september 2002 reporting medical errors: variables in the

_________________________________________________________________FEATURES

Reporting medical errors: Variables in the system 12shape attitudes toward reporting adverse eventsLori A. Roscoe, PhD, and Thomas J. Krizek, MD, FACS

ACS offers advocacy resources 18Jon H. Sutton

Statement on residency work hours 21

DEPARTMENTS

From my perspectiveEditorial by Thomas R. Russell, MD, FACS, ACS Executive Director 3Dateline: Washington 6Division of Advocacy and Health Policy

FYI: STAT 5

What surgeons should know about... 8Health data resourcesCynthia Kay Sykes

In compliance... 22...with HIPAA rulesDivision of Advocacy and Health Policy

Socioeconomic tips of the month 23Understanding local medical review policiesDivision of Advocacy and Health Policy

SEPTEMBER 2002Volume 87, Number 9

Stephen J. RegnierEditor

Linn MeyerDirector of

Communications

Diane S. SchneidmanSenior Editor

Tina WoelkeGraphic Design Specialist

Alden H. Harken,MD, FACS

Charles D. Mabry,MD, FACS

Jack W. McAninch,MD, FACS

Editorial Advisors

Tina WoelkeFront cover design

Tina WoelkeBack cover design

About the cover...A recent study of College

Fellows shows that most sur-geons are willing to take re-sponsibility for and to reporterrors that they detect. Theyalso largely support the con-cept of surgical protocols, ac-cording to “Reporting medicalerrors: Variables in the systemshape attitudes toward report-ing adverse events, (p. 12).However, as authors Lori A.Roscoe, PhD, and Thomas J.Krizek, MD, FACS, demon-strate, surgeons are skepticalabout the effects of mandatoryreporting systems. Their con-cerns are largely attributableto the possibility that individu-als who are not directly in-volved in patient care couldmisuse the information.

NEWS

In memoriam: C. James Carrico: 24Farewell to a friendErwin R. Thal, MD, FACS

Applicants sought for Wylie Scholar Award 25

Official notice: Annual Meeting of Fellows and Initiates,American College of Surgeons 25

Fellows and facts 27

Liability and patient safety issuesto be addressed at Congress 29

Report on physicians as assistants at surgery available 31

New service, Congress savings available from ACS Surgery 31

Highlights of the ACSPA Board of Directorsand the ACS Board of Regents meeting, June 7-8, 2002 36Paul E. Collicott, MD, FACS

Bulletin of the AmericanCollege of Surgeons (ISSN0002-8045) is publishedmonthly by the American Col-lege of Surgeons, 633 N. SaintClair St., Chicago, IL 60611. Itis distributed without charge toFellows, to Associate Fellows,to participants in the Candi-date Group of the AmericanCollege of Surgeons, and tomedical libraries. Periodicalspostage paid at Chicago, IL,and additional mailing offices.POSTMASTER: Send ad-dress changes to Bulletin of theAmerican College of Surgeons,633 N. Saint Clair St., Chicago,IL 60611-3211.

The American College ofSurgeons’ headquarters is lo-cated at 633 N. Saint Clair St.,Chicago, IL 60611-3211; tel.312/202-5000, fax: 312/202-5001; e-mail: [email protected]; Web site: www.facs.org.Washington, DC, office is lo-cated at 1640 Wisconsin Ave.,NW, Washington, DC 20007;tel. 202/337-2701, fax 202/337-4271.

Unless specifically statedotherwise, the opinions ex-pressed and statementsmade in this publication re-flect the authors’ personalobservations and do not im-ply endorsement by nor offi-cial policy of the AmericanCollege of Surgeons.

©2002 by the American Col-lege of Surgeons, all rights re-served. Contents may not be re-produced, stored in a retrievalsystem, or transmitted in anyform by any means withoutprior written permission of thepublisher.

Library of Congress number45-49454. Printed in the USA.Publications Agreement No.1564382.

The American College of Surgeons is dedicated to improving the care of thesurgical patient and to safeguarding standards of care in an optimal andethical practice environment.

VOLUME 87, NUMBER 9, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

2

Officers and staff of the American College of Surgeons

Officers

R. Scott Jones, MD, FACS, Charlottesville, VAPresident

Kathryn D. Anderson, MD, FACS, Los Angeles, CAFirst Vice-President

Claude H. Organ, Jr., MD, FACS, Oakland, CASecond Vice-President

John O. Gage, MD, FACS, Pensacola, FLSecretary

John L. Cameron, MD, FACS, Baltimore, MDTreasurer

Thomas R. Russell, MD, FACS, Chicago, ILExecutive Director

Gay L. Vincent, CPA, Chicago, ILComptroller

Officers-Elect (take office October 2002)

C. James Carrico, MD, FACS, Dallas, TX*President

Richard R. Sabo, MD, FACS, Bozeman, MTFirst Vice-President

Amilu S. Rothhammer, MD, FACS, Colorado Springs, COSecond Vice-President

*Deceased July 25, 2002.

