The Bulletin by the American College of Surgeons Tue, 11 Nov 2014 22:03:55 +0000 en-US hourly 1 Looking Forward – November 2014 Sat, 01 Nov 2014 05:59:24 +0000

The founders of the American College of Surgeons (ACS) established this organization with the goal of ensuring that surgeons had the proper education and training to provide high-quality care to their patients. To this day, Education remains one of the four Pillars of the College—along with Quality, Member Services, and Advocacy. To help surgeons make informed decisions about their investment in education and training, and to raise awareness about the exceptional lifelong learning opportunities that the ACS offers, we launched a new ACS Education and Training campaign during the Clinical Congress in October.

The time is ripe

In this era of evolving Maintenance of Certification (MOC) and licensure mandates, rapidly advancing surgical technology, and information overload, it is increasingly important that surgeons commit to lifelong learning. The ACS recognizes that surgeons in active practice have only so much time to devote to education and skills acquisition. And, although there are seemingly unlimited continuing medical education programs available at many institutions, online, and elsewhere, it can be challenging to find state-of-the-art, relevant, and inspiring education and training opportunities.

To keep pace with rapidly evolving science, technology, knowledge, and techniques over the course of a long career, surgeons need a trusted partner to teach them what they need to know in the way they prefer to learn. The ACS is well-positioned to be that principal source of knowledge and skills. We have more than a century of experience with testing and validating what works in surgical education and have access to top faculty and the latest technology.

Excellence in surgical care, including positive interactions with patients, effective teamwork, and exemplary leadership, are being built and reinforced through ACS Education and Training. The transformation of scientific and technical advances into surgical care is made possible through hands-on skills courses, and translation of outcomes data into improved quality of care is accelerated through innovative education. Finally, ACS Education and Training programs rekindle the excitement and joy of lifelong learning, resulting in greater professional expertise and confidence.

Worth noting:
Important educational opportunity in January

One upcoming educational program that may be of interest to many ACS Fellows is a one-and-a-half day conference on Patient-Reported Outcomes in Surgery (PROS). This course will take place January 29–30, 2015, at the ACS’ 20 F Street, NW, Conference Center in Washington, DC. Surgeons across all subspecialty areas are encouraged to attend.

Speakers will instruct participants on national and international best practices for patient-reported outcome measurement in clinical care and outcomes research. This meeting will engage surgeons, quality-of-life researchers, payors, regulators, and technology experts and will provide a unique opportunity for the establishment of cross-disciplinary, collaborative relationships.

The meeting is being sponsored by the Plastic Surgery Foundation (PSF)—the research arm of the American Society of Plastic Surgeons (ASPS)—and the International Society for Quality of Life Research with support from the ACS. The PSF received funding to convene the PROS Conference from the Agency for Healthcare Research and Quality grant program for large or recurring conferences. The ASPS designates this live activity for a maximum of 9.25 AMA PRA Category 1 Credits.

Registration and program information is available at For details contact Andrea Pusic, MD, FACS, Larissa Temple, MD, FACS, or Katie Sommers, MPH.

Campaign specifics

The ACS Education and Training campaign is designed to help surgeons, patients, and other stakeholders better understand the College’s 100-plus-year commitment to providing the finest surgical education and training programs. It will follow a model similar to the one we have used in the Inspiring Quality initiative. Just as that effort successfully built awareness about the value of ACS Quality Programs and their utility in improving outcomes and reducing health care costs, this campaign will demonstrate how ACS Education and Training programs can guide surgeons throughout their careers—from residency to retirement. It will show how the College’s programs enable surgeons to develop technical and nontechnical skills through leading-edge approaches, such as the use of simulation.

The campaign’s messaging will focus on three key points:

  • ACS Education and Training programs are the cornerstones of excellence in surgical patient care.
  • ACS Education and Training programs transform possibilities into realities.
  • ACS Education and Training programs instill the joy of lifelong learning.

The overarching aim of the campaign is to support the needs of individual surgeons across a lifetime of practice and to highlight the critical importance of ACS Education and Training to accomplish the following:

  • Increase participation in our education programs and products
  • Build awareness of ACS’ leadership and innovation in education and training
  • Help surgeons make informed decisions about their investment in education and training
  • Promote surgical care of the highest quality and patient safety
  • Make it easier for surgeons to participate in the joy and rewards of lifelong learning

An animated text video that visually tells the story of ACS Education and Training debuted at the Clinical Congress. Over the coming months, Fellows can expect to receive more information about lifelong learning through ACS podcasts, videos, media stories, and other avenues. A variety of exciting programs will be highlighted to demonstrate the scope and impact of the exceptional ACS Education and Training programs that continue to promote excellence and expertise in surgical care.

I encourage each of you to take the time to stay abreast of the ACS Education and Training programs and to take full advantage of these time-tested opportunities. The reality is that surgeons no longer have the option to practice based solely on what they learned in medical school. This campaign will help surgeons embrace the joy of lifelong learning and direct them to the information and skills they need now to continue to achieve the best outcomes for their patients into the future.

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FLS: Celebrating a decade of innovation in surgical education Sat, 01 Nov 2014 05:58:42 +0000

Dr. Fried

Dr. Fried

Dr. Soper

Dr. Soper

Dr. Swanstrom

Dr. Swanstrom

Dr. Schwaitzberg

Dr. Schwaitzberg

A new trainer box

A new trainer box

This year marks the 10th anniversary of the Fundamentals of Laparoscopic Surgery (FLS) program. In honor of this milestone, the program’s founders—all of whom are leading surgical educators, past-presidents of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), and Fellows of the American College of Surgeons (ACS)—are taking this opportunity to look back at the remarkable story behind the creation of FLS and its successful implementation.


SAGES launched the FLS program in response to the need for formal education in the underlying principles and basic skills of laparoscopic surgery. The highly anticipated launch of this program in October 2004 represented the culmination of many years of research and development by some of the leading surgeons in the field of minimally invasive surgery.

Prior to the creation of FLS in 1997, learning laparoscopic surgical techniques was a haphazard affair for many surgeons. “In the early days of laparoscopy, everybody was convinced of the value of this technique, but as it was actually becoming implemented, there were problems in a couple of regards: (1) a huge group of surgeons required training, as did residents, in an environment where not a lot of teachers were available; and (2) surgeons were being trained through industry-funded courses that were highly variable in terms of their format. People would attend courses and then go back to the hospital and get credentials,” said ACS Regent Gerald M. Fried, MD, CM, FACS, FRCSC, FCAHS, Edward W. Archibald Professor and chairman, department of surgery, McGill University, and surgeon-in-chief, McGill University Health Centre Hospitals, Montreal, QC.

“Unfortunately, when laparoscopic surgery was expanded widely, there were a lot of complications related to its introduction,” Dr. Fried continued. “And it put a really good technique at jeopardy, so that benefits that were obvious with the technique weren’t being realized and patients were suffering.”

Circa 1997, two like-minded surgeons who co-chaired SAGES Continuing Education Committee at the time, and who were performing laparoscopic surgery during its infancy in the early 1990s, Lee Swanstrom, MD, FACS, and Nathaniel Soper, MD, FACS, began sharing their ideas about how to teach the basic skills of laparoscopy. “I was reading the ATLS® (Advanced Trauma Life Support®) testing manual on the way to the SAGES meeting, and the preface to the manual featured the history of ATLS and how it had changed the way physicians care for patients. I thought ‘We need to do this for laparoscopy,’” explained Dr. Swanstrom, clinical professor of surgery, Oregon Health Sciences University and The Oregon Clinic, Portland. “Laparoscopy at the time was growing much less rapidly than we had hoped or expected. It was my feeling that this was in part because surgeons were uncomfortable with anything beyond laparoscopic cholecystectomy, as they had never mastered the basic underpinnings of laparoscopy. I met with Nat Soper and showed him the outline I had penciled out, and we were off and running,” Dr. Swanstrom said.

According to Dr. Soper, Loyal and Edith Davis Professor of Surgery and chair, department of surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, and former ACS Governor, “Lee and I were amazed that, at that point, we were almost 10 years into the laparoscopic revolution, but still it was apparent that a lot of people didn’t know a lot about the cognitive aspects of it, the underpinnings, the physiology of pneumoperitoneum, the potential risks and complications, and some surgeons had not really learned some of the fundamental techniques,” Dr. Soper said. “They knew how to do a one-handed gallbladder removal, but that’s it, and we really felt that we could put together something similar to the ATLS examination for laparoscopy.”

First steps

Shortly after the initial discussion between Drs. Swanstrom and Soper, SAGES called upon them to lead the development of FLS. “In the early days, it was really the four of us—Lee and I for the first several months, Sallie [Matthews, SAGES executive director] then came and met with us and helped work with us on the initial part, and then as we looked for the technical skills part to put with the cognitive side, we pulled Gerry [Fried] in,” Dr. Soper said.

In addition, Jonathan Sackier, MD, BCh, FACS, FRCS, professor of surgery, University of Virginia, Charlottesville, then a member of the SAGES board of governors and chair of SAGES continuing education committee, agreed that a consistent training program in laparoscopic skills, similar to ATLS, was needed. SAGES leadership convened a task force to discuss the development of a program that assessed laparoscopic skills and technical knowledge.

“SAGES understood that we needed to do better, needed to standardize the way education was delivered and make sure that we had some criteria to tell people that, yes, we feel that they achieved the knowledge and skills that prepared them to start to introduce laparoscopic techniques into their practice. That was the germination of FLS,” Dr. Fried explained.

“The following year, a group of SAGES members organized a planning meeting and a resident course,” added SAGES past-president and FLS committee chair Steven D. Schwaitzberg, MD, FACS, ACS Governor; professor of surgery, Harvard Medical School; and chief of surgery, Cambridge Health Alliance, MA. “We got a committee working on this project and a bunch of different people working on the different chapters for the cognitive portion, and it was off to the races,” Dr. Soper said.

With goals set, SAGES began the creation of a training program. The program would be a three-fold training package—
didactics, clinical judgment, and manual skills—and would ensure that surgeons were grounded in the basics of laparoscopy. Drs. Soper and Swanstrom drafted the basic program.

“We then heard about a pelvic trainer that Carl Westcott [MD, FACS, associate professor of surgery, Wake Forest University School of Medicine, Winston-Salem, NC] was working on at Wake Forest. We approached him and he was kind enough to donate the intellectual property for the trainer that became the FLS box,” Dr. Swanstrom said. “We had also approached Gerry when we read about the MISTELS [McGill Inanimate System for Training and Evaluation of Laparoscopic Skills] project he was doing.”

SAGES approached Sybill Storz, PhD, with the concept of FLS. She liked the idea, and Karl Storz Endoscopy-America Inc. [El Segundo, CA], provided the seed money that allowed the project to get off the ground. “I am not sure it would have happened if it hadn’t been for the generosity of all these folks,” added Dr. Swanstrom.

