I have served the American College of Surgeons (ACS) for more than a quarter of a century, most recently as Chair of the Board of Regents (2014–2015) after two years as Vice-Chair (2012–2014) and seven years as a member of the Board. My involvement with the College has helped to shape my impressions about much of the profession of surgery, but two observations are most notable. The first is my belief in the importance of professional organizations, especially the College, in protecting, maintaining, and nurturing the profession. The second is my belief in the importance of a professional organization that ties all of the surgical subspecialties together.
Guardians of our contract with society
The late bioethicist Edmund D. Pellegrino, MD, defined a profession as a group that possesses a special body of knowledge, practices within an ethical framework, fulfills some broad societal need, and has a social mandate that affords it significant discretion in setting standards for performance and educating its members. A profession has a special contract with the society in which it functions. In return for a degree of altruism on the part of the profession—that is, a duty to put the needs of others (our patients) before the needs of ourselves—the profession is granted certain privileges of self-regulation.*
A professional organization like the College is the embodiment of the contract between our profession and the society we serve. The ACS is the professional home of surgery in the U.S. It is the “self-regulating” body for the profession of surgery in the U.S.
Surgical organizations have an inherent interest in codifying and documenting the body of knowledge that defines the profession as it evolves over time, in setting standards of clinical and professional conduct, and in educating members about both the craft and ethical framework of the profession. They have a duty to collect data about the profession, to monitor the status of the profession, and to fully understand the relationship between the profession and the society it serves. The College is increasingly able to do this though its National Surgical Quality Improvement Program (ACS NSQIP®) and other clinical data registries.
Surgical professional organizations have an interest in training new professionals in the body of knowledge that defines surgery and in ensuring that certified professionals maintain their proficiency. They have an interest in the regulatory actions of our government as they relate to our profession and the particulars of the contract that we have with our society and our patients, including fiscal concerns. The College addresses these issues through its Division of Advocacy and Health Policy, housed at 20 F Street NW, Washington, DC, and has invested greatly in these endeavors over the course of my tenure.
Furthermore, a professional organization like the College has a duty to enforce the clinical and ethical standards that define membership in the profession and to ensure that the individual surgeon continues to meet those standards over the course of his or her career. Professional organizations maintain and ensure the fulfillment of the contract between the profession and society, looking out for the interests of both the surgeon and the patient. By serving the profession, they ensure that their members have the integrity to best serve our patients.
Serving and maintaining the profession entails providing a range of services and fulfilling a wide spectrum of functions: ensuring new members are properly trained and credentialed, training new surgeons, certifying that members are proficient and maintain their competencies, and ensuring ethical and professional standards of conduct. As regulatory demands become more complex, outcomes and performance data are becoming increasingly critical to the credentialing process and to the overall contract with society.
In the U.S., these various administrative and policy-making functions are distributed among a variety of professional organizations, particularly the surgical specialty societies, the Accreditation Council for Graduate Medical Education (ACGME), and the member boards of the American Board of Medical Specialties (ABMS). In general, the specialty societies are responsible for maintaining the fund of knowledge, interacting with government regulatory agencies, and providing educational programs; the member boards of the ABMS are responsible for initial certification and Maintenance of Certification (MOC); and the ACGME is responsible for training surgery residents.
The House of Surgery
I believe that one of our most pressing needs is to better align and coordinate the various duties of a professional organization and to do that across all surgical specialties. That does not mean eliminating the specialty societies, the ACGME, or the ABMS; rather, it means casting the College in a role as arbiter and enabler of other professional organizations that serve these various roles. Through its Surgical Quality Alliance and many other pathways, the College has greatly increased its interaction with the various surgical subspecialty societies over the last decade. The College has sought input from the specialties in the development of its quality manual, scheduled for release later this year; in the various online ACS Communities; in development of statements on a variety of topics, such as care of the geriatric patient; and to address common surgical issues.