Board of Regents

Edward R. Laws, MD, FACS, Charlottesville, VAChair*

Jonathan L. Meakins, MD, FACS, Montreal, PQVice-Chair*

Barbara L. Bass, MD, FACS, Baltimore, MDL. D. Britt, MD, FACS, Norfolk, VAWilliam H. Coles, MD, FACS, New Orleans, LAPaul E. Collicott, MD, FACS, Chicago, ILEdward M. Copeland III, MD, FACS, Gainesville, FLA. Brent Eastman, MD, FACS, La Jolla, CARichard J. Finley, MD, FACS, Vancouver, BCJosef E. Fischer, MD, FACS, Boston, MAAlden H. Harken, MD, FACS, Denver, CO*Gerald B. Healy, MD, FACS, Boston, MA*R. Scott Jones, MD, FACS, Charlottesville, VA*Margaret F. Longo, MD, FACS, Hot Springs, ARJack W. McAninch, MD, FACS, San Francisco, CA*Mary H. McGrath, MD, FACS, Maywood, ILJohn T. Preskitt, MD, FACS, Dallas, TXRonald E. Rosenthal, MD, FACS, Wayland, MAMaurice J. Webb, MD, FACS, Rochester, MN

*Executive Committee

Board of Governors/Executive Committee

J. Patrick O’Leary, MD, FACS, New Orleans, LAChair

Sylvia D. Campbell, MD, FACS, Tampa, FLVice-Chair

Timothy C. Fabian, MD, FACS, Memphis, TNSecretary

Julie A. Freischlag, MD, FACS, Los Angeles, CASteven W. Guyton, MD, FACS, Seattle, WARene Lafreniere, MD, FACS, Calgary, ABCourtney M. Townsend, Jr., MD, FACS, Galveston, TX

Advisory Council to the Board of Regents(Past-Presidents)

W. Gerald Austen, MD, FACS, Boston, MAHenry T. Bahnson, MD, FACS, Pittsburgh, PAOliver H. Beahrs, MD, FACS, Rochester, MNJohn M. Beal, MD, FACS, Valdosta, GAHarvey W. Bender, Jr., MD, FACS, Nashville, TNGeorge R. Dunlop, MD, FACS, Worcester, MAC. Rollins Hanlon, MD, FACS, Chicago,ILJames D. Hardy, MD, FACS, Madison, MSM. J. Jurkiewicz, MD, FACS, Atlanta, GALaSalle D. Leffall, Jr., MD, FACS, Washington, DCWilliam P. Longmire, Jr., MD, FACS, Los Angeles, CALloyd D. MacLean, MD, FACS, Montreal, PQWilliam H. Muller, Jr., MD, FACS, Charlottesville, VADavid G. Murray, MD, FACS, Syracuse, NYDavid C. Sabiston, Jr., MD, FACS, Durham, NCSeymour I. Schwartz, MD, FACS, Rochester, NYGeorge F. Sheldon, MD, FACS, Chapel Hill, NCG. Tom Shires, MD, FACS, Las Vegas, NVFrank C. Spencer, MD, FACS, New York, NYRalph A. Straffon, MD, FACS, Shaker Heights, OHJames C. Thompson, MD, FACS, Galveston, TX

Executive Staff

Executive Director: Thomas R. Russell, MD, FACSDivision of Advocacy and Health Policy:

Cynthia A. Brown, DirectorAmerican College of Surgeons Oncology Group:

Samuel A. Wells, Jr., MD, FACS, Group ChairCommunications: Linn Meyer, DirectorDivision of Education:

Ajit K. Sachdeva, MD, FACS, FRCSC, DirectorExecutive Services: Barbara L. Dean, DirectorFinance and Facilities: Gay L. Vincent, CPA, DirectorHuman Resources: Jean DeYoung, DirectorInformation Services: Howard Tanzman, DirectorJournal of the American College of Surgeons:

Wendy Cowles Husser, Executive EditorDivision of Member Services:

Paul E. Collicott, MD, FACS, DirectorDivision of Research and Optimal Patient Care:

Alden H. Harken, MD, FACS, Interim DirectorCancer:David P. Winchester, MD, FACS, Medical DirectorOffice of Evidence-Based Surgery:Margaret Mooney, MD, Interim DirectorTrauma:David B. Hoyt, MD, FACS, Medical Director

Executive Consultant:C. Rollins Hanlon, MD, FACS

SEPTEMBER 2002 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

3

From myperspective

‘‘’’

For those of you who may not yet haveheard, it is with great sadness that I re-port that the President-Elect of the Col-lege, C. James Carrico, MD, FACS, died

on July 25 after a long and gallant battle with can-cer. The College has expressed to his wife, Sue,their three children, and other family membersthe esteem and appreciation that we all held forJim and for his professional contributions notonly to the College, but to the academic institu-tions where he served.

On page 24 of this issue of the Bulletin, ErwinR. Thal, MD, FACS, Dr. Carrico’s colleague andfriend, offers some personal commentary onJim’s life and work. In this column, I would liketo reflect on Dr. Carrico’s permanent imprinton the College.

True leadershipThroughout his illness, Jim Carrico remained

remarkably attentive to his work and to this or-ganization. He was productive until his last dayswith us. Although Jim was prepared to die, heclearly was not ready. He was looking forwardwith great anticipation to becoming Presidentof the College beginning in October and hadgreat plans for his year of presidency.