“We wanted to cover only the fundamentals of laparoscopy and not try to get into highly specialized content. We thought that would be too complicated to do right out of the box,” explained Dr. Soper. “What we were interested in was truly what we called it from the very beginning—the Fundamentals of Laparoscopic Surgery.” The program would comprise two different components—knowledge acquisition and the technical aspect.

Dr. Fried’s contribution was critical in developing the technical portion. “Before I really got involved with SAGES, I was working on the same type of principles in my own departments at McGill, focusing more on the technical skills side,” Dr. Fried said. “We had worked on developing a skills simulation program that would allow us to teach skills in a very inexpensive way, but also to embed those metrics that would allow us to actually observe and define the performance. And then, when I came to SAGES and heard about the FLS program, it was just a natural fit.

“So we brought our manual skills part to the program. The didactic/knowledge component was well advanced in its process, and it was a nice merger to bring those two together. The goal was to make it different than a regular educational test where you just passively go into a room and observe things, or you do random things on animals; in contrast, FLS was highly structured, and there was this verification part that really ensured that we had some basis [on which] to give a diploma or not.”

Meanwhile, the cognitive portion of the FLS exam was facilitated through the consultation of educational psychometric specialist Kaaren Hoffman, PhD, associate professor, division of medical education, Keck School of Medicine, University of Southern California, Los Angeles, who led item writing sessions throughout the nation, Dr. Schwaitzberg said. “Beta testing of the complete FLS examination occurred at eight sites, which ultimately led to the validation of the examination. Tufts Medical Center, where I ran surgical training in MIS, served as one of the original beta test sites and a site for item writing and cognitive testing,” he added.

What did it take to create FLS?

“It took an unmet need to really create FLS,” explained Dr. Fried. “We were very naïve about how complicated it was to achieve our goals, and we learned a lot by experience. We got a lot of good advice from educators who had thought about this professionally for a long period of time. Then, we had to overcome a type of bias against being measured—some people are always a little bit concerned about it. In order to accept the measure, they have to really believe that the measurements are legitimate and measuring the right thing. So, it took solid science to actually support this.”

Dr. Soper remembers when the SAGES surgeons involved in developing the program committed to moving forward and incorporating an examination into the program. “We made the leap of saying, ‘OK, if we’re going to really do this, and do it right, this needs to be the go-to way of learning and examining people to make sure they do it right. So, we’re going to pair this with a high-stakes examination.’” That was both the stroke of genius and the challenge that delayed the fruition of FLS.

Partnership with the ACS

An important milestone in the evolution of FLS was the development of a partnership with the ACS. According to Dr. Soper, “As SAGES started to roll out [the FLS project], it became apparent that greater buy-in was needed and that just because SAGES said this was a good thing would not necessarily have the same clout as if we get this paired with a national organization that had weight and gravitas. That’s when we went to the College and Ajit Sachdeva [MD, FACS, FRCSC], Director, ACS Division of Education. We were able to get them to buy into the whole concept and essentially cosponsor it. I think this, to a great extent, pushed it into greater visibility and ultimately led to the ABS [American Board of Surgery] mandating it.” As a result of the partnership with the ACS, a joint FLS committee was created that is co-chaired by Dr. Fried, representing SAGES, and Lenworth M. Jacobs, Jr., MD, MPH, FACS, representing the ACS. The joint committee continues to be responsible for oversight of major decisions related to the FLS program.

Impact on field of general surgery

FLS’ impact on general surgery has been tremendous, according to Dr. Fried. “First of all, it did achieve its goal, and that was to standardize both a knowledge set and a skills set that people had to acquire. But, more importantly, it really introduced the verification of surgical training that has become a new model for other traditional programs; that is, not only to teach someone, but also to set goals. The other really interesting thing is it changed the approach from defining training by hours or rotations to a goal can be measured, so that the concept of metrics and measurable outcomes has really permeated the whole way that we train our residents now.”

“The impact of FLS has been significant since it created a standard of validated surgical training for residency education in America. On its present trajectory, the vast majority of surgeons in America will ultimately be FLS certified,” Dr. Schwaitzberg said. “FLS introduced the reality of validated competency measurements into surgical practice,” added Dr. Swanstrom, “capsulizing the program’s impact…. In many ways the original goals for the program were exceeded.”

Since the inception of FLS, more than 9,000 surgical residents, fellows, and practicing physicians have successfully completed the FLS program. From the time the ACS began cosponsoring FLS in 2005, more than 275 FLS on-site testing events have occurred at more than 150 different locations in the U.S. and Canada. More than 30 countries have purchased the FLS online didactics and the FLS Training System, and surgeons from more than 20 countries have taken the FLS exam.

In 2008, the ABS mandated that all general surgery residents seeking board certification pass the FLS exam to be eligible for the general surgery qualifying exam. That same year, the Covidien Educational Fund was launched, allowing more than 7,000 general surgery residents to access FLS at low or no cost over the next six years. In 2012, in a public statement, SAGES and the ACS recommended that all general surgeons who perform laparoscopy be certified through the FLS program.

Widespread influence

Because of the trailblazing efforts of the FLS developers and the positive results of the program, other types of training modules continue to spread throughout the field of general surgery. “The whole world is watching,” said Dr. Fried, “and I think the amazing thing is that all other specialty societies, whether you talk to gynecologists or urologists or even instrument vendors, are interested in taking that model and developing educational programs that are based on the same principles.”

Nonetheless, Dr. Soper said, he has been surprised that other surgical societies have not launched similar programs. “I think everybody realized how much work went in, and continues to go into, making this program viable and what it costs [to develop such a program]. There are very few things in surgical training that have really been developed well, to the point where they can withstand the scrutiny of high-stakes examinations. We need more of these things to be able to make sure that we’re training residents in the appropriate fashion.”

Reflecting on the fact that most surgical residents believe that laparoscopic surgery is now the norm, Dr. Soper can see that the art of surgery has come full circle. “At some point, I think that there is going to have to be someone who is taking on a way of standardized training in open abdominal surgery. As crazy as that sounds, what we’re finding is that [with] many surgeons now coming straight out of training, there are some operations they’ve only done laparoscopically. And they don’t feel comfortable doing an open gallbladder operation or an open common bile duct exploration, or some stomach operation that they’ve opened because of complications, because 99 percent are now being done laparoscopically,” he said. “So, there’s a concern that 20 years from now, when there’s some condition that requires an open operation, surgeons are not going to be nearly as comfortable as those of us who trained in the open era and learned laparoscopy on top of that experience, as opposed to the other way around.”

The future of FLS

The surgeons involved in FLS leadership believe that it is essential to regularly revisit the blueprint to make sure the program remains relevant and up-to-date. It has only been 10 years since the FLS launch, but the question that now comes up is, “Where do we go from here?” Should a similar program be developed for more advanced technical skills related to laparoscopy that can be used for a variety of procedures? A major focus of the FLS program now is on the international level, with groups in Asia, Latin America, the Middle East, Europe, and Africa becoming FLS trained and certified and expressing interest in making the program more widely available to their surgical constituencies. Efforts are under way to determine the feasibility of translating FLS into Spanish to make the program more accessible to surgeons in Latin America and other Spanish-speaking countries.

Final thoughts

“FLS has made a big impact on my career and changed a lot of the ways I think of surgical education, and importantly, it’s brought me together with some wonderful people that I’ve met through the FLS program that have enriched me personally,” Dr. Fried said.

“The opportunity to give back to the field as one of the original FLS authors, and then years later as an FLS Committee Chair, has been fantastic,” Dr. Schwaitzberg said. “The work of the committee is endless, as the team works to continually update the material, assess for relevance, and spread out internationally.”

Dr. Swanstrom concluded, “For me, the best part of surgery is the excitement of coming up with a new idea to make things better, developing it, teaching it, and then watching it change how patients are cared for. FLS is a perfect example of this: We thought laparoscopy could be done better, we worked together to build a new way of teaching and measuring competence, and we have now seen it change how surgery is thought of around the world.”

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RAS-ACS Symposium essays: Residents debate whether to reform or revolutionize surgical training Sat, 01 Nov 2014 05:57:33 +0000

Each year, the Advocacy and Issues Committee of the Resident and Associate Society of the American College of Surgeons (RAS-ACS) hosts a symposium at the Clinical Congress featuring a debate on timely issues in surgical training or practice. The topics are chosen based on solicited input from residents, fellows, and attending surgeons from across the nation. As part of the process of selecting contestants for the debate, applicants submit an essay to compete for a place on the panel.

The theme of the 2014 RAS-ACS symposium competition is “The five-year general surgery residency: reform or revolution?” Participants debated whether the current education paradigm is, and will continue to be, sufficient to train knowledgeable and confident surgeons in the future, or if the system needs to be dramatically changed to fit the demand of the current surgical environment. The following are the first- and second-place essays submitted from both sides of the debate.

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First-place essay—revolution: Surgical training: Time for a revolution Sat, 01 Nov 2014 05:56:49 +0000

New challenges and opportunities of many forms are already affecting surgical education today, but the question remains: What changes should we be striving for in the near and distant future? Multiple external forces indicate that the magnitude and quality of necessary changes warrant a rebirth of surgical training—a revolution in terms of what training to be a surgeon means and entails.

The ever-expanding, ever-changing nature of cumulative medical knowledge suggests that the corpus of material learned in training will become obsolete at an ever-increasing pace. We need to change what we are asking surgeons to do. Just as the Institute of Medicine called for the nation to have a health care system that learns, the goal of surgical training should not simply be to produce graduates who know, but who think.1

Competency should be measured not by demonstrating recall of management algorithms that are often outdated even by the time of an examination, but rather by judgment and interpretation in using technology and all available resources in the care of patients, as well as the ability to adapt to and employ constantly evolving recommended practices. As has long been recognized outside of medicine, the human mind is not well-suited for recall, and within medicine, it is formally acknowledged that we need new practice models that avoid reliance on memory.2,3 All specialties will need new patient care technologies and delivery systems so that evidence-based knowledge is no longer impeded by the multi-year bottleneck between dissemination of information, retention by practitioners’ memories, and ultimate delivery of care. This current system has created disparities in health care quality that are due solely to variability in physicians’ declarative memories—disparities that must be eliminated.

New approaches to training

New modes of training should be developed. The immense amounts of data collected in clinical care could be used to build thorough training modules for practicing episodic and longitudinal management of patients, simulating much of the guess-and-check kind of learning now conducted on hospital wards. Simulated patient management eliminates risk to real patients and offers trainees experience handling a wide range of scenarios in a far more efficient manner. Similarly, trainees could learn procedures through interactive video tutorials and other simulations, and direct patient care and operating privileges could be contingent on passing multimodal standardized modules in clinical management, surgical skills, and procedure simulations. Time spent on actual patient care would be to demonstrate competence and would be far more effective and efficient for all involved. The goal of training should be to get the best care to patients and not to simply get the most knowledge into trainees’ heads; only with a new role for technology and a new professional identity can it be distinguished that these are not synonymous.

