Future meetings - American College of Surgeons

Transcription

OCTOBER 2005
Volume 90, Number 10
FEATURES
Evidence-Based Reviews in Surgery: A new educational
program for ACS Fellows, Candidates, and Resident Members
Robin S. McLeod, MD, FACS, FRCSC
The prevention of retained foreign bodies after surgery
Verna C. Gibbs, MD, FACS, Mary H. McGrath, MD, MPH, FACS,
and Thomas R. Russell, MD, FACS
Statement on the prevention of
retained foreign bodies after surgery
ACS takes on specialty issues
Adrienne Roberts
8
12
15
17
22
Surgical lifestyles:
Surgeon as patient: Acquiring a new viewpoint
Karen Sandrick
30
From my perspective
Editorial by Thomas R. Russell, MD, FACS, ACS Executive Director
Dateline: Washington
Division of Advocacy and Health Policy
Socioeconomic tips
ACS Coding Hotline: Frequently asked questions
Division of Advocacy and Health Policy
Linn Meyer
Director of
Communications
Karen Stein
Associate Editor
Louis T. Wright and Henry W. Cave:
How they paved the way for Fellowships for black surgeons
John S. O’Shea, MD, FACS
DEPARTMENTS
Stephen J. Regnier
Editor
Diane S. Schneidman
Contributing Editor
Tina Woelke
Graphic Design Specialist
Alden H. Harken,
MD, FACS
Charles D. Mabry,
MD, FACS
Jack W. McAninch, MD,
FACS
Editorial Advisors
4
Tina Woelke
Front cover design
6
Future meetings
34
Clinical Congress
2006Chicago, IL,
October 8-12
2007New Orleans, LA,
October 7-11
2008San Francisco, CA,
October 12-16
Spring Meeting
2006Dallas, TX,
April 30-May 3
2007Las Vegas, NV,
April 22-25
2008To be announced
On the cover: The College co-sponsors Evidence-Based Reviews in Surgery for
ACS members (see page 8). (Photo courtesy of Punchstock.)
NEWS
Bulletin of the American
College of Surgeons (ISSN
0002-8045) is published
monthly by the American College of Surgeons, 633 N. Saint
Clair St., Chicago, IL 60611. It
is distributed without charge to
Fellows, to Associate Fellows,
to participants in the Candidate Group of the American
College of Surgeons, and to
medical libraries. Periodicals
postage paid at Chicago, IL,
and additional mailing offices.
POSTMASTER: Send address
changes to Bulletin of the
American College of Surgeons,
633 N. Saint Clair St., Chicago,
IL 60611-3211. Canadian Publications Mail Agreement No.
40035010. Canada returns to:
Station A, PO Box 54, Windsor,
ON N9A 6J5.
The American College of
Surgeons’ headquarters is
located at 633 N. Saint Clair
St., Chicago, IL 60611-3211;
tel. 312/202-5000; toll-free:
800/621-4111; fax: 312/2025001; e-mail:postmaster@
facs.org; Web site: www.facs.
org. Washington, DC, office
is located at 1640 Wisconsin
Ave., NW, Washington, DC
20007; tel. 202/337-2701, fax
202/337-4271.
Unless specifically stated
otherwise, the opinions expressed and statements made
in this publication reflect the
authors’ personal observations
and do not imply endorsement by nor official policy of
the American College of Surgeons.
©2005 by the American
College of Surgeons, all rights
reserved. Contents may not
be reproduced, stored in a
retrieval system, or transmitted in any form by any means
without prior written permission of the publisher.
Library of Congress number
45-49454. Printed in the USA.
Publications Agreement No.
1564382.
In memoriam:
Luis F. Sala, MD, FACS (1919-2005)
C. Rollins Hanlon, MD, FACS
Commission on Cancer grants
39 Outstanding Achievement Awards
37
38
In memoriam:
R. Gordon Holcombe, Jr., MD, FACS (1913-2005)
C. Rollins Hanlon, MD, FACS
41
2007 ACS ANZ Chapter Travelling Fellowship available
42
2006 Nizar N. Oweida, MD, FACS, Scholarship available
43
Fellows in the news
44
Discounted subscriptions to Epocrates
now available to ACS members
45
Trauma meetings calendar
45
Letters
46
ACOSOG news: Clinical trials update:
A follow-up report on the
American College of Surgeons Oncology Group
R. Scott Jones, MD, FACS
NTDB™ data points:
Alcohol is no industrial accident
Richard J. Fantus, MD, FACS, and John Fildes, MD, FACS
Chapter news
Rhonda Peebles
48
52
54
The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical
practice environment.
Space sold by Elsevier
From my
perspective
I
n the June issue of the Bulletin, I wrote about
the imminent physician workforce shortage
and its impact on emergency care. Since then,
several surgeons have shared with me some
rather disturbing information about how this looming crisis is affecting them.
Based on their stories, it is apparent that
unrealistic time commitments, astronomical
medical liability premiums, and decreased reimbursement are deterring some individuals from
upholding one of surgery’s noblest traditions:
willingly being on call for emergency cases.
This trend could have potentially devastating
consequences both for our most critically ill and
injured patients, as well as for those surgeons
who are trying to do the right thing by covering the emergency room (ER) and, on occasion,
providing charitable care.
Causes and effects
One surgeon who has written to me about this
situation is in private general surgery practice
with his son, and they are on staff at a suburban
Atlanta, GA, hospital that has a large trauma
service. The younger surgeon is on a required
24-hour rotation of nine general surgeons who
cover the ER. During that rotation, it is not unusual for him to complete multiple procedures
and a range of consultations. Needless to say, by
the following morning, he and his ER colleagues
are cognitively and physically spent and in no
condition to see patients the following day, let
alone operate.
Similarly, when I was in Wyoming recently,
a surgeon told me that he had been up for two
nights straight taking ER call in a critical access
hospital and had no backup for his upcoming
elective procedures. Although we all know a rush
of adrenalin generally kicks in when we need to
operate, we aren’t necessarily able to function
at anywhere near full capacity physically or
mentally. The consequences of operating in this
state could be quite negative.
It is ironic that we have set limitations on the
number of hours residents can be available to
work in the hospital out of concern about their
ability to function without proper rest, yet we
expect practicing surgeons to work two days in
a row with little concern for how well they will
be able to perform following their ER rotation.
“
It is ironic that we have set
limitations on the number
of hours residents can be
available to work in the
hospital...yet we expect
practicing surgeons to work
two days in a row with little
concern about how well they
will be able to perform
following their ER rotation.
’’
After all, people’s stamina and powers of recuperation are higher when they are younger, not
as they age. Furthermore, we need to consider what sort
of message overstressed attending surgeons are
sending to medical students and residents who
are concerned about whether they will have time
to pursue their personal interests and lifestyle
goals. Many young surgeons learn of these timeconsuming and exhausting ER rotations during
their interviews to get on staff at institutions.
Because these surgeons are now coming out
of an environment in which as residents they
are expected to commit a set amount of time to
VOLUME 90, NUMBER 10, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS
being on call, they have a hard time accepting
that they will need to be on call for extended
periods. Ultimately, many of them decide to seek
out privileges at facilities that receive fewer
trauma patients. Surgeons who take ER call find that their
frustration is compounded by the fact that they
are more vulnerable to liability claims. They are
serving more seriously injured and ill patients,
many of whom have other health problems that
have been inadequately treated, diagnosed,
or documented in the past. Although many
hospitals pay a portion of a surgeon’s liability
premium associated with ER care, this sort of
assistance does not extend to surgeons’ everincreasing liability premiums for the provision
of elective care. In order to pay those expenses,
surgeons need to perform more elective operations. The “catch-22” here is obvious.
In addition, given the Medicare payment cuts
that have occurred in recent years, many surgeons believe that they absolutely cannot afford
to lose time they would spend providing care to
their regular, nonemergency patients.
Sadly, many general surgeons who take ER
call are unable to count on their peers for support. In some instances, hospitals and general
surgeons have asked specialists to become more
available for ER cases. However, many of these
specialists see cases that are beyond their scope
of expertise and have to call upon general surgeons for assistance.
Solutions are needed
The number of surgeons who are willing devote their time to these endeavors is dwindling.
As a professional organization, the College needs
to determine how we can encourage surgeons of
all specialties and all ages to accept responsibility for providing ER coverage. What incentives
can this organization offer? Could hospitals and
payors provide some sort of stimuli?
One much-discussed solution of late is the
development of a new category of health care
professional known as the “surgical hospitalist” or “acute care surgeon.” These individuals
would be trained specifically in the provision
of the broad range of services associated with
in-hospital emergency care and would be employed by facilities that need a regular staff
of surgeons to handle a stream of urgent care
patients. Placement of these individuals on
institutions’ staffs would ease the need for
surgeons to provide extended on-call trauma
and critical care.
Other individuals believe that hospitals should
offer stipends to surgeons and other physicians
who take ER call. Some institutions already pay
physicians for each night they are on call.
Another alternative would be to develop highly
trained emergency medical service teams, who
could offer more advanced on-the-spot care. As a
result, patients who receive more thorough care
at the scene of injury or illness would require
less intense treatment when they arrive at the
hospital.
I am certain that many other solutions are
conceivable, and it is imperative that we seek
them out. It would be a great tragedy if surgeons were to abandon their tradition of serving
their hospitals, communities, and patients by
volunteering for ER call. Needless to say, the
College continues to welcome any suggestions
you have regarding how we can help to avert
this potential crisis.
Thomas R. Russell, MD, FACS
If you have comments or suggestions about this or other
issues, please send them to Dr. Russell at fmp@facs.org.
OCTOBER 2005 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS
Dateline Washington
prepared by the Division of Advocacy and Health Policy
College calls for
support of
value-based
purchasing bill
CMS issues
proposed rule
regarding Medicare
payment in 2006
On August 10, ACS Executive Director Thomas R. Russell, MD,
FACS, issued a special alert, encouraging College members to voice
their support for the Medicare Value-Based Purchasing for Physicians’
Services Act of 2005, H.R. 3617. This legislation was introduced July
28 by Rep. Nancy Johnson (R-CT), chair of the House Ways and Means
Health Subcommittee.
The College supports H.R. 3617 because, unlike other proposals
under consideration in Congress, it is consistent with surgery’s concerns and priorities regarding Medicare payment reforms. Specifically,
the bill would restructure the Medicare physician reimbursement formula to link payment to quality incentives and would institute reforms
aimed at preserving the financial viability of physician practices and
patient access to surgical care. Related provisions in the legislation
are as follows:
• Repeal the sustainable growth rate (SGR) methodology used to
determine the annual update for Medicare physician reimbursement
and base future payments on the Medicare Economic Index, which
measures annual practice inflation costs for physicians.
• Phase in a value-based purchasing program over several years,
starting with voluntary, initial reporting measures beginning in
2007.
• Base quality measures for the value-based purchasing program on
the efforts of physician specialty organizations, such as the College’s
work with the Surgical Care Improvement Project and the National
Surgical Quality Improvement Program.
If Congress fails to pass legislation similar to H.R. 3617, Medicare payments to physicians will be reduced 4.3 percent beginning
January 1, 2006, according to a proposed rule that the Centers for
Medicare & Medicaid Services (CMS) issued August 1. The pay cut
is a result of the flawed SGR system.
Other elements of the proposed rule would establish the following:
(1) a revised methodology for calculating physician practice expenses to
be phased in over four years; (2) modifications to the methods used to
calculate liability premium expenses; (3) a revised pricing methodology
for separately billable drugs and biologicals; and (4) a new multiple
procedure payment reduction for certain imaging procedures. According to CMS, these provisions would have the following net effect on
payments to the surgical specialties in 2006:
Cardiac surgery
Colon-rectal surgery
General surgery
Hand surgery Neurosurgery
Obstetrics-gynecology Ophthalmology
–0.5%
–0.2
0.4
–0.2
–0.3
0.2
–1.0
Orthopaedic surgery
Otolaryngology
Plastic surgery Thoracic surgery
Urology Vascular surgery –0.1%
–0.4
0.3
–0.4
1.8
0.7
These figures do not account for the estimated 4.3 percent reduction
in the fee schedule conversion factor. At press time, the College was
drafting comments on the proposed rule for submission by the September 29 deadline. To view the proposal, go to http://www.cms.hhs.
gov/physicians/pfs/ama.asp?URL=/regulations/pfs/2006/1502P.zip.
CMS issues quality
improvement
“roadmap”
President signs
patient safety
legislation
NQF endorses
voluntary
consensus standard
On July 25, the CMS issued a “roadmap” of the agency’s plans to
improve quality of care for Medicare and Medicaid patients. CMS has
identified strategies necessary to achieve this goal, including the following:
• Working through partnerships with other federal agencies, state
governments, and private sector groups to achieve specific quality
goals.
• Developing and providing quality measures and information as
a basis for supporting more effective quality improvement efforts.
• Reinforcing a commitment to quality and helping providers and
patients take steps to improve health and avoid unnecessary costs.
• Assisting practitioners and providers in enhancing efficiency,
particularly through the promotion of electronic health systems.
• Bringing effective new treatments to patients more rapidly and
helping develop better evidence so that physicians and patients can
use medical technology more effectively.
The agency has made administrative and structural changes to
implement these initiatives. For details, visit http://www.cms.hhs.
gov/quality/quality%20roadmap.pdf.
On July 29, President Bush signed the Patient Safety and Quality
Improvement Act of 2005, which the College believes will enable
surgeons to analyze medical errors and which holds great promise for
improving quality of care. Under the new law, a “patient safety work
product” of reported errors and near misses is privileged information
and cannot be used in legal or disciplinary actions. Data collected
can only be used in a criminal trial after the court determines that
the evidence is “material to the proceeding” and “not reasonably
available from another source.” The law also provides that surgeons
and other health care providers will be able to voluntarily submit
information to patient safety organizations certified by the Department of Health and Human Services, as long as patient confidentiality
is maintained. The purpose of the system is to create a searchable
database of medical errors that can be analyzed and used to develop
new care systems and best practices that would avoid similar errors
in the future.
As a step toward helping institutions to identify, catalog, and analyze medical errors and other patient safety concerns, the National
Quality Forum (NQF) announced on August 3 that it has developed a
“voluntary consensus standard” for patient safety taxonomy. According to NQF, the taxonomy will allow patient safety reporting systems
sponsored by various health care providers, professional organizations,
and state and federal agencies to communicate about and learn from
each other’s data. For more information, visit the NQF Web site at
http://www.qualityforum.org/news/home.htm.
A
53-year-old general surgeon laments,
“Everything I do in my practice today
is different from what I learned in
residency.”
Breast-preserving operations are the standard
and recently she has started doing sentinel lymph
node dissection. “Dr. X” adopted the laparoscopic
approach to performing cholecystectomies in the
mid-1990s and now does laparoscopic Nissens,
and she has recently started doing laparoscopic
colectomies for colon cancer. She performs
total mesorectal excision for all rectal cancers
and reconstructive surgery for both low rectal
cancers and ulcerative colitis and treats many
trauma patients nonoperatively. She participates
in multidisciplinary tumor board rounds and
most patients receive neoadjuvant therapy. She
has access to advanced imaging techniques such
as magnetic resonance and positron emission
tomography scanning as well as interventional
procedures for performing biopsy on masses and
draining abscesses.
What perhaps astounds her the most, however,
is that she now performs tension-free inguinal
hernia repairs whereas during her residency
she was taught the Bassini repair (which was
described in 1887) and she assumed it would be
the standard repair for another 100 years. Dr.
X is concerned that while she has adopted these
changes, she is uncertain whether they actually lead to improved outcomes in her patients.
Furthermore, there are continuous new developments in technology and other treatments and
she is worried about how she will keep up.
Dr. X’s concerns are not uncommon. It is
estimated that there are more than 2 million
new articles published each year in the medical
literature.1 Thus, it is a daunting task for practicing surgeons to always practice best medicine.
Traditional continuing medical education (CME)
courses have been shown to yield little change
in practice.2 Often surgeons continue to do what
they learned in residency many years ago or are
highly influenced by advertising or detailing by
pharmaceutical and surgical instrumentation
companies. The latter are often biased toward
their own products and do not necessarily have
strong evidence to support their use.
Critical appraisal skills enable one to apply
certain laws of logic to clinical investigative and
published data in order to estimate their validity, reliability, credibility, and utility.3 In other
words, such skills allow physicians to determine
if the reported data are “true” and if they are
applicable to one’s own practice. Although most
clinicians are mainly interested in determining
whether a treatment is effective, knowledge of
natural history, causation, risk factors, diagnostic tests, and measurement are equally important in order to treat patients appropriately.
To critically appraise an article requires some
knowledge of research design and methodology,
statistics, and possibly economics, as well as
an understanding of decision analysis, metaanalysis, and guideline development. Finally,
essential to critical appraisal is the physicians’
clinical knowledge, which allows them to put the
information in perspective. Not only are critical
appraisal skills necessary for reading the literature, they allow physicians to quickly evaluate
an article to see if it is even worth reading—an
essential skill given the overwhelming number
of articles published monthly in the literature.
Furthermore, critical appraisal skills are essential to the practice of evidence-based medicine in
order to apply the best evidence to the treatment
of individual patients.