Whenever those of us who knew Dr. Carricothink about him in the future, we will no doubtexpress continual amazement at his outstand-ing contributions to the College. Jim was an in-defatigable volunteer throughout his nearly 31years of Fellowship. In all, he served on 34 dif-ferent committees, beginning in 1975 when hewas appointed to the Pre- and PostoperativeCare Committee.

As a specialist in burn, trauma, and criticalcare, the Committee on Trauma was one of hispassions. He was appointed to that committeein 1982 and served as Vice-Chair of its Execu-tive Committee from 1986 to 1989.

Jim was active on the Board of Governors from1984 to 1990 and served as its Chair from 1989to 1990. Additionally, Dr. Carrico served threethree-year terms on the Board of Regents andwas Chair of the Board from 1999 to 2001. Inthat capacity, he was immensely helpful to me,and I will always appreciate his guidancethroughout my early days as ACS Executive Di-rector. He never lectured, offered dissertations,

or harangued about a certain issue. Rather,Jim’s advice was concise, direct, always well-re-ceived, and most often accurate.

Lasting legacyNo matter what role he was playing at any given

time within the College, Jim left a lasting impri-matur. His focus always was on doing what wouldbe in the best interests of the surgical patient andon ensuring that the College’s policies and pro-grams would lead to improved quality of care.

For example, he helped to establish and chairedthe Committee on Emerging Surgical Technologyand Education. Through this committee, he at-tempted to identify new technologies that wouldhave real clinical applications as well as the best,most appropriate means for training the surgicalcommunity in the use of these advancements. Iwill always associate Jim Carrico with forging thiscommittee, and I believe it will become an evenmore integral component of the College as we

I believe one need not look tooI believe one need not look tooI believe one need not look tooI believe one need not look tooI believe one need not look toofar to see how Jim Carrico’sfar to see how Jim Carrico’sfar to see how Jim Carrico’sfar to see how Jim Carrico’sfar to see how Jim Carrico’sessence survives in Fessence survives in Fessence survives in Fessence survives in Fessence survives in Fellowsellowsellowsellowsellowsof the College.of the College.of the College.of the College.of the College.


4

If you have comments or suggestions about this orother issues, please send them to Dr. Russell [email protected].

Thomas R. Russell, MD, FACS

evaluate the utility of new devices before they areintroduced for general use.

Another College committee that grew out ofDr. Carrico’s vision and understanding of themodern practice environment is the HealthPolicy Steering Committee. This committee hadJim’s total endorsement as a stepping stone to-ward the College’s development of a more re-sponsive and proactive voice in Washington, DC.

As we enter into the final phases of prepara-tion for the 2002 Clinical Congress in San Fran-cisco, I am reminded that Jim’s fingerprint willagain be evident on some significant aspects ofthe program. For example, the Congress will beone day shorter this year than it has been in thepast, and, on the front end of the program, wewill be combining the Opening Ceremony withthe American Urological Association’s lecture.

Jim always felt that one of the most impor-tant events at the Clinical Congress was the Con-vocation and the induction of the new Initiates.To that end, he felt strongly that the receptionfollowing the Convocation should include ampletime and opportunity for the Initiates and theirfamilies to meet the College leadership to helpfoster the lifelong relationship we hope all Fel-lows will build with this organization. Thus, thisyear, we will be welcoming and encouraging allof the new Initiates to meet the leaders of theCollege and other Fellows at the reception onThursday evening following their induction.

In his memoryBecause of the severity of his illness, Jim knew

he would be unable to complete his term asPresident-Elect of the College. So he suggested,and the Board of Regents enthusiasticallyagreed, that Richard R. Sabo, MD, FACS, theFirst Vice-President-Elect from Bozeman, MT,should complete Jim’s term as President-Elect.Under the terms of the Bylaws of the College,when the President is unable to serve his or herterm, the First Vice-President is to serve in thatcapacity. Thus, once Dr. Sabo is sworn in as FirstVice-President during the Convocation ceremo-nies on October 10, he will then assume the of-fice of President for the year 2002 to 2003. Priorto his death, Jim and Richard had many discus-sions regarding the goals of the College for thenext year, and we anticipate that Jim’s vision

and direction will be well carried out despite hisphysical absence.

I believe that this year’s Clinical Congress willbe a fitting tribute to Jim Carrico in many waysand can assure you that, in general, the meet-ing will be of great interest. It will cover a widerange of topics from the scientific to socioeco-nomic, and we will present 30 finely designedpostgraduate courses.

While we will always miss Jim’s vision anddedication to our College and will remain in-debted to him for the many changes he spear-headed through his quiet leadership, I believeone need not look too far to see how his essencesurvives in Fellows of the College. We see it ineach Fellow who sacrifices his or her time toshare an expertise by volunteering to work oncommittees, to write articles and letters for pub-lication in the Bulletin, and to speak at educa-tional meetings. Dr. James Carrico’s spirit liveson in your dedication to surgery and to this or-ganization.


