Surgeon perspectives on engaging in state advocacy

The American College of Surgeons (ACS) was very active in 2021, engaging in public policy debates in state legislatures on issues of importance to patients and surgeons. ACS Fellows took on leadership roles, representing the College before their state legislatures. The following ACS Fellows recently participated in the focus groups described in the article in this issue, “Surgeon advocacy in stage government: Listening and planning for future engagement,” and shared their perspectives on engaging in state advocacy.

Lisa Ferrigno, MD, MPH, FACS, State Chair, Colorado ACS COT

In my prior career, I was an HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) researcher. In that realm, the lines between medicine, science, and advocacy were blurred out of necessity. As a researcher, it was expected that we meet with politicians and potential donors to explain the science in an effort to gain funding to continue our work. Being an activist, advocate, and lobbyist was part of the job of a researcher; physicians had to become activists and advocates. When I first decided to go into trauma surgery, in part attracted to the potential opportunities for violence prevention research and advocacy, I was advised against such activity—that physicians best remain “apolitical”; for example, I was told to delete mention of firearms as part of an epidemiology of trauma talk.

Fortunately, the ACS and the [Committee on Trauma (COT)] have progressively added to their initial statement on firearms, culminating in the expanded statement, “Recommendations from the American College of Surgeons Committee on Trauma’s Firearm Strategy Team (FAST) Workgroup: Chicago Consensus I” in early 2019. A year later, the world as we knew it changed, and with the [coronavirus 2019] COVID-19 pandemic came a resurgence of interpersonal physical violence—not surprising given the relentless rhetorical violence that has become the “new normal.”

When I had an opportunity to listen in on a lunch Zoom call about the legislative process and current local initiatives as part of a multi-institutional firearm injury prevention group, I welcomed the distraction. There was discussion about the upcoming Colorado H.B. 21-1106, legislation to enact state standards for the responsible, safe, and secure storage of firearms. With several organizations in support of the legislation, as the Colorado State Chair of the COT, I wanted to lend our voice.

Working with the College’s State Affairs staff made working to support the legislation easy. They were able to confirm that the COT stance was in line with the legislation, help me with the testimony, and keep me on track with timing the day of the hearings. With other colleagues from Colorado Ceasefire [a statewide, grassroots gun violence prevention organization] and physicians from state and national organizations in pediatrics, emergency medicine, psychiatry, family physicians, and other specialties, we submitted a letter of support.

I was asked to present the story of a patient that might be relevant. As trauma surgeons, the stories of the patients we take care of are as varied and engaging as the breadth of pathology we encounter. We recycle light and humorous vignettes cleaned up for social gatherings with nonclinician family and friends. During my testimony at the hearing of the Colorado Senate Judiciary Committee, I relayed one of those “other” stories—not the one you recycle at a cocktail party, but the one that sends you home and makes you stifle a sob as you are going to sleep that night, so you can get some sleep to wake up and do it again.

The story was of an eight-year-old boy who shot his five-year-old sister. There was a loaded gun kept in [their] dad’s closet; the boy was trained to use it for “protection.” He thought his sister was an intruder, and he was ready to protect his family; and thus, the preparation for the scenario—an eight-year-old boy shooting his beloved sister point blank in the abdomen—was complete. It was the kind of case we might discuss many times—how to preserve the bowel and manage infections and feeding intolerance. But I also explained that while her life will be difficult and most certainly shortened, her brother and father will likely continue to live a tortured existence, with only moments of emotional respite, and perhaps their lives shortened by the need for self-destructive coping mechanisms.

When I finished, the Senate Committee Chair had to audibly clear his throat to speak. My colleagues from other specialties texted their appreciative and amazed feedback; it seems that after more than 10 years in practice, I had forgotten how unique our perspective as surgeons is. I changed into scrubs and drove to the hospital to take my call, hoping that dredging up one of those stories would make an impact.

Colorado H.B. 21-1106 passed. Did my or any one individual’s testimony seal its approval? I am not sure, but I am very assured that our perspective and support is unique, important, and heard. And that excellent support exists to make it happen, through the ACS and COT.

Kimberly Molik, MD, FACS, State Chair, Kansas ACS COT

Dr. Molik testified before Kansas legislative committees in support of legislation H.B. 2158 to strike the sunset date for the Kansas Trauma Advisory Committee granting the committee continued exemption from the state’s open meetings act. The legislation was signed into law by Gov. Laura Kelly (D) on May 26.

The role of surgeon-advocate is both a responsibility and a privilege. For the novice, there is excitement over the possibility of being able to make a change and educate our policymakers. However, with that opportunity comes the realization that the legislative field functions nothing like our operating rooms.

Health care bills are commonly discussed in a hurried fashion. Tracking exactly when the bill is debated and voted on can be difficult. It pays to get advice on timing your input. An issue or bill that one has spent hours or days studying could, for many legislators, be of only peripheral interest. Also, the bill you care about may be comingled in mind-bogglingly complex legislation, making it difficult to discern exactly what is being debated. Unlike a morbidity and mortality conference where there is one focused speaker, at legislative sessions, multiple conversations are occurring simultaneously during your presentation. Despite such frustrations, the work is terribly important.