Beginning in October, Fellows, Candidates, and
Resident Members of the College will have access
to Evidence-Based Reviews in Surgery (EBRS),
an Internet-based journal club designed to
teach practicing general surgeons and residents
critical appraisal skills. EBRS was initiated by
the Canadian Association of General Surgeons
(CAGS) in 2000 and, as a result of its success in
Canada, is now being jointly sponsored by CAGS
and the ACS. It is supported by an educational
grant from Ethicon, Inc., and Ethicon Endo-Surgery, Inc., divisions of Johnson & Johnson, Inc.,
and Ethicon and Ethicon Endo-Surgery, both
units of Johnson & Johnson Medical Products,
a division of Johnson & Johnson, Inc.
EBRS consists of eight monthly packages per
academic year, from October to May. Each package includes a clinical article that is relevant to
the practice of general surgery, plus a methodological article that can be used to assist in the
evaluation of the clinical article. In addition,
methodological and clinical reviews are provided
by experts in the field and surgeons may also
10
participate in an expert-led listserv discussion of
the article. Selected articles cover a spectrum of
important clinical and methodological topics. It
is hoped that participants will be able to evaluate
the clinical article being reviewed, further their
knowledge in the clinical topic, and learn critical
appraisal skills that can be used to evaluate other
articles that they read in the future.
Some topics covered in previous years include
the following:
• Comparison of laparoscopic versus open
colectomy for cancer
• Risk of cancer in Barrett’s esophagus
• Role of computed tomography angiography
in the diagnosis of suspected acute mesenteric
ischemia
• Guidelines for the management of ductal
carcinoma in situ and breast cancer
• Accuracy of FAST (focused assessment with
sonography for trauma) performed by trauma
surgeons
• Meta-analysis of bowel preps in colon surgery
• Evaluation of techniques for ventral hernia
repair
• Risk factors for retained foreign bodies at
surgery
EBRS has been highly successful in Canada
since its inception. Virtually all of the general
surgery training programs have adopted EBRS
as a means to teach critical appraisal skills to
their residents. In 2000, before making EBRS
available to the general membership of CAGS,
members were solicited to participate in a randomized, controlled trial to assess the effectiveness of EBRS.4 Participating general surgeons
were randomized to receive either a clinical
article only or the EBRS package of material plus
participation in the listserv discussion. At the
end of the one-year trial, participants completed
a validated examination to test their critical appraisal skills.5 Those in the intervention group
performed significantly better than those in
the control group. Since 2001, EBRS has been
available to all members of CAGS. The listserv
continues to generate lively debate and discussion among participants and feedback has been
uniformly positive. Surgeons practicing in rural
communities have found it to be particularly
worthwhile because it gives them an opportunity
Steering Committee of
Evidence-Based Reviews in Surgery
Robin McLeod, MD, FACS, FRCSC, Toronto, ON
(Chair)
Karen Brasel, MD, FACS, Milwaukee, WI
Jeffrey Barkun, MD, FACS, FRCSC, Montreal,
QC
Bill Fitzgerald, MD, FRCSC, St. Anthony, NL
Andrew Kirkpatrick, MD, FACS, FRCSC,
Calgary, AB
Harry Henteleff, MD, FACS, FRCSC, Halifax,
NS
Steve Latosinsky, MD, FRCSC, Winnipeg, MB
Helen MacRae, MD, FACS, FRCSC, Toronto, ON
Leigh Anne Neumayer, MD, FACS, Salt Lake
City, UT
David Rogers, MD, FACS, Springfield, IL
Mark Taylor, MD, FACS, FRCSC, Winnipeg, MB
Eric Webber, MD, FRCSC, Vancouver, BC
to discuss issues with other surgeons and receive
MainCert credits (the Canadian equivalent of
CME credits) from any location and without
taking time away from their practices.
EBRS can be used in several different ways. If
surgeons wish to participate in the current monthly discussion, they must register for the listserv.
If they do, they will then receive a monthly e-mail
reminder to read the articles. EBRS is completely
available electronically so participants do not
have to go to their library to obtain the monthly
articles; they simply have to click on a link, which
will bring them to a PDF version of the article.
In addition, a clinical scenario—which serves to
highlight the issues in the clinical article for discussion—will be posted on the listserv and users
can participate in the discussion, either actively
or by reading the comments of other participants
and the experts.
The listserv discussion generally lasts for
two weeks, after which the methodological and
clinical reviews are posted and participants are
asked to complete an evaluation and return it
electronically. In addition, if they complete a
series of multiple-choice questions, they will
receive six CME credits. Alternatively, members
of the College can access the articles and reviews
whenever they wish. EBRS now has a library
of more than 40 indexed articles and reviews,
which is becoming a valuable resource for surgeons wishing to obtain current best evidence
on some topics. However, CME credits cannot
be obtained by reviewing past packages. Finally,
EBRS maintains electronic subscriptions to
approximately eight to 10 medical and surgical
journals, including the Cochrane Database System Reviews. These journals can be accessed at
any time to download other articles not reviewed
within EBRS.
EBRS is available free of charge to all Fellows,
Candidates, and Resident Members of the American College of Surgeons. EBRS may be accessed
by going to the Division of Education page on the
ACS Web site (www.facs.org).
The first topic to be discussed in October of this
year is the management of asymptomatic primary
hyperparathyroidism. The remaining topics for
the year will include a review of quality of life
following laparoscopic colectomy, a meta-analysis
of drains in gastrointestinal surgery, a decision
analysis on the timing of elective colectomy in diverticulitis, usefulness of a decision aid for breast
cancer surgery, prognostic factors in melanoma,
and management of occult pneumothorax.
The members of the Steering Committee of
Evidence-Based Reviews in Surgery are listed in
the box on page 10. Comments regarding EBRS
are welcome at any time and may be directed to
Robin McLeod via e-mail at rmcleod@mtsinai.
on.ca. For more information about accessing
EBRS or to register for the listserv discussion,
please contact Marg McKenzie, EBRS administrative coordinator, via e-mail at mmckenzie@
mtsinai.on.ca, or via postal mail at Room 1560,
Mount Sinai Hospital, 600 University Avenue,

Toronto, ON, Canada M5G 1X5.
References
3. Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach
EBM. Edinburgh, Scotland: Harcourt; 2000.
4. MacRae HM, Regehr G, McKenzie M, et al. Assessment of critical appraisal skills. Am J Surg.
2004;187:120-123.
5. MacRae HM, Regehr G, McKenzie M, et al. Teaching practicing surgeons critical appraisal skills
with an Internet-based journal club: A randomized, controlled trial. Surgery. 2004;136:641646.
Dr. McLeod is head of
the division of general
surgery, Mount Sinai
Hospital, and professor
of surgery, health policy, management, and
evaluation, University
of Toronto, ON. She is a
Regent of the College.
1. Personal communication: Iain Chambers, former
director of the U.K. Cochrane Centre.
2. Davis DA, Thompson MA, Oxman, AD, Haynes
RB. Changing physician performance. A systematic review of the effect of continuing medical
education strategies. JAMA. 1995;274:700-705.
11
The
prevention of
by Verna C. Gibbs, MD, FACS, San Francisco, CA;
Mary H. McGrath, MD, MPH, FACS, San Francisco, CA;
and Thomas R. Russell, MD, FACS, Chicago, IL
T
he American College of Surgeons recognizes that patient safety is an item of the
highest priority. The College has a long-standing tradition of commitment to safe
care for surgical patients, and it is now taking the lead in an effort to eliminate the
occurrence of retained foreign bodies after surgery.
12
Since the practice of surgery began, surgical
instruments, sponges, and needles have been
left unintentionally in various body spaces after
an operation. Recently there has been increased
public interest in the unexpected discovery of
surgical retractors, scissors, or clamps after
various operations. However, although the cases
of retained surgical instruments get the biggest
headlines, the retention of surgical sponges
probably occurs more frequently. Every hospital,
surgeon, and perioperative care nurse in the
U.S. has likely thought about, if not experienced
firsthand, some aspect of this problem.
It has been estimated that one case of a retained item postsurgery occurs at least once a
year in any hospital where 8,000 to 18,000 major
procedures are performed annually (Gwande
AA; see Statement bibliography, page 17). This
estimate is based on claims data, but there likely
have been uncounted cases settled outside the legal system. Moreover, there are likely even more
cases in which near misses—incorrect counts of
instruments and sponges resolved with intraoperative searches or X rays—have occurred. These
measures to rectify near misses consume valuable
operating room personnel time and resources.
Reports in the surgical literature document
sponges discovered by various radiographic
techniques or as a result of the patient presenting with gastrointestinal fistulas or cutaneous
wounds. Once a sponge is identified, it must be
removed, necessitating informed discussion with
the patient, followed by additional surgery.
The working environment
An operation or invasive procedure is performed by a group or team of interdependent
health care providers—including anesthesiologists, surgeons, nurses, and surgical technicians—working toward a common goal with a
system committed to safe, efficient, and effective
functionality. In the operating room (OR), a busy
workplace, this intensely interactive group or
team of professionals performs exacting tasks
under considerable time pressure, which is
highly complex and internally dynamic work.
This work environment mandates durable and
systematically applied processes of care. These
safety practices must be robust enough to protect
patients under the most chaotic of circumstances
yet be simple enough to be applied and understood by all health care professionals, from the
novice to the master. All participants working in
the OR have a common ethical, legal, and moral
responsibility to do whatever possible to ensure
an optimal patient outcome.
There is no experimental evidence that directly
addresses the root causes of retained foreign
bodies, but anecdotal and experiential evidence
(including quality improvement reviews, riskmanagement reports, and closed claims studies)
suggests that these events occur because of poor
communication between perioperative care personnel and faulty processes of care in the OR. Examples of poor communication include surgeons
dismissing reports of a miscount as erroneous,
multiple intraoperative personnel changes without accurate cross-informational reporting, and
mixed messages between team members about
the timing for the emergence from anesthesia if
an intraoperative X ray to detect a missing item
is needed. Faulty processes of care include inadequate or incomplete wound explorations; poorly
performed sponge and instrument counts; and
incomplete, inadequate, or misread intraoperative X rays.
Communication in the operating room
Issues of communication are especially relevant
to the problem of retained foreign bodies because
misunderstandings and conflict may be the result
of many contributing factors—for example, crosscultural (nurse–surgeon), gender-related (male–
female), hierarchical (captain–crew: surgeon–OR
team), and structural (medical staff–hospital
staff). There can also be a wide divide between
the levels of training and experience among the
different people working together as OR staff,
and their styles of communication may be quite
different.
However, such differences are manageable. The
airline industry provides a good model for deal-
ing with communication among persons with a
broad range of backgrounds, as pilots, navigators,
cabin attendants, maintenance crews, air-traffic
controllers, baggage handlers, and others must
communicate effectively to ensure safe operations.
The airline industry has addressed this need by
developing team communication and performance
standards, training to these standards, reviewing
performance, and enforcing these standards equally across the playing field. Developing guidelines
and providing training could similarly enhance
communication and behavior among perioperative
care professionals as a way of improving surgical
instrument and sponge management in the OR.
Processes of care in the OR
The manual counting of sponges, sharps, and
instruments is a widely applied OR practice.
Although there is no solid published evidence for
the effectiveness of this practice, it is the only
modality currently used for tracking surgical tools.
Assistive devices—such as the widely used hanging pocket plastic counting device for sponges,
needle counter boxes, and wall-mounted boards or
screens for recording the number of items—have
proven useful.
Process review and improvement should be
implemented regularly, but they should be routine after any near miss or retained foreign body
event. A focused review or contributing factors
analysis often identifies areas within established
processes of care in need of revision.
In addition to manual counting, other safety
measures help account for surgical tools and
objects. Sponges, towels, gauze, and cotton pads
placed in the operative field should contain a
radio-opaque marker and only an X ray-detectable item should be placed in the surgical wound.
Anesthesiologists often use gauze sponges that
are non-radio-opaque in their work area, for
example, and they should be alert about keeping unmarked items away from the operative
field and disposing of them in containers separate from those used to track X ray-detectable
sponges. Surgeons should execute a methodical
exploration of the operative site before the closure of the wound; this is especially important
in the chest, abdomen, and pelvis, as these three
large body cavities are the most common sites
in which surgical items are lost (Gibbs VC: see
13
Statement bibliography, page 16). This exploration should be performed before the final sponge
and needle count—and it should be performed during every operation. In the event of an incorrect
count, the wound should be reopened as necessary
and reexplored.
The introduction of a requisite “time out” at the
start of surgery is an opportunity for everyone on
the OR team to exchange and confirm information. During the case, maintenance of an optimal
OR environment will allow all participants to
mindfully accomplish their work. It is helpful if
distractions, interruptions, noise, conversation,
and traffic are limited. When personnel changes
occur during a procedure, there must be mechanisms for the complete and accurate transmission
of relevant information about the surgical field
and its contents. Nearing the end of surgery,
the final count of surgical sponges, needles, and
instruments requires visual and audible confirmation between two perioperative care staff and the
conveyance of this information to the surgeon.
Setting aside time for focused performance of this
operative task will enhance accuracy and reduce
errors.
14
Institutional support and guidelines
Surgical facilities must provide the resources
necessary to ensure equipment and personnel,
such as X ray or other equipment, are available
to support perioperative surgical safety measures
as needed to check for an unintended item in the
operative field. When a confirmation X ray is requested, hospital technicians should be accessible
and expeditiously dispatched; expert radiological
review of the films should also be available.
Such resources are especially important in
trauma settings or when the patient is in a critical, life-threatening situation in the OR. In these
situations, usual counting procedures might be
suspended and replaced with a mandatory radiological evaluation in an alternative care setting
once the patient has been stabilized.
To create a safer OR, institutional policies
must be developed and rules established. Documented compliance with policies and procedures
should be simple—easy to access and easy to
understand—and it should be monitored for
accuracy and completeness. Deviation from
standards should be detectable and addressed
promptly. Furthermore, these policies must apply to and be followed by all perioperative care
personnel.
continued on page 56
Dr. Gibbs is professor
of surgery and chair,
department of surgery
QI committee, University of California, San
Francisco, CA.
Dr. McGrath is professor of surgery, division
of plastic surgery, University of California,
San Francisco, and a
Regent of the College.
Dr. Russell is the
ACS Executive Director,
Chicago, IL.
Statement on the prevention of
The following statement was approved
by the Board of Regents at its June 2005
meeting.
T
he American College of Surgeons recognizes patient
safety as being an item of the highest priority and
strongly urges individual hospitals and health care organizations to take all reasonable measures to prevent the
retention of foreign bodies in the surgical wound. The
ACS offers the following guidelines that can be adapted
to various practice settings, including traditional operating rooms, ambulatory surgery centers, surgeons’
offices, and other areas where operative and invasive
procedures are performed:
• Surgical procedures take place within a system of
perioperative care composed of surgeons, perioperative
registered nurses, surgical technologists, and anesthesia professionals. These individuals share a common
ethical, legal, and moral responsibility to promote an
optimal patient outcome.
• Prevention of foreign body retention requires good
communication among perioperative personnel and
the consistent application of reliable and standardized
processes of care.
• Recommendations to prevent the retention of
sponges, sharps, instruments, and other designated
miscellaneous items include:
—Consistent application and adherence to standardized counting procedures
—Performance of a methodical wound exploration
before closure of the surgical site
—Use of X ray-detectable items in the surgical
wound
—Maintenance of an optimal operating room environment to allow focused performance of operative
tasks
—Employment of X ray or other technology (for
example, radiofrequency detection, bar coding) as indicated, to ensure there is no unintended item remaining
in the operative field
15
—Suspension of these measures as required
in life-threatening situations
• Documentation should include, but not be
limited to, results of surgical item counts, notification of the surgical team members, instruments or items intentionally left as packing, and
actions taken if count discrepancies occur.
• Surgical facilities must provide resources
to ensure that necessary equipment and personnel are available to support these perioperative
surgical safety measures.
• Policies and procedures for the prevention
of retained foreign bodies should be developed,
reviewed periodically, revised as necessary, and
available in the practice setting.
Bibliography
Association of periOperative Nurses. Recommended
Practices for Sponge, Sharp, and Instrument Counts. AORN
Standards, Recommended Practices & Guidelines. Denver,
CO: AORN, Inc.; 2004:229-234.
Gibbs VC, Auerbach AD. The Retained Surgical Sponge.
In: Shojania KG, Duncan BW, McDonald KM, Wachter RM,
eds. Making Health Care Safer: A Critical Analysis of Patient
Safety Practices. Evidence Report/Technology Assessment
No. 43. Rockville, MD: Agency for Healthcare Research and
Quality; 2001. AHRQ Publication No. 01-E058. Available
at http://www.ahrq.gov/clinic/ptsafety/chap22.htm.
Gwande AA, Srudert DM, Orav TA, et al. Patient safety:
Risk factors for retained instruments and sponges after
surgery. N Engl J Med. 2003;348:229-235.
16
ACS
takes
on
specialty
issues
by
Adrienne
Roberts,
Government
Affairs
Associate,
Division of
Advocacy and
Health Policy
A
s part of its ongoing
efforts to represent all
surgeons regardless of
specialty, the American
College of Surgeons has become
increasingly involved in serving
the interests of the surgical specialty societies and advocating on
their behalf. To gain insight into
the surgical societies’ needs and
concerns, the College meets with
the leadership of these organizations regularly—semiannually
with the physician leaders in
Chicago, IL, and approximately
once a month with executive
staff in Washington, DC. The
following article demonstrates
how the College coordinates its
advocacy efforts with the surgical specialty societies.
Abdominal aortic
aneurysm screening
More than 1 million Americans are estimated to have
abdominal aortic aneurysms.
When detected before rupture
through a simple, painless, and
effective screening test, at least
95 percent of these aneurysms
can be treated successfully.