Focus on quality should also change the requirements for breadth of experience in current training. As the field of surgery has grown, general surgery graduates now pursue fellowships because of interest in subspecialty fields, and the current efforts in tracking training based on career intent can thus be augmented.4,5 Future endocrine, breast, or vascular surgeons should no longer need to acquire competency in hernia repairs and cholecystectomies; currently, these unnecessary requirements take away valuable training positions that could be used to compensate for the general surgeon shortage.6 Comparably, those residents who want to enter the most in-demand disciplines should not have to demonstrate proficiency managing conditions for which they will not bear responsibility in their careers. With these factors in mind, modular training can be constructed to fit an individual’s professional intentions—programs which likely would not require five to seven years of training.

Improving the efficiency, safety, and relevance of surgical education will increase the proportion of training expectations outside direct patient responsibilities, with a concomitant decrease in amount—but increase in quality—of time spent with real patients. Such restructuring could also be amenable for other much-needed modifications for career preparation. Many surgeons will ultimately have multiple responsibilities in addition to patient care, such as conducting research, administrative duties, policy work, teaching, and, most important, family.

Starting families should be a viable option for those who desire it, and flexible part-time training options for starting a family, pursuing research, and engaging in other professional interests should be developed in the U.S., particularly considering part-time training is already becoming a reality in other countries.7 Additionally, the methods through which countries like the U.K. reduce errors when average clinical hours decreased to only 43 per week should be explored for adaptation in the U.S.8 One possible schedule to address these issues could be a continuous four “on,” four “other” cycle for trainees and attendings alike, in which four days of patient duties alternate with four days for doing intensive educational activities, research, or time with family.

We have a duty to our patients to minimize risk and to provide them with physicians capable of handling their concerns, without solely entrusting delivery of surgical knowledge to an unreliable human memory. We have a duty to the general public to use training time and resources judiciously, and to avoid developing irrelevant competencies. We have a duty to the future of surgery to become balanced, well-rounded, “cosmopolite” professionals with diverse interests and commitments, especially to family, which are necessary for further innovation and for producing new generations of productive individuals.9

We now have the opportunity to enhance the future of surgery by developing new models of training and practice—focused on eventual careers, forged on an unprecedented partnership between clinicians and information technology, and based on simulation and remote curriculum modules—so that the educational benefits of direct clinical management can be coupled with the elimination of inefficiency and risk to patients. With these models, standards of quality could be raised, research accelerated, and innovation catalyzed. The benefits could be manifold, and perhaps these changes are only the beginning.


  1. Olsen L, Aisner D, McGinnis JM, eds. The Learning Healthcare System: Workshop Summary (IOM Roundtable on Evidence-Based Medicine). Washington, DC: National Academies Press; 2007.
  2. Johnson J. Designing with the Mind in Mind, Second Edition: Simple Guide to Understanding User Interface Design Guidelines. Amsterdam; Boston: Morgan Kaufmann; 2014.
  3. Kohn LT, Corrigan JM, Donaldson MS (eds). To Err Is Human: Building A Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000.
  4. Friedell ML, Vandermeer TJ, Cheatham ML, et al. Perceptions of graduating general surgery chief residents: Are they confident in their training? J Am Coll Surg. 2014;218(4):695-703.
  5. Eberlein TJ. A new paradigm in surgical training. J Am Coll Surg. 2014;218(4):511-518.
  6. Williams TE Jr, Ellison EC. Population analysis predicts a future critical shortage of general surgeons. Surgery. 2008;144(4):548-554; discussion 554-556.
  7. Royal Australasian College of Surgeons. Institution Women in Surgery Section, Flexible Surgical Training in Australia: It’s Time for Change (white paper). WIS Executive Committee. Available at: Accessed August 30, 2014.
  8. Cappuccio FP, Bakewell A, Taggart FM, et al. Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients’ safety: Assessor-blind pilot comparison. QJM. 2009;102(4):271-282.
  9. Rogers EM. Diffusion of Innovations, 5th Edition. New York, NY: Free Press; 2003.
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Second-place essay—revolution: Five-year general surgery residency: Reform or revolution? Sat, 01 Nov 2014 05:55:09 +0000

Surgical residents are in a unique, privileged position. Why? Because we are here; we beat the odds; we are surgeons in training. In 2012, there were 1,613 four-year university programs with 1.5 million first-time, full-time students, of which 21.1 percent (approximately 300,000 students) declared pre-med as their major.1,2 That same year, all of the available 1,146 surgical categorical positions were filled. All things being equal, if you were a college freshman, one of the 300,000 with a desire for a surgical categorical position in one of 1,146 spots, then you had a 0.4 percent chance of attaining your goal.

To top that off, the attrition rate for general surgery was 12 percent, the pass rate on the written qualifying exam was 81 percent, and the pass rate on the oral certifying exam was 72 percent. Combined with the high standards for entry into the College, these statistics mean that of the 1,146 residents starting residency, only 588, or 0.2 percent of the original 300,000 college freshman, became Fellows of the ACS.1,2

According to my calculations, based on data collected from the Association of American Medical Colleges and the National Resident Matching Program, we are the 0.4 percent who made it into surgery and the 0.2 percent who will qualify to become Fellows of the American College of Surgeons (ACS).1,2

Clearly we are in a privileged position, and our training is of the utmost importance. Very few people have the chance to acquire surgical training, and fewer successfully become Fellows of the College. With such a small product (surgeons) produced by this system, we must ensure that our training process produces surgeons in a timely manner, who are also “of the times” in terms of competency and skill level.

Product of the times

In 1889, William S. Halsted, MD, FACS, was named chair of the department of surgery at Johns Hopkins University, Baltimore, MD, an act that put into motion the basis of surgical education. Think of how technology evolved from the late 19th century to the early 20th century—from Bell’s telephone in 1875 to the smartphones devices of today. Yet, what advances have we made in surgical education? Surgical educators in Halsted’s era used the pyramid system, which resulted in the training of one outstanding individual. This was the only model used until 1931, when Edward Delos Churchill, MD, FACS, was named chief of surgery at Massachusetts General Hospital, Boston, and he developed the rectangular surgical residency model. The philosophy of this model was to “create a group of masters, in which no single personality dominates the institution.”3 So, what happened in surgical education between the 1930s and the early 1980s? Essentially nothing—it was the proverbial quiet before the storm.

Sea change

It could be said that “the flood” regarding developing education strategies for today’s surgical resident started with the Libby Zion case in 1984, followed by the New York State resident duty-hour restriction in 1989, and then the nationwide 80-hour workweek restrictions issued by the Accreditation Council for Graduate Medical Education (ACGME) in 2003. The restrictions on trainable hours continued in 2011, when the ACGME limited intern work hours to 16 hours per shift. Most of us will agree that a 120-hour workweek is too much, but the limitation to 80 work hours per week for residents leads to a cumulative amount of six months to one year of trainable time, resulting in the loss of more than five years; residents today have less time in training.

Adding to these challenges, residents are now asked to learn a broader range of surgical procedures. What were once open procedures are now laparoscopic, endovascular, endoscopic, and even robotic. There is also the issue with resident independence in the operating room; some say we have lost our autonomy. How often do we hear the elder attending say, “When I was the chief resident, I never saw my attending unless I needed him.” So, here we are, now with less training time during the same “classic” five-year residency, and yet we are asked to learn more skills in expanding subspecialties while the opportunities for surgical independence dwindle. How does the resident of today fill these multiple gaps? The answer is fellowship training.

Do these challenges make any sense? How have we tolerated these conditions? We must draw a line in the sand—it’s time for our surgical revolution! We are wasting time producing physicians who are half trained in many subspecialties—
physicians who will never be general surgeons. An article in the January issue of the Journal of the American College of Surgeons stated that general surgeons performed an average of 23 different types of operations.4 Why spend hours doing deep inferior epigastric perforator procedures with plastic surgery, thoracic robotic lobectomies, or endovascular aortic repair? These are great cases to see as a junior resident, to experience a subspecialty in order to see if that could be your passion, but once you discover these cases are not part of your career goals, why scrub in on these cases again? It’s not time spent wisely, and it may be taking the opportunity to practice the procedure from a fellow who is being trained in that subspecialty.

The revolution

How does the revolution start? We regulate ourselves, which means the ACS becomes the sounding board for the advancement of surgical education, and oversees the multitude of current regulatory bodies. The College needs to revolutionize the structure of surgical education to include direct admission to all fellowships for medical students who know what subspecialty they desire to pursue. Medical students who are unsure of their specialty may enter a two-year surgery residency position, where they will rotate through all of the subspecialties. At the midpoint of the second year, they will enter a standardized application process for all of the surgical subspecialties, including rural general surgery. The following fellowships would then be for the duration of three years, for a total training time of five years. Training under this model would produce a more proficient surgeon in less time.

Strong training models require excellent teachers, and we need to acknowledge that great surgeons do not always great teachers make. Every program needs a surgical educator—someone who is a trained teacher and can monitor the academic progress of his or her students. Currently, the attending surgeon is overstretched; between clinic, operating, and endless paperwork, it’s an impossible expectation to ask these surgeons to take hours out of their week to teach.

With respect to curriculum, we need standardization during the first two years of surgical education so that every resident in the country has the same academic baseline. Although the Surgical Council on Resident Education-based module system has helped immensely with addressing this challenge, a lack of standardization continues, and with approximately 679 modules, this system provides an overwhelming amount of information. If we can formulate a standardized curriculum for our elementary students, then we can do the same for surgical residents. The ACGME milestones are a step in the right direction, but this program, at best, sets an expectation without providing the necessary tools to accomplish these goals. The curriculum should also provide simulation training. With today’s technology, a second-year resident who scrubs their first laparoscopic cholecystectomy should have already made the necessary intraoperative moves 20-plus times on simulation.

The revolution will not be simple; it will require taking the path less traveled. It will take the two things of which we do not have an abundance—time to restructure the system, and monetary resources—to make these changes possible. However, if we do not support the revolution, then we will continue down the path of least resistance, which is simply to try to make our old system work in training new surgeons. The simplest way to do work in the current training model is to make the residency period longer—again, the easy way out. Surgeons have never taken the easy way. Let’s take ownership of our training process and take the power back. It’s time for a revolution.


  1. Association of American Medical Schools. Results of the 2012 Medical School Enrollment Survey. Center for Workforce Studies. May 2013. Accessed September 18, 2014.
  2. National Resident Matching Program. Results and data: 2012 main residency match. National Resident Matching Program. April 2012. Accessed September 18, 2014.
  3. Grillo HC. Edward D. Churchill and the “rectangular” surgical residency. Surgery. 2004;136(5):947-952.
  4. Decker M, Dodgion CM, Kwok AC. Specialization and the current practices of general surgeons. J Am Coll Surg. 2014;218(1):8-15.
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First-place essay—reform: Reformation of current surgical residency and fellowship training is the best solution Sat, 01 Nov 2014 05:54:55 +0000

The evolution of surgical training in the U.S. is best described as punctuated equilibrium—periods of stasis followed by abrupt change. In 1889, William S. Halsted, MD, FACS, rejected homespun apprenticeships and standardized surgical education with a pyramidal residency model.1 Inevitably, this model fueled competition, as the mastery of skills requisite for independent practice was only guaranteed to the single resident reaching the pyramid’s peak until Edward D. Churchill, MD, FACS, developed a rectangular model at the Massachusetts General Hospital, Boston, in 1938.2 This core training model remained relatively unchanged until disciplines such as neurosurgery and orthopaedics, driven by expanding knowledge in their disparate fields, began to forgo general surgical training altogether. In the current era, laparoscopy and the endovascular revolution, individual interests, health care reform, evidence-based practices, and quality initiatives are bringing surgical leaders to realize that mastery of the entire breadth of traditionally defined general surgical practice cannot be achieved by a single individual or training paradigm.

