The seventh annual Leadership & Advocacy Summit—a paired meeting with educational programs covering both leadership enhancement and advocacy training—convened May 19–22 in Washington, DC. The Leadership portion of the summit featured speakers from both the medical and academic worlds, with presentations describing a range of characteristics shared by strong team managers.
The Advocacy component of the meeting provided attendees with the opportunity to learn about the American College of Surgeons’ (ACS) perspective on key topics—including opioids and burdensome regulations—from College leaders and elected officials in preparation for organized visits to Capitol Hill. The following article summarizes the central topics and issues presented at both summit meetings.
2018 Leadership Summit
“This meeting continues to grow in numbers, and it continues to grow in engagement,” Patricia L. Turner, MD, FACS, Director, ACS Division of Member Services, said in her opening remarks. A total of 512 residents and surgeons attended this year’s Leadership Summit—a 5 percent increase from 2017.
This portion of the Leadership & Advocacy Summit featured presentations covering a range of topics, including the essentials of successful mentoring, ethics in surgical leadership, resident engagement, and the art of decision making and strategic thinking.
Mentoring and leading change
J. David Richardson, MD, FACS, professor and vice-chair, department of surgery, University of Louisville School of Medicine, KY, and ACS Past-President, encouraged attendees to “Find a Yoda.” The Star Wars character was wise and all-knowing, but he demonstrated to his mentee, young Luke Skywalker, three important elements of effective mentorship. “Yoda knew how things worked, he was not afraid to criticize shortcomings, and he ultimately was a champion for the positive qualities of his protégé.”
According to Dr. Richardson, mentors sometimes fail their mentees in the following ways:
- They are inadequately informed or educated but advise others anyway
- They are well-intentioned but not well-connected
- They suffer from “shelf-life failure” and are no longer relevant
“To be a responsible mentor, the key is to be unselfish and objective without destroying the mentee’s confidence,” he added, noting that more than one mentor or “a few Yodas” are often necessary depending on where the physician is on his or her career path.
Effective mentoring is key to a career in surgical leadership, Dr. Richardson said, but ultimately the physician is responsible for working toward opportunities in leadership. “It is difficult to advance without prior visibility,” he said. “Develop a strong work product—including podium presentations, abstracts, thoughtful discussions—and have faithful attendance at meetings like this one,” he said, referring to the summit. “And if you want to be a College leader, start with your ACS chapter.”
According to Vice-Admiral Raquel C. Bono, MD, FACS, Medical Corps, U.S. Navy, Director, Defense Health Agency, inclusivity is an important component of effective mentorship, as these relationships depend on contributions from all involved stakeholders. Dr. Bono noted that fostering “collective thinking” is necessary to manage change in a diverse, complex setting like the U.S. military.
“We have Army, Navy, and Air Force medicine, and each one approaches things in a slightly different way, and in some cases that makes sense,” said Dr. Bono. “We are practicing the same type of surgical care that we were all trained to do, but sometimes we have to think of that larger goal,” she added, calling inclusion the “challenge point” that is key to effective change management.
“Inclusion begins with considering how you feel,” she said, and a willingness to lean forward and accept the fact that change is uncomfortable.
“Implementing change in a diverse environment is challenging, even more so in the military,” Dr. Bono said. “We reference culture and tradition as if they were biblical or statute. As an effective leader, start out with an understanding of your own tolerance for change and how you can set up an environment to make change happen. True inclusion is not discounting anyone’s input. If we start parsing how people may contribute, we can lose the opportunity to pursue things in a new manner.”
The Ethics Work-Up
“Ethics is a branch of philosophy that involves systematizing, defending, and recommending concepts of right and wrong conduct,” said Mary L. Brandt, MD, FACS, professor of surgery, pediatrics and medical ethics, Baylor College of Medicine (BCM), division of pediatric surgery, Texas Children’s Hospital, Houston. Dr. Brandt’s presentation was framed within the “Ethics Work-Up,” a systematic method to guide decision making in ethically complex cases developed by the Center for Medical Ethics and Health Policy at BCM.