The further I get in my career, the more important it is to do more than just operate. Although that is the primary and most important way we help people, advocacy allows us to help patients outside the operating room. Advocacy allows us to fight for safer roads, safer schools, more hospitals, and, possibly, safer and longer lives for all of us. Advocacy allows us to educate our legislators on what is needed to ensure that quality surgical care is available to them and their constituents. Legislators need to know the difference between hospitals and a hospital system, why stronger seatbelt laws are needed, why statewide trauma registries are nonnegotiable…the list goes on. Advocacy is our opportunity to add our voice to the discussion on the laws that set the rules on how we treat our patients. This is our responsibility to our patients as much as any operation.

Katherine Fischkoff, MD, FACS, ACS New York Chapter member

The ACS New York Advocacy Day was an opportunity to share concerns and raise our legislators’ awareness on important issues facing New York surgeons. This May, I spoke about the moral distress often felt by surgeons and other health care workers who feel compelled to provide care believed to be nonbeneficial at the end of a patient’s life.

The Family Health Care Decisions Act was signed into law in 2010 after years of debate. It requires physicians in New York State to provide resuscitative efforts after a cardiac arrest unless a patient is DNR [do not resuscitate]. However, the statute is a blanket law, which applies to all patients, regardless of context. Many physicians feel this is inappropriate when a patient has an irreversible condition and is already receiving maximal cardiopulmonary support in the intensive care unit. A recent survey conducted by the ACS New York Chapter of its membership yielded the following findings:

• A total of 81 percent of respondents stated that they have performed or supervised cardiopulmonary resuscitation (CPR) they feel is futile
• A total of 96 percent indicated they did so because of the family’s expectations and request
• A total of 66 percent would not have performed or supervised CPR if it was up to their discretion

This topic is, of course, enormous and nuanced with many stakeholders, but we were proud to begin this conversation with our state representatives. Engaging in advocacy allows me to represent the voice of our surgeons and colleagues on such an important issue that directly affects patient care.

Cherisse Berry, MD, FACS, ACS Governor for Manhattan Council of the New York Chapter

Dr. Fischkoff and Dr. Berry participated in the ACS New York Advocacy Day of the ACS New York and Brooklyn–Long Island Chapters held virtually with state legislators and staff on May 20.

The 405 New York State trauma regulations state that each trauma center shall participate with the coordinating regional trauma center and other hospitals, emergency medical services agencies, and governmental disaster preparedness programs in participating in emergency and disaster planning, which would include the incorporation of resources and capabilities into plans to address mass casualty and other disaster events. This regulation requires having an integrated regional and state trauma system.

During the peak of the COVID-19 pandemic in New York in March and April 2020, it became clear that not only does an integrated trauma system not exist within New York City or New York State, neither does a trauma surge capacity plan, placing our patients at risk for poor outcomes. Currently, there is no plan for maintaining capacity for emergency medical services, such as trauma, emergency general surgery, stroke, ST-elevation myocardial infarction, and non-COVID intensive care unit patients within New York. More specifically, for trauma, there is no plan for decompressing the intensive care units within Level I trauma centers to maintain capacity for critically injured patients and burn patients within systems, across systems, within the region, within the state, and across state lines.

The ACS New York Advocacy Day provided the platform needed to discuss these concerns with our legislators and advocate for a solution. Our “ask” to legislators was to start the work toward an integrated state trauma system by financially supporting a regional and state ACS Trauma Systems Consultation for New York. The Trauma Systems Consultation Program of the ACS COT provides a comprehensive, on-site trauma system review by a multidisciplinary team of national trauma system experts, covering 18 general sections under the three core functions within the public health model: trauma system assessment, trauma system policy development, and trauma systems assurance.

Without participating in the advocacy day, our legislators would not have known the importance of emergency preparedness within an integrated trauma system and the current challenges that we face in adhering to state regulations. We were able to provide them with the first step in the solution to maintaining capacity for emergency medical services during a medical disaster such as a viral pandemic: The ACS Trauma Systems Consultation. The conversations with legislators that day was the first step in opening the door to achieving long-lasting public policy for the people of New York.

Get engaged

Engagement is the most important action that ACS Fellows can take to ensure that the surgical profession continues to be a leader in patient safety and quality health care outcomes. There are several ways that Fellows can engage to support ACS advocacy initiatives, including responding to Action Alerts from the College, participating in state chapter meetings and advocacy days, building relationships with elected officials, talking about public policy issues with colleagues, and attending the annual ACS Leadership & Advocacy Summit in Washington, DC.

To learn more about the ACS’s advocacy priorities in your state or to participate in ACS state chapter advocacy, contact your local chapter or visit the College’s website. For more information, e-mail state_affairs@facs.org.