The first three years of current training provide a solid foundation with exposure to the major subspecialties, core surgical techniques, critical care, and perioperative management of complex patients. The latter years, however, are inadequate in refining the technical skills and mastery required for independent practice, in part due to restrictions associated with the 80-hour workweek and decreased resident autonomy.3,4 Adding to these challenges is an unspoken requirement to pursue a niche if one desires a successful academic career. Consequently, 80 percent of current general surgery graduates pursue fellowship training, resulting in a training paradigm that lasts far too long in the face of burgeoning student debt and that counterintuitively allocates less than a quarter of total training time to the ultimate field of practice.5 It is also important to note that five years of training ingrains technical habits that may have to be partially unlearned in specific fellowships. These issues likely contribute to the decline in caliber of general surgery applicants and the difficulty some training programs have in filling positions.6

Current fellowship training also is flawed. Health care is embracing a disease-based approach to patient care, blurring the line between surgical and medical specialists. Surgeons have always taken pride in acting not as mere technicians, but as physicians who can offer operative therapy. Upholding this standard in the current era demands interdisciplinary knowledge and is epitomized by the vascular surgeon who has evolved into a specialist in the diagnosis, medical management, and operative management (open and endovascular) of vascular diseases. Similarly, surgical oncologists have become integral to the multidisciplinary cancer team and have acquired knowledge of radiation oncology and chemotherapy. Trauma and acute care surgeons have mastered critical care and are pursuing training in echocardiography and basic endovascular techniques for resuscitation, while rural surgeons seek training in rudimentary urology, orthopaedics, and gynecology.7-9 Interdisciplinary knowledge is also essential for minimally invasive and colorectal surgeons who have reclaimed endoscopy and are advancing the field with robotics, transanal endoscopic microsurgery, and natural orifice transluminal endoscopic surgery.10,11

Today, offshoots of general surgery demand mastery of a body of knowledge as expansive as the parent field. In officially recognized subspecialties such as vascular and cardiothoracic surgery, the result has been longer fellowship training. In other areas, there is a push toward distinct board recognition in breast, endocrine, bariatric/minimally invasive, colorectal, transplant, oncology, pediatric, hepatic/biliary/pancreatic, and acute care surgery, though only four of these areas had official certification as of 2012.9 The trend toward subspecialization is here to stay, and the means to this end must be consolidated.

Plastic, vascular, and cardiothoracic surgery have adopted integrated pathways recruiting trainees directly from medical school, attracting a higher caliber of applicant.12,13 Reallocation of time provides formal exposure to pertinent areas such as noninvasive duplex imaging, vascular medicine, echocardiography, cardiac catheterization, and critical care that is not currently obtained in traditional fellowships while simultaneously shortening training time.

These nascent training paradigms, however, are by no means without shortcomings. There is a natural concern that medical students, having only been exposed to a few months of surgery, may not be certain about the desire to pursue such highly specialized training. Surveys demonstrate that approximately 78 percent of 12,000 postgraduate year-one residents changed their predicted subspecialty focus by the fifth year of training and raise concerns about mid-training resident attrition.14-16 Additionally, faculty in these programs face the challenge of training residents with minimal technical skill and clinical acumen compared with traditional trainees who have had five years of surgical maturation.15-17 These integrated models raise concerns for the eventual direct recruitment of medical students into the array of subspecialties, noted earlier, and consequently, the demise of core general surgery training that unifies these fields.

For these reasons, residency reform cannot occur without concomitant fellowship restructuring. The ideal training model should be anchored by a core surgical residency program modeled after the first three years of the current training paradigm, followed by an additional one-to-three year fellowship in one of the areas mentioned in this article. Similar “3+3” pathways already exist in cardiothoracic and vascular programs, and this concept logically follows the recent adoption of early specialization pathways by the Accreditation Council for Graduate Medical Education. Because the first three years of this model would not lead to board certification, the greatest challenge for the American Board of Surgery would be to create certification for all of these various fields, which is already occurring and will ensure standardized training of the highest caliber.

This training paradigm would be apportioned properly and facilitate informed decision making in choosing subspecialty training, fostering the requisite skills for successful practice in the modern era. Even with these substantial gains, overall training time will be unchanged or reduced in some cases. Finally, a specific fellowship dedicated to training community surgeons, paralleling the fourth and fifth years of current training, will provide a path through which general surgery would survive among its offshoots. Dr. Churchill was indeed ahead of his time in 1938 when he said “a frozen five year curriculum is unthinkable as it allows no latitude for the development of individual interests and proficiency.”2


  1. Rutkow I. The education, training, and specialization of surgeons: Turn-of-the-century America and its postgraduate medical schools. Ann Surg. 2013;258(6):1130-1136.
  2. Grillo HC. Edward D. Churchill and the “rectangular” surgical residency. Surgery. 2004;136(5):947-952.
  3. Napolitano LM, Savarise M, Paramo JC, et al. Are general surgery residents ready to practice? A survey of the American College of Surgeons Board of Governors and Young Fellows Association. J Am Coll Surg. 2014;218(5):1063-1072.e31.
  4. Drake FT, Horvath KD, Goldin AB, Gow KW. The general surgery chief resident operative experience: 23 years of national ACGME case logs. JAMA Surg. 2013;148(9):841-847.
  5. Foley PJ, Roses RE, Kelz RR. The state of general surgery training: A different perspective. J Surg Educ. 2008;65(6):494-498.
  6. Cockerham WT, Cofer JB, Biderman MD, Lewis PL, Roe SM. Is there declining interest in general surgery training? Curr Surg. 2004;61(2):231-235.
  7. Velmahos GC. Acute care surgery: From de novo to de facto. Surg Clin North Am. 2014;94(1):XIII-XV.
  8. Villamaria CY, Eliason JL, Napolitano LM, Stansfield RB, Spencer JR, Rasmussen TE. Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) course: Curriculum development, content validation, and program assessment. J Trauma Acute Care Surg. 2014;76(4):929-35; discussion 935-936.
  9. Stain SC, Cogbill TH, Ellison EC, et al. Surgical training models: A new vision. Broad-based general surgery and rural general surgery training. Curr Probl Surg. 2012;49(10):565-623.
  10. Nussbaum MS. Surgical endoscopy training is integral to general surgery residency and should be integrated into residency and fellowships abandoned. Semin Laparosc Surg. 2002;9(4):212-215.
  11. Davis BR, Vitale GC. Endoscopy for the general surgeon. Adv Surg. 2008;42:277-297.
  12. Zayed MA, Dalman RL, Lee JT. A comparison of 0 + 5 versus 5 + 2 applicants to vascular surgery training programs. J Vasc Surg. 2012;56(5):1448-1452.
  13. Lee JT, Teshome M, de Virgilio C, Ishaque B, Qiu M, Dalman RL. A survey of demographics, motivations, and backgrounds among applicants to the integrated 0 + 5 vascular surgery residency. J Vasc Surg. 2010;51(2):496-502; discussion 502-503.
  14. Vick LR, Borman KR. Instability of fellowship intentions during general surgery residencies. J Surg Educ. 2008:65(6):445-452.
  15. Lebastchi AH, Tackett JJ, Argenziano M, et al. First nationwide survey of US integrated six-year cardiothoracic surgical residency program directors. J Thorac Cardiovasc Surg. 2014;148(2):408-415.
  16. Ward ST, Smith D, Andrei AC. Comparison of cardiothoracic training curricula: Integrated six-year versus traditional programs. Ann Thorac Surg. 2013;95(6):2051-2054; discussion 2054-2056.
  17. Flynn TC. How will the introduction of primary certificate training programs change vascular surgery training programs? Semin Vasc Surg. 2006;19(4):218-221.
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Second-place essay—reform: Revisiting the visions of Halsted, Churchill, and Dudley to fix surgical training a century later Sat, 01 Nov 2014 05:53:02 +0000

“We need a system […] which will produce not only surgeons, but surgeons of the highest type, who will stimulate the finest youths…to devote their energies and their lives to raising the standards of surgical science.”1

William S. Halsted, MD, FACS, delivered this statement at Yale University, New Haven, CT, in 1904, as part of his address on the Training of the Surgeon.1 Dr. Halsted crafted the first general surgery training system at the Johns Hopkins Hospital, Baltimore, MD, in 1889.2 In Dr. Halsted’s pyramidal system, only one resident in eight would complete training.2 Edward D. Churchill, MD, FACS, of Massachusetts General Hospital (MGH), Boston, on the other hand, wanted all of his trainees to finish as competent surgeons.3 Dr. Churchill, believing that “half a surgical training is about as useful as half a billiard ball,” and that residents should be able to develop their own proficiencies, did not adopt the pyramidal system, or the “frozen” five-year system.2-4 Allen Dudley, MD, FACS, in his presidential address to the American Surgical Association in 1907, commented that “the great misfortune of the specialist of the present day is the inadequate knowledge of other departments than his own.”4

Nowadays, becoming the consummate general surgeon is difficult—some would say impossible—with the expanding range of surgical diseases, disciplines, and the development of new therapies and techniques.5,6 In fact, since duty-hour restrictions were implemented, L.D. Britt, MD, MPH, D.Sc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon), Past-President of the American College of Surgeons, has expressed his concern with the increasing failure rate on the general surgery certifying exam.5,6 Dr. Britt further emphasized the importance of repetition in surgical training, which has become more challenging due to work-hour limits.5

Today, general surgery residents are pursuing fellowship training in a broad range of subspecialties, and an increasing number of these fellowships are becoming accredited, which requires board certification. Even as patients seek surgeons who are experts in a particular field, there is a growing concern that residents are finishing programs with less training and less independence.5

Rather than doing away entirely with the current training system, several improvements could be made. For example, surgical education, skill modules, and mentorship could begin earlier for those planning to apply for general surgery. Early specialization should uniformly be a part of surgical training programs while maintaining core general surgery rotations, and expanded use of “homework” assignments/self-assessments and simulation training courses should be incorporated into the general surgery training and education curriculum.