“Surgeons have the ability to take the complex and making it simple,” she said, referring to the “ABCs” of trauma resuscitation (Airway, Breathing, Circulation, Disability, and Exposure), which she applied to the Ethics Work-Up model as follows:
- Assess the information, including the parties involved
- Box: Step out of the box to consider alternate solutions
- Consider the appeals
- Appeal to established legal, ethical, and professional standards
- Appeal to consequences
- Appeal to rights
- Appeal to virtues
- Appeal to justice
- Decide the course of action and how to manage it
- End with how you could have prevented the ethical dilemma in the first place
Regarding the “Consider the appeals” step, Dr. Brandt focused on the “appeal to virtues” component. She defined a virtue as “a trait or quality that is deemed to be morally good and thus is valued as a foundation of principle and good moral being.
“There are hundreds and hundreds of virtues, but six virtues come up the most in medical ethics: compassion, courage, self-sacrifice, legitimate self-interest, integrity, honesty,” Dr. Brandt added.
“Ethics is rarely about what’s right and wrong…It’s often about two rights in conflict,” she added, quoting Paul Root Wolpe, PhD, director for the Center for Ethics, Emory University, Atlanta, GA, and underscoring the multiple “right” answers possible in a case study she presented to attendees.
Exhibiting a systematic approach to ethical dilemmas is a notable trait of strong surgeon leaders, as is the ability to effectively lead beyond your practice. “Accept your role as a leader outside of medicine, not by virtue of your skill set, but by virtue of your profession. Leadership is nothing more than influence,” said Anton J. Gunn, MSW, CDM, 937 Strategy Group, LLC, Johns Island, SC. Mr. Gunn, a leadership and health care reform expert, presented a model for increasing the individual surgeon’s sphere of influence in a presentation sponsored by the Young Fellows Association of the ACS.
To become an effective influencer, Mr. Gunn described the acronym as follows: “Great leaders know how to raise CAIN—because when you raise CAIN, you make a difference,” said Mr. Gunn. To become an effective influencer, Mr. Gunn described the following acronym:
- Communication: Communicate where we need to go in health care and how to get there.
- Attitude: Your mindset is more important than your skill set. You can be incredibly skilled, but if you don’t have the mindset, you might not be an effective leader.
- Influence: Share your core values. Are you adding your values to the community at large?
- Network: Build connections for lasting impact.
“Leaders who raise CAIN teach others to lead and work today for tomorrow’s impact,” Mr. Gunn said.
Leadership in crisis situations
Successfully guiding team members to ensure the optimal care of the patient is a multifaceted goal that includes strong mentorship, a clear understanding of medical ethics, and a self-awareness of your own core values. Leading during a crisis event requires these elements and other key traits including competence, confidence, and an ability to manage one’s own anger, fear, and fatigue.
Practical lessons for surgeons working in critical situations were presented by Ronald M. Stewart, MD, FACS, chair, department of surgery, University of Texas Health Science Center at San Antonio, TX, and Medical Director, Trauma, ACS Division of Research and Optimal Patient Care. These strategies were developed based on feedback from two key sources, according to Dr. Stewart—interviews with attending surgeons and senior surgical residents and a survey of members of the Texas Surgical Society. “We operationally defined a critical situation as ‘life or function at risk,’ ‘a surgeon’s decision or technical intervention is required,’ and ‘the situation occurs under time-sensitive or adverse conditions,’” Dr. Stewart explained.
The physician participants were presented with characteristics typically associated with surgeons and instructed to rank their usefulness in managing a critical situation. “Not surprisingly, surgeons unanimously ranked ‘competence’ as a very beneficial characteristic during a critical situation. ‘Composure’ elicited a similar response, with more than 90 percent ranking it a very beneficial characteristic in these situations,” Dr. Stewart said. Focus and preparation also ranked highly, as did confidence. “Confidence should not be confused with arrogance,” he said. “Confidence is the belief that we can and will achieve the goal, while arrogance is the belief that I am better than you. Be confident with humility.”
Dr. Stewart and colleagues also compiled a list of strategies surgeons reported using in critical situations, including the following: pre-event preparation; personal emotion control (management of anger, fear, and fatigue); fostering a setting that is “maximally” inclusive; and focusing a dialogue and consensus built around the right thing to do for the patient. “Consensus requires freedom with responsibility, and it generates trust. When we have trust, we get results,” Dr. Stewart said.