5

FYI: STAT❖

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ACS Executive Director Thomas R. Russell, MD, FACS, hosted ameeting of the surgical specialty societies in Chicago on July 12. Ofparticular interest, the groups agreed that the College should circu-late a coalition letter to the Accreditation Council for Graduate Medi-cal Education (ACGME) expressing support for provisions in aworkgroup document that would allow some flexibility in the en-forcement of resident duty hour limits. That letter, which wassigned by 19 national organizations, was sent to ACGME on August 1.The coalition letter can be found on the College’s Web site at: http://www.facs.org/dept/hpa/views/gme.html.

The Candidate and Associate Society of the American College of Sur-geons (CAS-ACS) invites all residents, residency program directors,and Associate Fellows attending the Clinical Congress in San Fran-cisco to attend a symposium on professionalism and how it is taughtin the medical educational environment. The symposium will be heldon Sunday, October 6, 2002, from 2:00 to 5:00 pm at the Moscone Con-vention Center. The speakers will be Ajit K. Sachdeva, MD, FACS,FRCSC, Director of the College’s Division of Education, and MichaelE. Whitcomb, MD, senior vice-president for medical education and di-rector, division of medical education, Association of American MedicalColleges. Dr. Whitcomb is also editor-in-chief of Academic Medicine,the leading journal devoted to issues relevant to academic medicine.There will be an open-microphone discussion following their presen-tations. For more information, contact [email protected].

Dr. Russell and LaMar S. McGinnis, Jr., MD, FACS, one of theCollege’s representatives to the American Medical Association’s Houseof Delegates, met with the Executive Committee of the AMA’sBoard of Trustees on July 16 to discuss issues related to advocacyand the organization’s relationships with specialty and state societies.

The 25th Annual Residents Trauma Paper Competition of theCollege’s Committee on Trauma (COT) is scheduled to take place onMarch 13, 2003, at the COT’s Annual Meeting. The “Call for Abstracts”and the “Guidelines for Submission” are posted at http://www.facs.org/dept/trauma/papers.html.

The College’s insurance program administrator now offers medi-cal insurance for members traveling abroad. For details, con-tact the plan administrator via e-mail at [email protected] or via phone at 800/433-1672. For an online quote,log onto http://www.acs-insurance.com, click Medical Plans, then Traveland Global Medical Plan.

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6

DatelineWashingtonprepared by the Division of Advocacy and Health Policy


6

Throughout the summer, the U.S. Senate debated Medicare pre-scription drug coverage. A variety of proposals were considered, butnone garnered the 60 votes needed to pass. One amendment thatwas offered, not specific to the drug benefit issue, was a medicalliability reform proposal. Authored by Sen. Mitch McConnell (R-KY), the amendment contained all the medical liability reforms theCollege and other specialty societies support, except for a cap onnoneconomic damages. Unfortunately, the proposal failed when itwas tabled by a vote of 57-42. The College continues to advocate forthe passage of the comprehensive medical liability reforms containedin the HEALTH Act that was introduced by Rep. Jim Greenwood(R-PA) as H.R. 4600 and by Sen. John Ensign (R-NV) as S. 2793.

Although the Senate did not follow the House and pass a prescrip-tion drug bill that included at least an interim solution to the crisisin Medicare physician reimbursement, leaders vowed to renew theirefforts when Congress returns from its August recess after LaborDay.

In response to the severe professional liability crisis in Nevada,the governor called a special session of the legislature to pass tortreform. Following the session, which ran from July 29 to August 1,the governor signed a bill that:

• Caps noneconomic damages at $350,000, except in cases ofgross malpractice or where the court finds there is clear and con-vincing evidence that the award should exceed the cap because ofexceptional circumstances.

• Implements expert witness standards.• Makes a defendant severally liable for economic damages.• Extends to physicians in all trauma centers and emergency

rooms a cap on civil damages of $50,000 for care of a traumaticinjury demanding immediate medical attention.

In addition, medical facilities will be required to report sentinelevents to the state repository for health care quality assurance. Suchinformation will be inadmissible as evidence in any administrativeor legal proceeding. Surgeons interested in the text of the legisla-tion should visit the Nevada legislature’s Web site at http://www.leg.state.nv.us/18thSpecial/bills/AB/AB1_EN.pdf.

On July 18, the Senate Appropriations Committee approved $5million for the Health Resources and Services Administration’s(HRSA’s) Trauma-Emergency Medical Services program for fiscalyear (FY) 2003. This program provides federal grants to assist statesin planning, developing, and implementing statewide trauma caresystems. The funding was included as part of the annual spendingbill for the Departments of Labor, Health and Human Services, andEducation. The House has yet to act on its version of the appro-priations bill. For FY 2002, Congress provided $3.5 million for thetrauma program, which has now been distributed.

Medicare andliability solutionselude the Senate

Tort reformmoves in Nevada

Senate approves$5 million fortrauma systems

JULY 2002 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

RM


7

In addition, the College is working with the 107th Congress toreauthorize the program for an additional four years and to empha-size the needs of trauma care systems as the nation addresses itsability to respond to acts of bioterrorism. In June, President Bushsigned H.R. 3448, the Public Health Security and Bioterrorism Pre-paredness and Response Act of 2002, which includes a provision thatauthorizes increased funding to “develop and implement the traumacare component of the State plan for the provision of emergencymedical services.”

