Surgery comes of age: The ACS and the evolution of the surgical profession

Until the late 19th century, concepts that modern surgeons may take for granted, such as standards of care, quality, education, and residency training, were largely foreign ideas to members of the profession. This article reviews how trailblazing surgeons and leaders of the American College of Surgeons (ACS) have led the evolution of surgery from an unregulated business to a highly respected profession of well-trained physicians dedicated to improving the care of the surgical patient. This article also describes the increasingly prominent role of women and young surgeons in developing and safeguarding standards of care.

Standards for education and practice

Most surgeons operating in the 19th century were self-taught and unsupervised.¹ Until the founding of the Johns Hopkins School of Medicine, Baltimore, MD, in 1893, U.S. medical schools were disjointed and functioned without a defined curriculum, allowing medical students to graduate without examining a single patient.^2,3 In 1910, the Flexner Report on medical education was published, demonstrating the need for a standardized medical school curriculum and education.³

The lack of standards in medical education also was apparent within surgical practice itself. Anyone could perform a surgical procedure, regardless of training and background. The appendectomy, for example, was one of the first operations developed in the U.S. in 1867, a procedure that resulted from a newly discovered understanding of the disease process for appendicitis.⁴ Hundreds of new procedures were created in the final years of the 19th century; unfortunately, morbidity and mortality rates for surgery as a whole were horrific. In 1880, surgical wound infection rates were at 90 percent, and abdominal surgery mortality rates were at 75 percent.⁵

In response to these growing concerns, in 1905 Franklin H. Martin, MD, FACS, established Surgery, Gynecology & Obstetrics (now the Journal of the American College of Surgeons) in an effort to share scientific knowledge and promote innovations to improve surgical practices. In 1913, Dr. Martin led the founding of the ACS. Dr. Martin formulated what would become the requirements for the foundation of the College while traveling on a train: “A standard of professional, ethical, and moral requirements for every authorized graduate in medicine who practices general surgery or one of its specialties….”⁶ These same professional, ethical, and moral standards conceived by Dr. Martin continued to be requirements throughout the 20th century and exist to this day.⁶

Other surgical organizations

The birth of the ACS changed surgical practice by creating a professional organization that provided leadership and instruction for all providers of surgical patient care, from medical students to established surgeons. At present, membership in the College is open to medical students, residents, and surgeons in all stages of their careers, with each phase of training serving as a stepping stone toward becoming a Fellow of the ACS.

While the ACS has grown to be the largest surgical organization in the world, it was not the first national surgical organization in the U.S. The American Surgical Association (ASA) was founded by Samuel Gross, MD, in 1880, making it the nation’s oldest surgical association.^7,8 Dr. Gross invited distinguished surgical practitioners, writers, and teachers to attend a meeting at the College of Physicians and Surgeons of New York City on May 31, 1880.^8,9 This organization would first be known as the American Surgical Society, but under Dr. Gross’ leadership the name was changed to the ASA in 1885 when a group of approximately 50 surgeons assembled in New York to adopt a constitution.^8,9 At the time, ASA fellowship requirements included being at least 30 years old, a graduate of a “respectable” medical school, and having a reputation as a practitioner, author, teacher, or original observer in surgery.⁸

More recently, the Association for Academic Surgery (AAS) was established during a 1967 meeting in Lexington, KY.¹⁰ George D. Zuidema, MD, FACS, was both a founding member and the first president of the AAS.¹⁰ Membership was initially open to any surgeon with an academic affiliation, and membership grew exponentially from 377 members at its founding to 1,400 members in 1976, and then to more than 2,700 members in the early 1990s—an 800 percent increase in less than 30 years.¹⁰ The stature of the AAS also has increased from 37 papers presented in 1976 to more than 140 in 1991, and to nearly 200 by 2001.¹⁰

Continued commitment to QI

With the growth of multiple organizations over time, surgical quality and excellence have remained priorities for the ACS. Surgical quality improvement (QI) efforts began as early as 1913 when the Boston, MA, surgeon Ernest Amory Codman, MD, FACS, pioneered the “end result idea” in medicine, which called for patients’ outcomes to be systematically recorded to determine the success of treatment practices and to prevent future mistakes.^11-13

QI is still a high priority for both leaders and members of the College. The centerpiece of the College’s QI initiatives is the ACS National Surgical Quality Improvement Program (ACS NSQIP^®). ACS NSQIP originated in the U.S. Department of Veterans Affairs (VA), and VA NSQIP was developed as a result of the scrutiny of VA hospitals in the mid-1980s in response to poor surgical care discovered through the National VA Surgical Risk Study.^2,12,14 Subsequent to VA NSQIP’s implemention in 1991, 30-day postoperative mortality and morbidity dropped 43 and 47 percent, respectively.¹⁵