All of this discussion brings us to my second main impression of the surgical profession after serving in the College’s leadership over the years—that some overarching professional surgical organization is needed to tie all of the surgical subspecialties together. I have always believed, and continue to believe, that the profession of surgery is a sufficiently distinct part of medicine to warrant its own professional identity.
The ACS, through its size, resources, and enduring commitment to professionalism, is best positioned to serve as a truly unifying organization for surgery in the U.S. Increasingly complex regulatory demands and access to more comprehensive “big data” collections, certification processes, and validation processes make it increasingly difficult for smaller professional organizations with access to less comprehensive datasets and fewer resources to adequately perform these functions. The College has invested heavily over recent years in a database integration project to help collect and codify important information about surgery and surgical procedures so that we will have the information we need to best serve the profession as we negotiate surgery’s position in the overall health care landscape of the future.
It is clear to me that there needs to be some umbrella entity that can look at the big picture, including graduate medical education, training and certification of residents, MOC, monitoring of continued competency, introduction of new technology, establishment and enforcement of ethical and professional standards, and the administration of disciplinary action. At present, the fulfillment of these functions seems to be occurring in a fragmented fashion, and the more surgeons subspecialize, the worse this situation becomes. I believe this fragmentation is one of the factors leading to the commonly heard dictum, “Physician, heal thyself.”
The current decentralization of key administrative functions is a part of the growing discomfort on the part of the public regarding professionalism in medicine and surgery and represents a real chink in the contract we have with society. One unifying professional organization should take responsibility for the care of the surgical profession and take ultimate responsibility for the contract we have with society and our patients.
Some may say that it is inappropriate and self-serving to think of a surgical organization as answering the needs of the profession rather than focusing exclusively on our patients, but I would argue otherwise. Our profession needs protection and nurturing to remain viable in the future. Unless the House of Surgery stays strong and true to its contract with society, unless we ensure the vitality and viability of our profession down the road, we ultimately harm our patients and the future of surgical care. Protecting our profession entails ensuring that we can continue to attract new, competent members; maintain and enforce clinical and professional standards; and maintain our contract with society as it evolves.
In my tenure on the Board of Regents, much has happened internally in the College’s leadership to redefine the organization. For example, the ACS Regents have reorganized themselves. Two new Regents were added recently, bringing the total number of Board members to 23, plus the President. This move occurred in an effort to ensure representation across all of the surgical specialties as recognized by the ABMS. The Regents were revitalized and steps were taken to increase engagement. Likewise, the Board of Governors was restructured along with all of the Divisions of the College in an effort to align and integrate all aspects of the organization.
David B. Hoyt, MD, FACS, has proved to be a rejuvenating force within the College since he came on board as Executive Director in 2010. The Washington Office relocated to 20 F Street NW, and our advocacy efforts have more than redoubled with the permanent staffing of that new facility. The Surgical Quality Alliance was formed to ensure cross-communication among the various surgical specialties. The ACS Health Policy and Advocacy Group was reorganized, and the annual Leadership & Advocacy Summit was greatly expanded.
ACS NSQIP has expanded and the College has invested heavily in the collection of big data to be used to help the College advocate for our profession and help guide us into an era of merit-based payment and patient-centered care. The Clinical Congress has been reorganized to include specialty tracks, which help the specialty surgeon more efficiently navigate the plethora of educational programming offered at this event. Our certification and verification programs also have been greatly expanded in areas like breast surgery and bariatric surgery.
The College website was rebuilt, and the ACS Communities that launched in conjunction with the redeveloped site have been fertile ground for cross-pollination among the surgical specialties. The communities also provide a platform for surgeons of all stripes to communicate about subjects of mutual interest, including the history of surgery and advocacy.
This is a short list of the College’s activities over the last decade. We really should be proud of all the organization has accomplished. We have developed and fulfilled an expansive agenda and experienced an unprecedented period of growth and accomplishment. I feel fortunate to have been involved in one of the most exciting periods in the history of the College.
*Pellegrino ED. Professionalism, profession, and the virtues of the good physician. Mt Sinai J Med. 2002; 69(6):378-384.