The art and practice of strategic thinking
“Strategic planning helps your practice and organization remain relevant and responsive to your patients,” said Nick Hernandez, MBA, FACHE, founder and chief executive officer of ABISA, a health care consulting company specializing in health care strategy and physician engagement, St. Petersburg, FL. “It helps you determine measurable goals, it is an ongoing process, and it assumes that the future can be influenced,” he said.
Mr. Hernandez recommends a 12-month execution period and specific prerequisites for engaging in strategic planning. “First, agree on the strategic planning process and consider its potential value for the practice or organization. Determine agreed-upon goals upfront and consider costs in terms of staff time and so on,” he said, noting that much of this preliminary work can be accomplished by engaging in a SWOT (also known strengths, weakness, opportunities, and threats) analysis.
Mr. Hernandez cautioned attendees to avoid the following four common mistakes when engaging in strategic planning:
- Forecasting too far in the future: Project administrators may have a tendency to think that the future will be a linear continuation of present conditions, and as a result, they underestimate the scope of changes that may occur.
- Planning in too much detail: This pitfall stems from a desire to leave as little as possible to chance. The natural response to an uncertain future is to plan in greater detail in order to cover every possibility, resulting in an extremely detailed strategic plan that can constrict effective action.
- Using strategic planning as a scripting process: When surgeon leaders fail to recognize the limits of forecasting, the strategic plan may become coercive and overly regulatory, restricting initiative and flexibility and compelling staff to focus on meeting plan requirements rather than creating solutions.
- Engaging in rigid planning: A disciplined framework for problem solving is warranted, unless it curbs creativity and the adaptability of the plan.
“Strategic planning combines elements of art—intuition, inspiration, and creativity—with science, specifically analysis and calculation,” Mr. Hernandez said, noting that executed correctly, this type of project planning can “reconcile the tension between the desire for preparation and the need for flexibility.”
Chapter success stories
Officers of the Florida Chapter, the Massachusetts Chapter, the Northern California Chapter, and the San Diego Chapter, CA, shared their success stories in an effort to inspire other chapter leaders to boost member engagement. Examples included the following: Stop the Bleed® training of legislators in Florida to bolster creditability with state policymakers; enhancing resident attendance at chapter meetings in Massachusetts through Top Gun and Survivor games; recruiting trainees by engaging with resident program directors in California; and lessons learned from pursuing public access to Stop the Bleed kits in San Diego.
Factors affecting leadership
David B. Hoyt, MD, FACS, ACS Executive Director, concluded the Leadership portion of the summit by noting, “This conference is about change and self-awareness, not just as an organization, but as individuals, too,” he said. “Burnout is the new epidemic,” he added, noting that surgeon well-being is essential to both patient safety and the functionality of health systems. Well-being is predicated on individual contentment, he said, and is a state of mind composed of three factors:
- Competency: Mastery of our work
- Autonomy: Influence in the way the work is performed
- Community: Egalitarian values rather than a hierarchy
External forces affecting surgeon leadership include “access to care (insurance reform) and payment reform,” Dr. Hoyt said. “For nearly 100 years, the ACS has led initiatives to improve quality in hospitals as well as the more specific fields of trauma, cancer, and surgical quality. Our experience has yielded systems, methodologies, and approaches that measurably improve the quality of care, save lives and prevent complications, and reduce the costs to the system,” he said, noting that when quality improves, costs decline.
2018 Advocacy Summit
The advocacy program of the 2018 Leadership & Advocacy Summit provided 358 attendees with the information and skills necessary to help shape health policy efforts in Washington, DC, and across the country.
Keynote speaker Nicolle Wallace, a political analyst, author, and former White House Director of Communications, spoke about the challenges involved in “decoding Trump to the media” and underscored the importance of keeping future generations engaged in politics. Ms. Wallace also spoke briefly about the polarizing issue of firearm-related violence and stressed the importance of finding common ground to develop sustainable solutions.