Early education and mentorship

When interest in surgery is expressed early in undergraduate and medical school years, it will continue and may even grow stronger by the time a student is ready to apply for a general surgery residency position.7,8 Various stakeholders have proposed that the fourth year of medical school should be restructured to implement a standardized curriculum for surgery applicants.9 If incorporated into education programs at an early stage, suturing workshops, skills labs, anatomy courses, and so on, can help facilitate the transition from medical school to a general surgery residency, making intern and junior years more efficient and productive. Mentorship and surgical education should begin even earlier in medical school, as soon as a student has expressed interest in surgery. Mentorship can help identify knowledge and skills gaps, and for this reason should certainly continue through residency. There may even be a benefit to providing mentorship after training to help facilitate the transition to independent practice.10,11

Early specialization

Early specialization, fast-track, or joint-specialization programs should be uniformly available, while maintaining a core general surgery knowledge base and skills set. These training programs usually offer several core years of general surgery training with the added benefit of pursuing a particular field of interest early in training as well as dual certification. Such programs now allow only certain fast-track options (such as cardiothoracic or vascular surgery) and are only available to residents within a particular institution. These programs should expand to allow early training in all specialties, including transplant and pediatric surgery, and should be available for outside residents who have completed and demonstrated competency in the core general surgery rotations, but who may be in programs that are unable to offer certain specialty tracks due to limited resources and volume.

Under this model, program directors will be tasked with tailoring surgical curriculum to specific specialization tracks. For example, after core general surgery rotations in the first few years of residency, a resident planning to pursue a career in breast surgery may spend more time on surgical oncology, breast, and plastic surgery rotations than another resident who is interested in trauma or cardiac surgery. This specialization may help to eliminate time spent in fellowship training. For those interested in nonspecialized general surgery careers, such as rural surgery, options should remain for completing a general surgery residency.

Expanded use of simulation, skills labs, and self-assessments

Programs should continue to incorporate and expand the use of simulation training and skills labs.12 Simulation allows for repetition in training, as mentioned earlier, and provides a way to measure skill acquisition.10 Additionally, using the Surgical Council on Resident Education program to structure surgical education along with required reading assignments, weekly quizzes, and periodic self-assessments may be effective in optimizing the learning experience and improving in-training examination scores.13

It has taken more than a century to create an effective and well-validated general surgery residency training system. Any attempt to make the current training system more efficient would necessitate increased help from the allied health professions to safely facilitate and coordinate patient-centered care. These improvements may also help with the increasing documentation requirements that accompany patient care and may help ensure safe sign-out exchange of patient information.14 Ultimately, the aforementioned ideas and concepts will improve the general surgery training system, producing stronger graduates, and perhaps reduce the additional time necessary for subspecialty training. We will have a system that will produce Dr. Halsted’s “highest quality surgeon,” providing an earlier opportunity to specialize, a concept Dr. Churchill supported, while maintaining core general surgery rotations and training, as Dr. Dudley would have wished.


  1. Johns Hopkins Medicine. Department of Surgery. History of Johns Hopkins Medicine. Accessed April 24, 2014.
  2. Pellegrini CA. Surgical education in the United States: Navigating the white waters. Ann Surg. 2006;244(3):335-342.
  3. Grillo HC, Edward D. Churchill and the “rectangular” surgical residency. Surgery. 2004;136(5):957-952.
  4. Allen DP. The teaching of surgery. Trans Am Surg Assoc. 1907;25:1-14.
  5. Smith MJ. Are today’s surgical graduates prepared for real life practice? Gen Surg News. 2013;40(3):1-2.
  6. Britt LD. Graduate medical education and the residency review committee: History and challenges. Am Surg. 2007;73(2):136-139.
  7. Scott I, Gowans M, Wright B, Brenneis F. Stability of medical student career interest: A prospective study. Acad Med. 2012;87(9):1260-1267.
  8. Sutton PA, Mason J, Vimalachandran D, McNally S. Attitudes, motivators, and barriers to a career in surgery: A national study of UK undergraduate medical students. J Surg Educ. 2014;71(5):662-667.
  9. Debas HT, Bass BL, Brennan MF, et al. American Surgical Association Blue Ribbon Committee Report on Surgical Education: 2004. Ann Surg. 2005;241(1):1-8.
  10. Pellegrini CA. Surgical education in the United States 2010: Developing intellectual, technical and human values. Updates Surg. 2012;64(1):1-3.
  11. Sachdeva AK, Flynn TC, Brigham TP, et al. Interventions to address challenges associated with the transition from residency training to independent surgical practice. Surgery. 2013;155(5):867-882.
  12. Sachdeva AK, Bell RH, Jr., Britt LD, Tarpley JL, Blair BG, Tarpley MJ. National efforts to reform residency education in surgery. Acad Med. 2007;82(12):1200-1210.
  13. De Virgilio C, Stabile BE, Lewis RJ, Brayack C. Significantly improved American Board of Surgery in-training examination scores associated with weekly assigned reading and preparatory examinations. Arch Surg. 2003;138(11):1195-1197.
  14. Bell RH. Surgical council on resident education: A new organization devoted to graduate surgical education. J Am Coll Surg. 2007;204(3):341-346.
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Optimizing the OR for bundled payments: A case study Sat, 01 Nov 2014 05:52:30 +0000

Of the innovative reimbursement models developed under the Affordable Care Act, bundled payment will likely have the greatest impact on surgeons. Unlike other new payment models, bundled payments directly affect surgeon and hospital reimbursement. At the same time, hospitals are relying on surgeons to help make bundled services cost-effective.

The keys to maintaining operating margins under bundled payment are cost control and care coordination. But cost management in the operating room (OR) is complex. Currently, most early participants in payment bundling are focusing on direct costs—expenses related to surgery, inpatient care, post-acute care, and readmissions. The indirect costs associated with running an OR receive less attention. Many see OR labor and time allocations as incremental costs that have a minimal effect on the profitability of the service bundle; unfortunately, this view misses an important dynamic of surgical services. The OR cost structure displays a strong “stepped” effect tied to resource use. Small differences in OR efficiency can dramatically alter resource use, creating a cost impact that can erase margins under any capped payment system.

To succeed under the bundled payment model, hospitals and surgeons must collaborate to control both direct and indirect costs. The first step in this process lies in understanding the mechanics of bundled payment and how perioperative inefficiency can increase indirect costs, making bundled payment financially unsustainable. This article looks at the evolving demands to improve cost-effectiveness and resource allocation and describes how one institution was able to optimize the OR for bundled payments.

A new calculus for OR cost-effectiveness

The Centers for Medicare & Medicaid Services (CMS) launched the Bundled Payments for Care Improvement (BPCI) initiative in 2013.* The program covers 48 Medicare severity diagnosis-related groups (MS-DRGs), approximately half of which involve surgery. BPCI participants have the option of selecting one of four different payment models (see Table 1). The most comprehensive option is Model 2, which provides a single payment for both the initial hospital stay and post-acute care. This option includes all costs incurred starting 72 hours before admission; hospital OR and inpatient costs; physician services; laboratory services; and costs incurred 30, 60, or 90 days after discharge, including skilled nursing facility and home health agency services and any readmission costs.

Table 1. CMS bundled payment models


Episode of care


Payment method


Acute care hospital stay only Inpatient stay in acute care hospital (physicians paid separately by Medicare) Retrospective


Acute care hospital stay+ post-acute care Hospital inpatient stay and all related services; episode ends 30, 60, or 90 days after discharge Retrospective


Post-acute care only SNF, IP rehab, LTC hospital or home health agency services; post-acute episode ends 30, 60, or 90 days after initiation Retrospective


Acute care hospital stay only All services provided during IP stay by hospital, physicians, other practitioners; includes 30-day readmissions Prospective

CMS sets a target price for each service bundle based on the institution’s historical claims, less a discount. Under Models 1, 2, and 3, providers submit claims and receive normal fee-for-service (FFS) payments for services included in the episode. CMS then performs a quarterly reconciliation of actual claims to the target price. If total claims are less than the target price, the participating facility receives the difference. If claims exceed the target, providers must repay CMS for the excess. (Model 4 uses a prospective payment methodology, whereby the participating hospital receives a single prospectively determined payment for a patient hospital stay and any 30-day readmissions; the hospital pays physicians and other practitioners for services provided during the inpatient stay.) CMS monitors post-discharge services to ensure costs are not being shifted outside of the bundle period.*

Surgeons are eligible for gainsharing under the BPCI initiative. Under Model 2, for instance, hospitals can share savings related to both cost target performance and internal cost reductions with physicians. (All gainsharing arrangements must comply with applicable Stark Law waiver requirements.)

For participating organizations, the transition to bundled payment makes it very important to monitor cost-effectiveness. But two separate components drive the potential for a positive margin on the bundled payment episode: hospital resource utilization (including the OR, as well as postoperative management) in the acute phase of care, and coordination of outpatient services after the acute phase.

The key to ensuring the cost-effectiveness of the episode is to minimize direct costs. On the acute care side, priorities include minimizing direct OR costs—supplies, implants, and labor—as well as hospital costs driven by length of stay and variations in care (for example, use of clinical pathways). For episodes that include post-acute care, major considerations include the cost of inpatient rehabilitation facilities, outpatient and/or in-home rehabilitation services, and postsurgical complications and readmissions.†

Yet even if a provider organization is keeping these costs under target levels and achieving profitability for the episode of care, it is still possible for the OR not to be cost-effective. To illustrate this point, consider the following example:

In a 10-hour block, a surgeon is able to perform three total knee arthroplasty (TKA) procedures. This example demonstrates moderately inefficient OR use, but under traditional FFS payment, billing would increase with procedure time and other cost allocations. As a result, the OR would cover the cost of a day of surgery and generate some margin.

Under bundled payment, however, the economics of the surgical block can be dramatically different. In this scenario, the target payment is capped for three TKA operations, but the OR still incurs the operational expenses of a full day of surgery. The bottom line: Payment may not cover OR operating costs if there are other costs generated that are above threshold expectations. Additionally, if profits are not generated under the bundled payment arrangement through cost efficiencies, no level of volume is sustainable.

Clearly, OR efficiency is important under bundled payment. Low utilization creates a high cost structure that may be unsustainable in a capped payment environment if costs are above target payments. How does this affect surgeons? Depending on the specifics of the gainsharing contract, OR losses on a service bundle could reduce surgeon payment. However, even if a surgeon group is contractually shielded from losses, it will miss out on potential gains—and the opportunity to develop bundled payment as a sustainable economic platform.

The bottom line is that surgeons participating in a bundled payment initiative should pay close attention to perioperative efficiency. As noted in the following case study, recently surgery department leaders at an East Coast academic medical center used efficiency improvements to gain control over indirect costs and optimize the OR for success within the BPCI program.

Case study from New York University (NYU) Langone Medical Center

The Hospital for Joint Diseases (HJD) is an orthopaedic surgery hospital that is part of NYU Langone Medical Center. Located in Manhattan, this 190-bed specialty facility consistently ranks among the top hospitals in the U.S. and draws referrals both regionally and nationally.

In 2013, NYU was selected to take part in the BPCI initiative. Medical center leaders elected to participate under Model 2 for several cardiovascular and orthopaedic surgery MS-DRGs, including spinal fusion and a range of joint replacement procedures. With its exclusive focus on orthopaedic surgery, HJD became an important facet of the initiative. At that time, efforts to control implant costs were already well under way at HJD.‡ In addition, surgical services leaders had recently begun work to improve perioperative efficiency. These initiatives dovetailed with the hospital’s foray into the bundled payment option.

