She was a second-year medical student on rotation in the emergency department (ED) at George Washington (GW) University Medical Center in Washington, DC, the day the trauma team ended up saving the life of the leader of the free world. The assassination attempt on President Ronald Reagan happened more than 30 years ago, but Lena M. Napolitano, MD, FACS, FCCP, FCCM, recalls the day’s events as if they transpired yesterday. In fact, the remarkable teamwork Dr. Napolitano witnessed in the ED that day, March 30, 1981, inspired the young medical student to select surgery as a career, and today continues to inspire her as an educator and leader in the area of trauma and critical care.
Experiences at GW
“I was doing my four years at GW, and at that point I had no plans of going into surgery as a career,” recalls Dr. Napolitano, a trauma surgeon, professor of surgery, and associate chair of surgery at the University of Michigan Health System, Ann Arbor. “But sometimes one incident can truly change your life. What was interesting to me as a medical student—although I was on the sidelines for this event—was witnessing the fact that a trauma team could save a life. The rapid care President Reagan received in those first few minutes clearly saved his life, and probably more so for Mr. Brady, who had a severe traumatic brain injury.” (James Brady, White House Press Secretary at the time, was hit in the head by a bullet.)
Joseph Giordano, MD, FACS, chief of vascular surgery at GW at that time, led the trauma team and supervised the care President Reagan received.1 Dr. Giordano—one of Dr. Napolitano’s early mentors—had been responsible for getting GW verified by the American College of Surgeons (ACS) Committee on Trauma as a Level I trauma center. Trauma patients’ risk of death is significantly lower when care is provided in Level I trauma centers compared with non-trauma centers, according to a national evaluation of trauma center care’s impact on mortality (2006), and research suggests continued efforts at regionalization of trauma care are key.2 “The prompt life-saving care delivered at GW, within minutes of his life-threatening injury, was life-saving for President Reagan, with the trauma team providing blood resuscitation for treatment of hemorrhagic shock, tube thoracotomy for hemothorax, and early surgical intervention with thoracotomy for ongoing hemothorax. Dr. Giordano spent four years setting up the Level I Trauma Center at GW and on that fateful day it saved the life of the President,” explained Dr. Napolitano.
Dr. Napolitano made the decision to stay at GW for her general surgery residency training, and she completed her surgery residency at GW, as well. All of the surgery chief residents (three men and Dr. Napolitano) in her year chose to pursue a career in trauma and critical care.
“It is interesting to take a look back,” noted Dr. Napolitano. “My career path could have been very different. When I saw the trauma team interaction on that day it really solidified my career path in trauma and critical care, which is what I do now. Everything happens for a reason. I became passionate about trauma and critical care because of what I saw that day.”
An important component of sustaining a teamwork environment in the OR is the development and recruitment of a diverse roster of health care professionals. “A glass ceiling remains for women at the higher level,” admitted Dr. Napolitano. “But at the lower level it really doesn’t exist anymore. For residents—it’s gone. We treat them alike, male or female, it makes no difference. So, that really is incredible, and kudos to the surgical leadership as a whole for moving this forward. When we look at taking a particular med student, we don’t think of gender. We think of letters of recommendation, and we think of accomplishments, which is a huge change from how it used to be. Remember, I was the one female in my class of surgical residents. Now many surgical residency programs are 50 percent women.”
According to a 2010 report published by the Association of American Medical Colleges (AAMC), of the 129,929 medical school faculty surveyed, 35 percent are women, and 65 percent are men.3 Nonetheless, “We aren’t seeing many women in the positions of associate professor, professor, and chair, and that is a problem,” she said. “To be fair, some of that has to do with what women desire—some desire a family and reduced workload. On the other hand, some leaders think women might not do as good a job as men can in these positions. Of all full professors in surgery, only 8 percent are women. Of the 158 total chairs in the Society of Surgical Chairs, only five are women.”4
Dr. Napolitano, an advocate of not only gender equality, but also overall diversity in surgical leadership, said disparities in medical school faculty should be addressed for the following reasons:
- Physician leaders develop health policies that influence regulation, financing, and delivery of health care.
