Surgeons strive to provide high-quality, high-value health care to patients both in and out of the operating room (OR). Surgical training enables residents and fellows to recognize the nuances of surgical disease, optimize modifiable patient factors, navigate the human body through operative principles, and manage surgical complications. But, at the same time, surgical training does not necessarily prepare trainees to recognize and address the broader range of factors that affect patient well-being, including access to care, education, social support, and socioeconomic status—all of which play a significant role in patient outcomes.1 With this in mind, it becomes clear that civic engagement and political advocacy at the local, regional, and national level have the potential to profoundly affect patient care.
Earnest and colleagues define advocacy as “action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.”2 Alhough individuals may engage in advocacy at the local, state, and federal levels, it is the collective voice of surgical societies that enables more effective implementation of common goals. For more than 20 years, surgical societies such as the American College of Surgeons (ACS) have made advocacy a component of their core mission, playing an active role in civil society on multiple levels. These various levels of involvement may range from grassroots efforts at the local level to address specific community needs, to political activism at the national level where engagement with legislators can influence policy. Led by the Division of Advocacy and Health Policy (DAHP), the ACS has been influential in establishing injury-prevention laws, protecting the bargaining power of private practice surgeons, and finding solutions to the ongoing opioid and firearm-related injury epidemics, to name just a few examples of the ACS’ policy-related accomplishments.3-5
In light of the coronavirus 2019 (COVID-19) pandemic that has exposed vital threats faced by our patients on a daily basis, it becomes evident that the responsibility of surgeons and surgical trainees no longer stops at the doors of the OR, at the end of clinic, or with the acceptance of a manuscript. Surgeons have a civic and professional obligation to come together and harness their expertise to advocate for policies that ensure the well-being of their patients. In the words of Donald Berwick, MD, MPP, “To try to avoid the political fray through silence is impossible, because silence is now political. Either engage or assist the harm. There is no third choice.”6
This article reviews the impact that surgical societies have on health policy and offers examples of how surgical societies have influenced policy. It also offers actions that surgeons and trainees can take to become more engaged in influencing policy decisions in their local communities and at the national level.
A legacy of advocacy
The history of surgical advocacy dates back to ancient Greece.7 The Hippocratic Oath is the symbolic cornerstone of physicians’ responsibilities and underscores the role of physicians as patient advocates.8 Over the centuries, controversies regarding the concept, scope, and practice of physician engagement in politics have been debated.2 The first medical organizations in the U.S. with an established advocacy-related component were the Massachusetts Medical Society and the American Medical Association, both of which affirmed that the ability of physicians to influence society extends beyond the bedside.7 In the early 20th century, surgical subspecialties began to emerge. Physicians who identified specific needs within their subspecialties accelerated collaboration toward achieving specific advocacy goals.
In 1913, the ACS was founded as a natural extension of the Clinical Congress that took place annually with the intent of fostering continuing education. In 1933, the American Academy of Orthopaedic Surgery was formed to facilitate nationwide representation and promote the open exchange of information and ideas.7,9 Similarly, the American Society of Plastic Surgeons (ASPS) was founded in 1931 to provide education, advocacy, and practice support for aesthetic and reconstructive surgeons.10 Surgical societies began to develop political action committees (PACs) in order to influence policy and to advocate for candidates who would champion issues of interest. The ACS Professional Association’s Political Action Committee (ACSPA-SurgeonsPAC) was founded in 2002, and the PlastyPAC was founded in 1990 by the ASPS.
These PACs have contributed substantially to garnering legislative support for physicians and their patients. At the federal level, the ACS has been instrumental in advocating for legislation such as the Saving Lives, Saving Costs Act, which established liability protection and helped to discourage frivolous litigation.11 In a similar vein, the ACS advocated for the Good Samaritan Health Professionals Act and the Health Care Safety Net Enhancement Act, which protect trauma providers from liability in emergency situations.12 These policies are of particular importance in situations where surgeons must treat emergent conditions with only limited information and resources, which places them at particularly high risk for liability.