Process problems at HJD were typical of inefficiencies found in most hospitals. Pre-surgical testing was not well organized, and the process for scheduling cases and communicating information to patients was inconsistent. As a result, the OR had high cancellation and delay rates. For the year ending July 2012, the same-day cancellation rate was 6.3 percent and the first case on-time start rate (within 5 minutes of schedule) was only 54.3 percent (n=19,234). In addition, case times for common procedures were relatively long. For instance, during the same period, the average case time (wheels in to wheels out) for multi-level spinal fusion was 221 minutes (n=895).

Overall, HJD’s participation in the BPCI initiative revealed an inefficient use of the OR. The prime-time utilization rate at HJD was just 47 percent. Low utilization is a problem for any hospital OR, given the cost of OR time and the importance of maintaining strong case volume. For a hospital entering into a bundled payment contract, low usage threatened to undercut cost savings achieved in other areas. HJD needed to increase effective capacity to operate profitably under payment caps.

New organizational structure

HJD launched its efficiency initiative by addressing the underlying reasons for poor perioperative performance. A hospital OR is the intersection point of several stakeholder groups, including surgeons, anesthesiologists, nurses, and many other clinical and support specialists. Consequently, OR efficiency can only be achieved when all the actions and goals of the stakeholders are aligned. On a practical level, this means the first step in an OR efficiency initiative must be an OR governance initiative.

In late 2012, HJD established a surgical services executive committee (SSEC) to oversee the OR. The SSEC brought together representatives from all stakeholder groups, including surgeons, anesthesiologists, nursing leadership, and hospital executive administration. The committee served as a forum for discussing the challenges of the OR and establishing the need for change. The physician-led SSEC also functioned as an operational “board of directors” for the OR. Committee members worked together to examine specific OR process problems and establish new policies and structures to improve perioperative efficiency.

The SSEC’s first priority was to reengineer the OR’s block schedule system. At the time, many blocks were assigned in relatively inefficient four-hour units. Surgeon use of assigned block time was not monitored, and block time rules were not enforced. Poor control created frequent schedule gaps, yet block ownership issues made it difficult for many surgeons to access the prime-time schedule. Consequently, the demand for add-on scheduling rose, which increased labor costs due to overtime and call pay.

To address this problem, the SSEC established a new set of block time rules. First, the committee eliminated four-hour blocks and began assigning more efficient eight-, 10- and 12-hour units. Second, surgeons were required to maintain a utilization rate of 80 percent in order to retain their block. The committee also set an expectation that surgeons arrive on time for all scheduled cases and instituted an automatic block time release calendar to enable the OR to fill unscheduled time. Lastly, the SSEC created several “open” rooms to accommodate add-on cases and unblocked surgeons.

The SSEC began monitoring surgeon use rates and, with appropriate warnings and probation periods, reallocating block time away from physicians who could not consistently fill their blocks. The reformed system rewarded high-utilization surgeons and became an important motivator to secure surgeon cooperation with other efforts to improve perioperative efficiency, such as scheduling process changes and new expectations regarding surgeon arrival times.

Streamlined throughput

As schedule allocation issues were being resolved, an SSEC task force began working to improve preoperative processes that affect OR throughput with the following initiatives:

Procedure scheduling

Scheduling processes at HJD were disorganized, leading to significant variation in the detail and accuracy of patient information. In addition, the scheduling system dictionary had been inadequately maintained. As a result, schedule entries often listed the incorrect procedure, which created many day-of-surgery delays and led to significant supply waste.

The first step in overhauling the scheduling process was to work more closely with surgeon office personnel. Task force members initiated a monthly meeting with surgeon office managers and clinical coordinators to discuss scheduling processes and develop process improvements. The group created new standards to ensure the hospital had complete information about the procedure and patient risk factors early in the preoperative process. In addition, the task force created standardized processes for “boarding” surgical cases. A clinical scheduling coordinator role was created to manage the schedule and ensure accuracy.

Preadmission testing

The preadmission testing (PAT) clinic at HJD used some testing protocols, but they covered only a limited number of patients, were difficult to follow, and were generally conservative. Due to disorganization in PAT, assessments were sometimes redundant. As evidence that the process was broken, the cancellation rate was higher for patients seen in the PAT clinic than for those who had never used the service.

The task force addressed the PAT clinic assessment inconsistencies by creating standardized requirements for pre-surgical optimization. Members of the task force created a standard pre-surgical testing matrix based on procedure invasiveness and patient comorbidities (see Table 2) and a common matrix for evaluating abnormal lab results. They also developed consistent medication management standards and established evidence-based protocols for the pre-surgical management of comorbidities, such as diabetes and anemia.
Table 2. New Pre-Surgical Testing Matrix

A multidisciplinary task force at the NYU Langone Medical Center HJD developed a standardized pre-surgical testing matrix based on procedure and patient risk factors. The table below details required testing for various medical conditions.

Medical evaluation




Basic metabolic







Cardiovascular and cerebrovascular disease






Pulmonary diseases (including sleep apnea, chronic obstructive pulmonary disease (COPD), emphysema) (1)






Sleep apnea












Hepatic disease







Renal failure, severe insufficiency (6)






Bleeding disorder (acquired or congenital abnormality)





Morbid obesity body mass index >40








Malignancy, active on chemotherapy, including leukemia







Hypertension,poorly controlled:diastolic blood pressure >110mmHg, systolic blood pressure >160mmHg




Neuromuscular disease (7), central nervous system (CNS) disease or seizure disorder


Rheumatoid arthritis




Seizures, CNS disease, and on meds that can affect bleeding






Alcohol consumption> 2 drinks per day




History of anemia hemoglobin (Hgb) <10



  1. For active, acute process, or history of COPD, moderate to severe asthma, recent pneumonia, oxygen therapy, dyspnea, tachypnea, and pulmonary function tests, if symptoms are severe
  2. If greater than 10-year history
  3. Hgb A1C / recommended but not required in diabetics
  4. If malignancy is in thorax
  5. Neck films and consider chest X ray (CXR)
  6. Renal failure: potassium day prior to or day of procedure (post-dialysis)
  7. Neuromuscular disease: amyotrophic lateral sclerosis, Parkinson’s, muscular dystrophy
  8. As indicated by examination

Task force leaders also developed a telephone screening process for triaging patients to the appropriate pre-op care. HJD staff now call all patients shortly after scheduling and use a risk-based questionnaire to determine which patients must visit the PAT clinic for special assessment. This process has helped reduce the patient volume in the PAT clinic while ensuring higher-risk patients receive an aggressive evaluation.

Final clearance

Previously, a significant portion of HJD patients arrived for surgery with unresolved medical issues. The task force addressed this problem by creating stronger processes for ensuring medical optimization prior to the day of surgery.

HJD staff held a short meeting every afternoon to examine the next day’s schedule for problems with equipment or staffing, but this meeting did not address clinical/patient issues. The task force strengthened the process by converting the meeting into a true clinical review. Now, representatives from anesthesia, nursing, central sterile processing, and other areas examine the schedule for the next 24, 48, and 72 hours. They identify patients who need further clearance and resolve any scheduling problems, which helps to ensure all patients are fully optimized and ready for surgery before the day of their procedure.

Case time reduction initiative

As noted previously, average case times at HJD were relatively long. In response, the SSEC created a physician-led task force to remove delays from the system of care. Key interventions included:

Redesigning operational metrics

The first step was to create a more useful clinical measurement strategy. Task force leaders redesigned perioperative operational metrics to focus on six key intervals:

  • Patient in to anesthesia-ready
  • Anesthesia-ready to prep end
  • Prep end to incision start
  • Incision start to incision close
  • Incision close to OR-discharge-ready
  • OR-discharge-ready to patient out

These intervals are useful because they allow OR leaders to analyze distinct phases of patient throughput separately. In addition, each interval is “owned” by a different individual, providing a built-in point of accountability within the system.
The task force performed an initial study to provide baseline data, then began monitoring and analyzing case time performance. Case time data were also provided to OR staff and individual surgeons via dashboard reports. Data transparency helped fuel organizational change among all stakeholders.

Creating parallel workflows

Previously, patients were not brought into the OR until all instrument tables were completely prepared, but this sequence delayed case starts unnecessarily. Now, patients are wheeled into the OR once the room has been cleaned, and staff finish setting up the back table as patient prep moves forward. Similar parallel processes have also been created in the closure and breakdown phases.

Improving anesthesia workflow

The case time task force also examined ways to make anesthesia processes more time-efficient. Previously, anesthesiologists began all patient IVs, arterial lines, and pain blocks inside the OR. As part of the efficiency project, anesthesiologists started performing these procedures in the preoperative holding area, thus using the time patients spend in the holding area instead of valuable time in the OR. This change reduced in-room prep times while smoothing out the anesthesia workflow.

Deploying specialty support

Many orthopaedic surgery procedures require complex setup that can be very time-consuming. HJD addressed this issue by hiring physician assistants (PAs) to provide support for complicated surgeries. Specialized PAs also help speed up case times by providing better intraoperative support and assisting with closing.

Establishing surgeon expectations

Task force leaders observed that if the attending surgeon was not in the OR during setup, positioning, and draping, the pace of work tended to slow down. When the attending did arrive, he or she often requested setup changes, creating further delays. In addition, when the attending surgeon was not present through the end of the case, closure could be extended significantly depending on the skills of the resident or fellow. To address both these issues, the SSEC established a requirement that the attending surgeon must be in the OR upon patient arrival and must stay through most of closure. These two changes helped ensure that OR teams maintain a steady work pace, further reducing average case times.

Planning for discharge throughput

The final case time interval (OR-discharge-ready to wheels out) was often extended because the post-anesthesia care unit (PACU) had no available capacity to receive additional patients. In many instances, the PACU was full because rooms were not ready on the surgical inpatient floor. Task force leaders addressed these problems by working directly with the PACU and inpatient nursing leadership to improve communication and capacity planning, enabling a timely OR discharge for a greater percentage of patients.

The SSEC also examined the impact of schedule issues on inpatient costs. Previously, a disproportionate share of spine and joint replacement procedures were performed on Friday. For these patients, discharge to a post-acute care facility could often be delayed due to weekend staffing issues. The result was extended length of stays for late-week orthopaedic procedures. The committee addressed this problem by working with surgeons and OR managers to schedule more spine and joint cases earlier in the week, effectively evening out case volumes and helping to reduce inpatient care costs.

Strong outcomes

Efficiency improvement initiatives at HJD led to significant gains in perioperative performance within a short time frame.
Between July 2012 and March 2014, improvements in upfront scheduling, pre-surgical testing, and perioperative coordination reduced the same-day cancellation rate from 6.3 percent to less than 1 percent. During the same period, first-case on-time starts increased from 54.3 percent to greater than 90 percent. Contributing to this improvement, the surgeon on-time rate increased dramatically.

