The Bulletin by the American College of Surgeons Tue, 09 Sep 2014 16:17:09 +0000 en-US hourly 1 Looking forward – September 2014 Mon, 01 Sep 2014 05:59:03 +0000

Dr. Mallon

Dr. Mallon

Codman headstone

“It may take a hundred years for my ideas to be accepted.” —Ernest Amory Codman, MD, FACS

Codman family

Dr. Codman’s great-nieces, Elizabeth Snyder (left) and Virginia Harlan

Codman headstone in Boston
Codman headstone up close

From left: Dr. Polack, Dr. Hendren, Dr. Hoyt, Dr. McGinnis, Dr. Warshaw, Mr. Altshuler, and Dr. DuPree

Few surgeons in the early 20th century could have predicted that outcomes measurement, public reporting, and patient-centered care would be hallmarks of the 21st century U.S. health care delivery system. One surgeon, however, did have this prescient vision: Ernest Amory Codman, MD, FACS, who first promoted these practices in his “end result idea.” Though much reviled at the time, this concept—which called for monitoring patient outcomes after discharge to determine which treatments worked and which didn’t and then sharing this information to improve patient care—now guides the quality improvement programs that the American College of Surgeons (ACS), other organizations, and government agencies have implemented.

To recognize the valiant contributions that Dr. Codman has made to American surgery and to patient care, the ACS and other groups that have benefited from his wisdom agreed to place a headstone at his previously unmarked interment site in Mount Auburn Cemetery, Cambridge, MA. Leaders of these organizations gathered at a dedication ceremony on July 22 to pay homage to the maverick surgeon from Boston.

Efforts to have a headstone placed at Dr. Codman’s gravesite were initiated soon after publication of a Bulletin article by ACS Past-President LaMar S. McGinnis, Jr., MD, FACS. In that article, Dr. McGinnis noted that when Dr. Codman died in 1940 of melanoma, he had limited financial means and asked his wife not to have a marker placed on her family’s burial lot, where his ashes were to be stored. Dr. McGinnis added, “I believe that The Joint Commission, the American Cancer Society, the American College of Surgeons, and the American Academy of Orthopaedic Surgeons should erect a headstone at the gravesite to properly acknowledge this visionary and our debt to him.”*

All of these organizations, as well as the West Virginia Chapter of the ACS; Massachusetts General Hospital (MGH), where Dr. Codman practiced for much of his career; the American Shoulder and Elbow Society; and the American Orthopaedic Association, contributed to the cause financially and/or sent representatives to the memorial service. (For a list of donors, visit the ACS website.)

Celebration of an extraordinary life

At the dedication ceremony, Dr. McGinnis and other champions of Dr. Codman’s work described his life and enumerated “the improper Bostonian’s” legendary contributions to surgery and medicine. Other speakers included Andrew L. Warshaw, MD, FACS, ACS President-Elect, and, like Dr. Codman, a “Preparation H” surgeon, meaning he studied, trained, and taught at Harvard Medical School; William J. (Bill) Mallon, MD, FACS, author of the definitive biography on Dr. Codman; E. Philip S. Polack, MD, FACS, who led the charge in West Virginia to raise money for a headstone; Erin S. DuPree, MD, chief medical officer and vice-president of The Joint Commission Center for Transforming Healthcare; and Boston pediatric surgeon W. Hardy Hendren III, MD, FACS, former Second Vice-President of the ACS (see Order of Service).

Order of Service

Ernest Amory Codman, MD, FACS

Memorial of His Life

Gathering at Grave Site

Opening Comments
David B. Hoyt, MD, FACS, ACS Executive Director

Memories of Dr. Codman and His Importance
LaMar S. McGinnis, Jr., MD, FACS, ACS Past-President

Anecdotes from His Life in Boston
Andrew L. Warshaw, MD, FACS, ACS President-Elect

Historical Personal Comments
W. Hardy Hendren, MD, FACS, ACS Past Second Vice-President

Comments on Dr. Codman’s Life in Medicine
William J. (Bill) Mallon, MD, FACS, author of Ernest Amory Codman: The End Result of a Life in Medicine, and editor-in-chief, Journal of Shoulder & Elbow Surgery

Comments—West Virginia Chapter
E. Phillip S. Polack, MD, FACS, Past-President, West Virginia Chapter

Comments—The Joint Commission
Erin S. DuPree, MD, chief medical officer and vice-president, The Joint Commission Center for Transforming Healthcare

Closing Comments
Dr. Hoyt

Bigelow Chapel

The other speakers and I described Dr. Codman’s influential career. We spoke of the “ether chart” that he and Harvey Cushing, MD, FACS, devised to document and demonstrate the safety of surgical anesthesia and of his role in presenting the first morbidity and mortality conference at MGH.

We acknowledged his pioneering work in diagnostic radiology, the multiple articles he wrote on the management of surgical complications of duodenal ulcer, and his contributions to the treatment of shoulder and wrist conditions.

We noted that the College and its affiliates owe a major debt to Dr. Codman for establishing the College’s first database—the Registry for Bone Sarcoma—and for his role in developing the ACS “Minimum Standards for Hospitals.”

Most of all, however, we thanked Dr. Codman for fighting to overcome the suboptimal conditions at many hospitals of the time, for fearlessly seeking solutions, and for being a crusader for the end result idea. We expressed our gratitude for his willingness to stand up for what he knew was right, even when the Boston medical establishment shunned him for his renegade ways. When the MGH establishment refused to embrace his recommendation that faculty earn promotions based on their outcomes rather than seniority, Dr. Codman started his own 12-bed hospital, which focused on implementation of the end result concept. He closed the faltering facility to tend to the needs of individuals who survived but were severely injured in the “Halifax explosion,” which occurred in December 1917 when a French cargo ship carrying wartime explosives collided with a Norwegian vessel off the coast ofNova Scotia. He then went on to contribute his expertise to caring for the troops fighting in World War I.

We spoke of his rebellious—some would say abrasive—streak, perhaps most apparent when, at a 1915 meeting of the Suffolk District Surgical Society, he unveiled the infamous cartoon of an ostrich with its head buried in the sand kicking golden eggs to Back Bay physicians. In his remarks, Dr. Hendren noted that for many years the only known copy of that illustration was smudged and difficult to read when reproduced. I am delighted to report that Dr. Hendren has procured a clean copy and presented it to the ACS at the dedication ceremony. (Watch a video of the dedication ceremony.)

In addition, two of Dr. Codman’s great-nieces attended the service. They recalled their visits with an uncle who was caring and gentle, enjoyed fishing and hunting, and loved his dog, who apparently suffered from a case of chronic canine halitosis.

Classic design for a timeless figure

The headstone we dedicated that sunny day in Cambridge pays fitting respect to this brilliant, enigmatic man. We selected classical sculptor, Daniel Altshuler of Gloucester, MA, to create the Codman memorial headstone based on his past experience in crafting similar works of art, including portrait heads of Nobel Prize Laureates Francis Harry Compton Crick and James Dewey Watson.

Dr. Warshaw and I selected some photos of Dr. Codman that Mr. Altshuler used to develop the bas-relief portrait on the headstone. Creating the headstone involved a painstaking process. He initially developed a drawing that he used to develop a clay model and finally the bronze cast of Dr. Codman with a caduceus on each side. Mr. Altshuler said that in crafting the portrait he sought to “capture this man’s seriousness and gentleness.” As the photo on page 9 reveals, he succeeded.

The bronze figure is set in the Quincy Granite used in most headstones at the historic cemetery. Complicating matters, the quarry that provided this stone in the past closed years ago. As a result, the artist worked closely with the cemetery to locate repurposed granite. In total, it took more than a year to complete the memorial headstone, but we were determined that this lasting tribute would reflect the exacting standards that Dr. Codman would have demanded.

It truly was an honor to participate in this long-overdue celebration of Dr. Codman’s life and enduring contributions to surgical patient care. But our salute to Dr. Codman cannot end with a memorial service. We must channel his spirit every day in our never-ending efforts to set the highest standards and to achieve better patient outcomes.

*McGinnis LS Jr. Common origins: The two ACSs—100 years of collaboration to improve the lives of cancer patients. Bull Am Coll Surg. 2012;97(4):6-15.

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A new era begins for ACS online properties Mon, 01 Sep 2014 05:58:47 +0000

This summer, the American College of Surgeons (ACS) retired our members-only Web portal,, migrating some features to our new public website for members-only viewers and replacing it with a state-of-the-art online community platform that enables College members to easily and effectively connect with one another on topics of shared interest. A few days later, we launched our new public website,, designed for easy access from desktops, tablets, and smartphones (see Figure 1). An 18-month period of discovery, evaluation, and content redevelopment preceded the launch of these new sites—both designed with the member experience as a top priority.

Figure 1. ACS home page

Figure 1. ACS home page

Become part of ACS Communities

ACS Communities, which can be accessed directly through the home page or by typing, now serves as the College’s members-only, online community. This networking tool provides an environment in which ACS members can not only connect, engage, and share critical information and best practices in real time, but also ask for advice, share experiences, exchange photos and videos, and build professional relationships. ACS Communities’ private forums are protected by multiple security levels that give members the ability to discuss the issues that matter most to them without jeopardizing patient confidentiality.

ACS Governor Tyler Hughes, MD, FACS, serves as the Medical Editor of the ACS Communities and has spent countless hours working with staff and member beta test users to make ACS Communities an outstanding place for you to connect with your colleagues.

Update your profile, join communities

It’s easy to log in and get started using ACS Communities. Unless you have specified otherwise in the College’s records, the default username is your eight-digit member ID, and the default password is your last name.

Profiles in ACS Communities facilitate collaboration among members by making it easy to find colleagues with similar interests and backgrounds. ACS staff used information from the member database to complete your new profile, including your name, organization, professional designations, areas of special interest, and so on (see Figure 2). Members are encouraged to fill in any gaps to take full advantage of ACS Communities’ offerings. For example, remember to upload a picture of yourself, if one is not currently in the ACS system. Digital ribbons underneath profile photos show level of involvement with the College, as well as with ACS Communities. Immediately under the ribbons is a listing of the communities to which you belong. You may join other communities that interest you by simply clicking “Join,” except for those that are closed to specific member groups, such as the Board of Governors. Use the “Communities” menu item to see all of the possible communities available for you to join. The initial communities created on the site include Board of Governors (closed), Resident and Associate Society (RAS-ACS), General Surgery, Colon and Rectal Surgery, and Rural Surgery. More communities will be added in the coming months.

Figure 2. Physician profile in ACS Communities

Figure 2. Physician profile in ACS Communities

Search for colleagues

Use the “Directory” link in the top navigation bar to find other members of the College. If you know someone’s name, company, or e-mail address, you can use the basic search to locate that individual. To search for people by location, areas of clinical concentration, education and training, and specialty, use the advanced search function. Once you’ve found the person(s) who you’re looking for, you can view profiles, send a message, or add as a contact.

Not only is ACS Communities accessible via desktop, tablet, or mobile device, but new features will be added in the coming months to make ACS Communities even more collaborative. The ACS is pleased to make this new tool available to members, so that users can share their knowledge with other members, and we hope that all ACS members will take advantage of this opportunity to become better surgeons. (A helpful “frequently asked questions” section, or FAQ, may be accessed from the top of any page in the event you need assistance.)

Using the new

Although it is ostensibly a public website, the new was developed expressly with you—the ACS member—in mind. You can navigate the new site with greater ease and utility on any modern, Internet-capable device. Instead of building three separate versions for various viewing devices, only one version of the site was developed using responsive Web design best practices. Responsive design means that as a user, you will see nearly the same information and enjoy the same functionality regardless of which device you use to visit Site content is scaled to provide the best view and navigation experience based on your device’s browsing capabilities.

Manage your membership features

All members of the College are encouraged to first sign in to the new site to take advantage of the secure content areas that are available to “members only.” In this location you will find that most of your ACS-related business needs can be handled through the “My Profile” section. You can manage continuing medical education (CME) credits, update your membership profile (click on the pencil icon), pay dues, update your case log in the Surgeon Specific Registry, track ACS purchases, find out who represents you on the ACS Advisory Councils and Board of Governors, learn what chapter you belong to and how to contact its officers, and discover other member benefit highlights.