In 1999, private sector hospitals started to adopt and implement NSQIP, and in 2004, the ACS launched ACS NSQIP at 14 hospitals.¹² Today, under ACS NSQIP Director Clifford Y. Ko, MD, MS, MSHS, FACS, approximately 770 hospitals use the program to improve surgical care quality.¹² One of the unique qualities of the ACS NSQIP is that the data collected are risk-adjusted and drawn from medical charts, and not from billing files, which are generally inadequate in measuring quality of care.¹⁴ Not only does ACS NSQIP provide guidelines for improvement, it also gives hospitals the necessary tools for improvement initiatives by providing the means and support to start new study projects.¹⁴ Dr. Ko stresses the importance of collecting quality data in order to make improvements with the understanding that each hospital has unique needs.¹⁴

With health care costs in the U.S. climbing to an alarming $2.9 trillion in 2013, health care policymakers have sought to lower spending through higher quality and more efficient patient care. A cornerstone of this effort has been the pay-for-performance (P4P) model.¹⁶ The idea behind P4P—a concept introduced in California in 2001 after the Institute of Medicine (now the National Academy of Medicine) report To Err Is Human documented serious health care deficiencies—is to reward health care providers who meet or exceed quality measures with incentive payments, while penalizing health care providers who do not meet the standards.^12,17 The Affordable Care Act includes various incentive programs, including the Quality Reporting and Hospital Value-Based Purchasing programs, where hospitals can earn incentive payments for improved performance on 12 measures, including the Centers for Medicare & Medicaid Services’ Surgical Care Improvement Program and the results of the Consumer Assessment of Healthcare Providers Survey.¹³

Increasing role of women in surgery

Surgical organizations have continued to evolve to meet the needs and challenges of surgical practice. However, it is difficult to appreciate the present stature of newer surgical organizations without understanding their humble beginnings. Notably, some of the organizations with the greatest growth and development in the last half of the 20th century have offered an expanded role for women and minorities.

The modern era of women in surgery began with the “beardless lad.” James Barry, MD—who was eventually discovered to be a woman named Miranda Stewart posing as a man—performed one of the first successful caesarean sections in 1820.¹⁸ In 1847, Elizabeth Blackwell, MD, who wished to “treat the tumors of women” and to “provide a gentler hand,” was accepted as a medical student by Hobart College (then Geneva Medical College) in Upstate New York, and graduated with honors. In 1849, she became the first woman to achieve a medical degree in the U.S.¹⁹

Thanks to strong mentors and trailblazing role models, the number of women who are general surgeons has consistently increased over the last 30 years—from 3.6 percent in 1980 to 13.6 percent in 2007. In 1980, 10 percent of general surgery residents were women; by 2010, that number had grown to 40 percent. At present, 15 women are chairs of departments of surgery in the U.S. and Canada.²⁰ Four women have served as Chairs of the ACS Board of Governors, three women have received the ACS Distinguished Service Award, two women have been ACS Presidents, and one woman has served as Chair of the ACS Board of Regents.

Patricia J. Numann, MD, FACS, the 92nd President of the ACS, was rejected by residency programs after earning her medical degree from the State University of New York (SUNY) Upstate Medical University, Syracuse. With determination and skill, she completed her training at SUNY and has spent her formidable clinical and academic career at this facility.

Dr. Numann also is the founder of the Association of Women Surgeons (AWS), established in 1982. “It was kind of a gamble,” said Dr. Numann, “but I always had faith in myself.” [Personal communication between Dr. Jadeja and Dr. Numann, April 10, 2016]. To help the AWS become recognized by the College, Dr. Numann turned to John P. “Jack” Lynch, then-Director of what was known as the ACS Organization Department, who, according to Dr. Numann, gave her somewhat frustrating advice. “Don’t let any women who aren’t Fellows join,” Dr. Numann recalled Mr. Lynch stating. “When you’re up to 50 percent, I will submit [your group for recognition]. Our organization had such young members that none of them [were old enough to become] Fellows yet!”

As Dr. Numann’s prominence in the ACS grew, she advanced to First Vice-President in 2010, and then to President in 2011. Reflecting on the success of the AWS and the move toward equality for women in surgery, Dr. Numann said, “We always respected the men. If it hadn’t been for enlightened men, women would never have gotten anywhere.”