- Those who serve as medical school faculty set research agendas, influence medical education, and serve as role models for the recruitment and retention of both minority and majority students.
- These physician leaders do more to address disparities than individually care for patients; they are in positions to address disparities by influencing health care training and health systems as a whole.
According to Dr. Napolitano, Chair of the ACS Board of Governors (B/G), only 7 percent of the Governors are women, and other minorities are also underrepresented on the B/G—which is why one of the Board’s goals in 2012 is to increase diversity in the nomination and selection process in an effort to better represent the ACS Fellows. In contrast, 20 percent of the ACS Board of Regents are women, fully representing the surgical workforce, based on the results of the most recent AAMC faculty report, which indicates that as of 2010, 19 percent of all surgical faculty are women.3
B/G 2012 goals
In addition to increasing diversity in the B/G nomination and selection process, B/G leadership—which includes Dr. Napolitano, Chair, along with Vice-Chair Gary L. Timmerman, MD, FACS, and Secretary William G. Cioffi, MD, FACS—have established specific goals for the board in 2012, and they include the following:
- Increased communication with B/G (electronic newsletter, webinars)
- Strategic planning—committees (examine current B/G committee structure and alignment and interaction with other ACS committees)
- Ten-year review of annual B/G survey (review survey process; new survey to be completed by July 30, 2012)
- National and international chapter activities (rejuvenate and reactivate chapters)
“We are eager to hear from individual ACS Fellows with regard to issues that they feel are important to the surgical community, and will strive to bring these issues forward to the ACS leadership. Please don’t hesitate to contact me,” said Dr. Napolitano.
Dr. Napolitano’s career trajectory was set in motion the day President Reagan and Mr. Brady were rushed into the ED some 30 years ago, but barring witnessing a life-changing moment such as saving the life of a sitting president, some medical students require a little guidance when contemplating their future.
“I suggest students and residents contemplate all of their options—and the role of a mentor is very important in that regard,” said Dr. Napolitano. “As a resident, you can’t possibly know everything that is going on in the surgical world or even in the world of medicine, and mentors can help steer you in the right direction. Residents can be on as many as 10 different surgical services and love them all, but what will probably sway them is a good role model. If they see surgeons who are happy and successful and enjoy coming to work every day—then they will want to be like them. Having a superb role model is very important, and that is particularly true for women.”
For each new generation of residents, work-life balance has become a greater concern, and a strong mentor can help students find a good match for their skills, while taking into consideration their life goals, according to Dr. Napolitano. “I was extremely fortunate to have excellent mentors throughout my training and career, many of them leaders in American surgery, including Dr. Giordano, Dr. Barbara Bass [MD, FACS], Dr. Anton Sidawy [MD, FACS], Dr. Anthony Meyer [MD, FACS], and many more.”
Resident duty hours
Resident duty hours—which were developed at least in part to contribute to growing demands for work-life balance—is a topic Dr. Napolitano has followed closely. Like many other surgical educators, Dr. Napolitano appreciates efforts to help residents enjoy work-life balance, but also has concerns about their effects on the surgical workforce and patient care.
“In addition to the potential for increased errors due to lack of continuity [of care] and increased hand-offs, other possible negative impacts [of duty-hour restrictions] include reduced clinical exposure and inadequate preparation for independent surgical practice,” said Dr. Napolitano. “We are concerned about their competency, but not just competency—their confidence level. Residents might not feel confident in their training, and as a result, they feel the need to go on to one-, two-, three-year fellowships for additional surgery training in an area of surgical specialty. Nearly 80 percent of graduating general surgery residents pursue additional training in a surgical subspecialty at present.”