Single sign-on technology is a new feature of ACS Web properties, meaning you will not have to sign in again to take advantage of most membership features, unless you log out or try to access these features from a different device. Moreover, you can now visit ACS Communities and the Journal of the American College of Surgeons online without having to log in again.

Spotlight on ACS pillars

The ACS home page is organized to emphasize the College’s pillars: Member Services, Quality Programs, Education, and Advocacy. These four pillars provide the backbone of the content for the entire website and are positioned on a prominent navigation bar that stays with you as you browse the website (see Figure 3). Clicking on any of the pillar navigation headings provides you with an extensive list of related programs and topics in those four content areas.

Figure 3. Navigation bar

Figure 3. Navigation bar

The Member Services Pillar provides an overview of the benefits of ACS membership. The new Member Benefits section has been organized by membership category—from medical student to ACS Fellow. In this area, you will find information on scholarship and fellowship opportunities, how to connect with your local chapter, and a link to the College job bank, ACS Career Connection.
Information regarding all ACS Quality Programs can be viewed in the same menu section of the website. This section provides an overview and specific details about our surgical quality initiatives in the areas of surgical quality improvement, bariatric and metabolic surgery, cancer center accreditation, breast center accreditation, trauma center verification and quality improvement, and the overall role that the College has played in providing leadership in quality surgical care in the U.S.

Likewise, the Education Pillar pulls in educational offerings from ACS trauma, cancer, and continuous quality improvement programs, in addition to presenting the wide range of outstanding programs that you’ve come to expect from the ACS Division of Education.

Visiting the Advocacy section on a regular basis will keep you up to date on the latest in advocacy and health policy activities at the federal and state levels—activities that represent the interests of you, the practicing surgeon, and your patients.

Federated search feature

The new website employs a federated search feature, meaning that one search box on the website can be used to search multiple sources of information. This function allows the general public to search for a qualified surgeon who is a Fellow, in addition to finding a treatment facility verified or accredited by the ACS.

Figure 4. Federated search box

Figure 4. Federated search box

By default, the search box in the header of the new website searches the text content of the current site (see Figure 4). But you can further seek out the “Search Options” menu next to the search box, which allows you to search various ACS databases. Using Search Options, you can search the following areas:

  • Website content
  • Find a Surgeon (our membership database)
  • Commission on Cancer (CoC)-Accredited Cancer Programs
  • Committee on Trauma (COT)-Verified Trauma Centers
  • ACS Accredited Education Institutes
  • National Accreditation Program for Breast Centers (NAPBC)-Accredited Breast Centers
  • Trauma Centers enrolled in Trauma Quality Improvement Program (TQIP®)

Other controls allow you to narrow your search. You can refine your facility search by state, city, ZIP code, country, distance, and several other variables that differ by program. You can also refine a surgeon search activity by using similar controls.

Utility bar features

The grey utility bar at the top of the home page contains several links that carry over to every page of the site (see Figure 5). “Events” takes you to an online calendar that lists CME opportunities offered by the College and events organized by ACS chapters and other appropriate groups, such as surgical specialty societies and academic medical centers. Further along that utility bar, “Shop” takes you to the ACS e-commerce section. Here you can find and purchase resources for lifelong surgical educational needs, standards manuals, reference tools, and have the option to register for courses, and contribute to the ACS Foundation. The “My Profile” link is also prominently placed in this bar so that you can easily view your profile and keep it up to date. A current profile means your colleagues and patients can always find you, and you can continue to receive e-mail and print communications from the ACS without interruption.

Figure 5. Utility bar

Figure 5. Utility bar

Website audiences

Another way to browse site content is to choose the audience to which you belong. The site has a global footer that lists the College’s key audience groups (see Figure 6). Surgeons, international surgeons, Associate Fellows, residents, and medical students are all directed to targeted information based on where they are on the surgical career path. Patients and families are directed to the ACS Patient Education Web pages, while the media are directed to our online newsroom, which features press releases reporting on ACS initiatives, news from the Clinical Congress and other meetings, and studies published in the Journal of the American College of Surgeons.

Figure 6. Global footer

Figure 6. Global footer

Users will also find a prominent “Find a Surgeon” feature in this footer, which has been developed in tandem with the federated search feature and represents a more prominent way for patients in your geographic area to find you.

The ACS encourages you to view the online tutorial video located on the home page, which contains brief descriptions on how to navigate the new website. With more than 2,200 pages and files online, we anticipate you’ll find much more to explore as you become acquainted with the new

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The SAGES FUSE program: Bridging a patient safety gap Mon, 01 Sep 2014 05:57:39 +0000

Operating rooms (ORs) and procedure suites are host to millions of patient interventions every year in the U.S. It is now well understood that many invasive procedures carry substantial risk and may lead to potentially serious complications. The risks have increased in the modern operating theater, which is defined by human interaction, increasingly challenging patient cases, and dazzling technology. Extensive knowledge, training, and skill in all of these domains are required to optimize clinical outcomes and patient safety.

SAGES FUSE Task Force Members

Souheil W. Adra, MD
General, bariatric, and advanced laparoscopic surgery, bariatric program, Bristol Hospital, CT

Sharon L. Bachman, MD, FACS
Associate professor of surgery, Virginia Commonwealth University School of Medicine, Inova Campus, Richmond; director, minimally invasive surgery, Inova Fairfax Medical Campus; surgical director, Arizona Simulation Technology and Education Center; interim director of research, department of surgery, Inova Fairfax Medical Campus, Falls Church, VA

L. Michael Brunt, MD, FACS
Professor of surgery; section chief, minimally invasive surgery; director, minimally invasive surgery clinical fellowship; director, Washington University Institute for Minimally Invasive Surgery, Washington University School of Medicine, St. Louis, Missouri

Director, division of gastrointestinal/minimally invasive surgery; associate professor of surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL

James S. Choi, MD, FACS
Hepatobiliary and pancreas surgery; chief of surgery, Kaiser Antioch, The Permanente Medical Group, Antioch, CA

Charles E. Cowles, MD, MBA
Department of anesthesiology and perioperative medicine, MD Anderson Cancer Center, Houston, TX

Suvranu De, ScD
Professor and head, department of mechanical, aerospace and nuclear engineering; director, center for modeling, simulation and imaging in medicine, Rensselaer Polytechnic Institute, Troy, NY

Brian J. Dunkin, MD, FACS
Professor of clinical surgery, Weill Cornell Medical College; John F., Jr., and Carolyn Bookout Chair in Surgical Innovation & Technology; medical director, Methodist Institute for Technology, Innovation, and Education, Houston Methodist Hospital, TX

Liane S. Feldman (co-author)
FUSE Task Force

Abraham Jacobo Frech, Jr., MD
General surgery, Beth Israel Deaconess Medical Center, Boston, MA

Pascal R. Fuchshuber (co-author)
Co-Chair, FUSE Task Force

Warren S. Grundfest, MD, FACS
Professor of bioengineering and electrical engineering, The UCLA Henry Samueli School of Engineering; applied science professor of surgery, The David Geffen School of Medicine at University of California, Los Angeles (UCLA)

Charlotte L. Guglielmi, MA, BSN, RN, CNOR
Perioperative nurse specialist, Beth Israel Deaconess Medical Center, Boston, MA

Jeffrey W. Hazey, MD, FACS
Interim chief, gastrointestinal surgery, and associate professor of surgery, The Ohio State University, Wexner Medical Center, Columbus

Daniel M. Herron, MD, FACS
Professor of surgery; chief, section of laparoscopic & bariatric surgery; vice-chair of surgical technology, Icahn School of Medicine at Mount Sinai, New York, NY

Joseph L. Hudgens, MD
Assistant professor and director of minimally invasive surgery, department of obstetrics & gynecology, Wiser Women’s Hospital, University of Mississippi Medical Center, Jackson

David A. Iannitti, MD
Clinical professor of surgery, University of North Carolina at Chapel Hill, Charlotte

Gretchen Purcell Jackson, MD, PhD, FACS
Assistant professor of surgery, pediatrics, and biomedical informatics, Vanderbilt University, Nashville, TN

Daniel B. Jones (co-author)
Chair, FUSE Task Force

Stephanie B. Jones, MD
Associate professor of anesthesia, Harvard Medical School; vice-chair for education, department of anesthesia, critical care and pain medicine, Beth Israel Deaconess Medical Center, Boston, MA

Jarrod P. Kaufman, MD, FACS
General and advanced laparoscopic surgeon; New Jersey State Chair, ACS Commission on Cancer; emeritus chair, melanoma workgroup, New Jersey Governor’s Task Force on Cancer Prevention, Early Detection, and Treatment; founding director, cutaneous oncology and melanoma program, Centrastate Medical Center, Freehold, NJ

Leena Khaitan, MD
Associate professor of surgery, University Hospitals, Case Medical Center, Chardon, OH

Omar Yusef Kudsi, MD, MBA, FACS
Assistant professor of surgery, Tufts University School of Medicine, Boston, MA

Amin Madani, MD
Resident, general surgery, McGill University, Montreal, QC

Dean J. Mikami, MD, FACS
Assistant professor of surgery, division of general surgery, The Ohio State University Medical Center, Columbus

Ellen Morrow, MD
Senior fellow and acting instructor, Center for Videoendoscopic Surgery, University of Washington, Seattle

Malcolm G. Munro, MD, FACOG, FRCSC
Professor, department of obstetrics and gynecology, David Geffen School of Medicine, UCLA; director, gynecologic services, Kaiser Permanente, Los Angeles, Medical Center

Ravi Munver, MD, FACS
Associate professor of surgery, Rutgers-New Jersey Medical School; vice-chair of urology and chief, minimally invasive and robotic urologic surgery, Hackensack University Medical Center, NJ

Jaisa Olasky, MD
Bariatric surgery, general surgery, Mount Auburn Hospital, Cambridge (MA) Health Alliance

Chan W. Park, MD, FACS
Assistant professor of surgery and associate director, surgical education and activities lab, Duke University Health System, Durham, NC

Dana Portenier, MD
Assistant professor of surgery, Duke University School of Medicine; chief, general surgery, and program director, Duke Regional Hospital, Durham, NC

Kinga A. Powers, MD, PhD
General surgery, trauma/surgical critical care, bariatric surgery, Carilion Clinic, Roanoke, VA

William S. Richardson, MD, FACS
Section head, general surgery, Ochsner Clinic, New Orleans, LA

Thomas N. Robinson (co-author)
Co-Chair, FUSE Task Force

Marc A. Rozner, PhD, MD
Professor of anesthesiology and perioperative medicine and professor of cardiology, University of Texas MD Anderson Cancer Center, Houston

Ganesh Sankaranarayanan, PhD
Research assistant professor, department of mechanical, aerospace, and nuclear engineering, The Center for Modeling, Simulation and Imaging in Medicine, Rennselaer Polytechnic Institute, Troy, NY

Daniel J. Scott, MD
Frank H. Kidd, Jr., MD, Distinguished Professorship in Surgery; professor and vice-chairman of education, department of surgery; surgery residency program director; director, Southwestern Center for Minimally Invasive Surgery, University of Texas Southwestern Medical Center, Dallas

Steven Schwaitzberg (co-author)
FUSE Task Force

Victoria Steelman, PhD, RN, CNOR, FAAN
Perioperative nurse specialist and assistant professor, College of Nursing, University of Iowa, Iowa City

Thadeus L. Trus, MD
Associate professor of surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH

Brenda C. Ulmer, RN, MN, CNOR
Perioperative nurse educator, Snellville, GA

Esteban Varela, MD, MPH, FACS
Associate professor of surgery, minimally invasive and bariatric surgery, Washington University School of Medicine, St. Louis, MO

C. Randle Voyles, MD, MS, FACS
Associate clinical professor, Baptist Health System, Surgical Clinic Associates PA, Jackson, MS

Eelco Wassenaar, MD, PhD
Acting assistant professor, department of surgery, University of Washington, Seattle

Heightened public awareness about safety in the OR has led many institutions to adopt a plethora of effective performance improvement programs and tools, such as team training and checklists.1 Despite these efforts, many gaps in OR safety education and training remain. A striking example is a lack of inculcation in the safe application of energy-based devices commonly used by surgeons, anesthesiologists, gastroenterologists, and nurses. These instruments can cause serious harm and death in patients when applied by individuals lacking a fundamental understanding of their function, design, and application. This lack of knowledge contributes to an estimated 600 OR fires annually in the U.S., a large number of accidents due to interference with implantable cardiac devices, as well as unrecognized and, therefore, life-threatening internal injuries among patients undergoing abdominal operations.2-13

This article analyzes how energy-based surgical devices have contributed to complications and mortality in the OR. It also looks at how surgeons have been trained to use these devices. In addition, this article describes the curriculum developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) called the Fundamental Use of Surgical Energy (FUSE) program ( The FUSE program was established to ensure that surgeons have a more comprehensive understanding of how to use energy-based surgical devices safely.

