Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) has conducted an annual survey of its members for more than 20 years. The purpose of the survey is to provide a means of communicating between the Governors and the ACS Board of Regents, Officers, and Executive Staff. This year, the B/G also conducted a survey of the International Governors, in addition to the traditional survey of domestic Governors.
The following article focuses on the survey of International Governors and is the first in a series of four articles highlighting key issues addressed in both the domestic and international surveys. Future articles in this series will center on issues of concern to domestic surgeons, including acute care surgery, firearm injury prevention, and payment reform under the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA).
As ACS Executive Director David B. Hoyt, MD, FACS, reported in his February “Looking forward” column, the College is making a heightened effort to respond to the needs of International Fellows and the global surgery community. International Fellows and their local chapters are important to the continued growth of the organization and to the College’s mission of ensuring that all surgical patients have access to quality surgical care.
Unquestionably, issues and concerns vary from region to region and country to country. In an effort to learn more about these issues and concerns, the ACS B/G conducted the first survey of International Governors in 2016.
The survey consisted of a series of demographic questions, followed by a series of in-depth questions on the following topics: surgical education conferences, chapter issues, ACS benefits to International Fellows, national surgical societies, and financial barriers to participation in ACS activities. Some of the highlights of the survey are described in this article. The complete results of the survey can be viewed online.
Demographics
The response rate to the International Governors survey was 82 percent, with 36 of 44 ACS Governors from 33 different countries participating in the survey. Most of the International Governors (72 percent) are 56 to 70 years old; more specifically, 41 percent are 61 to 65 years old (see Figure 1).
Figure 1. Age of International Governors
Most International Governors practice in large cities, with 74 percent of the respondents indicating that they practice in cities with populations of more than 1 million people (see Figure 2).
Figure 2. Population of the city where you practice
When asked to describe their practice setting, 52 percent of the respondents said they are at university-based practices, and 29 percent said they are in private practice (see Figure 3).
Figure 3. Surgical practice setting
Surgical education conferences
The survey included a series of questions aimed at learning more about the educational needs of International Governors. When asked to rank their preferred type of surgical education conference, the most popular response was the ACS Clinical Congress (80 percent). The second most popular response (77 percent) was a large international conference in another country (see Figure 4).
Figure 4. Preferred educational conference
The study results suggest that the ACS Clinical Congress is the preferred surgical education conference among International Governors. However, the International Governors who responded to the survey also indicated that they would like to see more international participants in Clinical Congress programs. In fact, all of the respondents said they would like to see more international speakers featured at the annual meeting. They particularly expressed interest in more international participation in Clinical Congress Panel Sessions (80 percent) and Named Lectures (46 percent). (See Figure 5.)
Figure 5. Which Clinical Congress programs would benefit from increased participation of International Fellows?
International ACS chapters
The ACS recognizes the importance of having strong and active international chapters that can respond to Fellows’ local needs. With that perspective in mind, International Governors were asked a series of questions regarding chapter issues. The survey, which asked participants to rank their preferences on a scale of 1 (most important) to 6 (least important), revealed that International Governors ranked “educational activities” as the greatest benefit of chapter membership (with an average score of 1.85), followed by “improving the surgical training of residents/medical students” (2.55). (See Table 1.)
Table 1. Ranking of benefits to ACS international chapters*
| Benefit | Average score |
| Educational activities |
1.85 |
| Improving the surgical training of residents/medical students |
2.55 |
| Advancement of surgical care for patients in our nation |
3.42 |
| Camaraderie with surgical peers |
3.47 |
| Social activities |
4.21 |
| Advocacy issues |
5.04 |
*Scoring is recorded as: 1 = most important and 6 = least important
To determine how the ACS can help international chapters become more robust, International Governors were asked to rank barriers impeding chapter growth. The most common response was “chapter members are not active in chapter activities” followed by concerns that there are “too many competing interests with the national surgical society or societies” (see Table 2).
Table 2. Barriers impeding international chapter growth*
| Category | Average score |
| Our chapter members are not active in chapter activities |
2.92 |
| Too many competing interests with the national surgical society (or societies) |
3.24 |
| Too many competing interests with specialty surgical societies |
3.41 |
| Surgeons are not willing to participate in leadership positions |
4.30 |
| There are not enough chapter members |
4.35 |
| Surgeons will not join our chapter because of financial barriers |
4.50 |
| It is difficult to find good administrative staff |
5.55 |
*Scoring is recorded as: 1 = largest barrier and 7 = smallest barrier
ACS benefits for International Governors
International Governors were asked to rank the ACS benefits of most importance to International Fellows. The highest ranking benefits were all education-based, with the Clinical Congress as the top-rated benefit, followed by the Journal of the American College of Surgeons, the Bulletin of the American College of Surgeons, and participation in Advanced Trauma Life Support® courses. The ACS Communities were rated as a midline benefit, suggesting an opportunity for increased use of the ACS Communities among International Governors (see Table 3).
Table 3. Ranking of ACS Benefits to International Governors
| ACS benefit | Number of times selected |
| Clinical Congress |
32 |
| Journal of the American College of Surgeons |
28 |
| Bulletin of the American College of Surgeons |
25 |
| Advanced Trauma Life Support courses |
24 |
| International Guest Scholarships |
17 |
| FACS designation |
16 |
| Opportunities for networking |
15 |
| Local ACS chapter membership |
12 |
| ACS NewsScope |
11 |
| ACS Surgery News |
11 |
| Selected Readings in General Surgery |
10 |
| ACS National Surgical Quality Improvement Program |
10 |
| ACS Communities |
9 |
| Surgical Education Self-Assessment Program |
8 |
| Surgical Risk Calculator |
8 |
| Commission on Cancer accreditation program |
5 |
| Community surgeons travel awards |
3 |
| National Accreditation Program for Breast Centers |
3 |
| Surgeon Specific Registry |
1 |
Interactions between national surgical societies and the ACS
All of the International Governors who participated in the study indicated that their country has at least one national surgical society. When asked if their national surgical society and the ACS engaged in any organized interactions, 71 percent responded “yes,” and 29 percent responded “no.” When asked if enhanced interaction between their national surgical society and the College would be beneficial, 85 percent said it would be helpful, and 15 percent said it would not. Suggestions for additional interactions included “ACS Clinical Congress/educational help,” and “Educational collaboration” (see Figure 6).
Figure 6. Would you like to see enhanced organized interaction between your national surgical society and the ACS?
Financial barriers
ACS Fellowship requires a certain financial commitment. The International Governors were asked how much of a financial barrier it is for a surgeon to join their local ACS chapter, join the College, or attend the ACS Clinical Congress. As Figure 7 indicates, chapter membership does not pose a large financial barrier, according to survey respondents. The financial burden is greater for joining the ACS, with the highest cost related to International Fellows attending the ACS Clinical Congress.
Figure 7. Financial barriers for international surgeons
Conclusion
International Fellows and their local ACS Chapters are important to the success of the College overall. This survey provided the B/G with a better understanding of the specific issues and concerns facing international Fellows. The B/G is considering conducting future surveys of the International Governors to learn more about the challenges these members encounter, as well as to give international Fellows an opportunity to make their opinions known to ACS leadership.