Increasing surgical specialization of our trainees is resulting in a significant shortage of general surgeons. According to statistics from the federal Health Resources and Services Administration, by 2020 demand is set to outstrip supply in several specialties, with non-primary care specialties in general projected to experience a shortage of 62,400 physicians. General surgery is predicted to be among the hardest hit, with a shortage of 21,400 surgeons. The number of practicing general surgeons is expected to fall to 30,800 by 2020 from 39,100 in 2000.5 The American Surgical Association convened a focused meeting to address the general surgery workforce shortfall, and recommendations to address this shortage have recently been published, including enhancing the number of general surgery trainees and the breadth of training, and incorporating more flexibility and breadth in general surgery residency training.6
Furthermore, work-hour restrictions may negatively affect the quality of care that trauma patients receive. Citing a recent study of 107,000 neurosurgical trauma patients conducted by the University of Florida, Gainesville, Dr. Napolitano noted that the Accreditation Council for Graduate Medical Education (ACGME) resident duty-hour restrictions were associated with an increase in complications, and no change in mortality for the teaching hospitals. (In the non-teaching hospitals, there was no change in complications and mortality.)7
“My concern is that we don’t have a lot of data that shows reducing work hours will result in a positive impact, and that, at the fellow and attending level, there has not been the same reduction in work hours,” explained Dr. Napolitano. “I believe that the management of duty hours should parallel a change in the culture of medicine that addresses the effects and consequences of uninterrupted consecutive duty hours for the medical profession as a whole—including staff physicians and nonresident learners.”
Staffing of the ICU
The ACGME resident duty-hour standards can also impact the staffing needs of intensive care units (ICUs), as the restrictions may result in a restructuring of the workflow plan—particularly because residents provide the bulk of care in these units. “One of the most important issues facing us in trauma and critical care is the challenges in the future of its workforce,” explained Dr. Napolitano. “Significant shortages are projected for surgical intensivists and trauma surgeons. We train far fewer surgical intensivists annually than medical intensivists. Of more than 2,100 residents enrolled in critical care fellowships annually, only 160 (7.6 percent) in 2009 were surgical critical care fellows. We need to be certain that we have a strategic plan for succession planning in trauma and surgical critical care.”8
According to an article written by Dr. Napolitano and colleagues, and published recently in The Journal of Trauma, an analysis of the critical care workforce revealed an estimated 35 percent shortage of intensivists by 2020, as a result of the aging population and the growing demand for intensivists, particularly surgical intensivists.8 Surgical critical care in the U.S. is particularly challenged by a significant shortfall of surgical intensivists, according to Dr. Napolitano, with only 2,963 surgeons currently certified in surgical critical care by the American Board of Surgery, and even fewer surgeons (1,407) recertified in surgical critical care as of 2011.
“We encourage students to pursue a career in trauma/surgical critical care by having them rotate with us as third- and fourth-year medical students. In particular, having a fourth-year medical student rotate as a sub-intern on our trauma/burn service and in our surgical ICUs is exciting for them as they have the opportunity to care for the critically ill and injured—and this can sometimes solidify their career choice.”
Quality of care
Dr. Napolitano is a member of and holds leadership positions in numerous professional organizations in surgery, trauma, and surgical critical care. A common motivation for her involvement in these organizations is an emphasis on quality of care. Delivering consistent quality care for Dr. Napolitano means developing and fostering a strong teamwork environment—similar to the collaborative team effort she saw in action at GW that fateful day in 1981.
“Teamwork is everything. Of course, it doesn’t always happen perfectly, and so that is an issue we continue to have to move forward with,” said Dr. Napolitano. “Let me tell you a quick story: Yesterday, I had a first start case at 7:30 am. It was not a complicated case. I was in the room to do the time out, and I expected everyone to be there and be prepared. We do our time out, go through everything we do for the patient, and I asked the residents to go scrub in, while I prepped the patient. We did the operation, and it went fine. At end of case, we debriefed in an environment where everyone is invited to speak their minds as equals. Well, our scrub nurse said she felt pressured. And I said, ‘What do you mean?’ and she said ‘I felt that you were rushing me.’” And I said, ‘We were rushing you! We should be ready to start the case at 7:30, especially since there was another case afterward. There’s no reason to lollygag around here, and if you were not prepared and didn’t have your hands washed because you had that extra cup of coffee, well, there’s a problem.’ The team can always do better—myself included. Sometimes people get lax or sometimes people don’t work to the best of their abilities, but we need to strive to do so,” said Dr. Napolitano.