The College has partnered
with the National Aneurysm
Alliance (NAA) to introduce a
Medicare benefit for ultrasound
screening for the detection of
abdominal aortic aneurysms.
The NAA is a group of specialty
organizations, patient advocates, medical technology manufacturers, and private citizens
dedicated to reducing sudden
death from abdominal aortic
aneurysms through education
and screening.
Furthermore, the ACS is urging members of Congress to
cosponsor the Screening Abdominal Aortic Aneurysms Very Ef-
17
ficiently (SAAAVE) Act S.390/H.R. 827, introduced
in February by Sens. Christopher Dodd (D-CT) and
Jim Bunning (R-KY) and Reps. John Shimkus (RIL), Gene Green (D-TX), and Ron Lewis (R-KY). By
extending ultrasound screening coverage to at-risk
beneficiaries, this legislation could help to prevent
the more than 15,000 deaths caused by abdominal
aortic aneurysms that occur each year. Surgeons
can urge their legislators to cosponsor these bills
through the College’s Legislative Action Center at
http://capwiz.com/facs/home/.
18
Imaging
The ACS has joined a growing number of medical
specialty organizations to form the Coalition for
Patient-Centered Imaging, which is committed to
improving patient care through access to in-office
imaging for diagnosis and treatment purposes.
The College supports in-office imaging because it
has proven to result in faster diagnoses, improved
patient compliance, better outcomes, and fewer
repeat office visits. Furthermore, in many cases,
imaging is replacing invasive diagnostic procedures
that once required hospital stays or outpatient
surgeries.
A challenge to Medicare’s willingness to pay
for these procedures is a recent report from
the Medicare Payment Advisory Commission
(MedPAC), which indicates that the growth
rates for imaging services and tests are higher
than growth rates for other Medicare services.
Although MedPAC’s data are questionable, opponents of in-office imaging use the erroneous
growth trends in medical imaging to limit the
ability of specialists to administer and interpret
office-based imaging services.
A recent study conducted by The Lewin Group,
however, contradicts MedPAC’s findings and demonstrates that recent use of imaging services in the
Medicare program is growing no faster than for
other Medicare Part B services. The Lewin report
also shows office-based imaging is replacing more
expensive, hospital-based, diagnostic techniques.
Meanwhile, a recent poll conducted for the Coalition for Patient-Centered Imaging by Fabrizio,
McLaughlin & Associates indicates that 85 percent
of Americans want the option of medical imaging
performed by their specialists. (Spectrum Science
Communications, March 11-15, 2005; sample size:
1,019 Americans, aged 18 years and older.)
Silicone breast implants
Representatives of the College have testified
several times in recent years before the Food and
Drug Administration’s (FDA) General and Plastic
Surgery Devices Advisory Committee. Most recently, Lorraine Tafra, MD, FACS, director of the
Anne Arundel Medical Center Breast Center in
Annapolis, MD, and past-president of the American Society of Breast Surgeons, testified April 11
on the College’s behalf. The panel met to discuss
and vote on two premarket approval applications
for silicone gel-filled breast implants from Inamed
and Mentor Corporations. The College’s statement
focused on breast reconstruction and augmentation
as life-enhancing procedures.
The device panel was chaired by Michael A.
Choti, MD, FACS, associate professor of surgical
oncology at Johns Hopkins in Baltimore, MD.
Other panelists included Cheryl A. Ewing, MD,
FACS, assistant professor in clinical surgery at
the Carol Buck Breast Care Center, University of
California–San Francisco; Ann Marilyn Leitch,
MD, FACS, professor of surgery at the University
of Texas Southwestern Medical School in Dallas;
Joseph LoCicero III, MD, FACS, professor and chair
of surgery at the University of South Alabama; and
Michael J. Miller, MD, FACS, associate surgeon and
deputy chair of plastic surgery at the University of
Texas, M.D. Anderson Cancer Center, Houston.
After three days of deliberations, including 15
hours of testimony from members of the public,
medical groups, and other interested organizations, the panel voted 5-4 against FDA approval of
Inamed’s device and 7-2 in favor of FDA approval
for Mentor’s. On July 28, Mentor received an approval letter from the FDA for its silicone implants.
The letter contains several stipulations that are
unavailable to the public but that Mentor must
meet to attain final approval. Discussions and other
efforts are currently under way between the FDA
and Mentor, so final approval will likely be granted
by year’s end.
Scope of practice
After heavy lobbying by the College, the Department of Veterans Affairs (VA) in December
2004 rescinded a directive allowing nonsurgeons
to perform laser eye surgery at Veterans Health
Administration (VHA) facilities. Under the VA’s
new guidelines, the performance of therapeutic
laser eye surgery is limited to only qualified ophthalmologists.
This issue first materialized in Oklahoma in
1998, when the state passed legislation allowing
optometrists to perform laser eye surgery. The VA
has a long-standing local facility privileging policy
that allows health care practitioners to practice
up to the limits of their state licenses. In 2003,
it was discovered that an optometrist licensed in
Oklahoma had performed glaucoma- and cataractrelated laser surgery at a VA medical facility in
Wichita, KS. The VA initially refused to revoke the
optometrist’s surgery privileges (despite Kansas’s
prohibition against nonphysicians performing
eye surgery) but then temporarily suspended the
individual’s privileges and placed a moratorium
on optometrists performing eye surgery in VHA
facilities.
To ensure that veterans receive safe eye care,
Rep. John Sullivan (R-OK) introduced H.R. 3473,
the Veterans Eye Treatment Safety Act, in November 2003. Strongly supported by the College,
this legislation sought to ensure that only licensed
medical or osteopathic physicians could perform
eye surgery at VHA facilities or under contract with
the VA. The bill enjoyed strong bipartisan support
and garnered 74 cosponsors, but it ultimately faded
from view once the VA issued its moratorium.
The College has worked with the American Academy of Ophthalmology (AAO) for the past year to
have the VHA rescind the directive that allows
optometrists to perform laser surgery. As part of
the Veterans Eye Treatment Safety coalition, along
with the AAO, the American Medical Association,
American Osteopathic Association, the American
States where oral surgeons
may perform cosmetic plastic surgery
Alaska
Arizona
Arkansas
Colorado
Delaware
Georgia
Illinois
Iowa
Louisiana
Mississippi
Oregon
Rhode Island
Tennessee
Virginia
West Virginia
Society of Cataract and Refractive Surgeons, and
the American Academy of Family Physicians, the
College fought for a VA policy that would provide
veterans with the right to have their eye surgery
performed by a physician.
Meanwhile, practitioners of otolaryngology have
concerns about the expanding scope of practice for
audiologists. In January, Rep. Jim Ryun (R-KS)
introduced H.R. 415, the Hearing Health Accessibility Act, which would provide direct access to
audiologists for Medicare beneficiaries “without
regard to any requirement that the individual…
be under the care of (or referred by) a physician.”
In response to a request from the American
Academy of Otolaryngology–Head and Neck
Surgery (AAO-HNS), the College sent a letter in
April to members of the House stating its strong
opposition to this legislation. The letter stated that,
“While we agree that all Medicare beneficiaries
deserve timely access to health care professionals
and their services, this legislation would remove
the physician from the most crucial segment of
any patient consultation—initial evaluation and
diagnosis.” To urge legislators to oppose this bill,
please visit the College’s Legislative Action Center
at http://capwiz.com/facs/home/ to send a letter to
Capitol Hill.
Also in April, the College and seven other medical
specialty groups sent a letter in opposition to the
Medicare Patient Access to Physical Therapists Act,
H.R 1333. Introduced by Rep. Melissa Hart (R-PA),
this legislation would inappropriately expand the
scope of practice of physical therapists and would
allow direct access to physical therapists without
first consulting a physician.
In other activity related to scope of practice,
since 2001, the College has actively participated
in efforts to stop the expansion of the scope of
practice of single-degree oral surgeons into cosmetic surgery of the head and neck. Legislation
has been introduced in numerous states to revise
the definition of dentistry to permit this expansion. (See box for those states where legislation
has been enacted.) As part of the Coalition for
Safe Plastic Surgery, the College, the American
Society of Plastic Surgeons, and others were
most recently successful in defeating this legislation (S.B. 438) in California in 2004, when
Gov. Arnold Schwarzenegger (R) vetoed the bill.
Many California surgeons used the Surgery State
19
Legislative Action Center to send letters to the
governor, urging his veto of this legislation. Not
to be deterred, the supporters of this legislation
have reintroduced it for consideration in the
2005 California legislature; S.B. 438 has already
passed the senate and is under consideration in
the assembly, where it will likely pass. Should
the legislation pass in the assembly, California
surgeons will again need to encourage the governor to veto it.
Fistula First
The College was an early supporter of Fistula
First, a major quality initiative for hemodialysis
patients introduced by the Centers for Medicare
& Medicaid in April 2004. An arteriovenous fistula is preferred to other types of venous access
for hemodialysis patients because it results in
significantly fewer complications, longer patency,
reduced hospitalizations, less patient morbidity,
and significantly lower costs. The objective of the
initiative is to place fistulas in 50 percent of new
dialysis patients and to maintain them in 40 percent of patients who remain on dialysis. The College
held a panel discussion about Fistula First at the
2004 Clinical Congress in New Orleans, LA, and
has several vascular surgeons working with quality
improvement organizations to remove barriers to
placing fistulas.
20
Certificate of need
Since the late 1990s, general surgeons at Albany
Surgical PC in Georgia have wanted to open an
ambulatory surgery center (ASC) but have been
stymied by a state rule that would give the facility a multispecialty designation. Under Georgia’s
certificate of need program, single-specialty ASCs
are exempt from obtaining a certificate of need to
build and operate their facility. Rather, they must
instead apply to the Department of Community
Health (DCH) for a letter of nonreviewability (per
regulations issued in 1998). Albany Surgical PC
filed a lawsuit to overturn the definition. As it
worked its way through the Georgia courts, the
American College of Surgeons and others filed
amicus briefs in support of Albany Surgical. After
years of legal wrangling, the Court of Appeals ruled
that general surgery did not qualify for the singlespecialty exemption, and the Georgia Supreme
Court affirmed that the regulation defining general
surgery as a multispecialty practice was authorized
by the certificate of need statute. However, the
courts did rule that the DCH had the authority to
determine the definition of a specialty.
The College has joined in other efforts to address
this matter. In 2004, the Georgia DCH considered
revising its guidelines pertaining to certificate of
need for ASCs, with the College and organized medicine urging the DCH to redefine general surgery
as a single specialty. DCH insisted it did not have
the authority to take this action, despite appellate
court rulings to the contrary. Subsequently, the
Board of Community Health was asked to consider
a similar action, but an opinion issued February 1,
2005, from the attorney general’s office reiterated
the position that the DCH lacks the authority to
revise the certificate of need statute.
In recent months, the attorney general has been
asked to reconsider the previous opinion and issue
an opinion in line with the courts’ view that the
DCH has full authority to promulgate rules defining a single specialty within the certificate of need
process. In addition, the Surgery State Legislative
Action Center (www.facs.org/sslac/index.html), a
Web-based advocacy tool sponsored by the American College of Surgeons, was activated to provide
Georgia surgeons with the opportunity to send a
letter to Georgia Gov. Sonny Perdue (R) urging him
to work with the DCH to address this issue.
During the 2005 legislative session, the Georgia
General Assembly enacted legislation to create a
commission to review the entire certificate of need
process in the state and develop recommendations
Provider tax coalition members
Allergan, Inc.
American Academy of Dermatology
American Academy of Facial Plastic and Reconstructive Surgery
American Academy of Ophthalmology
American Academy of Otolaryngology–Head
and Neck Surgery
American College of Surgeons
American Medical Association
American Society for Aesthetic Plastic Surgery
American Society for Dermatologic Surgery
American Society of Plastic Surgeons
Medicis Aesthetics; Mentor Corporation
for improvement. The commission has two years
to meet its goal, and the issue of the multispecialty
designation for general surgery will be part of the
deliberations. In addition, legislative action may be
taken during the 2006 legislative session to amend
the definition of general surgery.
Provider taxes
At least half a dozen states have considered legislation introduced during the 2005 legislative session to assess physician taxes on elective cosmetic
surgical and/or cosmetic medical procedures. The
American College of Surgeons has joined with
other medical specialty groups, industry allies,
and state medical societies to monitor and combat
these taxes. This coalition also has established a
Web site, featuring talking points, position papers,
and other advocacy resources for surgeons.
So far this year, the coalition has defeated passage of these taxes in the states considering them,
including Arkansas, Illinois, New York, Tennessee,
Texas, and Washington. Given the status of most
state budgets, these types of taxes are likely to be
proposed in many other legislatures over the next
few years, and physicians and their allies will need
to be prepared to combat them.
In 2004, New Jersey became the first and only
state to pass a 6 percent tax on elective cosmetic
procedures. New Jersey officials greatly overestimated the projected revenue and underestimated
the administrative burden to collect it. The New
Jersey Division of Taxation recently reported a 75
percent shortfall in first quarter collections. The
adjusted projected income from this tax is now
expected to be approximately $6 million, rather
than the $25 million originally projected.
Each state that has introduced a cosmetic surgery tax has earmarked the funds for a different
purpose, including children’s health care services,
Medicaid, stem cell research, or an unspecified
purpose. Under these bills, the tax would be assessed on elective cosmetic surgery and/or cosmetic medical procedures. These have been loosely
defined in most cases as “any procedure that is
directed at improving the patient’s appearance
and does not meaningfully promote the proper
function of the body or prevent or treat illness or
disease,” and an operation or procedure is considered medically necessary when both the physician
performing the procedure and the patient’s health
insurance provider believe it to be so. The American Society of Plastic Surgeons has
posted action alerts on the SSLAC, which it shares
with the College and many national surgical specialty societies. In support of this grassroots effort,
the College then sent e-mail notices to Fellows in
the affected states, resulting in hundreds of surgeons contacting their elected officials through
the SSLAC.
Policy scholarships
In May 2005, the College cosponsored seven
health policy scholarships with specialty societies and supported a scholar representing general
surgery. The scholars attended a weeklong leadership program in health policy management at the
Heller School for Social Policy and Management
at Brandeis University in Waltham, MA. During
the year following completion of the course, these
scholars will serve as pro tempore members of the
Health Policy Committee for the College and the
equivalent body for their specialty society. If no
formal equivalent body exists within the specialty
society, an individual may be called upon as the
“go-to” person by the society’s board on health
policy issues. In terms of their service to the College, it is anticipated that the scholars will attend
the winter meeting of the College’s Health Policy
Steering Committee in Washington and that they
may be asked to review applications for the next
round of health policy scholarships or to perform
additional duties as they arise as well. The College
anticipates that a new group of surgical leaders will
emerge from among the scholars.
Getting involved
As shown in this article, the College has been
using every available opportunity to help many
specialty groups advance their legislative and regulatory agendas. If you believe the College should
be involved in additional issues, please contact the

College’s Washington office at 202/337-2701.
Acknowledgments
The author would like to thank ACS staff contributors
to this article, including Mindy Baker, State Affairs Associate; Kate Early, Administrator, International Liaison
and Scholarships Section; and Geoff Werth, Government
Affairs Associate.
21
How they paved the way
for Fellowships for black surgeons
by John S. O’Shea, MD, FACS, Cambridge, MA
T
he 1912 Clinical Congress in Philadelphia
was attended by Dr. Wilberforce Williams, a black surgeon from Chicago, IL,
who expressed regret that “more of his
race had not taken advantage of the opportunity
to keep in touch with the latest discoveries in the
surgical world.”1 His attendance at the meeting
marked the beginning of a relationship between
the American College of Surgeons and surgeons
of African descent.1 In many ways, the history of
this relationship parallels the story of many U.S.
institutions of national scope and is not unlike
the story of U.S. democracy. A basic motivation
for the founding of the American College of Surgeons was to bring equality to surgical education,
making scientific and clinical advances available
not only to academic elites, but to all those involved in the practice of surgery in all regions of
the country. The early efforts to achieve this goal,
22
Above left: Dr. Wright as a student at Harvard Medical School (circa 1914). Photo courtesy of the Harvard
Medical Library and the Francis A. Countway Library
of Medicine. Right: Dr. Cave, circa 1951.
however, confronted social, cultural, and economic realities and compromises that threatened
to make surgical education for all an incompletely
fulfilled promise. Sixty years ago, through leadership and cooperation—most notably, the efforts of
Louis T. Wright, MD, FACS, and Henry W. Cave,
MD, FACS—the College took a major step toward
satisfying that promise, a decision that has been
equally beneficial to the College as well as to all
surgeons and their patients.
Daniel Hale Williams and the early years
Daniel Hale Williams, MD, FACS, of Chicago,
IL, was the first black surgeon to be admitted to
Fellowship in the College. Born in Pennsylvania
in 1858, he received his medical degree from
Chicago Medical School (now Northwestern University) in 1883. Dr. Williams gained notoriety
as only the second surgeon in the U.S. to report
the successful repair of a stab wound to the
pericardium in 1897. In 1902, he reported one of
the earliest successful attempts at splenorraphy.