The following day—in preparation for pre-planned Hill visits with members of Congress—summit participants attended several educational sessions during which they were briefed on the ACS’ legislative priorities, including the opioid epidemic, the Pandemic and All-Hazards Preparedness Act (PAHPA), and cancer research and prevention. A total of 306 Advocacy Summit participants representing 45 states engaged in 275 meetings May 22 on Capitol Hill.
In an effort to update attendees on the politics surrounding November’s election and their inevitable impact on Congress’ ability to move legislation forward, Monday’s luncheon, sponsored by the American College of Surgeons Professional Association (ACSPA)-SurgeonsPAC, featured speakers from the Democratic Congressional Campaign Committee (DCCC) and the National Republican Congressional Committee (NRCC). The evening concluded with a reception for 2018 SurgeonsPAC members who were able to speak one-on-one with members of Congress who also attended the event.
Understanding strategic advocacy
“In 2017 and 2018, approximately 6,000 bills were introduced in the House, and 3,000 in the Senate. A total of 171 bills have been signed into law, which is approximately 2 percent,” said Christian Shalgian, Director, ACS Division of Advocacy and Health Policy, stressing the importance of strategic advocacy efforts. Mr. Shalgian recommended framing each potential health care policy issue by addressing key questions, including the following: Where did the issue originate? Is the political climate ripe for taking action? What is the likelihood of success? Does the ACS have a role in the issue?
Using this model, ACS staff presented an overview of key ACS legislative efforts centered on the following issues: implementation of the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (also known as MACRA), firearm-related violence prevention, the opioid epidemic, and graduate medical education.
Patients over paperwork
“CMS [Centers for Medicare & Medicaid Services] publishes nearly 11,000 pages of regulations every year. Some of these regulations are necessary to ensure patient safety and program integrity, but many are overly burdensome, forcing providers to spend more time on paperwork than they do with their patients,” said Jean Moody-Williams, Deputy Director, Center for Clinical Standards and Quality, CMS.
To reduce administrative burden, CMS has established the Patients Over Paperwork initiative, which is intended to streamline regulations in order to increase efficiencies and improve the beneficiary experience. The initiative includes Customer-Centered Workgroups focused on receiving input from clinicians and other stakeholders through listening sessions, site visits, and subject matter expert interviews.
“What we heard from providers falls into three categories,” said co-presenter Melanie Combs-Dyer, Director, Provider Compliance Group, CMS. “CMS requirements are too excessive, documentation requirements are too hard to find—we have all these different websites, manuals, and so on—and providers are afraid of audits,” she said. According to Ms. Combs-Dyer, the Center for Program Integrity within CMS is attempting to minimize burdens by simplifying paperwork, making it easier to locate required paperwork, improving the audit process, enhancing the interoperability of electronic health records, and improving overall communication.
ACA: Current status
“The Affordable Care Act (ACA) has achieved substantial improvements in access to coverage and health care, particularly for low-income consumers and those with health problems,” said Timothy S. Jost, Robert L. Willet Family Professor of Law, Emeritus, Washington and Lee University School of Law, Lexington, VA. However, Mr. Jost also underscored a growing concern regarding the affordability of health insurance coverage for middle-income consumers, particularly households with incomes that exceed 400 percent of the federal poverty level—about $100,000 for a family of four—that do not have employer-based coverage.
According to Mr. Jost, the Trump Administration’s move to defund cost-sharing reduction payments and to eliminate the individual mandate penalty beginning in 2019 will result in millions of Americans losing coverage and a 10 percent increase in premiums in the individual market. To stabilize the individual insurance market, the administration has proposed lower-cost alternatives, such as expanded short-term coverage, which he said have very limited benefits, more exclusions, high cost sharing, and a history of rescissions.
“Where are we now? Coverage is still affordable for people with subsidies but less affordable for people without. There is some evidence that the number of uninsured is growing again. The ACA is still here. It hasn’t been repealed, but we’ve reached a stalemate,” said Mr. Jost, who noted that political conflict has hindered necessary improvements to the ACA.