The Senate confirmed general surgeon Richard H. Carmona, MD,FACS, as U.S. Surgeon General without opposition or debate on July23. This confirmation cleared the way for Dr. Carmona to assumethe position vacated by David Satcher, MD, in February.

Since the enactment of the Emergency Medical Treatment and Ac-tive Labor Act (EMTALA), there has been a great deal of confusionabout its applicability to various locations on and off the hospital cam-pus. In the final 2003 Prospective Payment System (PPS) rule releasedon August 1, the Centers for Medicare & Medicaid Services (CMS) clari-fied that EMTALA applies only to those provider-based departmentsthat are located on the main campus, and that EMTALA does not ap-ply to provider-based entities, such as rural health clinics, that are onthe hospital campus. CMS also announced that it needs more time toreview the 600 comments it received on the issue, so other changes toEMTALA that were published in the May 9 proposed PPS rule will beaddressed in a separate Federal Register notice. For more information,visit: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2002_register&docid=page+50081-50130, and scroll down to page50090.

Carmona confirmedas Surgeon General

EMTALArequirementclarified


8

What surgeonsshould know about...

In the last several years there has been a veri-table explosion in the quantity of electronicdata sources. The data have been gathered, or-

ganized, and stored by a small number of individu-als working for different organizations. Here areseveral Web sites that Fellows may find useful intheir efforts to search the Internet for informa-tion on various issues. A brief explanation of thetypes of information available through each siteand other contact information is provided when-ever possible.

Acronyms and Initialisms for HealthInformation Resourceshttp://www.geocities.com/~mlshams/acronym/

Acronyms for global information and data re-sources on health, medical, and veterinary sci-ences.

Agency for Healthcare Research andQuality Office of Health Care Informationhttp://www.ahcpr.gov/data/

Data from the medical expenditure panel surveyand health care cost and utilization project qual-ity indicators.

Clearinghouse phone: 800/358-9295Address: Executive Office Center, Suite 501, 2101E. Jefferson St., Rockville, MD 20852

Agency for Toxic Substances and DiseaseRegistryhttp://www.atsdr.cdc.gov

HazDat database, measuring health effects, mini-mal risk levels, child health.

Phone: 404/498-0110 or 888/422-8737Fax: 404/498-0057

Association of Public Data Users (APDU)http://www.apdu.org

Resources for the identification and applicationof public data, establishment of links betweendata users and producers, and data policy issues.

Contact: Teresa Hall Allen, Chief AdministratorAddress: P.O. Box 12538, Arlington, VA 22219Phone: 703/807-2327Fax: 703/528-2857E-mail: [email protected]

Association of State and Territorial HealthOfficialswww.astho.org

State data standards, reports, surveillance, andstatistics.

Address: 1275 K St., NW, Suite 800, Washington,DC 20005-4006Phone: 202/371-9090Fax: 202/371-9797

Bureau of Labor Statisticshttp://www.bls.gov

Safety and health statistics.

Cancer Statistics Review 1973-1993http://seer.cancer.gov/

This report includes incidence, mortality, and sur-vival data from 1973 through 1993.

Centers for Disease Control and Preven-tion (CDC)http://www.cdc.gov

This agency of the Department of Health and Hu-man Services maintains a site that provides accessto a variety of data. Sections on traveler’s health,data and statistics, diseases, injuries, health risks,specific populations, and prevention guidelines andstrategies are included. Most of the CDC’s periodi-cal publications are available free through this site.

Health data resourcesby Cynthia Kay Sykes, Office Manager, Washington Office, Division of Advocacy and Health Policy


9

CDC National Center for Health Statis-ticswww.cdc.gov/nchs/

Address: 6525 Belcrest Rd., Hyattsville, MD20782Phone: 301/458-4636

CDC National Prevention InformationNetworkhttp://www.cdcnpin.org

The CDC National AIDS Clearinghouse’s servicesare “designed to facilitate the sharing of HIV/AIDS,STD, and TB resources and information.” A ser-vice of the CDC, this site features health informa-tion divided into categories such as online tutori-als, databases, and a poster gallery. It also providesaccess to some CDC publications.

CDC, Youth Risk Behavior SurveillanceSystem Resultswww.cdc.gov/nccdphp/dash/yrbs/ov.htm

State and national results from a continuoussurvey of risk factors and youth.

Phone: 800/311-3435E-mail: [email protected]

Clinical Alerts and Advisorieshttp: / /www.nlm.nih.gov/databases/alerts /clinical_alerts.html

Clinical alerts and advisories from the U.S. Na-tional Institutes of Health expedited release ofresearch findings that could significantly affectpatient morbidity and mortality.

Clinical Trials Listing Servicehttp://www.centerwatch.com

The site is designed to be a resource for patientsinterested in participating in clinical trials, phy-

sicians who have patients who might benefitfrom inclusion in a trial, and for research pro-fessionals. It includes an international listingof more than 5,200 clinical trials actively re-cruiting patients. You may search the databaseby disease and geographic region.

ClinicalTrials.govhttp://www.clinicaltrials.gov/

The U.S. National Institutes of Health and theNational Library of Medicine collaborate to pro-vide this searchable database of clinical researchstudies.