He also left his mark on hospital administration
when, responding to a need in Chicago for an
interracial institution to provide care for patients
of color, opportunities for hospital staff appointments for black physicians, and educational possibilities for black nursing students, he founded
the Provident Hospital and its affiliated Training
School in 1891.2
Among the surgeons listed as references on
Dr. Williams’ application to the American College of Surgeons were founding members of the
College—Drs. J. B. Murphy, Albert Ochsner, and
Franklin Martin (all MD, FACS). Dr. Murphy said
Dr. Williams “...has had great experience and a
studious career, surgical standing far above the
average. Moral standing exceptional. Ethical
standing perfectly good.” When the list of initiates for the first Convocation was presented by
Dr. Martin, Dr. Williams’ application generated
considerable discussion among the Regents. The
discussion was partly, though not entirely, divided
along North-South sectional lines. At least one
southern surgeon expressed a strong opinion
that recognizing Dr. Williams as a Fellow and
the notoriety that would follow would be a source
of considerable social problems. Most of the Regents, however, fully supported the application
and one, Alton Ochsner, MD, FACS, threatened
to resign from the College if Dr. Williams was
not accepted.3 Dr. Williams’ application was accepted in 1913.
These discussions addressed fundamental questions regarding the future direction of the ACS.
If the College was to become a scientifically based
organization, committed to the advancement of
the profession of surgery, racial and cultural issues should not be problematic.
The number of black surgeons who applied
to the College in the first several decades of its
existence is difficult to know for certain, as the
official policy was to not record the race of applicants or Fellows. However, records show that
at least 35 applications from African-American
surgeons were received from 1913 through 1944,
only one of whom, in 1934, was accepted for
Fellowship on initial application. Five of these
applications were noted as “not submitted to local credentials committee,” possibly because of
insufficient credentials, and two of the applicants
were clearly rejected on the basis of not being
primarily engaged in the practice of surgery.
Of the remaining applicants, however, most
possessed excellent or, in many cases, outstanding credentials, and six were board-certified in a
surgical specialty; furthermore, among the applicants in the early 1940s, many were officers who
served during World War II, including a graduate
of the distinguished Tuskegee Flying School.4
The only black surgeon to be accepted for Fellowship during these years was Louis T. Wright,
MD, FACS, a man who was not only an outstanding surgeon but also contributed enormously to
the struggle for racial equality, leaving a legacy
that advanced the goal of fair and full access of
opportunity to African-American patients, medical students, physicians, and nurses to all aspects
of the U.S. health care system.
Louis T. Wright—progress for black surgeons
Louis Tompkins Wright was born in 1891, in La
Grange, GA, and in his early years was exposed
to what must have seemed contradictory influences. He witnessed not only the worst of racial
bigotry and hatred, but also observed the achievements that could be realized, regardless of color,
through talent and industry. Although both of
his grandfathers were prominent white men, Dr.
Wright’s father, Ceah Ketcham Wright, was born
into slavery. Possessed of extraordinary abilities
and aptitude, Ceah Wright managed to obtain a
medical education, graduating as valedictorian
from Meharry Medical School in 1883. By the
time he married Louis’ mother, Lula Tompkins,
Ceah had given up the practice of medicine to
become a full-time minister in the Methodist
Episcopal Church. He died at age 41, when Louis
was four years of age. By the time Louis was
eight, Lula had remarried, again to a physician,
Dr. William Fletcher Penn, Yale University’s first
African-American medical graduate, who would
tremendously influence Louis’ formative years.
Being the grandson of prominent white men
and the son and stepson of black men of extraordinary achievement did not insulate Wright from
the worst of racism in the South in the early 20th
century. In addition to observing lynching and
chain gangs as a small boy, he witnessed, at the
age of 15, the 1907 Atlanta riot from his front
door, where his stepfather had stationed him,
Winchester rifle in hand, with instructions to
shoot anyone who attempted to enter. The family
was rescued by a white neighbor, who hid them to
23
24
escape the threat of being shot or lynched.5
Having graduated as class valedictorian from
Clark University in Atlanta in 1911, and confident
in his abilities and encouraged by his stepfather,
Wright applied to Harvard Medical School. When
he presented himself at Harvard, his interviewer,
Dr. Channing Frothingham, realized that Wright
had graduated from the Clark University in
Atlanta, a school that offered elementary, high
school, and university instruction to blacks—not
the Clark University in Worcester, MA—and was
rather amazed that a student from “one of those
funny little schools” would consider applying
to Harvard.5 Convincing Dr. Frothingham to at
least test his abilities, Wright was referred to Dr.
Otto Folin, professor of biochemistry, who, after
a reportedly heated oral examination, told his
secretary to let the admissions committee know
that “Mr. Wright has had adequate chemistry for
admission to this school.”5
During his student years at Harvard, Wright
displayed the courage of conviction and an activism against racial inequality that he would develop
throughout his life. In April of his final year of
schooling, he missed three weeks in order to demonstrate against the Boston showing of The Birth
of a Nation, the D.W. Griffith film that glorified
the role of the Ku Klux Klan in the U.S. Wright
was supported in these efforts by his teacher, the
prominent surgeon Richard Cabot, MD. In June
of that year, Louis received his medical degree,
graduating cum laude and ranking fourth in his
class. He was also given the Hayden award for
scholarship during his four years.6
After his applications for internship at the
Massachusetts General Hospital, the Boston City
Hospital, and the Peter Bent Brigham Hospital
were rejected, Dr. Wright accepted a post at the
Freedman’s Hospital in Washington, DC, a federally subsidized institution established under a
policy of “separate but equal.” Following a oneyear rotating internship, Dr. Wright returned to
Atlanta and joined his stepfather, quickly building
a large clinical practice. Back home, he now faced
discrimination from whites and was ostracized
by a group of black physicians, mainly from
Meharry, who resented black graduates from
northern medical schools. In 1917, Dr. Wright
was commissioned as first lieutenant in the U.S.
Army Medical Corps, 367th Infantry Regiment,
92nd Division, stationed in France. He was placed
in charge of the surgical wards at Field Hospital
366 and was discharged as a captain, receiving
the Purple Heart following a German assault with
phosgene gas. In 1919, he settled in New York City
and opened an office for the general practice of
surgery on Seventh Avenue in Harlem.
The admission of Dr. Wright to ACS Fellowship
in 1934 generated a considerable firestorm of
debate, much like what had followed the admission of Dr. Williams in 1913. Faced with possible
disapproval by a substantial number of Fellows,
the College initially tried to avoid a head-on
confrontation. As in any federated organization,
including the U.S. government, central policies
can be subjected to a considerable variation on
the state and local level; this was the case in both
the American Medical Association (AMA) and the
ACS, where more subjective judgments such as
the “moral and ethical standards” of the applicant
were left largely to state and local credentials committees, making admission criteria essentially a
“states’ rights” issue.
By the late 1930s, however, many national medical organizations were forced to deal with the issue
of admission of minority applicants. The AMA was
forced to address possible inequities in its admissions policies following the 1939 publication in the
Journal of the American Medical Association of a
resolution by the Medical Society of the State of
New York, urging that membership in the AMA
not be denied solely on the basis of race, color,
or creed. In the face of the increasing awareness
of racial and religious (but, as yet, not gender)
discrimination, the College also felt the need to
make a formal statement regarding eligibility for
admission to Fellowship, and, in 1939, the Board
of Regents unanimously adopted the following
resolution: “Be it resolved that no applicant shall
be granted fellowship in the American College of
Surgeons whose admission would be injurious to
the good order, peace, or interest of the College,
or derogatory to its dignity, or inconsistent with
its purposes.”7
Henry W. Cave and the turning point
At a casual glance, Henry Wisdom Cave, MD,
FACS, may not have seemed an obvious candidate
to champion the cause of black surgeons. By all
accounts, he was a true “white southern gentle-
man.” Dr. Cave was born in Paducah, KY, in 1887,
the son of Edward Cave, a Presbyterian minister
from Virginia, and Nell Wisdom, a native of Tennessee. He graduated from Central University
of Kentucky in 1909 and received his medical
degree from Johns Hopkins University in 1913,
where, as a student and during his internship, he
came under the tutelage of Dr. William Stewart
Halsted. After a short period of study abroad, he
joined the staff of Roosevelt Hospital in New York
City in 1915, where he would remain for the rest
of his career. Like Dr. Wright, Dr. Cave served
with distinction in World War I as a captain
with Base Hospital No. 15 (Roosevelt-Mackay
Unit), stationed in Chaumont, France. Though
transplanted to the North, there was much of
Dr. Cave’s life that remained classically Southern. He married Mary Thompson of Texas, the
daughter of a distinguished professor of surgery.
The couple built a country home in Wilton, CT,
high on a hill, from where, on special occasions,
a huge silk Confederate flag was prominently
displayed.8
African-American surgeons continued to apply to the College in the early 1940s, and the
ambiguity of the formal statement from the
Board of Regents did little to defuse a growing controversy. Among those who were denied
Fellowship during this period were Charles R.
Drew, MD, chair of the department of surgery
at Howard University and chief surgeon at
Freedman’s Hospital in Washington, DC; Peter
Marshall Murray, MD, a well-known New York
City surgeon, and Lt. Col. Roscoe C. Giles, MD,
chief surgeon at the military hospital at Ft.
Huachuca, AZ. Efforts by Drs. Cave and Wright
to support fellowship applications of several
black surgeons who were seeking staff privileges
at New York City’s Sydenham Hospital in 1941
were met with the response that the issue could
not be addressed at the present time. (In 1943,
Sydenham Hospital became the first fully integrated voluntary hospital in the country.) The
inability of prominent black surgeons to gain
Fellowship resulted in an increasing amount of
negative publicity for the College. Responding
to the difficulties faced by Drs. Drew, Murray,
Giles, and others, Dr. Wright wrote a guest editorial that appeared in the Pittsburgh Courier on
March 25, 1944, entitled “Your New York and
Eleanor Roosevelt and Dr. Wright at the dedication
dinner for the founding of the Louis Tompkins Wright
Library at Harlem Hospital (1952). Photo courtesy of
the Harvard Medical Alumni Bulletin.
Mine,” where Dr. Wright protested an attitude
he called “harmful to the health of the American people, and the morale of millions of our
soldiers,” and he suggested that the immediate
correction of this attitude would “go a long way
toward causing the colored doctor to think that
the majority of his white professional brothers
believes in democracy, and that racial distinctions cannot be justified in the art and science
of surgery.”
In May 1944, Drs. Cave and Oschner and Frederick Coller, MD, FACS, were appointed to act
as a “Committee on the Relation of the Colored
Surgeon to the American College of Surgeons.”
With the assistance of Dr. Wright, Dr. Cave met
with a group of black surgeons from New York
City in order to get some idea of their professional qualifications, ethical standing, and “to
attempt to ascertain why they seemed so anxious
25
26
to become Fellows of the College.”9 Following this
meeting, Dr. Wright prepared a list of 11 black
surgeons on the staff of Harlem Hospital, not
including those working in surgical specialties
who he believed met the requirements for Fellowship. The College was now seriously addressing
the issue centrally, but Dr. Cave asked that black
surgeons be patient. He planned to attend the
next meeting of the Southern Surgical Association in order to begin a process of “education
and understanding” in the hopes of resolving the
matter in an “evolutionary rather than a revolutionary manner.”10 Before the problem could
be adequately addressed, however, the issue was
forced into stark relief in 1945.
Rejection letters typically contained nonspecific language such as, “A decision has been
reached not to confer this Fellowship at the present time,” or, “Under the present ruling, you are
not eligible for fellowship at the present time.”
In November 1944, Charles Bate of Tulsa, OK,
received the following response to his request for
an application to the Junior Candidate Group:
“By action of the Board of Regents, colored
surgeons are not being admitted to the College
at the present time. However, the subject is now
under consideration by a committee appointed
by the Board.”
In addition, in April 1945, at least two applicants for Fellowship—J. Arthur Hibbler, MD, of
Kansas City, MO, and George D. Thorne, MD, of
New York, NY—received letters stating the following: “Pursuant to a resolution of the Board
of Regents, Fellowship in the College is not
being conferred on members of the Negro race
at the present time. However, the Board has a
committee now charged with the task of making a complete study of the situation for future
consideration by the Board.”11
The source of the specific language that gave
the impression that a resolution barring black
surgeons from Fellowship had been adopted
by the ACS is unclear. The College never had
an official policy regarding admission of black
surgeons and the most likely explanation is that
an articulation of how to handle the situation
on a temporary basis was incorporated into the
letters. 12 If the intention was to obtain more
time to resolve the matter in a gradual manner,
the effect of the letters, especially the one sent
to Drs. Hibbler and Thorne, was much the opposite, raising the volume and intensity of the
negative publicity and making resolution of the
matter more urgent. In February 1945, Malcolm
T. MacEachern, MD, FACS, Associate Director
of the ACS, responding to an inquiry from Mr.
David Dorin, executive director of Sydenham
Hospital, stated that the College had no policy
barring blacks from Fellowship. Following Dr.
Thorne’s rejection letter, Mr. Dorin again wrote
to Dr. MacEachern, asking for clarification
of these contradictory responses and a clear
statement of the College’s position. 13 A number
of newspapers throughout the country carried
stories about the rejection of Dr. Thorne and
officials of the College found themselves responding to interview requests from national
news organizations, including Time and the
Associated Press.
In June 1945, in order to get some idea of
the opinions of the membership of the College
regarding this issue, Dr. Cave sent a letter
to a number of Fellows, which read, in part:
“Unofficially, I am anxious to obtain opinions
of various members of the College throughout
the country about their feeling of having more
colored surgeons as members…. It seems to me
that the College is such an important national
organization that the question of race, creed,
or color should not enter into the matter if a
candidate meets its qualifications. May I have
your views in regard to this?”14
Of the 227 Fellows who responded, 201 were
in favor of admitting qualified black surgeons
and 26 were opposed. Of more interest than the
final count were the individual responses to Dr.
Cave’s letter, which can be roughly grouped into
three categories. A small number were clearly
racist in tone and content, citing a belief in either
racial inequality or “the immutability of Southern mores.”15 A second group favored accepting
black surgeons on the basis of their scientific
and clinical qualifications but believed that the
social repercussions represented a potential
problem, with a few suggesting remedies such as
separate meetings or even a separate College. By
far the largest group of respondents was clearly
and strongly in favor of the free admission of
qualified black surgeons. Many of these letters
admonished the College that not to do so would
The Henry Wisdom Cave Testimonial Dinner given by the Harlem Surgical Society, February 7, 1951, in the
President’s Room at the New York Academy of Medicine. Seated at the center of the speakers table are Dr.
Henry W. Cave, Mrs. Henry W. Cave, and Dr. Louis T. Wright. Photo courtesy of the Journal of the National
Medical Association.
be undemocratic, un-American and “publicly and
scientifically indefensible.”16
Dr. Cave presented the findings of his committee to the Board of Regents in June 1945, moving
that the Regents act to admit to Fellowship, as
a matter of policy, black surgeons who met the
qualifications. A charged discussion followed Dr.
Cave’s report, including an “emotional outburst”
by James Mason, MD, FACS, of Birmingham,
AL. 17 The motion was passed and seconded.
Immediately following this meeting, all applications on file were carefully reviewed by the
Central Credentials Committee to ensure that
each was given fair consideration. At the 1945
Convocation of the ACS, four black surgeons
were initiated, in absentia, as Fellows: Drs. Peter Marshall Murray (New York City), Ulysses
G. Dailey (Chicago), Roscoe C. Giles (Chicago),
and Carl Glennis Roberts (Chicago).18 The first
black surgeon accepted for Fellowship from the
“deep South” was approved by the Alabama
State Credentials Committee, chaired by Dr.
Mason. (The meeting was also attended by a
delegate from the Board of Regents.) In 1946, 10
black surgeons were admitted to Fellowship and
the total admitted from the end of World War II
through 1950 was at least 38.
The legacy of Drs. Cave and Wright
Dr. Wright was personally aware of the harmful effects of a “separate but equal” approach to
medical education on the health status of African-Americans and worked tirelessly throughout
his career for equal access to all aspects of the
27
28
health care system. In 1931, he was the principal
author of a widely read open letter opposing efforts by the Julius Rosenwald Fund to build an
all-black hospital in New York City. The letter
was entitled “Equal Opportunity-No More-No
Less.”19 That same year, he joined the Board of
Directors of the National Association for the
Advancement of Colored People (NAACP), was
named chairman of that organization’s national
Board of Directors in 1934, and in 1944 formed
the NAACP National Medical Committee, a
group charged with fighting segregationist
policies in health care legislation, including the
Hill-Burton Hospital Survey and Construction
Act of 1946, urging that federal funds be apportioned only for the building of hospitals that
would be available to black and white patients
alike. Much of the national health care program
developed by the National Medical Committee of
the NAACP became core elements of President
Truman’s Civil Rights Commission report, To
Secure These Rights.20
Dr. Wright also had a prolific career as a clinical surgeon and researcher, making a number
of valuable contributions to the surgical literature. In 1952, the Louis T. Wright Library was
established at Harlem Hospital. A testimonial
banquet to inaugurate the Library and honor
Dr. Wright, held in April, was attended by more
than 1,000 people, including Eleanor Roosevelt,
who praised him for his contributions to the
people of the United States (see photo, page 25).
Dr. Wright died of a heart attack at his home in
October 1952.
During a long and distinguished career,
Dr. Cave continued to serve the profession of
surgery as well as the American College of
Surgeons. He was chief of the First Surgical
Division at Roosevelt Hospital in New York, NY
(1933-1953), and professor of Clinical Surgery
at Columbia University College of Physicians
and Surgeons (1945-1953). Initiated as a Fellow in 1922, Dr. Cave served five terms as a
member of the Board of Governors (1937-1953),
was elected Vice-President (1939-1940), served
on the Board of Regents (1940-1952), and was
the 30th President of the College (1950-1951).