Scope of the problem

Surgeons have used devices that apply energy to tissue therapeutically for millennia. Cautery—the direct application of heat to tissue—has been used therapeutically since 3000 BC to destroy tumors and achieve hemostasis.14 At the beginning of the 20th century, several engineers developed surgical instruments based on electrical energy. The best-known instrument was invented by William T. Bovie and applies high-frequency alternating current (radiofrequency electrosurgery) to tissues, combining the action of cutting and coagulation.15 After introduction into surgical practice by Harvey W. Cushing, MD, FACS, the “bovie” is still the most widely used energy-based device today. In the 1940s, surgical energy devices started to slowly evolve. Bipolar devices were introduced, with innovations such as the incorporation of cutting blades and real-time impedance measurement.

Nurses and anesthesiologists long ago recognized the gap in knowledge about the safe use of surgical energy devices. In 1979, Chambers and Saha reported a cardiac arrest due to electrocution in a young patient undergoing laparotomy. The patient died because an electrocardiogram (EKG) monitor with a direct earth ground created an electrical circuit that included the patient. Because of a faulty electrical switch in the operating table, the patient was electrocuted.16 Although this design has been abandoned and every OR electrical device must now comply with numerous safety requirements, injuries from electrical devices still occur. In 2010, Wills and colleagues reported a case of electroshock injury to a nurse in a state-of-the-art equipped OR.17

These reports of injuries related to electric monitoring devices have led to safer standards for common electronic devices used in ORs, including EKG machines, anesthesia monitors, operating tables, electrical outlets, and switches. Surgeons, however, were not involved in the development of these safety standards and remained largely unaware of the potential dangers associated with energy sources in the OR.

A vast array of devices for tissue dissection and efficient control of larger vessels without suturing have emerged. Today’s modern practicing surgeons use a range of devices that apply energy to tissues in many different ways, including electric current at radiofrequency wavelength, ultrasonic energy, and microwave-based, water jet-based, and plasma-based energy. This broad collection of energy sources allows the technology to be used in all forms of procedures—from open, laparoscopic, and robotic procedures to percutaneous interventions and endoscopic procedures. The advent of minimally invasive surgery has fueled the introduction of an exponentially greater number of surgical energy-based devices marketed to virtually every surgical specialty. In many ways it is because of these technical innovations that the advances in minimally invasive surgery, endoscopic interventional techniques, and percutaneous approaches to diseases have become possible. This technological boom has led to a multitude of energy device platforms, configurations, generators, cost points, and vendors.

Because of the increased complexity and number of energy devices used in surgical procedures, the susceptibility of surgeons to inadvertently harming patients has increased in the last two decades. The estimated prevalence of injuries related to electrosurgery during laparoscopic procedures is 1–2 per 1,000 patients.4 These devastating complications are often unrecognized bowel injuries and major vascular injuries.4,18 Unrecognized thermal injuries to the intestine during laparoscopic surgery are particularly dangerous because they are difficult to detect and carry a significant associated mortality.19,20 With more than 2 million laparoscopic procedures performed annually in the U.S., these energy-based surgical devices represent a major patient safety issue.21

Health care community’s response

The widespread use of energy-based surgical devices carries an increased risk of adverse events, largely because the devices are not completely understood. A common practice is for a surgeon to use a new device after a short primer by a vendor without understanding the fundamental principles of its function and safety. This gap in surgeon knowledge directly affects patient safety and must be addressed.

Individual surgeons, other health care professionals, and surgical societies both in the U.S. and abroad have tried to respond to this safety issue.22-26 These pioneers have shown us the specific complications associated with electrosurgical devices and the risks involved in their use, particularly in laparoscopy. Their seminal work included a survey sponsored by the ACS to assess the complication rate associated with the use of electrosurgical devices. This study demonstrated for the first time that most surgeons reported inappropriately high-power settings when using electrosurgical instruments (n=508).27 As early as 1998, the Society of Laparoendoscopic Surgeons proposed to educate surgeons on the safe use of laparoscopic monopolar electrosurgical devices, and in 2005, the Association of periOperative Registered Nurses (AORN) published basic recommendations on the safe use of energy devices.28,29 However, these efforts had a minimal impact on surgical practice.

Fundamental knowledge concerning the correct use and inherent dangers of energy-based devices remains incomplete. In contrast to textbooks written for anesthesiologists and nurses, surgical texts contain little relevant information regarding these instruments. Furthermore, surgeons are rarely required to train on the energy-based devices they use in the OR or to document their knowledge of device-related safety issues.

Lack of fundamental knowledge

Although many surgeons believe they understand how to use energy-based devices properly and safely, their actual effectiveness in using the instruments had never been formally tested until 2011 at a SAGES postgraduate continuing medical education course on the optimal use, safety profile, and knowledge of surgical energy-based devices. The faculty developed an 11-item multiple-choice pretest to measure what they considered to be critical knowledge. This pretest was administered to all postgraduate course participants and experienced SAGES surgeons. Course participants also completed a 10-item posttest covering the same content at the end of the course.30

In all, 48 experienced SAGES surgeons completed the test. The median number of correct answers out of 11 was 6.5, or 59 percent. One-third of SAGES leaders did not know how to correctly handle a fire on the patient; 31 percent could not identify the device least likely to interfere with a pacemaker; 13 percent did not know that thermal injury can extend beyond the jaws of a bipolar instrument; and 10 percent thought a dispersive return electrode should be cut to fit a child. The 27 postgraduate course participants had similar scores, with a median six correct answers out of 11.30-31 Similar results were seen for surgeons in training, revealing that knowledge regarding the safe use of energy devices does not seem to increase with experience and that surgical “experts” do not necessarily have greater understanding of energy devices compared with junior trainees.30-31

This issue is not specific to electrosurgery; it is evident in the use of newer energy technologies, as well. In April 2014, at the SAGES annual meeting, a short video of a laparoscopic superior mesenteric artery (SMA) dissection in a Whipple procedure was shown. Using ultrasonic shears, the uncinate process was separated from the SMA. One must stay very close to the vessel to remove all potentially involved lymphatic tissues. Laparoscopy, with its magnification and superior visualization, is particularly suited for this step of the procedure. As the surgeon dissected along the SMA with the ultrasonic shears, one could observe the development of an arterial pseudoaneurysm. The surgeon immediately recognized the potentially devastating complication and repaired the vascular injury. One key point gleaned from this video is that when energy devices with lateral thermal spread are used close to major arteries, injury from proximity to the instrument’s jaw can occur.

This example highlights the importance of understanding the characteristics of surgical energy devices as more and more complex laparoscopic procedures are performed. Perhaps the knowledge of the different thermal spread characteristics and temperatures generated by different vessel sealers and dissectors may help prevent such injuries. This particular example emphasizes the potential for unintended injury from energy devices through collateral thermal damage. Surgeons must be knowledgeable and aware of the side effects and must ascertain good control of the effector tip of any energy device used near a vessel or other tissue.

Need for training

Clearly, a standardized training program on energy-based devices is needed, particularly one that provides a rigorous framework for the introduction of these potentially harmful devices into routine clinical practice. Several key developments mentioned in this article support this conclusion.

Rapid expansion of new technologies

ORs have rapidly transformed from analog workrooms into sophisticated control centers of electronic health records, anesthetic delivery machines, high-definition screens, recording equipment, and a multitude of surgical energy devices.

OR fires

The estimated 600 OR fires that occur in the U.S. annually are preventable. In each case, the ingredients are a spark from an energy device, fuel, or oxidizer. Several professional societies have created videos, monographs, and posters highlighting the dangers of OR fires, but they still occur. The U.S. Food and Drug Administration recognizes this threat to patient safety and has organized a special task force to address this hazard, but few physician groups participate. There still is no common educational pathway to teach fire prevention by safely using surgical energy devices in the operative field.

Evolving industry ties to surgical education

Today, introduction of new surgical devices for use by surgeons is left in the hands of industry representatives, and knowledge regarding new devices is largely disseminated through industry-sponsored courses. Although a certain logic underlies this approach, it is inherently problematic. The primary goal of device representatives is not to teach function and safety, and they have no standards for determining whether a surgeon is able to use a new device safely. With rising concern about the influence of industry on surgeons, boundaries have been created to keep these parties separate. As a result, it has become increasingly difficult for industry representatives to teach surgeons and nurses how to use new devices. And yet, no alternative instruction model is currently available, which raises several important questions:

  • Where will the training to master new surgical energy devices originate?
  • Who will create a curriculum covering their functionality and safety profiles?
  • How should we offer appropriate training and certification?
  • What is the standard procedure when a surgeon or nurse is suddenly faced with unfamiliar equipment?
  • How will we mandate and pay for fire safety training?
  • Should there be a standard approach for how energy devices are introduced into the hands of surgeons—and who will create these standards?

Perhaps the most obvious solution is a nationwide, non-industry sponsored, multidisciplinary educational program with validated assessment in surgical energy-based devices to address the knowledge gap and to ensure patient safety and the use of best practices.

FUSE program

Educational programming can be based on either a top-down or bottom-up approach. The top-down approach would involve federally mandated programs, which is unappealing on many levels. It will be hard to create buy-in for yet another external mandate that will likely involve time away from patient care. Using the bottom-up approach, surgeons of all specialties, nurses, and anesthesia professionals would work together to create an educational program. The benefit of this approach, in which providers take responsibility for meeting stated goals, is that it is more likely to produce buy-in and meaningful change.

SAGES created the FUSE program using a bottom-up approach. Working in partnership with AORN, the American Association of Gynecologic Laparoscopists (AAGL), and the American Urologic Association, the FUSE team includes a variety of general and subspecialty surgeons, nurses, anesthesiologists, gynecologists, and engineers. Following in the tradition of two other SAGES educational programs—Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery—FUSE has two central components: a standardized curriculum for surgeons and allied health care professionals of all specialties, and a high-stakes certification test that meets rigorous psychometric and accreditation standards. Test results will serve as verification that the surgeon has attained the basic knowledge necessary to safely use energy-based devices in the OR.

The FUSE curriculum was first presented at a SAGES postgraduate course in 2011 and 2012. The material was expanded into a textbook on surgical energy and safety. The SAGES Fundamental Use of Surgical Energy Manual was published in 2012 and as an online multimedia curriculum that same year.32 The FUSE online curriculum is available from SAGES at

The FUSE curriculum includes 10 sections:

  1. Fundamentals of Electrosurgery
  2. Mechanisms and Prevention of Adverse Events with Electrosurgery
  3. Monopolar Devices
  4. Bipolar Devices
  5. Radiofrequency for Soft Tissue Ablation
  6. Endoscopic Devices
  7. Ultrasonic Energy Devices
  8. Microwave Energy Systems
  9. Energy-Based Devices in Pediatric Surgery
  10. Integration of Energy Systems with Other Devices

The content focuses on the key principles of safe and effective use of surgical and endoscopic energy devices. For example, Fundamentals of Electrosurgery (Section 1) covers the types of electric currents used; correct nomenclature; explanation of physics, such as Ohm’s law as it is applied to electrosurgery; electrosurgical generators; differences in “coag” and “cut” waveforms; monopolar versus bipolar systems; isolated versus ground-referenced systems; active and dispersive electrodes; physical effects of temperature and alternating current on cells and tissue; resistive heating; and the different tissue effects (desiccation, coagulation, fulguration). Section 2 describes the safe use of electrosurgical devices, current diversion including direct and capacitive coupling, insulation failure, and prevention and response to OR fires. A similar emphasis on fundamental principles and safe application is used in the sections on specific devices that include monopolar, bipolar, ultrasonic, radiofrequency ablation, and microwave and endoscopic devices. Special considerations for use of energy devices in pediatric patients and in patients with other medical devices (cardiac implantable devices) are addressed in additional sections. The FUSE manual contains supplemental hands-on chapters describing how to set up “live” stations for demonstration and teaching surgical energy principles and safe practice.