HJD’s case time initiative also achieved strong results. For example, between the fourth quarter of 2012 and the first quarter of 2014, the average case time for total hip arthroplasty declined by 12 percent and the average case time for total knee arthroplasty declined by 6 percent (see figure).

Case time reduction in orthopaedic surgery

Case time reduction in orthopaedic surgery

An OR initiative at HJD reduced average case times for several orthopaedic surgery procedures. As detailed in this figure, efficiencies in six process intervals cut average THA and TKA case times by 12 percent and 6 percent, respectively.


These improvements in operational performance, coupled with the reform of the block time system, helped to improve OR utilization. Between July 2012 and March 2014, prime-time utilization climbed from 47 percent to 81 percent.

Gains in efficiency and usage enabled HJD to accommodate additional volume without accruing additional costs. Indeed, the more attractive operating environment created by efficiency gains helped drive volume growth. In the third quarter of 2012, annualized surgery volume at HJD was 659 cases per room. In the first quarter of 2014, annualized OR volume grew to 712 cases per room—an increase of 8 percent.

The increases in OR efficiencies and improvement in pre-surgical testing enabled HJD to participate successfully in the CMS BPCI. Perhaps more importantly, gains in operational efficiencies and cost controls have positioned the institution to compete in a health care marketplace that is increasingly focused on value and cost of care.

Aligned goals

Bundled payment is a powerful mechanism for building productive partnerships between hospitals and surgeons. At HJD, shared responsibility for clinical and financial outcomes helped align hospital and physician goals. All stakeholders worked together to control both direct and indirect costs while maximizing patient outcomes. This collaboration is critical to ensuring that hospitals operate profitably under bundled payment and that surgeons benefit from current and future bundled payment initiatives.

*Centers for Medicare & Medicaid Services. Bundled Payments for Care Improvement (BPCI) initiative: General information. Accessed September 19, 2014.

†Bosco JA, Karkenny AJ, Hutzler LH, Slover JD, Iorio R. Cost burden of 30-day readmissions following Medicare total hip and knee arthroplasty. J Arthroplasty. 2014;29(5):903-905.

‡Bosco JA, Alvarado CM, Slover JD, Iorio R, Hutzler LH. Decreasing total joint implant costs and physician specific cost variation through negotiation. J Arthroplasty. 2014;29(4):678-680.

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Massachusetts Chapter develops new grassroots advocacy program Sat, 01 Nov 2014 05:51:07 +0000

For many years, the American College of Surgeons (ACS) has sponsored an annual spring Leadership & Advocacy Summit in Washington, DC. I have had the good fortune of participating in several of these events, which provide a wonderful chance for Fellows, ACS chapter officers, Governors and Regents, as well as young surgeons to learn about the legislative process and to gather with colleagues who face similar challenges. The program is growing: nearly 450 surgeons attended in 2014, up from 350 in 2013. However, we must do more to encourage greater participation of Fellows in advocacy and to foster collaboration between surgeons and policymakers, especially considering the relative number of representatives (435), senators (100), and Fellows of the College (approximately 79,600).

Faced with this realization, the Massachusetts Chapter of the ACS has promoted a novel grassroots advocacy concept on behalf of the College. This has become a core element of SurgeonsVoice, the College’s new advocacy instrument. This article discusses the rationale behind the District Office Contact by Surgeons (DOCS) program and how it works.

Introducing Fellows to advocacy

The notion of advocating with legislators about health care matters likely is unfamiliar to most Fellows, beyond what they read in publications such as the Bulletin. Although the ACS Advocacy Summit concentrates on active legislative issues, it occurs only once annually and attendance at the meeting can be costly to individual surgeons and to their chapters. Furthermore, such a limited encounter does not guarantee the opportunity to build relationships with legislators.

The goal of the DOCS program is to encourage grassroots advocacy among surgeons. Under this system, Fellows are to regularly meet with their U.S. representatives and senators and/or their staffs in their home district offices, typically every three to four months. Through this regular in-district contact, we have the ability as constituents to develop relationships with our members of Congress without traveling to Washington, DC. Furthermore, with none of the distractions of a typical day on Capitol Hill, program participants will have more time to discuss issues and reinforce our message. Fellows who are veterans of the ACS Advocacy Summit meetings and, perhaps, chapter officers or Governors, lead small groups of interested and locally respected Fellows—ideally from various specialties—to meet their elected representatives. It is a bonus if the surgeon-advocates personally know the representatives.

The DOCS program partners Fellows with ACS Washington Office staff who possess the knowledge of the issues and of the legislative process to educate Fellows before their visits. Briefings are conducted via teleconferences, webinars, and the SurgeonsVoice Web page. The material covered in these resources is regularly updated so that surgeons have the background necessary to comprehend contemporary health policy issues and to support specific requests of their legislators. This preparation also addresses meeting protocol and expectations for novice visitors. Different surgeons should participate throughout the year, cultivating a lasting “farm system” of Fellows over time. Debriefings follow the meetings, and the Fellows’ impressions of their legislators’ opinions will be conveyed to the ACS Division of Advocacy and Health Policy via their chapter staff.

What makes this model so attractive is that it empowers ACS chapters, giving them a clear raison d’être with respect to advocacy, while actively enlisting rank-and-file Fellows. Moreover, this program does not impose significant financial burdens on the chapter, nor will it require surgeons to take large amounts of time away from their practices. A greater number of Fellows will presumably become involved in the advocacy process and gain a deeper appreciation of the relevance and value of both the College and its chapters.

This is a “bottom-up” effort that the chapters will organize, including enrolling advocate surgeons, coordinating visitation schedules with district offices, and collecting surgeons’ residential zip codes. (It should be noted that the College database usually contains Fellows’ workplace addresses, which may be located in different congressional districts than where surgeons reside and vote.) It also is anticipated that individual chapters and the College as a whole will benefit from the experiences of Fellows who have served as representatives and senators at the federal and state levels.

Expanding the advocacy program

It is more practical for this grassroots advocacy program to begin with a national rather than a state focus. There are far fewer federal congressional districts than state districts, although the program may eventually serve as a model for statewide advocacy as the network of active Fellows matures. In addition, Fellows who are new to advocacy will probably be more enthusiastic about working on federal rather than state issues.

As members of Congress become acquainted with surgeon-constituents, it is expected that they will establish mutual trust and call upon surgeons to discuss health care matters, both legislative and personal. Furthermore, surgeons will become confident about inviting members of Congress and staff members to tour their operating rooms and clinics so that lawmakers will have a better understanding of how surgeons serve their patients. This system will also permit a rapid mobilization of engaged Fellows when urgent legislative situations arise.

The Massachusetts Chapter has developed the DOCS program in conjunction with College staff, including John E. Hedstrom, JD, and Christian Shalgian, Deputy Director and Director, respectively, of the ACS Division of Advocacy and Health Policy, Washington, DC. The DOCS program also benefitted from inspiration and guidance provided by ACS President Andrew L. Warshaw, MD, FACS, FRCSEd(Hon); Charles D. Mabry, MD, FACS, Chair, ACS Health Policy Advisory Council (HPAC); Ronald I. Gross, MD, FACS, HPAC Region Chief; and Peter T. Masiakos, MD, FACS, HPAC member. Oscar D. Guillamondegui, MD, FACS, Past-President of the Tennessee Chapter, played an influential role in introducing the Massachusetts grassroots advocacy program to the ACS Tennessee Chapter, a state with decidedly different politics than those in Massachusetts. In fact, this home-district office advocacy concept was presented at the executive planning session during the annual meeting of the Tennessee Chapter in Paris Landing on August 8, 2014. Notably, other chapters have expressed a strong desire to participate in this pilot program as well.

Grassroots activities via SurgeonsVoice form a critical component of the College’s overall advocacy efforts, which also include direct lobbying by ACS staff and the work of the ACS Professional Association’s political action committee, ACSPA-SurgeonsPAC. Successful advocacy requires that all three elements complement each other and function at a high level.

The participants in the Massachusetts grassroots advocacy program appreciate the College’s support and look forward to a rewarding collaboration among the ACS, its chapters, and Fellows through SurgeonsVoice and the DOCS program. We intend to create a model that can be implemented by all chapters and coordinated by the College’s Washington, DC, advocacy staff, which will be responsible for the education component of this program.

Fellows who are interested in nominating their chapter for participation in this grassroots advocacy effort should contact Sara Morse, Manager of Grassroots and Political Affairs, at How powerful it will be when members of Congress return from recesses at home and learn from their colleagues that, as a group, they have met with thousands of surgeons from across the nation.

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Transplant in a patient with comorbid psychiatric illness: An ethical dilemma Sat, 01 Nov 2014 05:50:57 +0000

This article addresses a difficult ethical dilemma that transplant surgeons may potentially encounter: whether a patient with a psychiatric illness is a good candidate for a liver transplant. This case study illustrates the challenges involved when considering the ethical principles of patient self-determination, distributive justice of scarce medical resources, “social worth,” and protection of vulnerable patient populations. Are patients with psychiatric illness able to provide consent for transplantation? Is it possible to avoid misallocating valuable donor organs and, at the same time, fairly allocate these resources? This article seeks to answer these questions and provide insight into this ethical dilemma.

Case study

A surgeon member of an interdisciplinary transplant team is called to consult on a patient admitted to a large community hospital. The patient is a 45-year-old man with a history of schizophrenia, obesity, dyslipidemia, and type II diabetes mellitus. He has been diagnosed with nonalcoholic steatohepatitis (NASH). After several days in the hospital, his model for end-stage liver disease score has worsened to 22. The admitting service now wishes to consult the transplant team about the possibility of liver transplantation for this patient.

While reviewing the patient’s chart, the surgeon comes across the patient’s psychiatric history. Since his diagnosis with schizophrenia at the age of 18, the patient has had numerous exacerbations of his psychotic symptoms in addition to problems with executive functioning—the brain process that controls reasoning, planning, and decision making. Since his mid-20s, he has been unable to live independently and currently lives with his sister. His parents live out-of-state and have not spoken to the patient in many years. His last psychiatric hospitalization was five years ago, and he receives federal disability. The patient has been adherent to his psychiatric treatment plans, attends his psychiatry appointments, and has never used alcohol, tobacco, or drugs. He has never attempted suicide and is not currently suicidal or homicidal. His current treatment includes oral haloperidol. For 10 years he was treated with olanzapine, a common side effect of which is weight gain; notably, the patient became morbidly obese over this period of time. His weight gain likely contributed to his development of NASH.

The surgeon speaks with the patient about his condition and what would be required of him post-transplantation at a level the surgeon considers appropriate for the patient’s mental capacity. The surgeon concludes that the patient understands most of what has been said, but also recognizes that his understanding of the entire transplantation process is not comprehensive. In the end, the patient states that he wants the surgeon to save his life.