In February 1951, the Harlem Surgical Society
honored Dr. Cave with a testimonial dinner,
held in the President’s Room at the New York
Academy of Medicine (see photo, page 27). Dr.
Wright was among the many speakers that evening, noting that as the leader in the movement
to open the doors of the ACS to qualified black
surgeons, Dr. Cave “did so not because they
were Negroes, but because they were qualified
surgeons and not to admit them was a handicap
for both the surgeons and their patients.” He
went on to say, “Dr. Cave represents America,
American surgery, and democracy at its best.
He is, in the words of King Lear: ‘One of God’s
spies who has taken upon himself the burden
and the mystery of things.’” 21 Dr. Cave died at
his New York home in May 1964.
A number of dynamics contributed to the
opening of admissions to Fellowships for black
surgeons in the mid-1940s. One factor was the
recognition of the sacrifices and accomplishments made by African-Americans in World War
II, in combat as well as noncombat roles, including medicine. For example, Charles R. Drew, MD,
FACS (his Fellowship was awarded posthumously—a rare honor), became a leading authority on
the storage of large quantities of blood plasma in
“blood banks” and organized the Blood Plasma
Programs of the U.S. in Great Britain in the early
years of the war. (He resigned his official post to
protest the insistence by government authorities
on the separation of plasma pools according to
race.) Certainly, pressure from mounting negative publicity, especially following the rejection
of Dr. Thorne, had a considerable effect.
In addition, a growing number of people, including a majority of the College membership,
simply concluded that discrimination had no
place in an organization dedicated to education
and clinical and scientific achievement. The most
important factor of all, however, was the leadership, cooperation, and courage of conviction
shown by Drs. Wright and Cave. Although they
had very disparate experiences of being born and
raised in the South, their combined efforts for
a common cause enabled the College to take a
critical step toward becoming a truly American
organization and making good on the promise of
the founders to make surgical education equal.
As the population of surgeons and their patients
becomes ever more diverse, the legacy of Drs.
Wright and Cave of equal opportunity can only

increase in significance.
Author’s note
This article is dedicated to the memory of Claude H.
Organ, Jr., MD, FACS, a Past-President of the College,
who passed away June 18 (see September Bulletin, page
31).
The author would like to acknowledge C. Rollins
Hanlon, MD, FACS, for reviewing this article, and Susan Rishworth, ACS Archivist, for her assistance with
research in the Archives.
15.
16.
17.
18.
References
1. Philadelphia Record. November 10, 1912. Located at:
Colored Surgeons, Archives of the American College
of Surgeons, Chicago, IL.
2. Beatty WK. Daniel Hale Williams: Innovative surgeon, educator and hospital administrator. Chest.
1971;60(2):175-176.
3. Minutes, Board of Regents, American College of
Surgeons, Philadelphia. November 11, 1913. Located
at: Archives of the American College of Surgeons,
Chicago, IL.
4. Grimm EK. Records compiled by the Executive Secretary, American College of Surgeons, 1945. Located
Chicago, IL.
5. Wright LT. “I Remember.” Washington, DC: Moorland-Springarn Research Center, Howard University; Wright Papers, No. 9. Cited by: Reynolds PP. Dr.
Louis T. Wright and the NAACP: Pioneers in racial
integration. Am J Public Health. 2000;90(6):884
6. Nercessian NN. Against All Odds. The Legacy of
Students of African Descent at Harvard Medical
School before Affirmative Action. 1850-1968. Hollis,
NH: Puritan Press; 2004:111-112.
Surgeons. May 13, 1939. Located at: Archives of the
American College of Surgeons, Chicago, IL.
8. Patterson HA. Henry Wisdom Cave, 1887-1964. Bull
Am Coll Surg. 1964;49:237-238.
9. Report of the Committee on the Relation of the Colored Surgeon to the American College of Surgeons,
1944. Located at: Archives of the American College
10. Grimm EK. Interview with A. de L. Maynard, New
York City, June 6, 1954. Located at: Archives of the
11. Grimm EK. Data compiled by the Secretary, Board
of Regents, American College of Surgeons, June 19,
Surgeons, June 2, 1945. Located at: Archives of the
13. Letter from D. Dorin to Malcolm T. MacEachern,
April 25, 1945. Located at: Archives of the American
College of Surgeons, Chicago, IL.
14. Letter from H.W. Cave to various Fellows of the
American College of Surgeons, June 4, 1945. Located
19.
20.
21.
Chicago, IL.
Letter from R. Matas to H.W. Cave, June 19, 1945.
Located at: Archives of the American College of
Surgeons, Chicago, IL.
Letter from J. Alexander to H.W. Cave, June 20,
Davis L. Fellowship of Surgeons. Chicago, IL: American College of Surgeons; 1981:333.
Freeman HP. The Harlem Hospital Story. Wright,
Maynard, Ferrer, and Freeman. In: Organ CH,
Kosiba MM, eds. A Century of Black Surgeons. The
USA Experience Norman, OK: Transcript Press;
1987:191.
Open letter to Mr. Edwin R. Eubree, President, Julius Rosenwald Fund, Chicago. “Equal OpportunityNo More-No Less,” from the Manhattan Central
Medical Society, January 28, 1931. Cited in: Freeman
HP. The Harlem Hospital Story. Wright, Maynard,
Ferrer, and Freeman. In: Organ CH, Kosiba MM,
eds. A Century of Black Surgeons: The USA Experience. Norman, OK: Transcript Press;1987:166.
Reynolds PP. Dr. Louis T. Wright and the NAACP:
Pioneers in racial integration. Am J Public Health.
2000;90(6):888-889
The Henry Wisdom Cave Testimonial Dinner,
given by The Harlem Surgical Society. JAMA.
1951;43(3):145-153.
Dr. O’Shea is a general surgeon residing in
Cambridge, MA, and
a masters candidate
in public administration, John F. Kennedy
School of Government,
Harvard University,
Boston, MA.
29
W
by Karen Sandrick, Chicago, IL
30
ith only one female general surgeon in Erie, PA,
it was natural for
women in that area to seek
out Kathleen Erb, MD, FACS,
for a physician visit regarding
their breast diseases. But new
female patients did not come to
Dr. Erb only because of her surgical skills. Equally important
to many of them was knowing
that she was a breast cancer
survivor.
Cindy Shields, a secretary
in the Erie school district, has
been seeing Dr. Erb for more
than 10 years for the evaluation of fibrocystic disease and
treatment of benign breast
tumors. Three years ago, after
a core biopsy of a lumpectomy
specimen detected malignant
cells, Mrs. Shields had a mastectomy plus four cycles of
chemotherapy and four rounds
of radiotherapy.
According to Mrs. Shields,
she had always felt comfortable
with Dr. Erb. “Some doctors
have their hand on the doorknob before you even finish
what you’re saying. [Dr. Erb]
didn’t. She would sit on a stool
and take the time to talk with
me,” she says. But realizing
that Dr. Erb had followed a
similar path forged a deeper
connection between physician
and patient, and it bolstered
Mrs. Shields’ resolve to improve her health.
Approximately a month before a scheduled
annual mammogram in the fall of 2001, Dr. Erb
found a lump during self-examination of one of
her breasts. Even after a mammographic examination, the tumor, approximately one centimeter
in size, remained radiographically occult because
the lesion wasn’t different enough in density to
isolate it from surrounding tissue. Once a sonographically guided core biopsy confirmed the
diagnosis of early-stage breast cancer, Dr. Erb
underwent partial mastectomy; sentinel lymph
node sampling; six cycles of cyclophosphamide,
methotrexate, and 5-fluorouracil adjuvant chemotherapy; and radiotherapy.
Yet, in a matter of months, Dr. Erb was back
in her office, treating Mrs. Shields and her other
patients. “It was wonderful to see her and how
strong she looked, because she had gone through
the same route ahead of me,” Mrs. Shields says.
“She was up and around and doing things and
pretty much back into everyday, normal routine,
and I thought, ‘That’s the way I can look in a
year. I can be OK, too.’”
Despite her clinical knowledge and experience,
Dr. Erb in many ways has been in the same position as any woman with a diagnosis of breast
cancer—forced to choose among many complex
and often confusing treatment options. For
example, much of the literature concerning chemotherapy for breast cancer makes a distinction
between the premenopausal and postmenopausal
states. Chemotherapy is generally recommended
for women with invasive breast cancer who are
premenopausal because of the aggressive nature
of breast malignancies in these women. It is also
seriously considered in pre- or postmenopausal
women who have invasive cancer confined to
the breast and tumors one centimeter or greater
in size.
“I was on the cusp,” Dr. Erb says. She was 50
years of age and having irregular menses at the
time the breast cancer was detected. She also
had early-stage cancer that had not spread to
the lymph nodes and was at the lower end of the
tumor size cutoff range for chemotherapy. “After
much discussion, I did elect to have chemotherapy, even though, looking into the future, I had
a low probability of recurrence of breast cancer.
Opposite: Dr. Erb (left) with Ms. Shields.
I was otherwise healthy and young enough that,
if five years down the road I would have a recurrence, I would look back and kick myself for not
having chemotherapy,” she says.
Dr. Erb also has adhered to the advice she gives
to patients she treats for breast cancer: become
as knowledgeable as you can about your disease
and your treatment options, make the best
choices you can for yourself, and don’t revisit
your decisions or second-guess yourself. Dr. Erb
recalls telling a recent patient, a young woman
who was devastated after being diagnosed with
breast cancer, to gather enough information
so she could be satisfied that she understood
the disease process and could make informed
decisions about what she would do. “For some
women, the situation is cut and dried: here is the
disease they have, and here is the best option,
and they scoot along that line,” Dr. Erb explains.
“For other women, there are potentially many
different things they can do. I often tell women
to conduct their own research so they can be
most at peace with their eventual decisions, they
can reassure themselves they’ve made the right
decisions, and they can move forward.”
Dr. Erb’s surgical expertise tended to dampen
the emotional assault that so often comes on
the heels of a diagnosis of breast cancer. In
particular, Dr. Erb recognized that she had, on
balance, a favorable form of cancer. “I knew and
understood fairly early on that the cancer was
still early stage, and I was able to take that information and conclude that the scope of things
was pretty good. A layperson doesn’t know that
there can be a wide range of breast cancers and
what happens with them,” she says.
Her work in surgery also made Dr. Erb well
aware of the potential consequences of having
and being treated for breast cancer. She had
frequently witnessed the adverse effects that
sometimes follow axillary lymph node dissection,
such as lymphedema of the arm. She therefore
demurred when offered the chance to participate
in a clinical trial that would assess the reliability
of negative sentinel lymph node testing by comparing the outcomes for women who had axillary
lymph node dissection with those for women
who did not have the surgery. “Obviously, I have
to use my hands all the time, and I was a little
reluctant to accept the high risk of lymphedema
31
32
with axillary lymph node dissection if the nodes
were negative. I almost hate to say that I was
not willing to be in the clinical trial, but I only
wanted a sentinel lymph node removal if my
lymph nodes were positive,” she said.
Her experience as a patient gave Dr. Erb fresh
insights she could bring to the care of other
women with breast cancer. Dr. Erb explains,
“Prior to this, I had had very few brushes with
the medical profession as a patient and never had
surgery before. Even though you talk with many
patients about their experience after surgery,
it’s different when you have it yourself. Until
then, you don’t know what the incisions or the
scars feel like. As a surgeon, you may look at an
incision and think it should be healed by now;
it shouldn’t be bothering the patient anymore.
But as a patient, you find out that incisions can
still bother you years after surgery.” Dr. Erb
says that although she had a relatively minor
procedure on the axilla three years ago, even
today, if she hasn’t fully stretched out her arm
in a few days, she will feel the resistance in the
armpit when she reaches for something. “Still,
in the underarm three years later, I can feel the
pull. That makes me understand what patients
may be going through,” she adds.
The experience also was the final impetus for
Dr. Erb to focus her general surgery practice
exclusively on breast care. Dr. Erb had a strong
grounding in breast disease from the beginning
of her surgical education. She trained at the
University of Pittsburgh, Pittsburgh, PA, when
Bernard Fisher, MD, FACS, distinguished service
professor at the University of Pittsburgh and
past chair and scientific director of the National
Surgical Adjuvant Breast and Bowel Project
(NSABP), was designing NSABP clinical trial
protocols. One of the foremost NSABP studies
explored what was considered to be a radical
question at the time: whether women with breast
cancer needed to have a complete mastectomy.
Dr. Erb recalls that, up until the early NSABP
mastectomy trials, the overwhelming majority of
women in this country and probably around the
world would undergo mastectomy for breast cancer. “Those were the days when a woman came to
the operating room with a lump in the breast and
signed a consent that stated the surgeons would
take out the lump and, if it was cancerous, they
Dr. Erb
would go ahead and do a mastectomy before she
woke up.” Her surgical residency at the University of Pittsburgh therefore introduced Dr. Erb
not only to the technical skills of breast surgery,
it also sowed the seeds for an inquiring mindset
that would not adhere to established therapies
by rote but would be willing to continually search
for more effective forms of surgical therapy for
patients.
When Dr. Erb joined the Surgical Service at
Saint Vincent Health Center in Erie in 1983,
she decided to perform the full gamut of general
surgery, rather than limit her practice to a subspecialty area, even accepting trauma call until
family responsibilities intensified with the birth
of her second son. “When I went through my
training as a general surgeon, there weren’t many
fellowships available as there are now. Although
some surgeons who came out of a general surgery
residency subspecialized in plastic or vascular
surgery, most did the full range of general surgery.
It seemed to me as a young surgeon, ‘Why would
I want to limit myself by subspecializing?’”
Nevertheless, over the years, breast care and
the treatment of breast cancer have become
the cornerstones of her practice, and her own
diagnosis of breast cancer was the professional
turning point.
During the course of her treatment, Dr. Erb
confined herself to office visits because she didn’t
want to “worry about patient responsibilities
when I was a patient myself.” But by the time
she completed her course of therapy, she was
ready to devote her practice to the breast. “I
think my practice would have evolved into breast
surgery at some point. My diagnosis pushed me
out the door, but I was headed toward that door
anyway,” she says.
From the fall of 2002 until early this year,
Dr. Erb focused her general surgery practice in
Erie on breast surgery, except for a few cases of
general surgery while on emergency call. She
started performing stereotactic core biopsies
and incorporated sonography into a global, practice-based breast surgery program. Dr. Erb also
served as medical director for the St. Vincent
Hospital Women’s Diagnostic Center, where she
provided the clinical viewpoint while the center
reorganized into a full-service and dedicated
imaging initiative for women.
Dr. Erb was a community leader in Erie in the
fight against breast cancer. She chaired the annual Making Strikes against Breast Cancer walk,
which raises funds for breast cancer research,
on two separate occasions, walking beside Cindy
Shields at one of them, and she has worked to
raise awareness of breast cancer in the media
and at community events.
In April of this year, Dr. Erb relocated to Pittsburgh, where she could join Thomas B. Julian,
MD, FACS, associate director of the Breast Care
Center of Allegheny General Hospital, and other
breast surgeons, as well as help train surgical
residents in breast surgery. She is networking
with referring oncologists and primary care
physicians and is joining a physician speaking
circuit, presenting general health care talks at
local department stores, speaking to women’s
groups, and participating in radio call-in talk
shows about breast cancer and other clinical
topics.
But Cindy Shields still goes to Dr. Erb for follow-up care. After a magnetic resonance imag-
ing examination and sonogram a few months
ago revealed an enlarged lymph node on the
contralateral side, Mrs. Shields underwent a
stereotactic core biopsy, which was negative, and
she continues to see Dr. Erb every six months.
Like any surgeon, Dr. Erb for years would
consider the question: If this happened to you,
what would you do? “My response always used
to be, ‘Well, I don’t know what I would do’…
until I faced the problem myself and then I could
say, ‘Here’s what I did.’” As Dr. Erb quickly
acknowledges, everyone is different, and her
experience with her disease will vary from that
of each of her patients, and as far as responding
to “what would you do,” the answer is different
for everyone. But she—and Cindy Shields—now

know their own answers.
Karen Sandrick is a freelance writer in Chicago, IL.
33
Socioeconomic tips
ACS Coding Hotline:
Frequently asked questions
by the Division of Advocacy and Health Policy
T
his column lists some questions recently
posed to the ACS Coding Hotline and the
responses. Fellows and their office staff
may consult the hotline 10 times annually
without charge as a benefit of membership in
the College.
The surgeon intended to do a screening
colonoscopy, but he discovered some polyps, which he removed. How is the procedure reported?
The rules for such a situation are as follows:
• Always code based on what actually
happens, not what was planned.
• Any surgery including “surgical endoscopy”
includes a diagnostic “look around” to identify
anything unknown and abnormal, so the surgeon
is working with as much information about the
patient as possible.
When an endoscopy is performed, generally
all of the organ is examined. Of course, if
a proctosigmoidoscopy or sigmoidoscopy is
performed, only a part of the colon is examined.
The surgeon would report Current Procedural
Terminology (CPT)* code 45384, Colonoscopy,
flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s)
by hot biopsy forceps or bipolar cautery, or code
45385, Colonoscopy, flexible, proximal to splenic
flexure; with removal of tumor(s), polyp(s), or
other lesion(s) by snare technique. The screening
colonoscopy would not be reported. (Note that
there is also a code to use when ablating tumors,
polyps, or other lesions: code 45383, Colonoscopy, flexible, proximal to splenic flexure; with
ablation of tumor(s), polyp(s), or other lesion(s)
not amenable to removal by hot biopsy forceps,
bipolar cautery or snare technique.)