The online curriculum provides multimedia content of the FUSE curriculum, including self-assessment test questions eligible for continuing medical education, maintenance of certification, and continuing education units. An example of a “page” from the online curriculum is shown in the figure.

Example from the FUSE online curriculum


The FUSE curriculum is designed to provide surgeons with the knowledge they need to pass the FUSE certifying exam, which has been developed to comply with the legal and technical requirements for professional certification. More specifically, psychometricians led 15 FUSE content experts through a systematic process to define the competencies required to use energy devices safely. For each section of the curriculum, two to 20 objectives were identified, for a total of 72 objectives. For example, see the table on this page for the objectives set forth for Section 1: Fundamentals of Electrosurgery and Section 2: Mechanism and Prevention of Adverse Events with Electrosurgery. Leaders from SAGES, along with selected members of AORN and AAGL, participated in development of the test blueprint by ranking each objective and determining the number of test items for the written exam. They determined that the assessment should, most importantly, measure health care professionals’ understanding of the fundamental principles of energy devices, their electrosurgical safety, and the integration of energy systems with other devices. Beta testing of the program and assessment was completed in April of this year. More than 170 surgeons and allied health professionals achieved a passing score in beta testing of the exam, making them the first cohort of FUSE-certified surgeons.

Example of educational objectives used to develop online curriculum and certification exam


Fundamentals of electrosurgery


Define proper electrosurgery terms


Given a clinical situation, identify the application of Ohms law, power equation, and energy


Identify the function (input and output) of an electrosurgical (RF) generator


Identify the characteristics of monopolar and bipolar instruments and the differences between them


Identify the characteristics of the RF electromagnetic spectrum and why it is used for surgical applications


Identify how radiofrequency electrical energy causes effects in cells and tissue


Identify the different effects of ranges of temperature on cells and tissue


Mechanisms and prevention of adverse events with electrosurgery


Identify general patient protection measures for setup and settings for the electrosurgical unit


Identify various mechanisms whereby electrosurgical injuries may occur


Identify circumstances, mechanisms, and prevention of dispersive electrodes-related injury

Further additions to the FUSE curriculum are currently under way, including a structured interactive bench-top simulation component. This goal-directed, hands-on, bench-top training session has been shown to improve learning and retention of vital knowledge on surgical energy-based devices at three months.33 Simulation of surgical energy is currently being developed into a portable, virtual reality simulation-based educational tool for surgical trainees.34


All members of the surgical team should be able to demonstrate and apply a fundamental understanding of the use of surgical energy in the OR in order to achieve optimal clinical results and create the safest possible environment for the patient and staff. The FUSE program bridges a gap in patient safety as it relates to best practice in the use of surgical and endoscopic energy devices. It addresses the most common types of energy devices, their impact on OR fire prevention, the safety of implantable electronic devices, and safe and appropriate use of energy devices within the operative field. This program is the first educational tool of its kind to address patient and OR team safety for energy devices in the surgical theatre or the endoscopy suite.

Future developments in the FUSE program will include specific modules tailored to individual energy devices. These modules will be designed in collaboration with industry to provide standardized education for the safe and appropriate use of new and current energy devices. Industry involvement will ensure that the FUSE program will continue to fill the unmet curricular, regulatory, safety, and competency assessment needs that exist for the use of energy devices by surgeons, endoscopists, anesthesiologists, and nurses worldwide.

fuseFUSE contact information

FUSE program:
FUSE didactics:

Authors’ note

FUSE is funded by unrestricted educational grants to SAGES FUSE Consortium Education Fund from the SAGES Foundation, Covidien, and Olympus. The authors derive no financial benefit from this project. All authors are members of the SAGES FUSE task force.


The authors would like to thank Jessica Mischna, manager, SAGES FUSE programs; Sallie Matthews, executive director, SAGES; Brenda Castaneda, manager, SAGES fundamentals programs; and Carla Bryant, director, SAGES fundamentals programs, for their invaluable support of the FUSE project, as well as the members of the SAGES FUSE task force for their contributions.


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  4. Nduka CC, Super PA, Monson JR, Darzi AW. Cause and prevention of electrosurgical injuries in laparoscopy. J Am Coll Surg. 1994;179(2):161-170.
  5. Sankaranarayanan G, Resapu RR, Jones DB, Schwaitzberg S, De S. Common uses and cited complications of energy in surgery. Surg Endosc. 2013;27(9): 3056-3072.
  6. Agarwal BB, Gupta M, Agarwal S, Mahajan K. Anatomical footprint for safe laparoscopic cholecystectomy without using any energy source: A modified technique. Surg Endosc. 2007; 21(12):2154-2158.
  7. Gol M, Kizilyar A, Eminoglu M. Laparoscopic hysterectomy with retroperitoneal uterine artery sealing using LigaSure: Gazi hospital experience. Arch Gynecol Obstet. 2007;276(4):311-314.
  8. Kriplani A, Garg P, Sharma M, Lal S, Agarwal N. A review of total laparoscopic hysterectomy using LigaSure uterine artery-sealing device: AIIMS experience. J Laparoendosc Adv Surg Tech A. 2008;18(6):825-829.
  9. Polychronidis A, Tsaroucha AK, Karayiannakis AJ, Perente S, Efstathiou E, Simopoulos C. Delayed perforation of the large bowel due to thermal injury during laparoscopic cholecystectomy. J Int Med Res. 2005;33(3):360-363.
  10. Siperstein A, Garland A, Engle K, et al. Local recurrence after laparoscopic radiofrequency thermal ablation of hepatic tumors. Ann Surg Oncol. 2000;7(2):106-113.
  11. Darai E, Ackerman G, Bazot M, Rouzier R, Dubernard G. Laparoscopic segmental colorectal resection for endometriosis: Limits and complications. Surg Endosc. 2007;21(9):1572-1577.
  12. Peterson HB, Ory HW, Greenspan JR, Tyler CW Jr. Deaths associated with laparoscopic sterilization by unipolar electrocoagulating devices, 1978 and 1979. Am J Obstet Gynecol. 1981;139(2):141-143.
  13. Willson PD, van der Walt JD, Moxon D, Rogers J. Port site electrosurgical (diathermy) burns during surgical laparoscopy. Surg Endosc. 1997;11(6):653-654.
  14. Schwaitzberg SD. Evolution and revolutions in surgical energy. In: Feldman LS, Fuchshuber P, Jones DB, eds. The Fundamental Use of Surgical Energy (FUSE) Manual. New York, NY: Springer; 2012:3.
  15. O’Connor JL, Bloom DA. William T. Bovie and electrosurgery. Surgery. 1996;119(4):390-396.
  16. Chambers JJ, Saha AK. Electrocution during anesthesia. Anesthesia. 1979;34(2):173-175.
  17. Wills JH, Ehrenwerth J, Rogers D. Electrical injury to a nurse due to conductive fluid in an operating room designated as a dry location. Anesth Analg. 2010;110:1647-1649.
  18. Cormier B, Nezhat F, Sternchos J, Sonoda Y, Leitao MM Jr. Electrocautery-associated vascular injury during robotic-assisted surgery. Obstet Gynecol. 2012;120(2 Pt 2):491-493.
  19. LeBlanc KA, Elieson MJ, Corder JM III. Enterotomy and mortality rates of laparoscopic incisional and ventral hernia repair: A review of the literature. JSLS. 2007;11(4):408-414.
  20. Bishoff JT, Allaf ME, Kirkels W, Moore RG, Kavoussi LR, Schroder F. Laparoscopic bowel injury: Incidence and clinical presentation. J Urol. 1999;161(3):887.
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  22. Voyles CR, Tucker RD. Education and engineering solutions for potential problems with laparoscopic monopolar electrosurgery. Am J Surg. 1992;164(1):57-62.
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  26. Alkatout I, Schollmeyer T, Hawaldar NA, Sharma N, Mettler L. Principles and safety measures of electrosurgery in laparoscopy. JSLS. 2012;16(1):130-139.
  27. Tucker RD. Laparoscopic electrosurgical injuries: Survey results and their implications. Surg Laparosc Endosc. 1995;5(4):311-317.
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  31. Feldman LS, Fuchshuber P, Jones DB, Mischna J, Schwaitzberg SD. FUSE (Fundamental Use of Surgical Energy) Task Force. Surgeons don’t know what they don’t know about the safe use of energy in surgery. Surg Endosc. 2012;26(10):2735-2739.
  32. Feldman LS, Fuchshuber P, Jones DB, eds. The Fundamental Use of Surgical Energy (FUSE) Manual. New York, NY: Springer; 2012.
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  34. Allen BF, Schwaitzberg SD, Jones DB, De S. Toward the development of a virtual electrosurgery training simulator. Stud Health Technol Inform. 2014;196:11-13.
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The benefits of PQRS participation and what the College is doing on your behalf Mon, 01 Sep 2014 05:56:42 +0000

The Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting System (PQRS) program is the first national program to link the reporting of quality data to physician payment. PQRS began in 2007, providing incentive payments only to eligible professionals (EPs) who voluntarily and successfully participated in the program. Although EPs include nonsurgeon health care professionals, such as other physician specialists, podiatrists, and nurses, for purposes of this Bulletin article, EPs are generically referred to as “surgeons.” In 2013, all surgeons began receiving either an incentive payment for participation or a penalty for lack of or unsuccessful participation. This policy will change again in 2015 when surgeons and other providers will no longer receive incentive payments for successful participation. However, surgeons who fail to comply with the program will receive penalties indefinitely.

Table 1 highlights the PQRS incentive and penalty amounts for 2014 and beyond. Penalties are applied to a surgeon’s total Medicare Part B fee-for-service (FFS) amount, two years after the “performance period” ends. This article provides examples of the scenarios surgeons could face for participation or nonparticipation in 2014, as well as an overview on the PQRS program. It also describes what the American College of Surgeons (ACS) is doing to assist members with participation.

Table 1. PQRS payment incentives and penalties

Calendar year Incentive Penalty*




1.5% (based on 2013 performance)

2016 and beyond

2.0% (based on 2014 performance)

*Penalties are applied based on an EP’s performance two years prior to the calendar year.

What the ACS is doing

In June, the ACS conducted a brief survey to determine the membership’s understanding of the PQRS program. The results of the survey, featured in Table 2, show that nearly half of the 189 respondents had not participated in PQRS and more than one-quarter were unaware of the incentives and penalties. The College has been doing its part to help surgeons by providing informational material and participation opportunities for surgeons so they can avoid the risks of nonparticipation and enjoy the benefits of the program. What is new for this year is that the ACS has received CMS approval for surgeons to submit data collected from two ACS registries in order to meet the 2014 PQRS reporting requirements—the Surgeon Specific Registry (SSR) and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). (See sidebar at the end of this article for details.)

Table 2. Fellow responses to ACS survey on PQRS awareness

Survey questions




Participated in PQRS in 2013 or previous years?






Do you plan to participate in 2014?






Are you aware that if you participate in PQRS for 2014, you could receive a 0.5% incentive payment?






Did you know that if you don’t participate in PQRS for 2014, you will receive a 2% penalty for your Medicare payment?






Would you be interested in knowing more about the ACS SSR that has been qualified by CMS for PQRS reporting for 2014?