Another trailblazer in expanding the role of women in surgery is Heather Logghe, MD, a resident who uses social media to bridge disparities in the profession. In 2015, Dr. Logghe—inspired by the Twitter hashtag #ILookLikeAnEngineer—started the #ILookLikeASurgeon campaign. Since then, more than 13,000 tweets have included this hashtag, earning nearly 34 million impressions in 20 languages from more than 75 countries. Commenting on the results of this viral hashtag, Dr. Numann said, “I think it’s wonderful. It’s important for people to understand it’s not what you look like, it’s who you are. It doesn’t matter if you are a woman or a man. It’s your behavior that defines you professionally.”

Looking to the future with the RAS-ACS

Another means of increasing the diversity of the ACS has been a heightened focus on resident involvement in the organization. One of the most prominent supporters of resident involvement was Olga Jonasson, MD, FACS.²¹ After serving as the first woman in the U.S. to chair an academic department of surgery at Ohio State University, Columbus, Dr. Jonasson moved back to her childhood home of Chicago, IL, in 1993 to lead what was then known as the ACS Education and Surgical Services Department.²² Dr. Jonasson recognized the need for an organization that could provide information about the College to residents and young surgeons, encourage resident involvement and leadership development, and provide a voice for residents and young surgeons in the ACS’ leadership. She created such an organization in 2000 by helping to form the Candidate and Associate Society of the ACS (CAS-ACS).²³

Initially the CAS-ACS served mainly as a gateway to ACS membership and had very little representation in the organization or at meetings. In 2002, with Dr. Jonasson’s support, the CAS-ACS organized its symposium. James Cipolla, MD, FACS, now section chief of emergency surgery at St. Luke’s University Health Network in Bethlehem, PA, was the first resident member of the ACS Advisory Council for General Surgery, and he recounts the first CAS-ACS symposium at the Clinical Congress: “A call went out to all surgical programs to nominate a resident to attend this first-ever symposium. Our goals were to establish a governance structure. We elected an Executive Council, established resident representation on various ACS committees, and established annual programs (the first topic we discussed, I recall, was the concept of duty hours—the 80-hour-limit rule was not yet in effect).

“We decided to meet biannually at the ACS Spring Meeting and the ACS Clinical Congress. Eventually the Spring Meeting became resident-centric due to our efforts, and many recurring events, such as Resident Jeopardy and Spectacular Case Presentations, were introduced—and some still exist today.” [Personal communication between Dr. Terzian and Dr. Cipolla, April 12, 2016.] The CAS-ACS continued to evolve, and in 2004 the organization was renamed the Resident and Associate Society of the ACS (RAS-ACS).²³

Membership in the RAS-ACS happens automatically whenever a physician becomes a Resident Member or Associate Fellow of the ACS. Resident membership is available to surgical trainees who are enrolled in an Accreditation Council for Graduate Medical Education-accredited training program focused on one of the 14 surgical specialties recognized by the ACS—cardiothoracic surgery, colon and rectal surgery, general surgery, gynecology and obstetrics, gynecologic oncology, neurological surgery, ophthalmic surgery, oral and maxillofacial surgery, orthopaedic surgery, otorhinolaryngology, pediatric surgery, plastic and maxillofacial surgery, urology, and vascular surgery—or who have finished an initial residency and are involved in either surgical research or a surgical fellowship program. Associate Fellows are surgeons who have experienced fewer than six years of unsupervised surgical practice or are graduates of surgical residency programs and have entered into another surgical residency, research, or fellowship program.

Many benefits and opportunities are associated with being a part of the RAS-ACS. The RAS-ACS provides leadership opportunities through committees (Advocacy and Issues, Membership, Education, and Communications), and offers chances to participate in ACS committees, chapters, and Advisory Councils. It also provides scholarships to attend the annual Leadership & Advocacy Summit. Members can participate in RAS-ACS essay contests, which can lead to publication in the ACS Bulletin.

RAS-ACS members also are eligible for free admission to the ACS Clinical Congress, a free subscription to the Journal of the American College of Surgeons, discounted rates for enrollment in the ACS Surgical Education and Self-Assessment Program, and access to the Fundamentals of Surgery Curriculum. The RAS-ACS also provides its members with career planning resources, networking opportunities (including international networking), advocacy, career cultivation, and connections to fellowship/scholarship opportunities through the ACS Division of Research and Optimal Patient Care’s Clinical Scholars in Residence program.²³

A lasting and continuing legacy

Several key founding and guiding principles remain prominent themes within the ACS. One of the more important challenges for surgeons is to find innovative ways to remain dynamic and to continually improve. To obtain FACS status, a surgeon is required to receive education and technical training and to meet professional qualifications, surgical competency, and ethical conduct requirements in order to meet the highest standards established by the College. This lasting legacy, now often taken for granted, is due to the efforts of the many dedicated members and leaders of the ACS who have continued to raise the standards of surgery in the past century.

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References

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