Undoubtedly, many of you are familiar with the phrase “the seven year itch.” It was first used in the play The Seven Year Itch to describe an inclination to evaluate your marriage after seven years and gained popularity in 1955 with the release of the movie version directed by Billy Wilder and starring Marilyn Monroe and Tom Ewell. It is now used to describe any situation in which people feel the need to make a change after being in the same role for seven or more years.
I recently concluded my seventh year as Executive Director of the American College of Surgeons (ACS) and admittedly have been feeling a bit of an itch to see the goals I set when first assuming this position come fully to their fruition.
One of my primary goals when I first became Executive Director was to improve the stature and capabilities of our Quality Programs. I wanted to ensure that the public better understood the College’s role in quality improvement and safeguarding the well-being of surgical patients. We succeeded in increasing public awareness of the impact of quality improvement in health through our multi-year ACS Inspiring Quality Forum tour. Each stop along the tour included presentations and discussions by surgeon leaders, members of Congress, and patient advocates.
Expansion of our accreditation programs was another component of this objective. We have continued to grow our verification programs, including the accreditation activities in cancer, trauma, breast, bariatric, geriatric, and pediatric surgery. Advances in these areas continue, and will expand to other surgical specialties and subspecialties in the coming years. The next step will be in setting standards for quality improvement overall based on the ACS quality manual that is in development.
Making certain that surgeons have the tools they need to measure and evaluate their performance has been a key mission in the last seven years. To this end, we have initiated the database integration system, which will bring together, under a unified platform, our clinical registries, including the National Surgical Quality Improvement Program, the National Cancer Database, the National Trauma Data Bank®, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data bank, and the Surgeon Specific Registry. This project, which is being implemented incrementally, will make it easier for surgeons to meet American Board of Surgery (ABS) Maintenance of Certification requirements and Medicare payment mandates under the Centers for Medicare & Medicaid Services’ new Quality Payment Program (QPP). We anticipate that within the next three years, by my 10th year as Executive Director, this database of the future will be fully integrated and in widespread use.
The QPP was created through the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA). The QPP replaces the flawed sustainable growth rate (SGR) methodology that was used for many years to calculate Medicare physician reimbursement. Repealing the SGR was a major goal for all of organized medicine seven years ago. Now that we have achieved this objective, the College’s focus has turned to ensuring that surgeons are able to comply with the QPP’s reporting requirements and performance measures. We have established a resource center for surgeons who are seeking information about the QPP and other MACRA provisions moving forward and working with health policy experts at Brandeis University, Waltham, MA, and Brigham and Womens’ Hospital, Boston, to propose alternative payment models.
We anticipate that the new presidential administration and Republican-controlled Congress will leave QPP untouched—at least for a while. However, we also speculate that they will attempt to either repeal the Affordable Care Act (ACA) or overturn a number of its provisions. The College needs to be prepared to offer viable health care reforms and to take a stance on any modifications that may affect access to surgical care. We will need to offer alternatives that uphold our principles of ensuring the provision of quality and safe care, patient access to surgical care, and reduction of health care costs. These values served us well when the ACA was being developed and will serve us well as the law is revised and implemented.
We also need to continue to push for liability reforms that will ensure patients are justly compensated for any harm they experience while under a surgeon’s care. In addition, we need to address ongoing issues with the electronic health record and with the sustainability of graduate medical education (GME) and the surgical workforce.
With the addition of Patrick V. Bailey, MD, FACS, Medical Director, Advocacy, and Frank G. Opelka, MD, FACS, Medical Director, Quality and Health Policy, in our Washington Office in 2014, we have become better positioned as an authoritative source of information inside the Beltway. I anticipate that this trend will continue and look forward to working with the new administration.
Surgical education and training have been at the heart of the College’s mission since the organization’s inception. We believe the ACS’ education and training programs are the cornerstones of excellence, transform possibilities into realities, and instill the joy of lifelong learning.
Of particular concern in recent years have been reports that a significant percentage of general surgeon residency graduates leave training feeling uncertain about their ability to perform advanced procedures autonomously and to manage a practice. In response, the College launched the Transition to Practice in General Surgery program, which supports the transition to independent practice in general surgery through the following activities:
- Individualized, hands-on learning tailored to individual needs
- Independence and autonomy in clinical decision making
- Practical general surgery experience under the guidance of notable practicing surgeons
- One-year, paid staff appointments at institutions accredited by the ACS
- Exposure to important elements of practice management
This program continues to grow, with 25 institutions in 21 states now participating.
In addition, the College has been working with other stakeholders, including the ABS, the Accreditation Council for Graduate Medical Education, the Association of Program Directors in Surgery (APDS), and the Residency Review Committee for Surgery (RRC), to develop a roadmap to secure the future of general surgery. Concepts discussed in these meetings include the following:
- Development of boot camps, which may be added to residency requirements
- Possible addition of further training after five years of core general surgery training
- Modifications to duty hour requirements in light of findings from the ongoing Flexibility In duty hour Requirements for Surgical Trainees Trial studies
- Development of a Competency-based Education and Skills Assessment, with the ACS claiming responsibility for creating a tool to track progress and compare residents and programs and working with the APDS to develop skills training
- Provision of opportunities for mentored autonomy
- Institution of community rotations
- Establishment of guidelines for self-assessment during residency
- Capstone training
- Initiation of an effort to have surgeon reviewers participate in 10-year reviews of residency programs
- Creation of a faculty development requirement, with the ACS and APDS establishing the curriculum
- Proposal for a model for career-long record keeping starting in medical school
Today’s residents are tomorrow’s surgeons. Given the aging population that will be seeking their services, it is imperative that the House of Surgery takes responsibility for ensuring that graduates of general surgery training programs have the full range of skills and the confidence necessary to care for these vulnerable patients.
Member services and communication
The College has re-energized the internal bodies that serve as the voice of the membership—the Board of Governors, the Advisory Councils, the Young Fellows Association, the Resident and Associate Society, and the ACS chapters. As a result, the College is a more diverse, dynamic, and nimble organization than ever before.
We are offering more opportunities for engagement, including a revitalized Operation Giving Back program with an emphasis on international and domestic volunteerism. Likewise, the annual Leadership & Advocacy Summit in Washington, DC, provides members with opportunities to hone their leadership skills and advocate on their patients’ behalf. Furthermore, we strengthened our emphasis on international development and have established a Regental committee to provide direction in this regard.
The College has continued to make its communications vehicles more interactive and user-friendly. We launched a fully rebuilt website in 2014 along with our ACS Communities, which allow members to share their concerns and interests in a protected environment. We also are working to have all of our major publications, including the Bulletin and the Journal of the American College of Surgeons, move to fully digital platforms.
I am proud of the strides the College has made in the last seven years and am itching to see us continue to grow and flourish in the next three. As always, please let us know your suggestions for the College’s future.