Financial importance of participating in PQRS

Unlike other CMS programs, PQRS does not have opt-out “exemptions.” EPs must participate to avoid penalties. Under the PQRS program, an EP is defined as any health care professional who is getting paid under or based on the Medicare physician fee schedule.1

2014 PQRS individual reporting options

Surgeons and group practices may participate in the PQRS program in a variety of ways. Surgeons may report individually and choose one of the methods from the following reporting options that are described in greater detail in Table 32:

  • Claims-based reporting option for individual EPs
  • Registry-based reporting option
  • Electronic health records-based reporting option
  • Qualified clinical data registry (QCDR) reporting option

Table 3. Summary of requirements for the 2014 PQRS incentive for surgeons
Individual reporting criteria for satisfactory reporting of individual quality measures via claims, qualified registries, and EHRs and satisfactory participation criterion in qualified clinical data registries

Reporting period

Measure type

Reporting mechanism

Satisfactory reporting criteria/satisfactory participation criterion

12-month (January 1–December 31) Individual measures Claims Report at least 9 measures covering at least 3 National Quality Strategy (NQS) domains; if less than 9 measures covering at least 3 NQS domains apply to the EP, report 1 to 8 measures covering 1 to 3 NQS domains, and report each measure for at least 50 percent of the Medicare Part B fee-for-service patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.* For an EP who reports fewer than 9 measures covering 3 NQS domains via the claims-based reporting mechanism, the EP will be subject to the claims Measures Applicability Validation (MAV) process, which would allow [CMS] to determine whether an EP should have reported quality data codes for additional measures and/or covering additional NQS domains.
(January 1–December 31)
Individual measures Qualified registry Report at least 9 measures covering at least 3 of the NQS domains; if less than 9 measures covering at least 3 NQS domains apply to the EP, report 1 to 8 measures covering 1 to 3 NQS domains for which there is Medicare patient data, and report each measure for at least 50 percent of the EP’s Medicare Part B FFS patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.* For an EP who reports fewer than 9 measures covering 3 NQS domains via the registry-based reporting mechanism, the EP will be subject to the registry MAV process, which would allow [CMS] to determine whether an EP should have reported on additional measures and/or measures covering additional NQS domains.
†12-month (January 1–December 31) Individual measures Direct EHR product and data submission vendor Report 9 measures covering at least 3 of the NQS domains. If an EP’s certified EHR technology does not contain patient data for at least 9 measures covering at least 3 domains, then the EP must report the measures for which there is Medicare patient data. An EP must report on at least 1 measure for which Medicare patient data are available.
(January 1–December 31)
Measures groups Qualified registry Report at least 1 measures group, and report each measures group for at least 20 patients, a majority of whom must be Medicare Part B FFS patients.
(July 1–December 31)
Measures groups Qualified registry Report at least 1 measures group, and report each measures group for at least 20 patients, a majority of whom must be Medicare Part B FFS patients.
12-month(January 1–December 31) Measures selected by qualified clinical data registry Qualified clinical data registry Report at least 9 measures covering at least 3 NQS domains and report each measure for at least 50 percent of the EP’s applicable patients seen during the reporting period to which the measure applies. Measures with a 0 percent performance rate would not be counted.* Of the measures reported via a qualified clinical data registry, the EP must report on at least one outcome measure.

*Subject to the Measures Applicability Validation process for claims-based or registry-based reporting.
Finalized in the CY 2013 PFS final rule (see Table 91 at 77 FR 69194).

Each option requires adherence to some complex rules and time lines. The ACS has assembled a list and discussion of each of these options. Successful compliance with any of the appropriate reporting options will allow EPs to earn an incentive payment of 0.5 percent.

Note that group practices have the option to participate in PQRS through the Group Practice Reporting Option (GPRO). These options differ from the individual EP options listed in Table 3. The only circumstance in which a group practice may choose from the GPRO reporting options is if the group practice has sent a request to CMS to participate via the GPRO option by September 30, 2014, and has received CMS approval.3

Likely scenarios

Surgeon may face one of three scenarios in the coming years based on their participation in the 2014 PQRS program, as follows.

Scenario one: Smart Surgeon A

Surgeon A is participating in the PQRS program for calendar year (CY) 2014 using the ACS SSR, allowing Surgeon A to complete and meet all of the requirements necessary to successfully comply with the 2014 PQRS program. This surgeon has a Medicare allowable payment amount of $100,000 in 2014. As a result of successful participation in PQRS 2014, Surgeon A will receive a bonus payment of 0.5 percent, or $500, and, more importantly, will avoid a 2 percent penalty, or $2,000, in 2016. In addition, Surgeon A will be identified as a successful PQRS participant on the CMS Physician Compare website.4

Scenario two: Poor Surgeon B

Surgeon B does not participate in the PQRS program in CY 2014 because of time constraints. Like Surgeon A, Surgeon B has a Medicare allowable amount of $100,000 in 2014. However, due to nonparticipation, Surgeon B will not receive an incentive payment. Instead, Surgeon B will receive a penalty of 2 percent of the total Medicare charges, or $2,000, in 2016. Note that the penalty is applied to Surgeon B two years after the current CY, otherwise known as the performance period. Furthermore, Surgeon B will not be listed as a PQRS participant on the CMS Physician Compare website.

Scenario three: It gets worse for Surgeon B

What could be worse? The penalty can double by adding in the effect of the CMS value-based payment modifier for physicians. The value-based payment modifier provides for differential payment to a physician or group of physicians under the Medicare physician fee schedule and based on the quality of care furnished compared to cost during a performance period.5

If Surgeon B belongs to a group practice of 10 or more physicians in 2014 and that group does not participate in one of the PQRS GPRO options, or if 50 percent of that group does not participate in PQRS via one of the individual reporting options, Surgeon B will receive an additional 2 percent penalty under the value-based payment modifier in 2016. Thus, Surgeon B will face a combined PQRS and value-based payment modifier penalty totaling $4,000 based on a Medicare allowable amount of $100,000 in 2014. On the other hand, successful PQRS reporters, like Surgeon A, will be eligible for value-based payment modifier bonuses.

As outlined in the previous scenarios, successful participation in PQRS is essential for avoiding substantial payment penalties. The PQRS payment penalty will occur indefinitely in future years. In addition to the PQRS and value-based payment modifier programs, other CMS quality programs, such as the Electronic Health Record (EHR) Incentive Program, have penalties that take effect around the same time. (Additional information on the EHR Incentive Program is available.)

Resources for surgeons

Additional background information and PQRS resources are available at, as well as

Furthermore, ACS staff members are available to answer questions and assist members participating in the 2014 PQRS program, and to facilitate enrollment in the SSR and the MBSAQIP. For PQRS-related questions, surgeons can contact the following ACS staff:

  • General PQRS program questions: Sana Gokak, ACS Division of Advocacy and Health Policy, 202-337-2701 or
  • Information on the SSR: Bianca Reyes, ACS Division of Research and Optimal Patient Care (DROPC), 312-202-5000 or
  • Information on the MBSAQIP: Rasa Kraprikas, ACS DROPC, 312-202-5000 or
  • CMS is also available to answer PQRS-related questions at 1-866-288-8912 or

ACS programs to assist in PQRS reporting

The ACS recognizes that it may be difficult for most surgeons to comply with PQRS reporting by using the claims- or EHR-based method. The registry-based reporting option, available through the ACS SSR, and the QCDR, available through ACS MBSAQIP, may be better options for some surgeons to pursue.


The SSR, formerly known as the ACS Case Log, allows surgeons to track their cases and outcomes in a convenient, easy-to-use, and confidential manner. The SSR can also be used to comply with regulatory requirements, such as submitting 2014 PQRS data. The SSR allows individual EPs to report on the four measures within the Perioperative Care Measures Group or the five measures (if applicable) and/or surgical outcome measures within the General Surgery Measures Group. Surgeons can choose to report on 20 majority Medicare patients for either one of these groups and will have until January 31, 2015, to submit CY 2014 patient information in the SSR. The SSR will submit the PQRS data to CMS.

The SSR is available at no cost to ACS surgeon members and will be available to non-member surgeons later this year for a nominal fee. Surgeons who have used the Case Log in the past can log on to the SSR with the same username and password and begin entering cases at For current users, the SSR can produce a report that indicates the surgeon’s eligible PQRS cases, based on measures group Current Procedural Terminology codes. These cases may be easily edited with PQRS-specific data through the report. If surgeons have not used the Case Log in the past, they can register at Surgeons will need to consent to and sign up for PQRS reporting through the SSR if they want the registry to submit data on their behalf.


The MBSAQIP has been approved by CMS as a QCDR for PQRS 2014. MBSAQIP participants will have the opportunity to voluntarily elect that their MBSAQIP QCDR quality measures results be submitted to CMS for PQRS participation. Metabolic and bariatric surgeons will receive reports of their QCDR measures results so they can track, and have the opportunity to improve, their results. The MBSAQIP will submit approved 2014 QCDR measures during the first quarter of 2015 on behalf of MBSAQIP participants who elect to have their data submitted. One benefit of using the MBSAQIP is that data are already being collected as part of participation in the MBSAQIP, whereas other options to satisfy PQRS may have additional data burden. Specifications of the approved MBSAQIP QCDR quality measures are available at


  1. Centers for Medicare & Medicaid Services. Physician quality reporting system list of eligible professionals. Available at: Accessed June 12, 2014.
  2. Centers for Medicare & Medicaid Services. Revisions to payment policies under the physician fee schedule, clinical laboratory fee schedule & other revisions to Part B for CY 2014. Available at: Accessed June 10, 2014.
  3. Centers for Medicare & Medicaid Services. Group reporting options. Available at: Accessed June 12, 2014.
  4. Gokak S. What surgeons should know about…The physician compare website. Bull Am Coll Surg. 2013;98(2):52-53. Available at: Accessed June 12, 2014.
  5. Centers for Medicare & Medicaid Services. Summary of 2015 physician value-based payment modifier policies. Available at: Accessed June 23, 2014.
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Surgeons as state advocates Mon, 01 Sep 2014 05:55:21 +0000

The American College of Surgeons (ACS) advocates for several health policy issues that affect health care at the state level. As the strained political climate intensifies in Washington, DC, due to the upcoming 2014 elections and the many effects and implications of the Affordable Care Act that have surfaced, much of the action on major health policy issues is increasingly occurring at the state level. Hence, surgeons need to be prepared to advocate in their state legislatures for policies that move the needle toward establishing a high-quality, high-value health care system. This article outlines why the surgeon’s voice is critical in health care policy debates, how surgeons can be effective advocates, and how the College can support such efforts at the regional level.

The importance of surgeon advocates

In 1932, former U.S. Supreme Court Justice Louis Brandeis wrote in the opinion New State Ice Co. v. Liebmann that “a state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.”* Justice Brandeis’ statement rings true now more than ever in health policy, where states are looking for innovative ways to address the problems facing the U.S. health care system, including stabilizing Medicaid, fighting for medical liability reform, expanding scope of practice, improving public health, increasing transparency with respect to cost and quality, and implementing the Affordable Care Act. With the current partisan gridlock in Washington, little is being accomplished at the federal level, making state governments that much more powerful. In 2014, statehouses considered hundreds of bills addressing various facets of medical liability reform, scope of practice, and health care reform, as well as policies related to specific health care issues, such as cancer prevention, treatment, and diagnosis, as well as injury prevention.

As the state legislatures turn their focus increasingly toward health care policy issues, input from those constituents most affected by the policies being discussed, particularly surgeons, is increasingly important. For surgeons, the responsibility to patients extends far beyond the operating room. State lawmakers are making decisions that directly affect the practice of surgery and surgeons’ ability to provide high-quality care to patients. Surgeons are natural leaders who can and should capitalize on the power they have as thought leaders and respected members of the community to influence the health care policy formulated in state legislatures.