34
*All specific references to CPT terminology and phraseology are:
© 2004 American Medical Association. All rights reserved.
Around the corner
October
• Medicare will implement the Correct Coding Initiative version 11.3 on October 1.
• Medicare requires updated ICD-9-CM diagnosis codes on October 1. ICD-9-CM is available by purchase from the American Medical
Association and other vendors. The updates are
also available at www.cms.hhs.gov/medlearn/
icd9code.asp. Look in the box labeled “Effective 10/1/2005” and download Table 6A, New
Diagnostic Codes (pdf 32kb), Table 6C, Invalid
Diagnosis Codes (pdf 27kb), and Table 6E, Revised Diagnosis Code Titles (pdf 117kb).
• Economedix will hold two teleconferences
this month. The first, on October 12, is “Scheduling Techniques for Improved Productivity.”
The second, on October 26, is “ICD -9-CM
Coding & ICD Changes for 2006.” For more
information and to register, go to http://yourmedpractice.com/ACS.
• ACS will sponsor basic and advanced coding workshops for surgeons and their office staff
on October 17 and 18 at Clinical Congress in
San Francisco, CA. Also at Clinical Congress, a
practice management course entitled “Charting
a Sound Course for Surgical Practices” will be
presented October 17. Advance registration has
closed but spaces may still be available at on-site
registration.
November
• Economedix will hold three teleconferences
this month. The first, on November 2, is “E&M
Coding…Beyond the Basics.” The second, on
November 16, is “CPT Coding & 2006 Updates
for Surgeons.” The third, on November 30, is
“Building a Bottom-Line Budget for 2006.” For
more information and to register, go to http://
yourmedpractice.com/ACS.
The surgeon is doing the approach for
a spinal procedure for a neurosurgeon.
Should the code for the partial vertebral
body excision procedure with a –62 modifier (two surgeons) be used, or is there a
separate procedure code?
A partial vertebral body excision is one of
many spinal codes that can be reported with a
–62 modifier. It is important that the neurosurgeon and general surgeon agree to use the same
code(s) with a modifier –62 attached and that
each surgeon dictates a report for his or her part
of the operation. Follow the introductory notes
in CPT for the spine and each subsection under
the spine for guidance on which codes may have
a –62 modifier attached to them.
Remember that in many instances, the neurosurgeon will report codes in addition to the
codes the general surgeon reports. It is also
possible that the general surgeon will serve as
an assistant surgeon on some procedures. If this
is the case, he or she should bill the approach
with a –62 modifier and other services with a
modifier –80 (assistant surgeon) or modifier
–82 (assistant surgeon when qualified resident
not available). The operative report for the
general surgeon should cover only the part of
the operation reported with a –62 modifier; the
remainder of the operation will only be covered
in the neurosurgeon’s report.
How should I report repair of a scar on
the trunk?
A repair of a scar usually includes excision of
a benign lesion and may require an intermediate or complex repair. You would choose the
appropriate anatomical site and size from codes
11400-11446. For lesions requiring more than
simple closure, report the excision and the appropriate intermediate (codes 12031-12057) or
complex repair (codes 13100-13153). Note that
full thickness repairs of the lip are located in
codes 40650-40654, and full thickness repairs of
the eyelid are located in codes 67961-67975.
If you are reporting more than one repair,
add the lengths together as long as they are
described by the same code. For example, repairing separate scars on the cheek and forehead
would both be covered by codes 13131-13133,
so their lengths would be added and only one
code reported.
What is the diagnostic code for changing
a generator for a pacemaker because of a
recall?
ICD-9-CM (International Classification of
Diseases, Ninth Revision, Clinical Modification) code 996.01 is the code for the problem
presented. Codes 996.01 through 996.59 are all
mechanical complications of various devices,
implants, or grafts. Surgeons doing replacement insertion of any type should be sure that
the billing staff knows who should pay for the
surgery. The manufacturer of the device should
pay for replacements resulting from recalls.
If you are going to bill the manufacturer, be
sure to follow the instructions provided by the
manufacturer.
Can two surgeons in the same practice assist each other?
Yes, of course they can, if assistance is medically necessary. The surgeon who assists reports
the procedure code with a modifier –80 (or modifier –82, if they are at a teaching institution and
no qualified resident is available).
How do I report a situation where a patient
had to be returned to the operating room
to control bleeding and/or to evacuate a
hematoma following mastectomy?
You should report code 35820, Exploration for
postoperative hemorrhage, thrombosis or infection; chest, along with modifier –78, Return to
the operating room for a related procedure during the postoperative period. That –78 modifier
has two functions. First, it shows acknowledgment on the physician’s behalf that, “I know this
occurred during the postoperative period of the
original mastectomy, but, because it required a
return trip to the operating room, it is enough
work that the surgeon ought to get paid.” Second, the global period gets reset so that the
second surgery becomes the beginning of the
global period. Notice that there are identical
35
codes for the neck, abdomen, and extremity in
the series of codes 35800-35860.
The surgeon attempted, but could not
complete, surgery on a patient who had
extensive internal and external hemorrhoids. A month later, the patient returned
to the operating room for a successful
hemorrhoidectomy. How should I code the
second surgery?
Sedation with or without analgesia (conscious
sedation); oral, rectal and/or intranasal. Then,
be sure you do not bill for conscious sedation
with one of the codes in CPT Appendix G, Summary of CPT codes, which includes conscious
sedation. However, please note that Medicare
and some other payors will not pay the surgeon
for conscious sedation because it is considered

an inherent part of the procedure.
Use code 46260, Hemorrhoidectomy, internal
and external, complex or extensive, and attach
a modifier –78, Return to the operating room
for a related procedure during the postoperative
period, if you are still in the global period for
the first procedure.
How do I bill for a recurrent tumor after mastectomy? I normally would bill a
lumpectomy or mastectomy code, but the
patient has had a mastectomy so there is
no breast tissue.
Your instinct is quite right. If there is no
breast tissue, you cannot say that breast tissue
was removed. Report code 21555, Excision tumor, soft tissue of neck or thorax; subcutaneous,
or code 21556, Excision tumor, soft tissue of neck
or thorax; deep, subfascial, intramuscular.
What code do I use to report the excision of
a lesion lateral to the pectoralis muscle?
If it was in breast tissue, use code 19160,
Mastectomy, partial (e.g., lumpectomy, tylectomy,
quadranectomy, segmenectomy.) If it was in the
thorax, use either code 21555 or code 21556.
(See the previous question for their definitions.)
If you cannot tell from the operative report
whether it was in the breast or thorax or, if in
the thorax, how deep it was, ask the surgeon.
Why do we not always get paid for conscious sedation?
36
First, be sure you are billing appropriately.
The codes to use are 99141, Sedation with or
without analgesia (conscious sedation); intravenous, intramuscular or inhalation, or 99142,
College
news
In memoriam:
Luis F. Sala, MD, FACS (1919-2005)
by C. Rollins Hanlon, MD, FACS, ACS Executive Consultant, Chicago, IL
After several years of poor
health, Luis F. Sala, MD, FACS,
passed away on June 23, 2005,
ending an outstanding surgical
and civic career. He is appropriately remembered as the recipient of the American College of
Surgeons’ highest honor, the
Distinguished Service Award,
in 1989.
Following basic education in
San Juan, PR, and bachelor of
science (“cum laude”) and medical degrees from Georgetown
University in Washington, DC,
Dr. Sala served as captain in
the U.S. Army Medical Corps
from 1945 to 1947. Residency
education at the Graduate
Hospital of the University of
Pennsylvania from 1947 to
1951 earned him a master of
science in surgery. In 1953, he
was board certified in surgery
and achieved Fellowship in the
American College of Surgeons.
His participation in College
activities included extensive
committee work in trauma
and cancer and nine years as
Governor, ending as Secretary
of the Board of Governors from
1973 to 1974. For many years,
he provided valuable service
on the College’s International
Relations Committee, including its Executive Committee;
he was also President of the
Puerto Rico Chapter of the
College.
Dr. Sala’s involvement in
other professional organiza-
Dr. Sala
tions was varied and extensive.
He was president of the Puerto
Rico State Board of Health
and an active officer of the
Puerto Rico Medical Association, including its presidency
from 1965 to 1966. He served
as chair of the department of
surgery of the Damas Hospital
and directed the residency program as professor of surgery at
the Ponce School of Medicine.
As dean and president of that
school, he devoted himself to
the elevation of surgical standards and medical education
both locally and throughout
Latin America.
He served as visiting professor in a number of regional
and international venues. In
1989, the ACS Board of Regents
conferred on him the Distinguished Service Award, citing
a lifetime of service to surgical
education, hospital standards
and accreditation, and numerous civic projects.
His civic endeavors included
the presidency of the Friends of
the Art Museum of Ponce and
many committee memberships
as advisor to the president
of the Catholic University of
Puerto Rico. He was a member
of the Young Men’s Christian
Association of Ponce and on the
board of directors of the Boys’
Home of Ponce. For 19 years,
he served as chairman of the
District Committee on Health
of the Boy Scouts of America,
which recognized him in 1962
with an award for distinguished
services to boyhood. He was
a member of the Knights of
Columbus and a Knight of the
Holy Sepulcher.
Dr. Sala is survived by his
wife, Judith, and four sons, the
eldest also a Fellow of the College. Despite his immense contributions in so many organizational, civic, and professional
areas, his manner was always
mild, unassumingly gentle, and
friendly. His life was a genuine
inspiration to those who were
privileged to know him.
37
Commission on Cancer grants
39 Outstanding Achievement Awards
38
The Commission on Cancer
(CoC) of the American College
of Surgeons has granted its
CoC Outstanding Achievement
Award (OAA) to CoC-approved
cancer programs at 39 facilities
(see list at right).
Established in 2004, the CoC
OAA recognizes cancer programs that strive for excellence
in providing quality care to cancer patients. A facility receives
the OAA following the on-site
evaluation by a physician surveyor, during which the facility
demonstrates a commendation
level of compliance with seven
standards—cancer committee leadership, cancer data
management, clinical services,
research, community outreach,
and quality improvement—that
represent the full scope of the
cancer program. A facility also
receives a compliance rating for
29 additional standards.
The 39 programs received
the OAA as a result of surveys
performed in 2004. This number
represents approximately 9 percent of the programs surveyed
during this period. A majority of
recipients are community-based
facilities; teaching hospitals,
National Cancer Institute-
designated comprehensive cancer centers, and network cancer
programs also received the
award.
Established in 1922 by the
the CoC is a consortium of
professional organizations dedicated to improving survival
The CoC has granted its CoC Outstanding Achievement Award to
CoC-approved cancer programs at the following 39 facilities:
Medical Center East, Birmingham, AL
City of Hope National Medical Center, Duarte, CA
Sutter Roseville Medical Center, Roseville, CA
Naval Medical Center, San Diego, CA
VA San Diego Healthcare System, San Diego, CA
Good Samaritan Hospital, San Jose, CA
Presbyterian Intercommunity Hospital, Whittier, CA
Memorial Hospital, Colorado Springs, CO
George Washington University Hospital, Washington, DC
Northside Hospital, Atlanta, GA
Piedmont Hospital, Atlanta, GA
DeKalb Medical Center, Decatur, GA
Advocate Good Shepherd Hospital, Barrington, IL
Evanston Northwestern Healthcare, Evanston, IL
Elkhart General Hospital, Elkhart, IN
Goshen Hospital, Goshen, IN
University of Kansas Medical Center, Kansas City, KS
Taylor Regional Hospital, Campbellsville, KY
St. Elizabeth Medical Center, South, Covington, KY
Beth Israel Deaconess Medical Center, Boston, MA
Bixby Medical Center, Adrian, MI
McLaren Regional Medical Center, Flint, MI
Audrain Medical Center, Mexico, MO
Randolph Hospital, Asheboro, NC
Regional West Medical Center, Scottsbluff, NE
Exeter Hospital, Exeter, NH
CentraState Healthcare System, Freehold, NJ
Virtua Health, Marlton, NJ
Roswell Park Cancer Institute, Buffalo, NY
Bassett Healthcare, Cooperstown, NY
Middletown Regional Hospital, Middletown, OH
Southwestern Regional Medical Center, Tulsa, OK
Merle West Medical Center, Klamath Falls, OR
St. Luke’s Hospital & Health Network, Bethlehem, PA
Avera St. Luke’s Hospital, Aberdeen, SD
Avera Queen of Peace, Mitchell, SD
Scott and White Memorial Hospital, Temple, TX
Gulf Coast Medical Center, Wharton, TX
ProHealth Care, Inc., Waukesha, WI
Space sold by Elsevier
and quality of life for cancer
patients through standard setting, prevention, research, education, and the monitoring of
comprehensive quality care.
Its membership includes Fellows of the American College of
Surgeons and representatives
of 41 national organizations
that reflect the full spectrum of
cancer care.
The CoC= s core functions
include setting standards for
quality, multidisciplinary cancer
patient care; surveying facilities
to evaluate compliance with
the 36 CoC standards; collecting standardized, high-quality
data from approved facilities;
and using these data to develop
effective educational interventions to improve cancer care
outcomes at the national, state,
and local levels. There are currently more than 1,400 CoC-approved cancer programs in the
U.S. and Puerto Rico, representing close to 25 percent of all
hospitals. These CoC-approved
facilities diagnose and/or treat
80 percent of newly diagnosed
cancer patients each year.
The approvals program, a
component of the CoC, sets
quality-of-care standards for
cancer programs and reviews
the programs to ensure that
they conform to those standards. Approval by the CoC is
given only to those facilities
that have voluntarily commit-
ted to providing the highest
level of quality cancer care
and that undergo a rigorous
evaluation process and review of
their performance. To maintain
approval, facilities with CoC-
approved cancer programs must
undergo an on-site review every
three years. Receiving care at a
CoC-approved cancer program
ensures that a patient will have
access to the following:
$ Comprehensive care, including a range of state-of-theart services and equipment
$ A multispecialty team approach to coordinate the best
treatment options
$ Information about ongoing
clinical trials and new treatment options
$ Access to cancer-related
information, education, and
support
$ A cancer registry that collects data on type and stage of
cancers and treatment results
and offers lifelong patient follow-up
$ Ongoing monitoring and
improvement of care
$ Q u a l i t y c a r e c l o s e t o
home
Cancer patient data are reported by each CoC-approved
cancer program to the CoC=s
National Cancer Data Base
(NCDB), a joint program with
the ACS. The NCDB currently
contains patient demographics, tumor characteristics, and
Pay your dues online!
Just visit www.facs.org
and go to the “Members Only” tab
40
treatment and outcomes information for more than 16 million cancer patients diagnosed
and treated at hospital cancer
programs in the U.S. from 1985
to 2003. These data account for
approximately two-thirds of
newly diagnosed cancer cases
in the U.S. each year.
NCDB data are used regularly
to monitor the quality of patient
care delivered in CoC-approved
cancer programs and to improve cancer care outcomes at
national and local levels.
The CoC requires programs
to implement quality improvement initiatives that promote
the delivery of quality, multidisciplinary cancer care and
lead to ongoing educational
interventions with local providers in the CoC-approved cancer
programs.
Through an exclusive partnership with the AC S, the
CoC provides the public with
information on the resources, services, and cancer treatment experience for each CoC-
approved cancer program. This
information is available to the
public on the ACS Web site at
www.cancer.org, and through
the ACS National Cancer Information Center at 800/ACS2345.
For more information about
the CoC, visit its Web site at
www.facs.org/cancer/index.
html.
In memoriam:
R. Gordon Holcombe, Jr., MD, FACS
(1913-2005)
by C. Rollins Hanlon, MD, FACS, ACS Executive Consultant, Chicago, IL
The American College of
Surgeons lost one of its most
dedicated supporters on August 4, 2005, when R. Gordon
Holcombe, Jr., MD, FACS, of
Lake Charles, LA, died at the
age of 91 after a long illness.
A Fellow of the College for
60 years, Dr. Holcombe was the
primary architect of the Fellows Endowment Fund, which
was established on a voluntary
basis of contributions through
the College chapters, starting
with the Louisiana Chapter in
the 1970s. (See “Tracing the
‘roots of philanthropy’ at the
chapter level,” an article by
Lynn H. Harrison, Jr., MD,
FACS, which appeared in the
Bulletin [vol. 86, No. 5, pages
35-37].)
The current balance of the
Fund exceeds $3 million;
a portion of its earnings is
used annually to support ACS
scholarships and Fellowship
award programs.
In 1980, the Board of Reg e n t s r e c o g n i z e d D r. H o l combe as the 25th recipient
of the Distinguished Service
Award for his remarkably
sustained record of service
in civic, organizational, and
military spheres.
Moreover, in appreciation of
his significant contributions
to the financial strength of the
College, the Committee on De-
Dr. Holcombe
College endowment support.
Ultimately, the lives of surgical patients will benefit from
improved care because of
scholarships and fellowships
funded through the endowment he set in motion.
Dr. Holcombe is survived by
three children, Ann Elise Holcombe, Elizabeth Holly Holcombe Strapulos, and Richard
Gordon Holcombe III.
Donations in his memory
may be made to the Louisiana Chapter of the ACS, c/o
633 N. Saint Clair St., Chicago, IL 60611, or to Friends
of McNeese State Library,
c/o Frazar Memorial Library,
4205 Ryan St., Lake Charles,
LA 70605.
velopment in 2004 established
the R. Gordon Holcombe, Jr.,
MD, FACS, Award to recognize
ACS chapters for outstanding
financial support. When the
award was introduced during
the 2004 Clinical Congress
in New Orleans, LA, Dr. Holcombe’s Louisiana Chapter
was the first recipient.