At the state level, ACS leaders were instrumental in establishing the Uniform Emergency Volunteer Health Practitioners Act to facilitate licensing reciprocity for disaster personnel who would like to provide care to patients outside of their home state in times of crisis. This legislation has been passed in 15 states, and is an example of a recent and ongoing effort where continued surgeon support is vital.8
In plastic surgery, the PlastyPAC was influential in advocating for the Women’s Health and Cancer Rights Act of 1998 and the Breast Cancer Patient Education Act of 2015, which ensured insurance coverage and appropriate education for breast cancer patients who desire breast reconstruction following mastectomy. Because many patients, particularly those in medically underserved areas, may be unaware of the options and coverage available to them with respect to breast reconstruction, these initiatives were a vital first step toward connecting patients with appropriate resources and addressing health care disparities.13
With regard to orthopaedic surgery, the Sports Medicine Licensure Clarity Act was passed with the support of the Orthopaedic PAC in order to allow orthopaedic surgeons to more effectively treat patients across state lines.8 Regionally, the Massachusetts Orthopaedic Association advocated for state legislation to allow the expansion of ambulatory surgery centers in order to offer more convenient access to high-quality comprehensive care. Additionally, the Pennsylvania Orthopaedic Society advocated for legislation that limits insurance companies from retroactively denying claims after 14 months.
Present policy initiatives
Surgical societies are uniquely positioned to enact social change and public health measures through member-led initiatives and policy. In addition, surgical societies can engage in direct advocacy with legislators, not only under the direction of their members, but also as representatives of the patients they serve. There are numerous contemporary examples of surgical societies elevating public awareness of patients’ needs through advocacy, policy, and education initiatives.
Surgical societies are uniquely positioned to enact social change and public health measures through member-led initiatives and policy. In addition, surgical societies can engage in direct advocacy with legislators, not only under the direction of their members, but also as representatives of the patients they serve.
The ACS Commission on Cancer (CoC) is one group that is working to counteract the negative effects of the COVID-19 pandemic on public health. The CoC is a consortium of professional organizations aimed at improving quality of life and survival for patients with cancer.14 Multiple surgical societies work together on behalf of cancer patients through the CoC, with representatives from the Society of Surgical Oncology, Society of Urologic Oncology, American Head and Neck Society, American Association of Endocrine Surgeons, Society of Gynecologic Oncology, and American Society of Colon and Rectal Surgeons, among others. At present, these societies are working through the CoC to encourage patients to return to regular cancer screening after millions of Americans have postponed care because of the pandemic. The CoC estimates that one-third of American adults have missed recommended screening tests during the pandemic, and 43 percent have missed routine preventative appointments because of COVID-related concerns.15 Furthermore, the CoC estimates that for common cancers like colon, cervical, and breast, screening decreased by more than 80 percent in the spring and summer of 2020. This decline in testing is estimated to contribute to more than 10,000 excess deaths from colon and breast cancer alone over the next decade. These estimates do not account for other common types of cancer for which patients were not screened.
To counteract the troubling effects of screening delays, members of the CoC have partnered with the National Comprehensive Cancer Network and the American Cancer Society to launch an awareness initiative encouraging the public to resume screening as soon as possible. This initiative emphasizes that cancer screening and prevention save lives, and, through targeted marketing and public awareness, the CoC is working to reverse the deleterious effects of COVID-19 care delays.
Another example of patient-directed advocacy is the recent American Urological Association (AUA) white paper and advocacy campaign surrounding the adoption and continued use of telehealth.16 A survey of U.S. urologists revealed that 71.5 percent of urologists adopted some form of telehealth to maintain or improve patient access during the COVID-19 pandemic. Perhaps surprising to both patients and physicians, both parties reported high levels of satisfaction with telehealth visits. Furthermore, telehealth visits have been found to be well-adapted for common problems like benign prostatic hypertrophy and erectile dysfunction, as well as routine posttreatment surveillance for diseases like prostate and localized kidney cancer.