One surgeon who is actively advocating for colleagues and patients at the state level is J. Patrick Walker, MD, FACS, Immediate Past-President of the South Texas Chapter of the ACS. “No one knows more than we do what is best for our patients,” noted Dr. Walker, a general surgeon at East Texas Medical Center, Crockett (e-mail communication with the authors, May 6, 2014). “Don’t count on the beneficence of the government to do what is right for your patient.”

Seasoned College staff view surgeons as the best advocates on health care issues, providing a strong and experienced voice as a guide for state legislators as they consider policies that have wide-ranging effects on surgical practice and the practice of medicine overall. In fact, it is widely understood that lawmakers want and need to hear what surgeons have to say.

Building important relationships

Advocacy is about influencing the individuals who make policy decisions in order to advance a cause. Before undertaking any sort of advocacy campaign, it is important to build relationships with elected officials, their legislative staff or state agency staff, peers, and other organizations.
“The first step in the political process has to be building a relationship with your legislator,” Dr. Walker said. It is important to cultivate relationships with both elected officials and other stakeholders before you need to lobby an issue, because these individuals are more likely to be responsive than are legislators or policymakers who are just getting to know you and what you do and are uncertain as to why they should listen to you.

Reaching out to your ACS state chapter is a good place to start. Many chapters already have legislative committees and advocate on surgery’s behalf, so they can steer advocates in the right direction or provide useful contacts. The ACS also provides funding to chapters for state lobby days, and attending one of these events can be a great introduction to state lawmakers and the legislative process.

Attend a fundraiser

Fundraisers for political candidates provide a great venue for building a relationship with current and aspiring lawmakers. Although not always viewed in a positive light, attending a fundraising event or donating a small amount to a campaign can help improve access to legislators when action is necessary.

Dr. Walker recommends participating in an event in the legislative off-season, when the legislators are less likely to have their attention pulled in multiple directions. “There is no question that fundraising is a great way to get to know a politician,” Dr. Walker said. “You don’t have to raise massive amounts of money. They appreciate your effort.” It is critical to keep in mind that laws vary from state to state with regard to how much an individual may contribute to a candidate’s campaign, and it is recommended that any Fellow wanting to make a contribution first consult with the state elections board to determine what is permissible. If a surgeon is unable to make a financial contribution, other ways to support a campaign include volunteering in the campaign office and serving as a health policy advisor.

Benefits of face-to-face meetings

Another powerful tactic in building a relationship with legislators and their staff is to meet with them face-to-face, either in their office or by inviting them to visit your practice. “Legislators and their staff love hearing front-line stories from us about the care we provide to our patients, who live in their districts and are their constituents,” said Naveen Sangji, MD, a surgical resident at Massachusetts General Hospital, Boston (e-mail communication with the authors, May 13, 2014). “We can highlight our requests, which are typically patient-centered, with personal stories and experiences. The impact of that is immeasurable. We have the power to make a real difference in our home states.”

Indeed, personal stories and information are vital to make a lasting impression, and these meetings offer a way to relay those stories and information. A site visit provides an opportunity for the legislator to see where surgeons work, to interact with the patient care team, and to learn what it takes to run a successful practice. Lawmakers also get to experience firsthand how the policies they make affect patients, physicians, and constituents.

Leverage legislative staff

It is also important to build a rapport with legislative staff. Legislators are responsible for a range of issues and can’t possibly be experts on every issue that affects surgery. Hence, they leave much of the research and fact gathering to their staff, who help prepare legislators for hearings, write correspondence, make scheduling decisions, and more. Quite often advocates are discouraged when they find they will be meeting with legislative staff rather than their elected officials directly; however, meetings with staff can be as beneficial as meeting with a legislator. Keep in mind that legislators will always go back to staff for advice and recommendations on how to move forward with a policy position or how to vote. Remaining on good terms with legislative staff can go a long way toward gaining access to the legislator and achieving advocacy goals and gaining access to the legislator.

Communicate effectively

The cornerstone of a productive relationship with state lawmakers is effective communication. Advocates can communicate via letter, fax, e-mail, telephone, in-person meeting, and social media outlets, such as Facebook and Twitter. Legislators want to hear from their constituents and are sensitive to their opinions. Thoughtful, sincere, and precise comments are extremely useful and may be used by a legislator or regulator when debating or discussing a bill or proposed rule, and can help build a solid, long-term relationship. When preparing to advocate on an issue, “Know what you want, and know how to explain it succinctly and with persistence,” Dr. Walker suggested.

An easy way to write an e-mail to a legislator is through the Surgery State Legislative Action Center (SSLAC), described in the “ACS resources” section of this article. The ACS State Affairs team will send several SSLAC alerts throughout the year, and it is important for surgeon advocates to take action when these alerts are received.

Telephone communication is useful when the issue is urgent and an opinion must quickly be provided. The call is usually directed to the staff person who manages health care issues, which in itself can be seen as positive because it can be a step toward developing that important personal connection.

An in-person meeting, either in the capitol or in the district office, is a more effective tactic when building a long-term relationship with policymakers and their staff. Lastly, attending a town hall meeting hosted by your legislators can also be an effective way to raise a specific issue in front of not only legislators, but also their other constituents. By their nature, town halls do not allow for much one-on-one interaction, but they are a chance to increase awareness of an issue affecting surgeons and surgical patients in the community.

Understanding the issue is important, but it is equally important to connect with legislators and their staff. Tell them your story. Tell them why this issue is important to you and your patients. Provide strong, convincing data. Nothing is better than a good narrative about a real situation backed up with good data to explain how an issue is affecting their constituents.

ACS resources

One substantive resource for Fellows who want to get involved in state advocacy is the ACS State Affairs team. The College not only provides support to ACS chapters in their advocacy efforts, but also works with state medical and specialty societies, allowing a broad understanding of what is happening on the ground and where surgeons may be most effective.

The ACS State Affairs team offers a wide variety of services, including the following:

  • Speaking at chapter events or other stakeholder group meetings. Topics range from specific, regional issues to advocacy training workshops. A sample program outline, objectives, and a timetable are provided.
  • Coordinating plans for a lobby day at the state capitol or a legislative site visit.
  • Assisting with advocacy efforts for or against legislation introduced in the state legislature.
  • Providing input on advocacy planning and strategy issues, including development of a chapter advocacy and health policy committee.
  • Developing background information/briefing materials and researching legislative issues.
  • Drafting testimony for presentation at state legislative committee hearings.

Dr. Walker noted that the ACS State Affairs staff was helpful in his advocacy efforts. “The College State Affairs team was always supportive and helped me with briefs, supplied a copy of the bill and some testimony from other states. They offered to come to Austin, but, in truth, the best testimony is always a physician who only has the best interests of his or her patient at the center of the issue,” Dr. Walker added.

As previously mentioned, the College provides an online tool, the SSLAC, where the ACS, along with more than a dozen other surgical specialty societies, posts alerts on critical issues pending in state legislatures. The SSLAC can be accessed at This online tool is easy to navigate, user-friendly, and an excellent way for surgeons to begin to participate in state advocacy. The SSLAC is a public website, and any interested party may use and share alerts with others. In addition to serving as the conduit for e-mail campaigns, the SSLAC also contains general information on state lawmakers.

The ACS Facebook and Twitter pages are useful in promoting advocacy, disseminating SSLAC alerts, and interacting with industry and political leaders. Follow the ACS on Twitter, and “like” the College on Facebook. As the use of social media continues to grow, online social media is becoming a more acceptable form of professional communication at the College. If you come across material that should be featured on ACS social media platforms, contact the ACS State Affairs team.

The ACS State Affairs staff also coordinates the State Advocacy Representative (StAR) Program, through which the College and StARs share information, mainly through regular conference calls. Each state has at least one StAR whose main responsibility is to be the eyes and ears for the College at the state level. StARs monitor legislation in their state and then confer with the State Affairs team. Becoming a StAR for your state is a great way to stay informed and can be a precursor to becoming more actively engaged in advocating for the College’s state legislative priorities.

Get involved

As Dr. Walker’s and Dr. Masiakos’ stories indicate (see “Success stories“), surgeons can effect real change in the state legislatures. If you are interested in getting involved in advocating for your patients and the practice of surgery in your state, contact the ACS State Affairs team:

These individuals will work with you to identify opportunities to advocate for policies that affect surgical practice and patient care in your state. With a can-do attitude and perseverance, surgeons can help to shape policy that ensures patients have access to high-quality care in their states.

*Brandeis J. Dissenting. New State Ice Co. v. Liebmann, 285 U.S. 262, 311. 1932. Available at: Accessed May 15, 2014.

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Surgeons as state advocates: Success stories Mon, 01 Sep 2014 05:54:32 +0000

Several surgeons have found that applying the tools and information presented in this article has been useful in ensuring the passage of sound health policy. Peter Masiakos, MD, FACS, a pediatric surgeon at Massachusetts General Hospital, Boston, put the concepts and resources discussed in this article to use in achieving passage of “Sean’s Law,” an Act to Regulate the Use of Off-Highway and Recreation Vehicles. This legislation provides stricter safeguards for the use of all-terrain vehicles (ATVs) by prohibiting children under the age of 14 from operating these powerful machines.

Dr. Masiakos

Dr. Masiakos

Dr. Masiakos was inspired to advocate for the legislation after providing care to Sean Kearney. “On a Sunday afternoon in late October of 2006, Mark and Katie Kearney of Plymouth, MA, dropped their eight-year-old son off at a friend’s home for a play date. Several hours later, Sean sustained a severe brain injury because of an ATV accident. I cared for Sean in the [intensive care unit] until he died from his injuries five days later. On that day, the Kearneys asked me how this could have happened to Sean. I did not realize the far-reaching implications that their question would have in redefining the laws regulating ATV use in Massachusetts and redefining my responsibilities as a pediatric surgeon,” he recalled (e-mail communication with the authors, May 8, 2014).

To help build the case for the legislation, “I requested injury data from the state’s Department of Public Health. The information that I received was astounding. For the year spanning 2004 to 2005, the most recent complete data set, there were 935 pediatric ATV-related injuries recorded in Massachusetts, about 30 percent of all reported ATV injuries. The average age of the injured child was 13.3 years. Once I established my knowledge base, I started meeting with specific legislators and testified at the initial hearing of the bill,” Dr. Masiakos said. “I provided data about injury prevention to the politicians and answered the questions about injury outcomes and cost containment. I used the medical literature to teach them the facts. In time, they would call me to discuss the ATV bill and then other injury prevention bills that were being written,” he said. (In 2011, the Bulletin published an article written by Dr. Masiakos on the dangers of ATV use and the development of Sean’s Law.)

“On July 31, 2010, after nearly four years and two legislative sessions, a new law was passed,” he said, encouraging other surgeon advocates to be patient yet persistent in their dealings with lawmakers. “Many of us feel that we cannot effect change at the grassroots level. I have discovered that this is not true. Getting over the initial inertia associated with this attitude is the most challenging issue. Once the ball gets rolling, the process is quite rewarding,” Dr. Masiakos said.

“The second challenge is to overcome the urge that we have as surgeons to expect that things will get done quickly,” Dr. Masiakos added. “Very little in government is done quickly. You must enter the process with an unflappable attitude. You must be prepared to lose some arguments and to encounter some legislators that you cannot win over. The key to successful advocacy is to find a policymaker with a sympathetic ear who will champion your cause, and not quit.”

Dr. Walker

Dr. Walker

Dr. Walker also discovered the rewards and frustrations of political advocacy when he worked to achieve passage of the Texas’ Uniform Emergency Volunteer Health Practitioners Act (UEVHPA). “It began about six years ago, when I first heard about the UEVHPA at our chapter meeting. I thought the idea was great and a noble project. I didn’t know it would take three legislative sessions and numerous meetings and committee appearances for the bill to pass,” Dr. Walker said.

“I was good friends with my state representative at the time, so I approached him with the issue. He agreed that it would be a worthwhile undertaking, but by the time it got to the Homeland Security and Public Safety Committee, the trial lawyers were already exhibiting opposition to it. We ran out of time in that session, so I brought it back the next session,” Dr. Walker said, noting that the Texas legislature convenes every other year. The bill again stalled in committee because “the entire legislature was tied up in budget negotiations, and almost no bills were passed out of committee.”