Because of his unique vision
that translated into action, Dr.
Holcombe’s presence will be
felt for generations, through
surgeons who will benefit
each year as recipients of
41
2007 ACS ANZ Chapter
Travelling Fellowship available
The International Relations Committee of the
American College of Surgeons announces the availability of a travelling fellowship, the Australia and
New Zealand (ANZ) Chapter of the American College of Surgeons Travelling Fellowship.
Purpose
The purpose of this fellowship is to encourage
international exchange of information concerning
surgical science, practice, and education and to
establish professional and academic collaborations
and friendships.
Basic requirements
The scholarship is available to a Fellow of the
American College of Surgeons in any of the surgical specialties who meets the following requirements:
• Has a major interest and accomplishment in
basic sciences related to surgery
• H o l d s a c u r r e n t f u l l - t i m e a c a d e m i c
appointment in Canada or the U.S.
• Is younger than 45 years on the date the
application is filed
• Is enthusiastic, personable, and possesses
good communication skills
42
Activities
The Fellow is required to spend a minimum of two
or three weeks in Australia and New Zealand:
• To attend and participate in the Annual
Scientific Congress of the Royal Australasian
College of Surgeons (RACS), which will be held in
Christchurch, New Zealand (May 6–11, 2007)
• To participate in the formal convocation
ceremony of that congress
• To attend and address the ANZ Chapter
meeting during that congress
• To visit at least two medical centres in
Australia and New Zealand before or after the
Annual Scientific Congress of the RACS to lecture
and to share clinical and scientific expertise with
the local surgeons
In the event that the selected applicant is from
a surgical specialty that is not participating in
the RACS Congress, specific negotiations will be
necessary to ensure the Travelling Fellow’s participation in a national meeting of that specialty.
The academic and geographic aspects of the itinerary will be finalized in consultation and mutual
agreement between the Fellow and the President
or designated representative of the ANZ Chapter
of the ACS. The surgical centres to be visited depend to some extent on the special interests and
expertise of the Fellow and his or her previously
established professional contacts with surgeons
in Australia and New Zealand.
The successful applicant’s spouse is welcome
to accompany him or her. There will be many opportunities for social interaction, in addition to
these professional activities.
Financial support
The ANZ Chapter and the College will provide
a sum of $12,000 U.S. to the successful applicant,
who will also be exempted from registration
fees for the Annual Scientific Congress. He/she
must meet all travel and living expenses. Senior
chapter representatives will consult with the Fellow about the centres to be visited in Australia
and New Zealand, the local arrangements for
each centre, and other advice and recommendations about travel schedules. The Fellow is to
make his/her own travel arrangements in North
America, as this makes available reduced fares
and travel packages for travel in Australia and
New Zealand.
The ACS International Relations Committee
will select the Fellow after review and evaluation
of the final applications. A personal interview may
be requested prior to the final selection.
The closing date for receipt of completed applications is November 15. The successful applicant
and an alternate will be selected and notified by
March 2006. Applications for this travelling fellowship may be obtained by writing to the Inter-
national Liaison Section, ACS, 633 N. Saint Clair
St., Chicago, IL 60611-3211, or obtained online
at http://www.facs.org/memberservices/traveling.
html/ or www.facs.org.
2006 Nizar N. Oweida, MD, FACS,
Scholarship available
The Board of Governors of the American College
of Surgeons announces the availability of a scholarship for young rural surgeons, the Nizar N. Oweida,
MD, FACS, Scholarship of the ACS.
Purpose
The Oweida Scholarship provides an award of
$5,000 to subsidize the participation of a young
rural-based Fellow or Associate Fellow in attendance at the annual Clinical Congress of the
American College of Surgeons.
Basic requirements
The Oweida Scholarship is available to a member of the American College of Surgeons in any of
the surgical specialties who meets the following
requirements:
• Serves a rural community in the U.S. or
Canada
• Is a Fellow or Associate Fellow in good
standing
• Is younger than 45 years on the date the
application is filed
Activities
The Oweida Scholar will attend the annual Clinical Congress of the American College of Surgeons,
which will be held in Chicago, IL, October 8–12,
2006. He or she will also attend the annual scholarship luncheon on Sunday, October 8, 2006, to meet
the members of the Scholarships Committee and
awardees from other programs and to receive his
or her stipend.
Financial support
The successful applicant will receive a sum of
$5,000 U.S. This amount is to be used to help
defray travel expenses for the Clinical Congress,
Postgraduate Course fees, hotel costs, and per
diem expenses during the Clinical Congress.
Preferential housing in a thrifty hotel near the
Congress site will be made available to the scholar.
The scholar will make his or her own travel arrangements.
The Executive Committee of the Board of Governors will select the scholar after review and
evaluation of the applications. Applicants for the
Oweida Scholarship should submit the following
items:
• One copy of the applicant's current curriculum
vitae.
• A one-page essay, discussing the following
specific items:
—Why the applicant wishes to receive the Oweida
Scholarship
—Why the applicant believes he or she is qualified
to receive the scholarship
—Why the applicant characterizes his or her
practice as rural
The closing date for receipt of completed applications is December 15. Please send applications for
this scholarship to: Scholarships Section, American
College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611-3211. A scholar and an alternate
will be selected and all applicants will be notified
of the outcome of the selection process by March
31, 2006.
The Oweida Scholar must attend the full week
of the Clinical Congress in the year for which the
scholarship is designated; the award cannot be
postponed. The Oweida Scholar will provide a
brief report on his or her experiences at the Clinical Congress for possible future publication in the
Bulletin of the American College of Surgeons. A
simple accounting for the award is also required.
These items are due by December 1, 2006.
Questions may be directed to the ACS Scholarships
Administrator, 312/202-5281. Requirements for the
Oweida Scholarship are also posted on the College’s
Web site at www.facs.org.
43
Fellows in the news
J o r g e C e r v a n t e s , M D,
FACS, Mexico City, Mexico, was
installed for a two-year term as
president of the Mexican Board
of Surgery. Dr. Cervantes was
also awarded the gold medal
Excellence in Medicine Award
by the American British Cowdray Medical Center, where he
is a professor of surgery in the
National University of Mexico
Program.
James M. Cook, MD, FACS,
was recently elected president
of the Pacific Northwest Vascular Society. Dr. Cook is a
vascular surgeon with Radia
Center for Vascular Disease
in Everett, WA, and is on staff
at Providence Everett Medical
Center. He is also a member of
the Washington State Medical
Association and the Society for
Vascular Surgery.
Lake City, UT, founded IVU
in 1995.
In May, E. Carmack Holmes,
MD, FACS, Los Angeles, CA, a
surgical oncologist and executive director of the Center for
Advanced Surgical and Interventional Technology at the
University of California–Los
Dr. Klingensmith
Dr. Mellinger
Dr. Merrick
Dr. Wren
At the American Academy
of Cosmetic Surgery (AACS)
21st Annual Scientific Meeting, where he served as chair,
Claude H. Crockett, MD,
FACS, was named AACS president for 2005. Dr. Crockett is
in private practice in Bristol,
TN.
44
International Volunteers
in Urology (IVU), a nonprofit
organization that provides
urological education and treatment to developing countries,
celebrated its 10th anniversary
in 2005. Catherine deVries, MD, FACS, a pediatric
urologist with Primary Children’s Medical Center in Salt
Angeles Medical Center, has
been inducted into the Johns
Hopkins University Society
of Scholars and was awarded
honorary membership in the
Royal College of Physicians and
Surgeons of Glasgow. His honorary membership recognizes
Dr. Holmes’ contributions to
the profession and his links to
Scotland, where he has lectured
many times.
The following Fellows were
awarded the 2005 Association
for Surgical Education (ASE)
Outstanding Teacher Award:
Mary Klingensmith, MD,
FACS; John Mellinger, MD,
FACS; Hollis Merrick, MD,
FACS; and Sherry Wren,
MD, FACS. The awards were
presented at the ASE’s annual
meeting in March. (See photos,
previous page.)
James A. Large, MD, FACS,
was awarded the Raymond H.
Alexander, MD, FACS, Award at
the Florida Chapter’s 2005 annual meeting. Dr. Large, a PastPresident of the chapter and
long-time member of its executive council, was recognized for
his years of dedicated service to
surgery and medicine in Florida
and on a national level.
Lee E. Smith, MD, FACS,
was elected chair of the Federation of State Medical Boards
(FSMB) board of directors in
May. Dr. Smith, a facial plastic
reconstructive surgeon from
Princeton, WV, was elected at
the FSMB House of Delegates
annual meeting.
Discounted subscriptions to Epocrates
now available to ACS members
Through a special arrangement with the American College of Surgeons, Epocrates is
offering members of the College
a 25 percent discount on paid
subscriptions, Epocrates Rx ®
free drug and health formulary
information, and software and
hardware bundle packages. Epocrates Rx Pro is the first
handheld drug reference guide
to provide comprehensive information—such as dosing, common uses, drug interactions,
and adverse reactions—on more
than 400 alternative medicines.
Epocrates Rx Online is a new
Web-based desktop version
of Epocrates Rx that can be
referenced from any computer
with Internet access. One in
four physicians in the U.S. is
now connected to the Epocrates
Network, and its products and
services allow physicians to improve quality of care and save
time by making more informed
clinical decisions. For more information online,
visit http://www.facs.org/members/epocrates.html.
Trauma meetings calendar
The following continuing medical education courses in trauma
are cosponsored by the American
College of Surgeons Committee
on Trauma and Regional Committees:
• Advances in Trauma, December 9–10, Kansas City, MO.
• Trauma and Critical Care
2006, March 20–22, Las Vegas,
NV.
• Trauma and Critical Care
2006—Point/Counterpoint
XXV, June 5–7, Williamsburg,
VA.
Complete course information
can be viewed online (as it becomes available) through the
American College of Surgeons
Web site at: http://www.facs.
org/trauma/cme/traumtgs.html,
or contact the Trauma Office at
312/202-5342.
45
The following comments were
received in the mail or via e-mail
regarding recent articles published
in the Bulletin and the “From my
perspective” columns written by Executive Director Thomas R. Russell,
MD, FACS.
46
Specialist shortage
I just finished reading the column
“From my perspective” on shortages
of surgical specialists (Bull Am Coll
Surg. 2005;90(6):4-5). I have long
thought that the surgical stage is
due for a major change. When I
was a member of the admissions
committee of the University of New
Mexico School of Medicine, I noted
that the medical school applicants
had a different perspective on the
role of medicine in their lives from
that of my generation. For many, it
seems, medicine is more of a career
than a calling. Although they clearly
recognize it is an important job, they
are less interested in keeping the ridiculous schedules many of us older
surgeons followed over the years,
and medicine is often secondary to
family and a more reasonable and
pleasant lifestyle. This change in
attitude is not a bad thing, as such
physicians will be more well-rounded
individuals and will see themselves
as more than their credentials.
As I look back, I really did lead a
ridiculous life, although I enjoyed
it immensely and would not have
done anything differently. However,
in recent years, I have heard about
the difficulties in recruiting young
medical school graduates to the
field of general surgery and, given
the demands on time, such lack of
interest is understandable. Thus,
change is now imperative.
Steps have already been taken
in modifying the training of general surgeons. But training is only a
small part of the problem. It is what
happens after training that also
needs change. The residents have to
see that the life of a general surgeon
can be great inside and outside of the
operating room/office. I believe the
model lies in something Dr. Russell
mentioned in the column: the “hospitalist” of internal medicine.
I foresee the “surgical hospitalist.” I understand that such a model
already exists in Phoenix, AZ, and I
suspect elsewhere. The surgical hospitalist will see and care for all of the
acute surgical problems including
trauma, and the “other general surgeons” will do all the elective work.
The hospitalists will work as a team
and in shifts. The “elective general
surgeon” will be relieved of a great
deal of the afterhours work that
makes general surgery so stressful,
unpredictable, and unattractive to
young physicians.
There are obviously many details
that need to be considered and addressed, but this is doable. This
model allows a more reasonable
lifestyle for all general surgeons.
Change is inevitable. We just have
to be innovative enough to stay in
tune with each new generation.
Brian Miscall, MD, FACS,
Albuquerque, NM
I felt compelled to respond to Dr.
Russell’s editorial about a surgical
specialist shortage in the June issue
(“From my perspective.” Bull Am
Coll Surg. 2005;90(6):4-5). I am a
general surgeon, practicing for 12
years. I practice in two medium-sized
hospitals in a town of 50,000, with
a catch area of 100,000. I currently
serve as chief of staff at one hospital.
Over the years, call has become a
terrible burden. Many subspecialists
are available only some of the time,
and the emergency physician then
calls the general surgeon on call.
This situation puts the general surgeon in the position of dealing with
issues that he or she is not comfortable addressing, which would not be
a problem if this were a liability-free
environment. In my community, one
general surgeon quit and went into
business; another stopped doing call
at the busier hospital and set up a
vein clinic. Call was a major factor
in these decisions.
Trauma is another significant
problem. I try to refer all trauma
cases to a tertiary care center, if
possible, but we have trouble getting
these hospitals to accept transfers
at times. Our hospitals are not sufficiently equipped to deal with major
trauma and I certainly do not feel
that I am the best-qualified person
to deal with major trauma.
What other group of people
would be willing to deal with such
challenges under the current set of
circumstances? General surgeons
take call with no financial consideration, deal with situations we feel illequipped to handle, often receive no
compensation, and open ourselves
to litigation. These circumstances
are the reason physicians are unwilling to continue to take call and
are looking for alternatives. Until
there is legitimate liability reform
and some protection for physicians,
this problem is only going to worsen.
Hospitals aren’t concerned about
this problem because they want all
of the patients to use their institutions. Administrators feel it is the
physician’s duty to provide this coverage, but they do not compensate
us in any way and do not share any
of the risk.
I hope that something can be done
soon, or many more physicians will
find alternative means and professions. Thank you so much for your
efforts.
Mark D. Jessen, MD, FACS,
Bowling Green, KY
Air bags OK for drivers
Congratulations to the developers
of air bags for their protection, decreasing the death rate of drivers in
automobile accidents by almost one
half (“It’s in the bag.” Bull Am Coll
Surg. 2005;90(7):63-64). However, it
seems that no one speaks of air bags
in the front-seat passenger side (also
known as the “death seat”).
Air bags on the front passenger
side are so dangerous that infants
and young children must be placed
in the back seat or they may be
killed by air bag deployment. But
no statistics are provided about the
effects of air bags on older children
and adults sitting in the “death seat”
during an accident.
Air bags are fine for drivers. But
what about passengers?
Robert F. Heimburger, MD, FACS,
Birmingham, AL
Additional resources
for quality improvement
In the “From my perspective”
column in the August 2005 Bulletin, Dr Russell states, “We believe
NSQIP [National Surgical Quality
Improvement Program], as the first
nationally validated, risk-adjusted,
outcomes-based program that has
been demonstrated to measure
and improve the quality of surgical care...” (Bull Am Coll Surg.
2005;90(8):5).
The Society of Thoracic Surgeons
(STS) applauds the NSQIP system
for its advances in promoting surgical quality and we wholeheartedly
endorse its use of clinical data and
statistical risk adjustment.
I should point out, however, that
the STS National Cardiac Surgery
Database has been in existence for
16 years and has always contained
sophisticated, rigorously validated
statistical risk models that use
clinical data to risk-stratify patients
undergoing cardiac surgery. We
have models of operative mortality
for coronary artery bypass graft
(CABG) and valve replacement and
also have risk-adjustment models
of operative morbidity for CABG
procedures. These models are incorporated into the standard STS
Database software for use by all
participants. We also have compelling data to demonstrate improved
outcomes in the last decade in spite
of progressively rising patient risk.
We presently have an abundance
of clinical information on just fewer
than 3 million patients registered
in the database. Although the exact
penetration in the U.S. is difficult to
determine, it appears that 70 percent to 80 percent of cardiac surgery
centers are now participating in the
STS Database.
This letter is meant as just a
friendly reminder of another very effective clinical database in surgery.
Fred H. Edwards, MD, FACS,
Jacksonville, FL,
chairman, STS Database
Response
We thank Dr. Edwards for his
thoughtful letter reminding us
about the STS Database. Of course,
he is absolutely correct—the STS
Database is excellent, robust, and
proven. The thoracic surgeons are
way out front in quality improvement as well as in most other realms
of surgical care. We are honored to
be their colleagues. R. Scott Jones, MD, FACS,
Director, ACS Division of
Research and Optimal
Patient Care
47
ACOSOG news: Clinical trials update
A follow-up report on the American
College of Surgeons Oncology Group
by R. Scott Jones, MD, FACS, Director,
ACS Division of Research and Optimal Patient Care, Chicago, IL
48
According to its mission statement, the American College
of Surgeons is “dedicated to
improving the care of the surgical patient and to safeguarding
standards of care in an optimal
and ethical practice environment.” Improving surgical care
requires at least three fundamental efforts: processes of care
based on the best knowledge and
technology available, monitoring
the outcomes of those processes
of care, and continual improvement of the applicable knowledge and technology. Improving
the care of surgical patients
requires new knowledge and new
technology; therefore, it requires
basic and clinical research. The
results of the American College
of Surgeons Oncology Group’s
(ACOSOG) clinical trials provide
crucial, unique resources for
improving the care of surgical
patients.
