact their member of Congress via one of the two methods provided. There can be no argument that the minimal time required to invest in our collective advocacy efforts relative to this matter pales in comparison to the time required to comply with the proposed CMS policy we seek to prevent being published in the final PFS rule.

Until next month …

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

The American College of Surgeons (ACS) is offering 2-year Resident Research Scholarships to surgeons in training who are interested in pursuing careers in academic surgery. Eligibility for these scholarships is limited to the research projects of residents in general surgery or a surgical specialty. The closing date for receipt of the completed online application and all supporting documents is Sept. 1, 2016.

General policies covering the granting of the ACS Resident Research Scholarships are as follows:

The applicant must be a Resident Member of the College who has completed two postdoctoral years in an accredited surgical training program in the U.S. or Canada at the time the scholarship is awarded, July 1, 2017, and may not complete formal residency training before June 2019. Scholarships do not support research after completion of the chief residency year.

The scholarship is awarded for 2 years, and acceptance of it requires commitment for the 2-year period. The award is to support a research plan for the 2 years of the scholarship, July 2017 through June 2019. The projects of residents who are involved in full-time laboratory investigation will receive priority. Study outside the United States or Canada is permissible. Renewal of the scholarship for the 2nd year is required and is contingent upon the acceptance of a progress report and research study protocol for the 2nd year, as submitted to the Scholarships Section of the College by May 1, 2018.

Application for these scholarships may be submitted even if the resident has made a comparable application to other organizations. If the recipient is offered a scholarship, fellowship, or research award from another organization, it is the responsibility of the recipient to contact the ACS Scholarships Administrator to request approval of the additional award. The Scholarships Committee reserves the right to review potentially overlapping awards and adjust its award accordingly.

The scholarship is $30,000 per year; the total amount is to support the research of the recipient and may be used for salary or stipend, research materials, and travel related to the research. Indirect costs are not paid to the recipient or the recipient’s institution.

The scholar must attend the ACS Clinical Congress in 2019 to present a report on the research as part of the Scientific Forum and to receive a certificate at the annual meeting of the Scholarships Committee.

Approval of the application is required from the administration (dean or fiscal officer) of the institution. Supporting letters from the head of the department of surgery (or the surgical specialty) and from the mentor who will be supervising the applicant’s research must be submitted. The College encourages diversity of applicants and institutions; only in exceptional circumstances will more than one scholarship be granted in a single year to applicants from the same institution.

For further information regarding this scholarship, click here, or contact the Scholarships Administrator at [email protected].

The American College of Surgeons (ACS) is offering 2-year Resident Research Scholarships to surgeons in training who are interested in pursuing careers in academic surgery. Eligibility for these scholarships is limited to the research projects of residents in general surgery or a surgical specialty. The closing date for receipt of the completed online application and all supporting documents is Sept. 1, 2016.

General policies covering the granting of the ACS Resident Research Scholarships are as follows:

The applicant must be a Resident Member of the College who has completed two postdoctoral years in an accredited surgical training program in the U.S. or Canada at the time the scholarship is awarded, July 1, 2017, and may not complete formal residency training before June 2019. Scholarships do not support research after completion of the chief residency year.

The scholarship is awarded for 2 years, and acceptance of it requires commitment for the 2-year period. The award is to support a research plan for the 2 years of the scholarship, July 2017 through June 2019. The projects of residents who are involved in full-time laboratory investigation will receive priority. Study outside the United States or Canada is permissible. Renewal of the scholarship for the 2nd year is required and is contingent upon the acceptance of a progress report and research study protocol for the 2nd year, as submitted to the Scholarships Section of the College by May 1, 2018.

Application for these scholarships may be submitted even if the resident has made a comparable application to other organizations. If the recipient is offered a scholarship, fellowship, or research award from another organization, it is the responsibility of the recipient to contact the ACS Scholarships Administrator to request approval of the additional award. The Scholarships Committee reserves the right to review potentially overlapping awards and adjust its award accordingly.

The scholarship is $30,000 per year; the total amount is to support the research of the recipient and may be used for salary or stipend, research materials, and travel related to the research. Indirect costs are not paid to the recipient or the recipient’s institution.

The scholar must attend the ACS Clinical Congress in 2019 to present a report on the research as part of the Scientific Forum and to receive a certificate at the annual meeting of the Scholarships Committee.

Approval of the application is required from the administration (dean or fiscal officer) of the institution. Supporting letters from the head of the department of surgery (or the surgical specialty) and from the mentor who will be supervising the applicant’s research must be submitted. The College encourages diversity of applicants and institutions; only in exceptional circumstances will more than one scholarship be granted in a single year to applicants from the same institution.

For further information regarding this scholarship, click here, or contact the Scholarships Administrator at [email protected].

The American College of Surgeons (ACS) is offering 2-year Resident Research Scholarships to surgeons in training who are interested in pursuing careers in academic surgery. Eligibility for these scholarships is limited to the research projects of residents in general surgery or a surgical specialty. The closing date for receipt of the completed online application and all supporting documents is Sept. 1, 2016.

General policies covering the granting of the ACS Resident Research Scholarships are as follows:

The applicant must be a Resident Member of the College who has completed two postdoctoral years in an accredited surgical training program in the U.S. or Canada at the time the scholarship is awarded, July 1, 2017, and may not complete formal residency training before June 2019. Scholarships do not support research after completion of the chief residency year.

The scholarship is awarded for 2 years, and acceptance of it requires commitment for the 2-year period. The award is to support a research plan for the 2 years of the scholarship, July 2017 through June 2019. The projects of residents who are involved in full-time laboratory investigation will receive priority. Study outside the United States or Canada is permissible. Renewal of the scholarship for the 2nd year is required and is contingent upon the acceptance of a progress report and research study protocol for the 2nd year, as submitted to the Scholarships Section of the College by May 1, 2018.

Application for these scholarships may be submitted even if the resident has made a comparable application to other organizations. If the recipient is offered a scholarship, fellowship, or research award from another organization, it is the responsibility of the recipient to contact the ACS Scholarships Administrator to request approval of the additional award. The Scholarships Committee reserves the right to review potentially overlapping awards and adjust its award accordingly.

The scholarship is $30,000 per year; the total amount is to support the research of the recipient and may be used for salary or stipend, research materials, and travel related to the research. Indirect costs are not paid to the recipient or the recipient’s institution.

The scholar must attend the ACS Clinical Congress in 2019 to present a report on the research as part of the Scientific Forum and to receive a certificate at the annual meeting of the Scholarships Committee.

Approval of the application is required from the administration (dean or fiscal officer) of the institution. Supporting letters from the head of the department of surgery (or the surgical specialty) and from the mentor who will be supervising the applicant’s research must be submitted. The College encourages diversity of applicants and institutions; only in exceptional circumstances will more than one scholarship be granted in a single year to applicants from the same institution.

For further information regarding this scholarship, click here, or contact the Scholarships Administrator at [email protected].