“Last year, I was ready. I made sure to get the bill submitted early, pushed hard to get it read before the committee, and was available to testify when called. The trial lawyers were no longer expressing significant opposition to the issue, the Texas Medical Board signed off in advance, and there was very little opposition. It sailed through committee, on to the House floor, and we had arranged for Senate approval in advance. The governor signed it, and our bill became a law!”

Masiakos P. Advocating for state injury prevention laws. Bull Am Coll Surg. 2011;96(2):31-35. Available at: Accessed July 9, 2014.

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Founding surgeon reflects on 25 years of UNICAR, the Guatemalan Heart Institute Mon, 01 Sep 2014 05:53:32 +0000

UNICAR surgeons

Sanger surgeons Dr. Mark Stiegel and Dr. Robicsek assisting Dr. Coye, the local thoracic surgeon, perform the first open-heart surgery in Belize.

Woman and child awaiting care in a Guatemala clinic

Woman and child awaiting care in a Guatemala clinic.

Pediatric ICU in Cobán, Guatemala

The present pediatric ICU at the hospital in Cobán, Guatemala.

Cardio echo tech

Charlotte-trained cardiac echo tech performs scan on Guatemala patient.

Dr. Cruz (left) and Sergio Leal, MD, electrophysiologist at UNICAR.

Dr. Cruz (left) and Sergio Leal, MD, electrophysiologist at UNICAR.

Map of Guatemala

The network of noninvasive (echo) cardiology stations (dots) and heart catheterization laboratories (circles) established by the Outreach Program. The echocardiograms are taken by nurses specifically trained in echocardiography in Charlotte, NC. The images are transmitted and interpreted at UNICAR.

Dr. Coye

Dr. Coye (left), receiving the Order of the British Empire for the Belize Heart Program.

Dr. Cruz

Dr. Cruz receiving the Order of the Quetzal at UNICAR’s anniversary celebration.

Staff at UNICAR congregate in front of the UNICAR building in Guatemala City.

Staff at UNICAR congregate in front of the UNICAR building in Guatemala City.

In past decades, cardiac care, particularly cardiac surgery, in Central America remained well behind the medical progress made in industrialized countries. Among the six countries of the subcontinent, only Costa Rica had well-organized cardiac care, whereas medical and surgical care for heart conditions throughout the rest of Central America was either vastly inferior or nonexistent. Even today, in most of these countries, only a few cases are performed by fledging cardiac surgical programs or by visiting “brigades” of cardiac teams from the U.S. and Europe. The general public has virtually no access to cardiac surgical care, whereas wealthy individuals have the option of flying to Mexico City, Mexico, or to the U. S. for their operations. There is, however, an exception; a bright spot in the dark picture—Unidad de Cirugía Cardiovascular de Guatemala (UNICAR), the Guatemalan Heart Institute. This is a brief overview of UNICAR.


I have always been interested in Central American archaeology, and in the 1960s and 1970s, spent most of my free time roaming the Mayan ruins of Guatemala. On one of my Mayan jaunts in 1971, my friend, John M. Keshishian, MD, FACS, a thoracic surgeon from Washington, DC, introduced me to the country’s president at the time, Carlos Manuel Arana Osorio, who also was deeply interested in pre-Columbian cultures. One evening, sitting at the campfire, President Osorio asked me what I did when I was not in the jungle.

“Mainly operating on hearts,” was my answer.

He suddenly became very interested and asked, “Do we have heart surgery in Guatemala?”

“No,” I said.

I did not have to wait too long for his next question: “Could you start a heart surgery program?”

“Yes,” I replied, “but you have to help me.”

From that point on, it was only a matter of time until it became possible to start developing a cardiac program. The fact that the president was personally involved allowed us to rapidly cut through the usual Central American bureaucratic red tape. The Guatemalan Ministry of Public Health and Social Assistance assigned a young Guatemalan surgeon, Raul Cruz Molina, MD, who trained at Baylor College of Medicine, Houston, TX, to serve as the future head of the cardiac program. Dr. Cruz immediately flew to Charlotte, NC, where he began an 18-month intensive cardiac surgery fellowship at Carolinas Medical Center, then Charlotte Memorial Hospital. His supportive team of cardiologists, anesthesiologist, perfusionists, and intensive care nurses trained at these institutions, as well.

The entire operation began on a shoestring budget. Because Guatemalan health care professionals usually stayed with their hosts, the only training-related cost incurred was airfare. At the same time the training occurred, we were able to procure used and refurbished perfusion equipment and vital-sign monitors. In a year and a half, the Guatemalan team was ready to initiate the program.

Cardiac surgery comes to Guatemala

In 1974, with a grant from the Heineman Foundation, I returned with our friends to Guatemala and carefully selected some patients with relatively simple anomalies, such as atrial and ventricular septal defects and pure mitral stenosis, as the first surgical candidates.  (The diagnostic studies were conducted in Charlotte.)  And then—the great day arrived. The Guatemalans were backed by a full Charlotte-based team of eight.  The operations performed at Roosevelt Hospital in Guatemala City went smoothly and the patients came through well. We usually slept after surgery in the spartan recovery room.

The program proceeded in an orderly fashion. Dr. Cruz gradually accepted more and more complex cases. Soon, however, it became evident that the trafficking of patients between Guatemala and Charlotte for diagnostic studies would exhaust our limited financial resources. So, we again called on President Osorio for assistance. From then on, a Guatemalan Air Force transport plane carried 35 to 40 patients in need of diagnostic work to the Charlotte-Douglas International Airport. Patients requiring heart catheterization underwent the procedure around the clock. It was a most welcome event that Federico Alfaro, MD—now a renowned cardiologist practicing in Guatemala and then a resident at Baylor Houston, TX—heard of the project and arrived unexpectedly in Charlotte at midnight one day in March of 1978 and joined our efforts.

After diagnosis, patients were flown back to Guatemala, where those who needed surgery were operated on by Dr. Cruz and his crew, actively supported by the Charlotte team. These efforts started to evolve, and in 1976, under the leadership of Dr. Cruz, the cardiac program was officially established at the Roosevelt Hospital, the largest health care institution in Guatemala. The Carolinas Medical Center team continued to play a supportive role; however, within a year, their numbers decreased from eight to three, then to a single surgeon, and finally to none. By and large, the Guatemalans were on their own in the operating room.

UNICAR: An ongoing success story

Over the course of the next three decades, the Guatemalan cardiac program at Roosevelt grew from a service of a half-dozen beds to a modern department of cardiac surgery. The program not only performed an important clinical task, it also served as the nucleus of training for Guatemalan cardiac surgeons. An especially important year in Guatemalan cardiac surgery was 1989—the opening of UNICAR, the Guatemalan Heart Institute, in a dedicated building on the Roosevelt Hospital campus.

Incorporated as UNICAR, the Guatemalan cardiology and cardiac surgery program now serves not only Guatemala, but receives patients from neighboring Honduras, Belize, and Nicaragua. With its home-trained staff supplemented with noted cardiac surgeons and educators, specifically Rafael Espada, MD, and Aldo Castaneda, MD, FACS, both of Guatemalan origin, the scope of services involves not only complex adult but also neonatal cases, and in 1977 led to the establishment of UNICAR’s internationally recognized department of pediatric surgery.

In 2000 UNICAR, having already received acclaim from around the globe, obtained autonomic status, and in 2013 the number of open heart operations exceeded 800. Both Dr. Cruz and our supportive team were recognized by receiving the highest civilian decoration of the Guatemalan government: The Order of the Quetzal. In addition, I was recently honored with the Rose of Peace from the First Lady of Guatemala, Rosa María Leal de Perez, and Dr. Adrian Coye received the Order of the British Empire for his work with the Belize Heart Program.

In addition, the Carolinas Health Care System formally established the International Medical Outreach Program in 2004. Since my retirement from clinical practice, I have been working with the program full-time. Having access to de-accessioned material from the system’s 40 hospitals and engaging their staff in volunteer work rather than just shipping a large amount of hospital equipment and disposable material to different countries in the world, we have delivered to Central America seven heart catheterization laboratories, furnished five intensive care units and a burn institute, built an echocardiographic network connecting 10 rural hospital with UNICAR and the Sanger Heart and Vascular Institute, and established an online consultation between Guatemala, Belize, and Charlotte. We also started and are maintaining cardiology and cardiac surgery programs in Belize. Our immediate plans include furnishing and supporting a network of rural infirmaries and establishing several women’s cancer screening units.

Why UNICAR works

So, what has been the secret of UNICAR’s success? How did UNICAR conquer the difficulties that still plague the cardiac surgical programs of other Central American countries?

The answer is complex. The primary factor was, without question, the dedication and hard work of our Guatemalan colleagues and the support they received from a government committed to its task, despite the country’s ongoing financial difficulties. Did the International Medical Outreach Program also play a role? Undoubtedly. We were at the right place at the right time. I want to emphasize, however, one very important point: We have been surgically active in Central America for a long time, but seldom have we actually operated. We assisted the local surgeons and ensured that their initial results were good. We made certain these surgeons received reliable support from the team and remained available for any need that arose. This approach differs radically from the visiting brigades, where the work is done entirely by the visitors who, after a limited number of procedures, depart and leave very little behind except for ongoing need and a feeling of helplessness. Some lives may be saved, and the visitors have a feeling of satisfaction, but the local health care providers are deprived of the glory of being the “first” to deliver high-level care. They provide no continuity of care and often create resentment or even hostility within the local health care community.

Is the approach of shipping patients to the U.S for surgical care any better? Again, this process may save a few lives, but it does not respond to the needs of a country, and the cost is enormous. The total cost to initiate and maintain UNICAR has been less than the cost of a few heart operations at a U.S. hospital.

Our cooperation and friendship with UNICAR still continues today, including an ongoing exchange of health care and other skilled professionals between Guatemala City and Charlotte. Recently, our engineers assisted in converting UNICAR’s recordkeeping system from manual to digital. We are also helping UNICAR to establish a unique, nationwide referral network of echocardiographic laboratories, a service previously available only in a few private clinics. Tests are performed in echo stations located in 12 rural hospitals by technicians who trained at both UNICAR and in Charlotte. The images are transmitted digitally and read at UNICAR, which then relays the results to the patient’s treating physician. Any images may also be transmitted and problems discussed “live” through a special digital communication “bridge” with the cardiologists and surgeons of UNICAR and Carolinas Medical Center.

Carolinas Medical Center and the Heineman Foundation are proud to be friends with UNICAR, 25 years, 21,768 hemodynamic studies, and 13,047 heart operations later. We look forward to many more successful years.

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Surgical training abroad: It’s not about the cases Mon, 01 Sep 2014 05:52:48 +0000

Emergency room entrance to Parirenyatwa Hospital in Harare, Zimbabwe.

Emergency room entrance to Parirenyatwa Hospital in Harare, Zimbabwe.

Surgical team makes formal teaching rounds at Parirenyatwa hospital in Harare, Zimbabwe. Dr. Cloyd next to Prof. Godfrey Muguti (back row).

Surgical team makes formal teaching rounds at Parirenyatwa hospital in Harare, Zimbabwe. Dr. Cloyd next to Prof. Godfrey Muguti (back row).

Visiting Stanford faculty David Spain, MD, FACS (far left), and Dr. Wren (fourth from right) before teaching rounds.

Visiting Stanford faculty David Spain, MD, FACS (far left), and Dr. Wren (fourth from right) before teaching rounds.

“How many cases did you do?” This quickly became the most common question I was asked after returning from a month-long surgical rotation in Zimbabwe. As the first resident to embark on a new international surgery elective at Stanford University, Palo Alto, CA, I certainly felt some pressure to compile a good operative case load to prove the value of the rotation to our program. However, once I arrived in Zimbabwe, the lessons I learned simply from practicing in a new and unique environment rapidly became more important than the number of cases logged. The focus that my peers, attending surgeons, and family and friends placed on operative volume seemed to only distract from these lessons.