Combined Health Information Databasehttp://chid.nih.gov

Titles, abstracts, health information, and healthresources.

Computer Retrieval of Information onScience Projectsh t t p : / / c o m m o n s . c i t . n i h . g o v / c r i s p 3 /Crisp_Query.Generate_Screen

CRISP includes information on the projectsfound in ClinicalTrials.gov and informationabout nonclinical trials as well.

Fatality Analysis Reporting Systemwww.nhtsa.dot.gov/people/ncsa/fars.html

Data on causes of fatal traffic accidents.

FEDSTATShttp://www.fedstats.gov

More than 70 federal agencies produce statis-tics of interest to the public. The Federal Inter-agency Council on Statistical Policy maintainsthis site to provide easy access to the full rangeof statistics and information produced by theseagencies for public use.


10

Food and Drug Administrationhttp://www.fda.gov

Food and Nutrition Information Center(USDA)http://www.nal.usda.gov/fnic

Food and Nutrition Information Center (USDA)is one of several information centers at the Na-tional Agricultural Library. This site provides ac-cess to FNIC’s databases and resource lists, alongwith food and nutrition links.

Centers for Medicare & Medicaid Serviceshttp://www.hcfa.gov/stats/

If you are looking for information on diagnosis-related groups or the free computer programsavailable to assist you in preparation of accu-rate claims, this site may provide the informa-tion you need.

Medical Yellow Pageswww.medsite.com

Categorized health data.

National Association for Public HealthStatistics & Information Systemswww.naphsis.org

Address: 1220 19th St., NW, Suite 802, Washing-ton, DC 20036Phone: 202/463-8851Fax: 202/463-4870E-mail: [email protected]

National Association of Countieswww.naco.org/counties/counties/index.cfm

County-level demographic and other data.

National Association of County and CityHealth Officialswww.naccho.org

Public health advocacy information, data allianceproject, and publications.

Address: 1100 17th St., 2nd Fl., Washington, DC 20036

Phone: 202/783-555Fax: 202/783-1583

National Association of Health Data Orga-nizationswww.nahdo.org

Address: 375 Chipeta Way, Suite A, Salt Lake City,UT 84108Phone: 801/587-9104Fax: 801/587-9125E-mail: [email protected]

National Institutes of Health (NIH)www.nih.gov

NIH Information Indexw w w. n i h . g o v / h e a l t h / I n f o r m a t i o n I n d e x /HealthIndex/Pubincov.htm

Diseases currently under investigation by NIH,NIH-supported scientists, major NIH research ar-eas, and important health-related topics.

National Library of Medicinehttp://www.nlm.nih.gov

Practice guidelines

Primary Care Clinical Practice Guidelineshttp://medicine.ucsf.edu/resources/guidelines/

Site located at UCSF that links the user to guide-lines made available on the Web by many differ-ent organizations and journals (emphasis seemsto be given to full-text online). When summa-ries, abstracts, complete documents, and/or PDFversions are available as alternate forms the sitelists links to each form separately. The guide-lines are organized by organ system, but are alsoavailable through search and alphabetical indexfeatures.

National Guideline Clearinghousehttp://www.guideline.gov/index.asp

Evidence-based clinical practice guidelines froma searchable database. Some of the resources ob-tainable through this site are several hundredpages long.


11

Clinical Practice Guidelines, Quick Refer-ence Guides for Clinicians, andConsumer’s Guides from the NationalLibrary of Medicinehttp://text.nlm.nih.gov/

Reference material

Dictionary.comhttp://www.dictionary.com/

Access to an online English dictionary, the onlineversion of Roget’s Thesaurus, and lists of links todictionaries in other languages.

Dictionary of Cell Biologyhttp://on.to/cellbiology

Quick access to definitions of terms frequentlyencountered by those reading the modern biologyliterature. The Web site provides access to the thirdedition of the dictionary, which was published in1999.

Merriam-Webster Online Dictionaryhttp://www.m-w.com/dictionary.htm

Online version of the collegiate dictionary and thecollegiate thesaurus.

Taber’s Online Medical Dictionaryhttp://www.rxlist.com/cgi/tabersearch.cgi

You will need to scroll to the bottom of the page tosee the search box if you have a small computerscreen.

The White House—Health-Related Re-sourceswww.whitehouse.gov/government/handbook/health.html

Online health-related resources from the U.S. gov-ernment comprised of the following major sec-tions: leading causes of death in America; preven-tion; health care; health and environment; alco-hol, smoking, and other drug information.

U.S. Census Bureauwww.census.gov

Census State Data Centers; current populationestimates and projections; current economic indi-cators; National Center for Health Statistics; Na-tional Health Data Standards; CDC Wonder;Monthly Vital Statistics Report.

Phone: 301/763-4636Fax: 301/457-4714

U.S. Department of Commerce: NationalTechnical Information Service (NTIS)www.ntis.gov

Databases, resources, Statistical Abstract of theUnited States.

World Health Organization StatisticalInformation Systemhttp://www.who.ch/whois

Describes and, to the extent possible, provides ac-cess to statistical and epidemiological data andinformation presently available from the WorldHealth Organization and elsewhere in electronicor other forms.