Long-term solutions to the opioid epidemic
“Illicit opioid overdose deaths are going up, while prescription opioid overdose deaths are leveling off, creating the perception of an epidemic or crisis,” said John M. Daly, MD, FACS, FRCSI(Hon), Co-Chair, ACS Patient Education Workgroup, referring to a recent study published in the Journal of the American Medical Association. Dr. Daly noted the variation in the limits and restrictions placed on prescribers by payors and state legislatures, some of which may expose specific patients to unnecessary suffering. He underscored the ACS’ commitment to preventing opioid abuse through the use of prescription drug monitoring programs (PDMPs), establishment of an opioid tracking system for military veterans, and corrections in provider reimbursement by modifying the relationship between pain score and payment.
Douglas Throckmorton, MD, Deputy Center Director for Regulatory Programs, U.S. Food and Drug Administration, outlined the agency’s four strategies for managing the opioid crisis, as follows:
- Decrease exposure and prevent new addiction (appropriate duration labeling, packaging, storage, and disposal)
- Support the treatment of those with an opioid use disorder
- Foster development of novel pain treatment therapies, including abuse deterrent formulations and pain treatment alternatives
- Improve enforcement and assess benefit-risk ratio
In a related presentation James Arnold, Chief, Liaison & Policy Section, Diversion Control Division, U.S. Drug Enforcement Agency (DEA), said, “The DEA is not here to interfere with the legitimate practice of medicine and research needs. Our mission is to prevent, detect, and investigate the diversion of pharmaceutical controlled substances from legitimate channels of distribution while ensuring an adequate and uninterrupted supply of controlled substances to meet legitimate medical and scientific needs.”
According to Mr. Arnold, the sharpest increase in drug overdose deaths (20,000 deaths in 2016) are related to fentanyl and fentanyl analogues (synthetic opioids). He also noted an uptick in what he called “re-emerging old threats,” including heroin, cocaine, methamphetamine, and marijuana. As for prescription opioid overdose deaths, more than 40 percent of these deaths in 2016 were due to three of the most common prescription opioids: methadone, oxycodone, and hydrocodone.
Sean Fearns, Chief, DEA Community Outreach and Prevention Support, outlined areas of collaboration between the agency, physicians, and other stakeholders. Examples include Operation Prevention, which has educated more than 2 million students on the impact of opioid abuse, and the DEA’s 360 Strategy, a three-pronged approach involving coordinated law enforcement efforts, diversion control enforcement on DEA registrants operating outside the law, and community outreach.
ACS advocacy in action
To prepare summit attendees to engage with members of Congress, ACS Division of Advocacy and Health Policy staff presented talking points on several topics, which can be summarized as follows:
- Limit solutions that impose federal mandates on physicians, such as prescribing limits or Continuing Medical Education
- Create interoperable PDMPs that integrate with a clinician’s clinical workflow
- Develop enhanced options for nonopioid therapy
- Request the inclusion of the following:
- Mission Zero Act
- National trauma system development
- The Good Samaritan Health Professionals Act
Cancer research and prevention
- Continue to support funding for these initiatives
Stop Overregulating My OR
- Address administrative burden regarding evaluation and management documentation guidelines
Ensuring access to general surgery
- To curb the impending shortage of general surgeons, support the Ensuring Access to General Surgery Act
Firearms research and violence prevention
- Support a $50 million request for firearm morbidity and mortality prevention research through the Centers for Disease Control and Prevention as part of the fiscal year 2018 appropriations package
Several invited congressional speakers underscored the importance of the College’s legislative efforts regarding these issues, particularly firearm research and violence prevention, trauma care, and the opioid crisis. They also offered suggestions for meeting face-to-face with legislators, such as avoid discussing unrelated issues (keep the agenda focused) and refrain from discounting a meeting with a staff member, who may be an advocate’s best ally in the legislative office. Congressional speakers included Minority Whip Rep. Steny Hoyer (D-MD); Rep. Roger Marshall, MD (R-KS); Rep. Neal Dunn, MD, FACS (R-FL); Rep. C.A. Dutch Ruppersberger (D-MD); and Rep. Eric Swalwell (D-CA).
The next ACS Leadership & Advocacy Summit will take place March 30–April 2, 2019, in Washington, DC.