Letters to the Editor

Editor’s note: The following comments were received regarding recent articles published in the Bulletin.

Letters should be sent with the writer’s name, address, e-mail address, and daytime telephone number via e-mail to dschneidman@facs.org, or via mail to Diane Schneidman, Editor-in-Chief, Bulletin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611.

Letters may be edited for length or clarity. Permission to publish letters is assumed unless the author indicates otherwise.

Apps incorporating clinical photography offer the potential to improve care

We read with interest the insightful article “Sharing clinical photographs: Patient rights, professional ethics, and institutional responsibilities” published in the October 2015 Bulletin (Bull Am Coll Surg. 2015;100[10]:17-22). Our own research experience using clinical photography for postoperative assessment has revealed several practical challenges related to secure image transmission and storage, image quality, and incorporation of remote assessments into surgeon workflow.

We are active clinicians and surgical researchers at the University of Washington, Seattle; University of Wisconsin, Madison; and Vanderbilt University, Nashville, TN, and are developing and testing Web- and smartphone-based tools incorporating clinical photography to manage postoperative patients. We have found that both patients and surgeons accept online approaches to care, and these techniques can be tailored to meet the needs of diverse populations, including the elderly.

We also have observed that wound images generated by patients and even providers are of variable quality and may be difficult to interpret. Patients have different degrees of experience with digital photography and may have physical impairments, such as poor vision or tremor, which can impair their ability to capture a focused image suitable for clinical diagnosis.

Furthermore, a health care professional can only evaluate the portion of the patient that is included in the image, creating a risk for missing key findings. Issues of secure data transmission and storage also have come to light, as has the increase in volume of information to be managed. Current clinical processes and informatics systems may not have the capacity to handle this deluge of additional patient data.

Despite these challenges, mobile applications incorporating clinical photography offer the potential to increase access to patient-centered care and improve outcomes. As a surgical community, we recognize an opportunity to establish standards for the capture, transmission, assessment, and documentation of digital images that inevitably will be used to provide surgical care.

Kristy Kummerow Broman, MD, MPH
Nashville, TN

Benjamin Poulose, MD, MPH, FACS
Nashville, TN

Heather Evans, MD, MS, FACS
Seattle, WA

Sara Fernandes-Taylor, PhD
Madison, WI

Time to change the general surgery MOC exam

I read with interest the article “The American Board of Surgery Maintenance of Certification Program: The first 10 years” in the July 2015 issue of the Bulletin (Bull Am Coll Surg. 2015;100[7]:15-19). The general surgery Maintenance of Certification (MOC) examination is offered annually and comprises approximately 200 multiple-choice questions designed to assess a surgeon’s cognitive knowledge and clinical judgment. The exam lasts five hours and is offered at testing facilities throughout the country. Surgeons must pass this examination every 10 years.

Most surgeons find the time and expense necessary to take these tests onerous. Some have argued that it has spawned a cottage industry that funnels profits into professional societies, test preparation book publishers, and testing companies.

A major argument in favor of board certification is that it maintains and improves the quality of care for patients. Two recent studies in the Journal of the American Medical Association sought to evaluate the role of MOC with respect to physician quality and medical costs, respectively.* Physicians certified before the 1990 requirement for recertification were compared with those certified after 1990. Medical outcomes were no better, and overall costs were barely lower in the recertifying group. Both studies concluded that MOC is expensive, time-consuming, and has no effect on quality of care.

It’s time to change the MOC examination from one that tests the ability of surgeons to reproduce recently crammed material to one that helps them improve their knowledge. Open-book examinations with generous time allotments and access to current resources should replace the current exams. They should be offered online at a reasonable cost. The ability to find and retain accurate information is more valuable than the ability to shoehorn it into memory. These examinations could even be required more often than every 10 years, as their purpose would be educational rather than administrative.

In January 2014, when the American Board of Internal Medicine announced a series of new requirements for MOC that would have generated additional fees, several leading physicians formed a new recertification organization: the National Board of Physicians and Surgeons (NBPAS). The leaders of the American Board of Surgery should set an example for all medical specialties by changing the MOC requirements as outlined above or in accordance with the NBPAS requirements. The result will be more knowledgeable practitioners, many sighs of relief, and improvement in our health care system.

Steven G. Friedman, MD, FACS
New York, NY

Remembering Dr. McSwain

I have fond memories of Norman E. McSwain, MD, FACS, who died last summer and whose obituary was published in the October 2015 Bulletin (Bull Am Coll Surg. 2015:100[10]:56-58). The first time I met him was as a visiting professor at Tulane University Hospital, New Orleans, LA. He picked me up at the airport and we chatted on the way to the hospital. He was dressed in a blue work shirt, wearing a bolo tie and black cowboy boots. I had grown up in eastern Washington, which was cattle country with many wheat fields. He reminded me of my childhood and being with people who were down to earth. After my talk the next morning, Norm invited me to come to his home in the French Quarter and spend the evening. His home was a true museum with mementoes of the Civil War and Native American culture. His clothing was a reflection of his personality. I don’t remember him wearing a regular tie but often a bolo tie, turquoise and other colors, was de rigueur. My wife Jane and I miss him and his compassion for his friends, family, and patients.

Donald D. Trunkey, MD, FACS
Portland, OR

Service members injured in combat should not have to seek volunteer care

I was surprised and angered by the article about Timothy A. Miller, MD, FACS, and Operation Mend, which was published in the December 2015 Bulletin (Bull Am Coll Surg. 2015;100[12]:28-30). Any service member injured in battle and requiring plastic and reconstructive surgery should not have to seek surgical care from a volunteer organization. This type of care should be available from the best plastic surgeons, such as Dr. Miller, and paid for in full by the federal government.

I’m sure Operation Mend is a wonderful organization and does surgery of the highest quality, but there should be no need for it. Men and women injured in battle deserve the best care possible and should not have to rely on a volunteer organization to provide their care.

W. Slocum Howland, Jr., MD, FACS
Highlands, NC


*Lee TH. Certifying the good physician: A work in progress. JAMA. 2014;312(22):2340-2342.

Gray BM, Vandergrift JL, Johnston MM, et al. Association between imposition of a maintenance of certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA. 2014;312(22):2348-2357.

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