Disclaimer: Inclusion of a Web site here does notconstitute ACS endorsement of the site’s contents.

�


12

by Lori A. Roscoe, PhD,and Thomas J. Krizek, MD, FACS,

Tampa, FL

Reportingmedical erors:

Variables in the systemshape attitudes

toward reporting


12

adverseevents


13

gery has been challenged by these recommenda-tions, and concerns about surgeon reaction wereraised by Dr. Krizek in his Ethics and PhilosophyLecture at the 2001 Clinical Congress of the Col-lege.13 Thus, while it appears that voluntary re-porting of errors and near-misses may provide thedata needed for system-wide improvements, resis-tance to such voluntary error reporting systemsmay be grounded in fears that such data would bemisused or would result in litigation.

This pilot study sought to assess surgeon char-acteristics and case-specific circumstances thatmay influence the voluntary reporting of adverseevents. The specific aims of this project were: (1)to assess surgeons’ attitudes about reporting ad-verse events; and (2) to determine the individualcharacteristics and situational factors that mayinfluence whether errors are reported or con-cealed.

Study methods

A total of 783 surveys were sent to a randomsample of surgeons listed in the American Collegeof Surgeons 1998 Yearbook with the only exclu-sion criteria being that those selected had to belisted as practicing medicine in the U.S. A total of218 completed questionnaires were returned andanalyzed (yielding a response rate of 28%). Thequestionnaire was three pages long and requiredabout 15 minutes to complete.

Participants were asked to read about two sce-narios in which an adverse event occurred duringthe surgical management of a patient and wereasked to respond to a series of yes-or-no questions.The scenarios varied in terms of the harm to thepatient, the relative ease with which the errorcould be concealed, the age of the patient, and howdirectly the surgeon was involved in the medicalmistake. Participants were asked to respond toboth cases regardless of whether the case situa-tions were reflective of their particular practicepattern.

Participants also were asked to indicate theirage, their gender, the state in which they practice,their specialty, and whether they currently super-vise medical students and/or residents. Two open-ended questions sought opinions on whether sur-gical protocols lessen the chance that errors willoccur during surgical management of patients (in-

S urgeons are seriously concerned about theprevalence of medical mistakes. Medical er-rors can injure or kill patients, ruin pro-fessional reputations and careers, endan-

ger the trust that patients have in medical careprofessionals, and are costly.1 Two large studies,one in New York and one in Colorado and Utah,found that adverse events occurred in 3.7 percentand 2.9 percent of hospitalizations, respectively.2-3

The results of these studies imply that between44,000 and 98,000 patients die each year as a re-sult of medical errors, which exceeds the eighthleading cause of death (suicide) in the U.S.4

These retrospective studies most likely relied onmedical chart review by physicians and nursesand, therefore, may have significantly underesti-mated the magnitude of the problem.5 A report byDr. Krizek in the July 2000 Bulletin anticipatedand reviewed this situation and detailed the datafrom a study performed earlier at the Universityof Chicago.6 Those data were derived from a pro-spective observational study, which found that 46.9percent of 1,047 patients in surgical intensive careunits experienced an adverse event; 17.7 percentof the patients experienced a serious event that wasdefined as threatening either to life or limb.7-8

While medical error may be a prevalent and se-rious problem, medical mistakes may also be thebest source of data about how systems may be im-proved to avoid them. Most medical errors are de-scribed as “organizational accidents,” because theymost often result from problems within complexorganizational systems, not from individual mis-takes.9-10 A recent Institute of Medicine reportabout medical errors and patient safety includeda recommendation that, in addition to the man-datory reporting of patient deaths and serious in-juries attributable to error, hospitals establish vol-untary reporting systems for tracking errors thatmay expose patients to risk but do not necessarilyresult in serious injury (“near-misses”).11

The success of voluntary reporting systems thattrack a full range of adverse events depends onthe willingness of health care professionals to iden-tify and report such events. When errors are dis-covered the most likely response is to punish theindividual most directly associated with the error,even though errors generally result from interac-tive causes rather than from individual negli-gence.12 The entire culture of surgeons and of sur-


14

cluding preoperative, intraoperative, and postop-erative), and what effect mandatory reporting sys-tems may have on reducing the incidence of sur-gical errors.

The average age of respondents was 50.5 years(minimum 38, maximum 85), and 91 percent weremale. When the 5 percent of respondents who in-dicated that they were retired were excluded, theaverage age was 49.2 years (minimum 38, maxi-mum 68). Participants were in surgical practicein 41 states, with 10 percent from Florida and 10percent from New York. The majority of respon-dents indicated that they were general surgeons(36%), with 12 percent specializing in plastic sur-gery and 8 percent in otolaryngology.

Nearly half of the respondents were in specialtygroup practices (44%), 31 percent were in solopractice, 18 percent were associated with academichealth centers, and 7 percent practiced in HMOsor the Veterans Affairs system. Sixty percent ofrespondents supervised medical students and/orresidents.