The team’s evaluation proceeds. Assuming that no medical or surgical contraindications for transplantation arise during the rest of the work-up, the following four options are available to the transplant surgeon:

  • Postpone making a decision about the transplant until the patient’s surrogate gives written informed consent
  • Recommend that the transplant team wait to place him on the transplant list
  • Conclude this patient is a poor transplant candidate and recommend that the team not place him on the transplant list
  • Conclude this patient is a good transplant candidate and recommend that the team place him on the transplant list

Discussion of options

Option 1: Wait until the patient’s surrogate gives informed consent

This option is based on an assessment that informed consent for a surgical procedure with significant risk may not be possible for someone with a major psychiatric illness. Informed consent is dependent upon the decisional capacity of the patient or the patient’s surrogate. Decisional capacity requires the ability to understand the basic facts involved in the medical decision, to appreciate the personal significance of the medical decision, to assess all available information, and to express a clear and consistent choice. In other words, the patient or the patient’s surrogate is consistent in choosing among available options.1,2

Some health care professionals may argue that the stringency of establishing a standard for capacity in a single patient should be determined by the level of risk attendant to the result of the decision.2,3 In this case, the risks inherent with the decision to accept an organ and the patient’s responsibility of caring for the organ after transplant are great. Incapacity might be suspected, but not concluded, due to the patient’s diagnosis of schizophrenia. Based upon the potential for poor outcome or the ineffective use of valuable and scarce medical resources, it could be argued that this patient’s mental illness should at least require a formal capacity assessment, which may preclude him from making the decision.

A term often confused with capacity is legal competency, which must be assessed by trained personnel within the legal system. Decision-making capacity in these situations is determined clinically rather than legally. Therefore, the treating physician must, based on his or her best clinical judgment, assess the patient’s ability to complete cognitive tasks and make a determination regarding the patient’s decisional capacity.3 Although a number of instruments are available to assist clinicians in assessing capacity, a formal guideline or best practice for assessment of decisional capacity has yet to be developed.2,3

If the patient is evaluated clinically and considered incapable of making a reasonable decision, a surrogate decision maker must be identified. If the patient has not formally established a durable power of attorney for health care-related matters, then the treating physician should turn to the patient’s family for a surrogate who either knows the patient sufficiently to represent the patient’s values and goals or who is otherwise capable of making decisions based on the patient’s best interests. In many states, decision-making responsibility among family members for patients without decisional capacity follows a hierarchy that prioritizes parents above siblings. However, in this case, it would be ethically compelling for the treating physician to turn to the patient’s sister with the expectation that she is available, knows the patient well, and is invested in the patient’s well-being.

This option is not available for potential organ recipients with psychiatric illnesses who lack decisional capacity and for whom a surrogate decision maker cannot be identified.

Option 2: Recommend waiting to place him on the transplant list

Following multidisciplinary evaluation of transplant candidates, sometimes the decision is made to wait in order to monitor one or more factors used in the final decision to list a patient for organ transplantation or to gather other information; these candidates are to be reconsidered for transplantation at a later time.

In this case, a final decision may be postponed for a number of reasons. The surgeons may decide to monitor the patient’s mental status further for a number of reasons, including the decision to obtain a written plan from his psychiatrist for management of the patient’s psychiatric symptoms post-transplantation, to further assess his support system, or to enroll him in social and/or financial support programs as needed. The American Medical Association (AMA) formally encourages transplant teams to intervene to overcome such obstacles to post-transplantation care whenever possible.4

Current United Network for Organ Sharing (UNOS) criteria dictate that listed candidates are given priority based on medical urgency and time spent on the waiting list.5 Thus, although it may be reasonable to await further evaluation of this patient before making a decision, it is still important to proceed expeditiously.

Option 3: Recommend leaving him off the transplant list

This option is based on the assessment that severe psychiatric illness may complicate the post-transplantation course to such a degree that commitment to “distributive justice” (that is, equitable rationing of scarce resources) requires that organs be allocated to patients without these co-morbidities.

Awareness that psychosocial factors affect the survivability of organs post-transplant has been integrated into government regulation of transplant decisions. The U.S. Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) requires that every transplant candidate receive a comprehensive psychosocial evaluation. To be reimbursed for transplant services, the facility must evaluate candidates “for issues that could affect the patient’s compliance with the post-transplant treatment that is necessary to maximize the chances of a successful transplant, such as substance abuse or behavioral or psychiatric issues.”6 Furthermore, federal law mandates transparency of outcome statistics, and CMS takes these data into account when determining re-approval of transplant centers.6 This mandate creates an incentive for transplant programs to recruit the lowest-risk transplant candidates available, although professional organizations and transplant programs also recognize the difficulties candidates with mental illness may face in these situations.

Current American Association for the Study of Liver Diseases practice guidelines for the evaluation of liver transplant candidates note that “psychosocial issues often are the greatest deterrent to successful liver transplantation.”7 A survey of American transplant programs (72 liver, 217 kidney, and 127 cardiac transplant programs) found that schizophrenia, past or present suicidality, intellectual disability (defined as IQ <70 by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), and substance abuse disorders all numbered among the contraindications to heart, liver, and kidney transplants.8 Among all programs surveyed, the rate of denying a transplant for psychosocial reasons alone was between 2.8 percent and 5.6 percent.8 Specifically, among surveyed liver transplant programs, the rate varied by site from 0 percent to 20 percent.8

Option 4: Recommend placing him on the transplant list

Some physicians strongly believe that they should serve as the patient’s advocate regardless of the potential for misallocation of scarce medical resources. The World Medical Association’s Statement on Human Organ Donation and Transplantation proposes that transplant physicians’ ethical obligation to seek the well-being of their patients should usually be primary.9 Physicians should be careful that this ethical obligation does not lead to unethical and illegal tactics to get a patient transplanted. In 2003, three Chicago, IL, medical centers were forced to settle lawsuits after an insider at one of the centers alleged irregularities, suggesting that physicians at the medical centers had intentionally misdiagnosed and hospitalized their patients to accelerate the process of receiving a transplant organ.10

Proponents of this option might also argue that this patient’s mental illness is not severe or unstable enough to classify him as a high-risk transplant candidate. A total of 31 of 48 (67.4 percent) liver transplant programs surveyed in one study excluded patients with active psychotic symptoms.8 As such, the number of schizophrenic patients having received a donor organ is small. Case series have shown both positive and negative outcomes regarding graft survival following transplantation.11,12 It is unclear whether the factors that made these candidates acceptable transplant candidates despite their psychotic illness might have improved their post-transplantation outcomes.

Some health care professionals may recommend listing this patient based upon the assertion that denying transplantation due to mental illness constitutes a social worthiness judgment—that is, based on aspects of a patient’s social status rather than medical criteria. The AMA’s Council on Ethical and Judicial Affairs has stressed that social worth should not be factored into the allocation of scarce medical resources.4

Ethical bottom line

Decisions regarding transplant organ allocation rely on a two-step process. The first step involves the procurement of donor organs and the decision as to which transplant candidate will receive these organs. The U.S. Congress passed the National Organ Transplant Act of 1984 to create a national organ procurement and allocation organization known as the Organ Procurement Transplantation Network (OPTN) to carry out these duties.5,13 UNOS has contracted with the federal government since 1986 to administer the OPTN.5 Regional organ procurement organizations (OPOs) coordinate organ procurement and contract to allocate these organs to participating regional transplant hospitals.5 Federal law mandates that both OPOs and transplant hospitals hold membership with the OPTN, which provides oversight of their transplant procedures and outcomes.6 Since 2000, the UNOS criteria that dictate organ allocation to listed candidates have been based primarily on medical urgency.14

The second step regarding transplant organ allocation involves listing decisions made by multidisciplinary teams at transplant hospitals, such as the team described in this case study. Each transplant hospital has a standard set of criteria that an interdisciplinary transplant team follows when making listing decisions for the transplant candidates that present to their hospital. The variability of these criteria between transplant programs is well known, especially with regard to psychosocial criteria.8

Discussion about listing transplant candidates with mental disorders reached a public forum in 1995 with the case of Sandra Jensen. When Ms. Jensen was denied transplantation at two centers because she had a cognitive disability, a third-party physician argued that the decision violated the Americans with Disabilities Act of 1990 (ADA). One team reversed its decision before legal action was filed, and Ms. Jensen received her transplant. The decision launched a national discussion about the appropriateness of transplantation for patients with mental disabilities.5 Some argue that even using non-diagnosis–based criteria, such as a history of medication noncompliance, might violate the ADA if the behavior occurs more frequently in people with mental illness.15 To date, UNOS has not provided ethical guidance to programs regarding the eligibility for transplant of people with mental illnesses or disabilities. In the absence of guidelines from national transplant organizations, the decision to provide a transplant organ to a patient with psychiatric illness therefore requires careful consideration of ethical principles in addition to a complete medical and psychosocial evaluation.


  1. Kodner IJ, Siegler M, Freeman DM, Choctaw WT. Chapter 52: Ethical and legal considerations. In: Wolff BG, Pemberton JH, Wexner SD, Fleshman, JW. The ASCRS Textbook of Colon and Rectal Surgery. 1st ed. New York, NY: Springer; 2006.
  2. Dunn LB. Nowrangi MA, Palmer BW, Jeste DV, Saks ER. Assessing decisional capacity for clinical research or treatment: A review of instruments. Am J Psychiatry. 2006;163(8):1323-1334.
  3. Appelbaum PS. Assessment of patients’ competence to consent to treatment. N Engl J Med. 2007;357(18):1834-1840.
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  6. U.S. Government Printing Office. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare program; Hospital conditions of participation: Requirements for approval and re-approval of transplant centers to perform organ transplants. Federal Register. 2007;72(61):15198-15280.
  7. Murray KF, Carithers RL Jr. AASLD practice guidelines: Evaluation of the patient for liver transplantation. Hepatology. 2005;41(6):1-26.
  8. Levenson JL, Olbrisch ME. Psychosocial evaluation of transplant candidates: A comparative survey of process, criteria, and outcomes in heart, liver, and kidney transplantation. Psychosomatics. 1993;34(4):314-323.
  9. World Medical Association. World Medical Association Statement on Human Organ Donation and Transplantation. October 2006. Available at: Accessed September 12, 2014.
  10. Schoenberg N. A man of principle. Chicago Tribune. January 25, 2004. Available at: Accessed September 12, 2014.
  11. DiMartini A, Twillman R. Organ transplantation and paranoid schizophrenia. Psychosomatics. 1994;35(2):159-161.
  12. Coffman KL, Crone C. Rational guidelines for transplantation in patients with psychotic disorders. Curr Opin Organ Transplant. 2002;7(4):385-388.
  13. U.S. Department of Health and Human Services. Organ Procurement and Transplantation Network. Ethical principles in the allocation of human organs. Available at: Accessed October 8, 2014.
  14. U.S. Department of Health and Human Services. Organ Procurement and Transplantation Network. Policies. Available at: Accessed October 8, 2014.
  15. Orentlicher D. Psychosocial assessment of organ transplant candidates and the Americans with Disabilities Act. Gen Hosp Psychiatry. 1996;18(11):5S-12S.
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