Valuable experiences

One of the most valuable aspects of training abroad is exposure to new disease processes in a unique patient population. The patient with right lower quadrant pain and fever does not have appendicitis, but rather has perforated typhoid. The cause of the small bowel obstruction is not adhesions from prior surgery, but instead is intra-abdominal tuberculosis. Due to the absence of, or poor adherence to, cancer screening, patients with breast or colon cancer often first present with disease in advanced stages—a situation to which those of us who trained recently or are in training in the West are typically unaccustomed.

One of the first patients I met at Parirenyatwa Hospital in Harare, Zimbabwe’s capital, was a woman with a large lower extremity wound from a crocodile bite. Inaccessibility of adequate care in this rural area forced the wound to go largely untreated for several weeks. She eventually presented to the only university-affiliated hospital in the country with pseudomonas wound sepsis, which required aggressive debridement, antibiotics, and eventually soft tissue coverage. I witnessed countless cases like this one during my month abroad: The young child who required a scalp skin graft after being bitten by a venomous snake, the untreated epileptic with a large third-degree burn after falling into his cooking fire, and the woman who developed a Marjolin’s ulcer in a chronic burn scar. A significant portion of my experience was learning to manage late complications of burns and traumatic wounds.

The presence of multiple operating rooms (ORs), and a small intensive care unit could make it easy to forget the significant constraints on available resources, but seeing patients who are expected to produce the necessary funds before receiving care was a new experience. You quickly learn a few simple rules—almost everything is reusable, hardly anything is disposable, and nothing is wasted. This is especially true of blood products, which are a scarce commodity.

An anesthesia colleague told me of a striking case involving a patient undergoing a resection of a large neck tumor who had significant intraoperative bleeding. Although cross-matched blood had been prepared preoperatively, the anesthesia team would not administer it until the surgeon had proven he could control the hemorrhage. For similar reasons, trauma patients could only receive blood transfusions if survival was expected. Triage of scarce resources was a new concept for me.

Without access to computed tomography or magnetic resonance imaging, greater reliance on plain radiographs and occasionally sonography is required. Without daily labs available, postoperative management depends on astute history and physical exam skills. Without routine access to advanced endoscopy, surgery is the mainstay treatment for choledocholithiasis, bleeding peptic ulcer disease, or gastrointestinal obstruction. Without capabilities for minimally invasive surgery, familiarity with open surgery is required. This type of experience cannot be gained nowadays at large academic medical centers in the U.S., and the lessons learned through this international experience were invaluable.

Challenges to international training

Considering all I learned on this rotation, both in the OR and out, I would recommend this experience for other general surgery residents, particularly those who plan to practice in rural areas. In fact, a 2009 survey of general surgery residents in the Resident and Associate Society of the American College of Surgeons (RAS-ACS) indicates that most surgery residents would value this opportunity (n=724). Notably, 92 percent of the respondents said they were interested in an international health elective, and 82 percent stated they would prioritize an international experience over other electives.1

Despite this strong interest among trainees, many obstacles have prevented wide adoption of formal international surgical training. Factors such as funding, timing of experience (that is, vacation, research years, or elective time), and identification of supervising surgeons who have received Residency Review Committee (RRC) approval are difficult to address. In part because of these challenges, a recent survey of U.S. general surgery residency program directors showed that only 11 percent of programs had formal international health electives, though many had reported informal international opportunities.2

Many of these informal programs consist of short-term missions, whereby U.S. volunteers from surgery, anesthesia, and nursing visit a resource-poor area, bring necessary equipment and supplies, provide basic surgical services, and then return home. In this scenario, the primary objective is philanthropic; resident education is secondary and mainly achieved through operative experience. (This type of experience also more closely mirrors what residents see and learn in the U.S. and not the practices of health care professionals in the local resource-constrained environment.) In fact, a previous survey of general surgery residents (n=52) found that 94 percent believed that the acquisition of technical and clinical skills was what they most expected to gain from participation in an international training program.3 Due to trends in training in the U.S. with regard to work hours, increased supervision, and decreased autonomy, some residents may increasingly feel that international case experiences are an opportunity to augment or replace those training gaps. Importantly, the involvement of trainees in surgical volunteerism in developing countries may raise important ethical issues that are sometimes set aside, such as quality of unsupervised practice and potential displacement of local trainees.4

Collaboration breeds opportunities

With these challenges in mind, the department of surgery at Stanford University has developed an international partnership with the University of Zimbabwe College of Health Sciences (UZCHS). U.S. residents complete a one-month general surgical rotation during postgraduate year three, working alongside Zimbabwean residents, interns, and medical students and learning from Zimbabwean faculty. The experience includes elective and emergency surgery, formal inpatient rounds, preoperative conferences, and didactic lectures. It is based primarily at the university-affiliated Parirenyatwa Hospital.

Approval from the Accreditation Council for Graduate Medical Education and the RRC has permitted credit towards American Board of Surgery graduation requirements. The on-site supervising surgeon is Zimbabwean, making this experience one of the first of its kind. The reciprocal agreement includes Stanford faculty providing educational modules as requested by UZCHS and visiting opportunities for Zimbabwean faculty and residents at Stanford.

The Stanford-Zimbabwe rotation has been constructed in a way to maximize the learning opportunities of training in a resource-poor environment halfway across the world. It is designed not only to offer a rich operative experience but also to emphasize a diverse patient population, uncommon disease processes, atypical patient presentations, cultural competency, and the practice of medicine with significant constraints on available resources. Although the operative experience gained while abroad is an important part of the international surgical experience, for me, the lessons learned outside the OR were just as valuable.

It is our hope that the Stanford-UZCHS relationship will serve as a collaborative model that other surgical training programs will choose to follow. This type of international partnership should serve to both enhance the training of U.S. residents and at the same time equip health care professionals in underserved nations to better care for their patients.


  1. Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg. 2009;208(2):304-312.
  2. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. Elective global surgery rotations for residents: A call for cooperation and consortium. World J Surg. 2011;35(12):2617-2624.
  3. Powell AC, Mueller C, Kingham P, Berman R, Pachter HL, Hopkins MA. International experience, electives, and volunteerism in surgical training: A survey of resident interest. J Am Coll Surg. 2007;205(1):162-168.
  4. Ramsey KM, Weijer C. Ethics of surgical training in developing countries. World J Surg. 2007;31(11):2067-2069; discussion 2070-2071.
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Statement on bicycle safety and the promotion of bicycle helmet use Mon, 01 Sep 2014 05:50:18 +0000

The following statement was developed by the American College of Surgeons (ACS) Committee on Trauma and was approved by the Board of Regents at its June 6–7 meeting.

The ACS and its Committee on Trauma recognize the importance of injury prevention in the spectrum of care of the trauma patient. Cycling remains an important means of transportation and recreation; however, the bicycle rider can be at significant risk of serious injury.

The College recognizes the following facts:

  • Approximately 800 people die and 500,000 people are injured in the U.S. annually due to bicycle-related injuries. Bicycle crashes are the fourth largest contributor to childhood injury costs and quality-of-life losses and the leading cause of injury in school-age children. Adolescents and adults ages 45 years and older have the highest bicycle death rates.1
  • Helmets reduce the risk of head injury by at least 45 percent, brain injury by 33 percent, facial injury by 27 percent, and fatal injury by 29 percent. One study suggests that helmet use may reduce the risk of head injury by 85 percent and severe brain injury by 88 percent.2,3
  • Bicycle-related injuries and deaths have decreased in states that have enacted youth bicycle helmet laws.4
  • Non-legislative educational programs have been proven to increase helmet use by children.5
  • Helmets can benefit adult riders as well as children. As more helmet laws target youth, the proportion of adults comprising bicycle fatalities has risen.6
  • Peer and adult companion helmet use is associated with increased bicycle helmet use by children.7

In addition to head injuries, significant abdominal wall, solid organ, hollow viscus, as well as major vascular injuries are common after abdominal pelvic handlebar injury.8

Therefore, supported by these and other epidemiologic and outcomes data, the ACS supports efforts to promote, enact, and sustain universal bicycle helmet legislation and enforcement.


  1. Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system (WISQARS). Available at: Accessed July 7, 2014.
  2. Dellinger AM, Kresnow M. Bicycle helmet use among children in the United States: The effects of legislation, personal and household factors. J Safe Res. 2010;41(4):375‐380.
  3. Thompson RS, Rivara FP, Thompson DC. A case‐control study of the effectiveness of bicycle safety helmets. N Engl J Med. 1989;320(21):1361‐1367.
  4. Meehan WP, Lee LK. Fischer CM, Mannix RC. Bicycle helmet laws are associated with a lower fatality rate from bicycle-motor vehicle collisions. J Pediatrics. 2013;163(3):726-729.
  5. Ekman DS, Ekman R. Twenty five years of bicycle helmet promotion for children in Skaraborg District, Sweden. Int J Inj Control & Safety Promotion. 2012;19(3):213-217.
  6. Yilmaz P, Gabbe BJ, McDermott FT, et al. Comparison of the serious injury pattern of adult bicyclists between South-West Netherlands and the State of Victoria, Australia 2001–2009. Injury. 2013;44(6):848-854.
  7. Khambalia A, MacArthur C, Parkin PC. Peer and adult companion helmet use is associated with bicycle helmet use by children. Pediatrics. 2005;116(4):939-942.
  8. Nadler EP, Potoka DA, Shultz BL, Morrison KE, Ford HR, Gaines BA. The high morbidity associated with handlebar injuries in children. J Trauma. 2005;58(6):1171-1174.
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Statement on intimate partner violence Mon, 01 Sep 2014 05:49:40 +0000

The following statement was developed by the American College of Surgeons (ACS) Committee on Trauma and was approved by the Board of Regents at its June 6–7 meeting.

The ACS recognizes that intimate partner violence (IPV) is a major public health problem for intimate partners of both genders, including heterosexual and same-sex partners, with victims frequently needing surgical care.

  • IPV, also referred to as domestic violence, can be defined as actual or threatened physical, sexual, verbal, or emotional abuse by a current or former partner or spouse.
  • IPV among women of child-bearing age is the leading cause of serious injury and the second-leading cause of injury and death. There is no distinction for age, race, culture, status, class, education, or religion. The cumulative lifetime risk of battering for women is estimated to be 24 percent to 54 percent. IPV is associated with 33 percent to 50 percent of female homicides and 25 percent of female suicide attempts.1
  • IPV abuse victims are at increased risk for developing major depression, post-traumatic stress disorder, and getting involved with drugs and abusing alcohol.2
  • The failure to diagnose IPV is the failure to identify a disease process that is likely to recur, possibly with lethal consequences. Routine screening with explicit questioning using the Partner Violence Screen without the partner present is the most effective way to make the diagnosis.3 Access the three-question Partner Violence Screen.
  • It is the responsibility of the treating surgeon not only to care for the immediate injury and to reassure the patient, but also to identify resources in his or her hospital and to help identify resources in the community.4,5
  • Surgeons are encouraged to play a leadership role in their communities, hospitals, and medical schools in initiatives to prevent and treat domestic violence.4,5

The ACS supports legislation and policies that enhance judicial and law enforcement tools to combat IPV, to improve services for victims of IPV, and to prevent violence, including youth violence and violence against women.


  1. Sisley A, Jacobs LM, Poole G, Campbell S, Esposito T. Violence in America: A public health crisis—domestic violence. The Violence Prevention Task Force of the Eastern Association for the Surgery of Trauma. J Trauma. 1999;46(6):1105-1113. Accessed December 13, 2013.
  2. American Congress of Obstetricians and Gynecologists. Violence against women fact sheet. Available at: Accessed January 4, 2014.
  3. Feldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of three brief screening questions for detecting partner violence in the emergency department. JAMA. 1997;277(17):1357-1361.
  4. Mattox KL, Moore EE, Feliciano DV, eds. Trauma. 7th ed. New York: McGraw Hill; 2013;890-895.
  5. Davis JW, Sise MJ, Albrecht R, Kuhls DA. American Association for the Surgery of Trauma Prevention Committee topical updates: Getting started, fall prevention, domestic violence and suicide. J Trauma. 2011;70(4):996-1001.
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