In addition, telehealth allows access to subspecialty care, eliminating barriers such as travel distance or indirect costs to patients because of missed time from work. However, continued challenges remain in the use of telehealth, including issues regarding delivery of care across state lines, continued payor support by commercial insurance companies and the Centers for Medicare & Medicaid Services (CMS), and patient access and familiarity with the necessary technology. Nevertheless, the AUA is engaged in widespread advocacy to decrease future barriers to telehealth use, and these efforts may serve as a model for other surgical subspecialties that might benefit from the adoption of telehealth.
For more than 20 years, the ACS has continuously served as one of the most influential shapers of health care policy in the U.S. At present, one of the most important policy initiatives that the ACS is supporting is legislation surrounding expansion of graduate medical education (GME).17 As the result of present and projected shortfalls in the physician workforce in the U.S., particularly among surgeons, the ACS has long been a proponent of expanding GME in order to better match the number of training slots in the U.S. with the growing workforce needs. At present, legislation has been introduced to expand GME by 10,000 positions, with 2,000 new positions receiving funding each year from 2023 to 2029. The ACS DAHP has full-time lobbyists and policy advisors who are working with legislators regularly to ensure that this legislation addresses workforce allocation, diversity, and geographical needs, with a focus on rural and underserved areas. The College also helped draft a letter of support for this legislation in collaboration with many other health care organizations. Clearly, this is an evolving area of critical policy, and the ACS DAHP will continue to monitor developments and offer counsel to policymakers as this legislation moves through Congress.
An example of a surgical society in action within the realm of education is the nationwide initiative by the ACS Committee on Trauma aimed at teaching civilians how to approach bleeding in the field as first responders through the STOP THE BLEED® campaign.18 Given that trauma, particularly as the result of firearm-related violence, is a substantial and prevalent public health issue in the U.S., the ACS has implemented a practical, scalable, and widely available training program aimed at the lay public for hemorrhage control. STOP THE BLEED® is a 30- to 60-minute instructor-led course that teaches the basics of hemorrhage control in almost any situation. The ACS’ goal is that hemorrhage-control techniques conferred through the STOP THE BLEED® campaign be as widespread as cardiopulmonary resuscitation. To date, the STOP THE BLEED® initiative has now trained more than 1 million individuals on hemorrhage control, trained 70,000 instructors, and held 76,000 courses worldwide in a variety of community and professional settings.
The opportunities for engagement in advocacy and health policy available to surgeons and surgical trainees are virtually endless and range from institution-specific to national and even international initiatives. Grassroots advocacy is an accessible and often effective way to become personally involved and make an impact. This activity can include using individual expertise within the context of advocacy goals through letter-writing campaigns and testifying before governing bodies at the local, state, or federal levels.
The opportunities for engagement in advocacy and health policy available to surgeons and surgical trainees are virtually endless and range from institution-specific to national and even international initiatives.
Federal advocacy might receive the most attention; however, connecting with local networks such as one’s ACS regional chapter can yield policy changes that are often more immediate and tangible. Surgeons also can be a local sponsor for national campaigns such as the STOP THE BLEED® movement referenced earlier. For more information, visit stopthebleed.org to find an instructor or class near you. Better yet, arrange programming at your local, regional, or national surgical meeting to train your members in hemorrhage control.
With respect to involvement in national programs, residents can join the ACS Resident and Associate Society Advocacy & Issues Committee, which addresses issues in resident training, medical care, and health care policy. Residents and attending surgeons can support the SurgeonsPAC and stay up to date on ACS advocacy initiatives by subscribing to the biweekly ACS Bulletin Advocacy Brief. Lastly, attending the annual spring ACS Leadership & Advocacy Summit can connect motivated surgeons with similarly driven surgeon leaders and policymakers.
Policies can have a profound impact on surgeons and their patients. Legislation, ultimately, creates the regulatory environment that can either facilitate or create barriers to patient care. Surgical societies have historically had a significant effect on national health policy. Surgeons who accept a proactive role in meaningful health policies have become even more important in addressing the challenges associated with the current political climate. Myriad advocacy opportunities are available to surgeons and include possibilities at the local, state, and national levels.