“As a general surgeon, I might have 10 different teams I work with, while a neurosurgeon will work with the same scrub nurse and the same OR team because of their specialty training and needs. I get all the trainees in the OR,” she said with a chuckle. “Team-building and interaction is very important in regard to improving care, and making sure we don’t forget something, whether we are in the OR, in the trauma bay, or in the ICU. And there must always be a team leader to optimize team performance and patient outcomes. Training residents to be effective team leaders is an important component of our mentoring in acute care surgery.”
One key approach to improving quality care—for all members of a surgical team—is the analysis of accurate outcomes data. Dr. Napolitano called the ACS National Surgical Quality Improvement Program (NSQIP®) “the benchmark for quality care in surgery” and finds the number of participating hospitals in the program—nearly 500 hospitals use ACS NSQIP tools and reports currently—to be an encouraging sign. However, she also noted the challenges related to both the number of competing programs currently available in the marketplace and the staffing required to collect high-quality data used to track outcomes.
“The validity of ACS NSQIP is quite clear,” added Dr. Napolitano. “A recent study compared ACS NSQIP to the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) method for assessing inpatient adverse events, and identified that AHRQ-PSI identified less than one-third of the ACS NSQIP clinically important adverse events. The measurement of surgical quality is dependent on the reliability of the method used, and this study clearly documented the superiority of the ACS NSQIP program.”9
“For the future, I think everyone is hopeful that with electronic medical records there will be an electronic transfer of data into ACS NSQIP, and less humans running around to collect data,” she said. “This will be a big help with our quality efforts in surgery.”
- Giordano J. How we saved Reagan’s Life. The Daily Beast. Available at: http://www.thedailybeast.com/newsweek/2011/03/13/how-we-saved-reagan-s-life.html. Accessed June 18, 2012.
- MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, Salkever DS, Scharfstein DO. A national evaluation of the effect of trauma center care on mortality. N Engl J Med. 2006; Jan 26;354(4):366-378.
- Association of American Medical Colleges. Women in U.S. academic medicine: Statistics and benchmarking report 2009–2010. Available at: https://members.aamc.org/eweb/upload/Women%20in%20U.S.%20Academic%20Medicine%20Statistics%20and%20Benchmarking%20Report%202009-2010.pdf. Accessed June 18, 2012.
- American College of Surgeons. Membership directory: The Society of Surgical Chairs 2011. Available at: SSC Directory. Accessed June 18, 2012.
- Association of American Medical Colleges. Physician shortage spreads across specialty lines. Available at: https://www.aamc.org/newsroom/reporter/oct10/152090/physician_shortage_spreads_across_specialty_lines.html. Accessed June 18, 2012.
- Polk HC Jr, Bland KI, Ellison EC, Grosfeld J, Trunkey DD, Stain SC, Townsend CM. A proposal for enhancing the general surgical workforce and access to surgical care. Ann Surg. 2012;255(4):611-617.
- Hoh BL, Neal DW, Kleinhenz DT, Hoh DJ, Mocco J, Barker FG II. Higher complications and no improvement in mortality in the ACGME resident duty-hour restriction era: An analysis of more than 107,000 neurosurgical trauma patients in the Nationwide Inpatient Sample Database. Neurosurgery. 2012;70(6):1369-1382.
- Napolitano LM, Fulda GJ, Davis KA, Ashley DW, Friese R, Van Way CW III, Meredith JW, Fabian TC, Jurkovich GJ, Peitzman AB. Challenging issues in surgical critical care, trauma, and acute care surgery: A report from the Critical Care Committee of the American Association for the Surgery of Trauma. J Trauma. 2010;69(6):1619-1633.
- Cima RR, Lackore KA, Nehring SA, Cassivi SD, Donohue JH, Deschamps C, Vansuch M, Naessens JM. How best to measure surgical quality? Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution. Surgery. 2011;150(5):943-949. [Epub 2011 Aug 27].