In 1993, the ACS Board of
Regents approved the concept
of supporting a new group dedicated to surgical oncology and
established a committee of seven
surgical oncologists to develop
the group’s organization and
structure. The ACS and the
Commission on Cancer approve
more than 1,400 cancer centers
that, with proper organization
and leadership, could form a
network to support the imple-
mentation and conduct of clinical trials. The ACS chapters, the
Commission on Cancer, the
Liaison Physicians, and the ACS
Communication and Education
division resources can all make
important contributions to the
success of ACOSOG clinical
trials.
In addition, the ACS—in partnership with the American Cancer Society—operates the Na-
tional Cancer Database (NCDB).
The NCDB can promote accrual
of patients into ACOSOG clinical trials by providing important
demographic information and
by identifying the types and
volumes of cancer patients being
treated in the cancer centers.
Analysis of the NCDB can provide data to assist the design and
development of clinical trials. Although the ACS has a particular
National Institutes of Health (NIH)
www.nih.gov
Founded in 1887, the NIH today is the federal focal point for medical
research in the U.S.
According to its Web site, “The goal of NIH research is to acquire
new knowledge to help prevent, detect, diagnose, and treat disease and
disability, from the rarest genetic disorder to the common cold.”
National Cancer Institute (NCI)
www.cancer.gov
The NCI, one of the 27 NIH institutes, was established under the
National Cancer Act of 1937.
The NCI coordinates the National Cancer Program, which conducts
and supports research, training, health information dissemination, and
other programs with respect to the cause, diagnosis, prevention, and
treatment of cancer, rehabilitation from cancer, and the continuing care
of cancer patients and the families of cancer patients.
Cancer Therapy Evaluation Program (CTEP)
ctep.info.nih.gov
The mission of the CTEP is to improve the lives of cancer patients
by finding better ways to treat, control, and cure cancer. The CTEP
accomplishes this mission by funding an extensive national program
of cancer research and by sponsoring clinical trials to evaluate new
anticancer agents.
interest in the ACOSOG, it must
be recognized and emphasized
that the ACS Fellowship and all
ACS resources should support
surgically related trials of all of
the other National Cancer Institute (NCI)-sponsored oncology
groups as well as the ACOSOG.
The ACS credits the origin and
accomplishments of ACOSOG
to Samuel A. Wells, Jr., MD,
FACS, Durham, NC, whose vision of ACOSOG materialized
into the first National Institutes
of Health (NIH)-funded surgical oncology group in 1997.
ACOSOG became the first new
cooperative group added to the
NCI-Cancer Therapy Evaluation
Program (CTEP) in two decades.
(See box, this page.) In the first
grant cycle, from 1997 to 1999,
ACOSOG established its leadership, administrative structure,
membership model, and scientific programs concept.
Between 1999 and 2004, NCI
funded the second ACOSOG
grant. In January 2001, ACOSOG
moved to Duke University in
Durham to broaden the operational base within the Duke
Clinical Research Institute.
During this grant period, 4,500
surgeons joined the ACOSOG
multispecialty membership. A
total of 18 studies assigned more
than 10,000 patients to clinical
trials. Several unique working
groups and four core Organ Site
Committees evolved: breast, gastrointestinal, thoracic, and sarcoma. The breast group accrued
6,442 patients, with two studies
closed, one open, and three pending at the end of the grant period; the gastrointestinal group
accrued 355 patients with two
studies closed, one open, and two
pending; the thoracic group ac-
crued 3,392 patients, with three
studies closed, one open, and two
pending; and lastly, the sarcoma
group accrued 455 patients, with
one closed study, two open, and
one pending.
The well-organized NIH site
visit in October 2004 received an
award of three years’ funding.
Leadership transition occurred
with David Ota, MD, FACS, Durham, NC, and Heidi Nelson, MD,
FACS, Rochester, MN, replacing
Dr. Wells as Co-Chairs. Stephen
L. George, PhD, Durham, NC,
assumed the statistical leadership position.
The ACOSOG has entered
the third NIH grant cycle and
continues to evolve rapidly. This
article and the monthly articles
to follow will inform surgeons
about the progress and results of
trials and discuss ACOSOG activities and opportunities. This
first article in the series outlines
past accomplishments, future
goals, and strategies. Future articles will provide information on
the evolving scientific programs,
meetings, and workshops, and
how to participate in clinical
trials. The goal of ACOSOG is
to improve the care of cancer
patients through innovation and
research.
The third funding cycle begins
with three operational themes,
including focus, consistency
(communication), and partnership. The group elected to focus
the scientific programs on the
four primary organ site centers,
including breast, gastrointestinal, thoracic, and sarcoma.
The head and neck group has
maintained active accrual to
Z0360 on lymphatic mapping
in sentinal lymphadenectomy
and will complete accrual of 161
patients in February 2006. The
melanoma and neurosurgical
working groups continue to meet
but will not have active scientific
programs until after the next
site visit in 2007.
The leaders of ACOSOG will
communicate and strengthen
its partnerships and relationships with ACS, Duke Clinical
Research Institute, Duke University, NCI, CTEP, and corporations seeking clinical research
support.
The scientific themes continue to focus on the following:
Cooperative Groups of the NCI-CTEP Program
(founding year)
ACRIN
American College of Radiology Imaging Network (1999)
ACOSOG
American College of Surgeons Oncology Group (1996)
NCCTG
North Central Cancer Treatment Group (1977)
GOG
Gynecologic Oncology Group (1970)
COG
Children’s Oncology Group (1970)
RTOG
Radiation Therapy Oncology Group (1968)
NSABP
National Surgical Adjuvant Bowel and Breast Project (1958)
SWOG
Southwestern Oncology Group (1956)
CALGB
Cancer and Leukemia Group B (1955)
ECOG
Eastern Cooperative Group (1955)
49
(1) surgical innovations, (2)
novel preoperative and postoperative adjuvant therapies,
and (3) management of early
stage disease of micrometastases. Examples of surgical innovative trials include
Z4032 Sublobar R esection
versus Sublobar R esection
plus Brachytherapy, Z4033
Pilot Study of Radiofrequency
Ablation in Stage I Non-small
Cell Lung Cancer Patients,
Z6041 Phase II Trial of Neoadjuvant Chemoradiation and
Local Excision for T2 Rectal
C a n c e r, Z 0 3 6 0 Ly m p h a t i c
Mapping for T1,2 Clinical N0
Oral Cavity SCC, and Z1052
Cryoablation of Early Breast
Cancer.
This article and the following
series of ACOSOG articles intend to broaden the participation of surgeons in ACOSOG at
all levels. ACOSOG will strive
to develop greater community
surgeon participation during
the next two and a half years.
The ACS and ACOSOG are
currently poised to reduce
death, disability, and overall
misery from solid cancers in
North America and abroad.
The single most important
determinant for the success
of this opportunity is the commitment, support, engagement,
50
and participation in this project
of every Fellow of the American College of Surgeons. Even
Fellows who do not provide
cancer care should urge their
colleagues specializing in oncology to enroll their patients in
trials and to support ACOSOG.
All Fellows who treat cancer
should become members of
ACOSOG and actively enroll
patients in the trials. Brisk accrual gives the most applicable
trial results. Fellows of the College have never had such an opportunity to address the needs
of society while providing the
best care for their individual
patients.
NTDBTM data points
Alcohol is no industrial accident
by Richard J. Fantus, MD, FACS, Chicago, IL, and John Fildes, MD, FACS, Las Vegas, NV
52
In the early 1900s, workers
in the U.S. faced remarkably
high safety and health risks
on the job. Efforts by workers,
employers, unions, government
agencies, and scientists have
made considerable progress in
improving these conditions. By
the end of the 20th century,
fatal workplace injuries had
declined steadily from a high of
62 per 100,000 workers to four
per 100,000 workers. Industries
with the highest average rates
for fatal occupational injury
during the later part of that century include mining, agriculture/
forestry/fishing, construction,
and transportation/communications/public utilities. The leading causes of these fatal injuries
were motor vehicle-related injuries, workplace homicides, and
machine-related injury.
There are cause of injury codes
(E codes) that are used to denote
the place where an injury occurs.
E code 849.3 relates to injuries
occurring at an industrial place
and premises. This E code accounts for more than 35,000
records in the National Trauma
Data Bank TM Annual Report
2004. These injuries resulted
in an overall mortality rate of
2 percent, an average length of
stay of five days, length of stay in
an intensive care unit of slightly
more than one day, and average
medical costs close to $38,000.
Total charges for this group add
Alcohol-related industrial injury
up to more than $1.3 billion.
This figure does not begin to
scratch the surface of total cost,
however, because it doesn’t include the financial losses related
to decreased productivity as a
result of employees’ absence
from the workplace.
Taking a closer look at this group
reveals that of those tested for
alcohol after the injury, one in 10
tested positive. These data are depicted in the chart on this page.
As prevalent as alcohol consumption has become, it is not
hard to imagine that alcohol
consumption and its negative
consequences could spill over to
the workplace. Consumption of
alcohol on the job, arriving to
work with a hangover as result of
previous consumption, or being
a working alcoholic is associated
with an increased risk of injury on the job. According to the
Employee Assistance Society of
North America (EASNA), alcohol
abusers have a risk of being involved in an industrial accident
two to three times higher than
those who do not abuse alcohol.
In addition, EASNA’s studies
demonstrate that alcohol has
been implicated in 40 percent of
industrial fatalities.
For more information, visit the
EASNA Web site at http://www.
easna.org. Fortunately, workplaces today have employee assistance
programs that are designed to assist these individuals, as “alcohol
is no industrial accident.”
Throughout the year, we will be
highlighting these data through
brief monthly reports in the
Bulletin. The full NTDB Annual
Report Version 4.0 is available on
the ACS Web site as a PDF file
and a PowerPoint presentation
at http://www.ntdb.org. If you
are interested in submitting
your trauma center’s data, contact Melanie L. Neal, Manager,
NTDB, at mneal@facs.org.
Chapter
news
by Rhonda Peebles, Division of Member Services
To report your chapter’s news, contact Rhonda
Peebles at 888/857-7545, or via e-mail at rpeebles@
facs.org.
Nebraska contributes to mentoring
program for first-year med students
In response to a request from the medical
school at the University of Nebraska, the Nebraska Chapter surveyed its members and identified eight rural surgery sites where first-year
medical students can have a practice rotation.
According to Chapter President Ronald L. Ernst,
MD, FACS, in the past, medical students were
required to obtain a three-week, rural “experience” with a family practice rotation. Now the
first-year medical students will have the option
of completing a rural surgery rotation. Thus far,
the new mentoring has been well received by the
medical students, and approximately 35 medical
students have signed up for the rotation. For
more information, contact Dr. Ernst at 402/5645333, or via e-mail at ronernst@neb.rr.com.
South Florida Chapter: Drs. Cole and Carneiro.
Ohio Chapter seeking volunteers
54
Gary B. Williams, MD, FACS, Chapter President, is seeking volunteers to serve on various
chapter-level committees, including Bylaws,
Carrier Advisory Representative, Cancer, Communications, Community Hospital, Delegate
(and Alternate) to Ohio State Medical Association, Distinguished Service Award, Health Policy
and Advocacy, Medical Education/Program,
Membership, Resident Education, Resident Essay Contest, Trauma, Young Surgeons, and Association of Women Surgeons Representative.
In addition, the Ohio Chapter will begin
implementing its grassroots/advocacy plan,
the “KeyMD” program, which is designed to
further enhance the relationships of surgeons
and the Ohio Chapter with the Ohio General
Assembly.
To volunteer for the KeyMD program, or to
obtain a committee assignment, contact the
executive office at 877/677-3227, or via e-mail
at ocacs@ohiofacs.org.
Brooklyn-Long Island Chapter, left to right: Dr. Turner;
Dr. Anderson; Robert F. D’Esposito, MD, FACS,
Immediate Past-President; and Dr. Bernstein.
South Florida meets
during ACS Spring Meeting
During the ACS Spring Meeting in Hollywood,
FL, the South Florida Chapter conducted its 16th
Surgical Research Forum on April 18. In all, 13
residents and medical students presented, and
cash awards for first, second, and third places
were given in two research categories: clinical
and surgical. The first-place winners were Denise M. Carneiro, MD, and Patrick Cole, MD (see
photo, page 54).
Brooklyn-Long Island hosts
ACS President-Elect and Young
Surgeons
On June 2, the Brooklyn-Long Island Chapter
conducted its annual Young Surgeons Dinner,
and Kathryn D. Anderson, MD, FACS, the College’s President-Elect, addressed the group. In
addition to the social event, an annual business
meeting was conducted and new officers were
elected, including Michael O. Bernstein, MD,
FACS, President; James W. Turner, MD, FACS,
Vice-President; and Charles V. Coren, MD, FACS,
Secretary (see photo, page 54).
Virginia focuses on rural surgery
The Virginia Chapter recently completed a
rural surgery survey to examine rural surgical
services and education needs in Virginia. Noteworthy findings from the 37 survey respondents
included the following:
• More than half the respondents practiced in
towns with fewer than 30,000 residents.
• For more than one-half of the respondents,
two or three general surgeons practice within the
same community.
• More than 60 percent of the respondents
were satisfied with the amount of on-call coverage
they provided.
• On average, nearly three-fourths of the respondents were on-call six to 15 nights per month,
and more than 80 percent were able to arrange for
Chapter meetings
For a complete listing of all of the ACS chapter education programs and meetings, please visit the ACS Web
site at http://www.facs.org/about/chapters/index.html.
(CS) following the chapter name indicates a program cosponsored with the College for Category 1 CME
credit.
November
Date
Chapter
Location/contact information
Nov. 2 Delaware
Nov. 2 Connecticut (CS)
Nov. 19 Massachusetts (CS)
Nov. 26 Manitoba (CS)
December
Dec. 3 Location: Bowman Center, Newark, DE Contact: Barbara Coons, 302/658-7596
Location: Sheraton Four Points Hotel, Meriden, CT Contact: Christopher Tasik, 203/674-0747
Location: Dedham Hilton Hotel, Dedham, MA Contact: Aurelie Alger, JD, 978/927-8330
Location: Theatre “C” Basic Science Building, Winnipeg, MB
Contact: Lawrence Tan, MD, FACS, 204/787-3791
New Jersey (CS)
Dec. 7 January
Jan. 20
Jan. 20–22 Jan. 21–22 Brooklyn-
Long Island (CS)
South Florida (CS)
Southern California
(CS)
Louisiana (CS)
Location: Westin Princeton Forrestal Village, Princeton, NJ Contact: Art Ellenberger, 973/239-2826
Location: Long Island Marriott, Uniondale, NY Contact: Teresa Barzyz, 516/741-3887
Location: Hyatt Regency Pier 66 Resort & Marina
Contact: Bill Bouck, 305/687-1367
Location: Four Seasons Biltmore, Santa Barbara, CA Contact: C. James Dowden, 323/937-5514
Location: Ritz Carlton-New Orleans, New Orleans, LA Contact: Janna Pecquet, 504/569-9516
55
Chapter
coverage when pursuing educational and vacation
activities.
• In response to a query concerning education
needs, slightly more than 80 percent of the respondents indicated they needed “on-site proctor for
training in new procedures.”
• More than half the respondents believed that
specialty coverage was inadequate; the specialties
most lacking were plastic surgery, urology, and
vascular surgery.
For more information about the Virginia Chapter’s Rural Surgery Survey, contact Susan McConnell, Executive Director, at 804/643-6631, or via
e-mail at smcconnell@ramdocs.org.
Federal District (Mexico)
North Carolina
Ohio
Panama
Metropolitan Philadelphia
Saudi Arabia
South Carolina
Switzerland
Tennessee
North Texas
South Texas
Thailand
Utah
Venezuela
Vermont
Virginia
October chapter anniversaries
Chapter
Alabama
Belgium
San Diego (California)
Manitoba (Canada)
Colombia
Delaware
Jacksonville (Florida)
France
Hong Kong
India
Jamaica
Japan
Kansas
Years
54
6
32
49
39
48
48
18
10
12
13
18
54
Years
45
49
50
8
19
14
55
6
53
35
35
8
54
39
55
40
Clarification
The Chapter News column in the August Bulletin contained a story (page 47) regarding Philip T.
Siegert, MD, FACS, and his work with the College
as it updated its standards for office-based and
ambulatory surgical facilities. In addition to Dr.
Siegert, the following individuals were responsible
for the revisions enacted through the efforts of the
Committee on Ambulatory Surgical Care of the
ACS Board of Governors (all MD, FACS): James
W. Large; Peter F. Noyes; Alan Sugar; and Ronald
B. Berggren, Chair.
PREVENTION OF RETAINED FOREIGN BODIES, from page 14
56
The future
Eventually, technological advances in instrument and sponge detection, such as scanners
or handheld detectors, may make it easy to
account for surgical tools without cumbersome
counting procedures. The task of improving
patient safety is an exceptional platform for
emerging new technologies. There are many
companies in various stages of development with
innovations to make the surgeon’s job safer.
The incorporation of new technology that can
facilitate accounting of surgical tools (such as
bar-coding instruments or detection systems for
sponges including radio-frequency identification
and electronic surveillance systems) should be
evaluated and considered for adoption as they
become available.
Summary
The goal of this surgical patient initiative is
to bring the incidence of retained foreign bodies
after surgery to zero. The College encourages
every Fellow to adopt the recommendations provided in the ACS Statement on the Prevention of
Retained Foreign Bodies after Surgery (see page
15) and to move forward to refine policies and
processes of care. With effective perioperative
care systems, the surgical patient can be assured

that there will be “NoThing Left Behind.”

Future meetings - American College of Surgeons

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