Although certain initiatives are specific to particular surgical subspecialties, surgical societies need to work together to highlight fundamentals that bridge disciplines. Strength in numbers and common goals will amplify the voice of surgeons and patients to positively engage with elected officials and decision-makers. By uniting on universal fronts, surgeons will be more effective in improving patient care and safeguarding surgical standards in our evolving regulatory landscape.
- Haider AH, Scott VK, Rehman KA, et al. Racial disparities in surgical care and outcomes in the United States: A comprehensive review of patient, provider, and systemic factors. J Am Coll Surg. 2013;216(3):482-492.
- Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: What is it and how do we do it? Acad Med. 2010;85(1):63-67.
- Stewart RM, Kuhls DA, Rotondo MF, Bulger EM. Freedom with responsibility: A consensus strategy for preventing injury, death, and disability from firearm violence. J Am Coll Surg. 2018;227(2):281-283.
- Stokes S. ACS Leadership & Advocacy Summit: A resident’s perspective. Bull Am Coll Surg. August 2018. Available at: https://bulletin.facs.org/2018/08/acs-leadership-advocacy-summit-a-residents-perspective/. Accessed June 28, 2021.
- ACS Letter to the House Ways and Means Committee Regarding Opioids March 15, 2018. Available at: www.facs.org/-/media/files/advocacy/federal/ways_and_means_opioid_031518.ashx. Accessed June 28, 2021.
- Berwick DM. Moral choices for today’s physician. JAMA. 2017;318(21):2081-2082.
- Sethi MK, Obremskey A, Sathiyakumar V, Gill JT, Mather RC, 3rd. The evolution of advocacy and orthopaedic surgery. Clin Orthop Relat Res. 2013;471(6):1873-1878.
- Davis DE. Importance of advocacy from the orthopedic surgeon. Orthop Clin North Am. 2021;52(1):77-82.
- American Academy of Orthopaedic Surgeons. History of AOSSM. Available at: www.aaos.org/about/meet-the-aaos/. Accessed May 4, 2021.
- American Society of Plastic Surgeons. About ASPS. Available at: www.plasticsurgery.org/about-asps. Accessed May 4, 2021.
- O’Neill KM, Raykar N, Bush C, et al. Surgeons and medical liability reform: A guide to understanding medical liability reform. American College of Surgeons. December 2014. Available at: www.facs.org/-/media/files/advocacy/regulatory/liability/2014-surgeons-and-medical-liability-primer.ashx. Accessed June 28, 2021.
- Koo K, Sangji NF, Kuy S, Ogunleye AA. The ACS and advocacy: A tradition of protecting our patients and advancing our profession. Bull Am Coll Surg. August 2016. Available at: https://bulletin.facs.org/2016/08/the-acs-and-advocacy-a-tradition/. Accessed June 28, 2021.
- Daar DA, Abdou SA, Robinson IS, Levine JP, Thanik V. Disparities in postmastectomy breast reconstruction: A systematic review of the literature and modified framework for advancing research toward intervention. Ann Plast Surg. 2018;81(4):495-502.
- ACS Commission on Cancer. About the Commission on Cancer. Available at: www.facs.org/quality-programs/cancer/coc/about. Accessed April 24, 2021.
- ACS Commission on Cancer. Resuming cancer screening and care during COVID-19. Available at: www.facs.org/quality-programs/cancer/coc/resuming-care. Accessed April 24, 2021.
- Gettman M, Kirshenbaum E, Rhee E, Spitz A. Telemedicine in urology. American Urological Association. Available at: www.auanet.org/guidelines/guidelines/telemedicine-in-urology. Accessed May 1, 2021.
- American College of Surgeons. ACS Bulletin Advocacy Brief. March 25, 2021. Legislation expanding GME introduced in the Senate. Available at: www.facs.org/publications/advocacy-brief/032521/. Accessed April 27, 2021.
- American College of Surgeons. Stop the Bleed. Available at: www.stopthebleed.org. Accessed April 24, 2021.