The findings

The first case presented to the respondents wasas follows:

An 80-year-old woman has an indurated area inher breast at the site of a breast biopsy (negativefor cancer) performed six months ago. During yourexploration, under local anesthesia, in your ownoffice surgical facility, you discover that a 4 x 4sponge had been left in the site and represents thecause of the firmness. There is no evidence of can-cer in the breast. Since your assistant was dis-tracted at the time you discovered the foreign body,there are no witnesses.

Most respondents (99%) believed that the dis-covery of the sponge should be shared with thepatient, and 90 percent believed that they had aresponsibility to report the finding of the spongeto the facility where the biopsy was originally per-formed. Only 1 percent of the respondents re-ported that the age of the patient was a factor inwhether or not they would report the adverseevent, with the comment that older patients maybe less likely than younger patients to pursue liti-gation against physicians.

A quarter of respondents (26%) indicated thatthey believed reporting the incident to the patientwould result in litigation against them, regard-less of where the initial surgery was performed.Two-thirds of respondents (62%) believed that re-porting such events would result in improved pa-tient care in the future.

The second case presented to the respondentswas as follows:

A 45-year-old man had closed fractures of thetibia and fibula of the same lower extremity andmultiple other injuries. The cast you applied hasbecome too tight as swelling occurred over the last12 hours. Since the patient was not conscious, anychanges in sensation could not be determined, andthe nurses and residents did not recognize thechanges in the color of the foot. Despite release ofthe cast pressure by you, the patient has subse-quently shown a persistent peroneal nerve palsyon that side; months later it appeared that his foot-drop would be permanent.

The majority of respondents (84%) felt that as“captain of the ship” they were most responsiblefor the complication described in this scenario, and86 percent felt that the incident should be reportedto the hospital and other agencies responsible forthe quality of patient care. Three-quarters of re-spondents (75%) indicated that having strict pro-tocols for the management of patients with mul-tiple injuries would lessen the occurrence of com-plications such as the one described in the casestudy, and 66 percent felt that surgeons caring forpatients with apparently similar problems shouldfollow the same protocol.

Impact of surgical protocols

In addition to offering their responses to the twocases just described, study participants were askedwhether they believe surgical protocols lessen thechance that errors will occur during the surgicalmanagement of patients and whether they thinkmandatory reporting systems would help to reducethe incidence of errors.

Approximately 75 percent of respondents indi-cated that they believe that the use of surgical pro-tocols would lessen the incidence of errors. Manyqualified their comments with statements such as,


15

“protocols best fit straightforward procedures,”“errors will occur in spite of protocols,” and “thereneeds to be room for individualization dependingon circumstances.”

Participants who believed that protocols wouldnot affect error rates commented that errors typi-cally result from lack of training and personnelshortages, rather than the absence of protocols orstandard procedures, and that the use of proto-cols may encourage staff to “stop thinking.” Sev-eral respondents indicated that protocols may bea two-edged sword: while they may reduce errors,they also may encourage litigation if they are notprecisely followed, regardless of whether adversecircumstances result. Further, surgeons may as-sume that protocols are being followed becausethey exist, while their existence may not be obvi-ous to substitute or “float” personnel.

Mandatory reporting systems

Nearly half of the respondents felt that manda-tory reporting would affect errors. Some respon-dents supported their views with statements suchas: “There will always be errors when humans areinvolved”; “mandatory reporting systems onlymake it easier for lawyers to gain access to data”;and “mandatory reporting is no substitute for agood relationship between doctor and patient.”

Approximately one quarter of the respondentssaid they believed that mandatory reporting of er-rors would have a positive effect and may reduceerrors. Respondents indicated that reporting sys-tems may make physicians more vigilant, addingthat “anytime that a process is monitored or mea-sured, it tends to improve,” and mandatory report-ing “makes patients feel that the institution andphysicians are interested in their well-being andare making an attempt to reduce errors.”

About 15 percent of the respondents indicatedthat they didn’t know how reporting systemswould influence errors. Some respondents indi-cated that the impact would depend on the estab-lishment of entirely new systems and would beunlikely to be effective if they were “added on”and nothing else was changed.

The remaining 10 percent of respondents indi-cated that they believe that instituting mandatoryreporting systems may have a negative effect onthe handling of medical errors. Common objec-

tions to mandatory reporting cited in the studyincluded: (1) it may increase the pressure to con-ceal, rather than analyze, errors; (2) reporting isunworkable given the current legal system; and(3) it may not result in constructive solutions, justmore punishment or censure, which ultimately failto reduce errors.

Conclusions

Patient safety and the reduction of errors inmedical care are important issues. The results ofthis survey indicate that these issues are impor-tant to surgeons, and that the majority of surgeonsfeel a responsibility to report adverse events topatients and to their institutions, as well as to as-sume personal responsibility for the safety of theirpatients.

Yet there is evidence that medical errors occurat epidemic levels and that the current system inmost hospitals and clinics requires that blame be

Opposition or reluctance

to report errors is not

likely due to deficiencies

in the character, values, or

competence of individual

surgeons, but rather to

the systems-level variables

and conditions that

constitute current medical

care delivery systems.

‘‘

’’


16

placed and punitive sanctions be imposed on thosemost closely associated with the mistake. Punish-ments range from mortification in front of one’speers at a morbidity and mortality conference tomore lasting hardships, such as the loss of one’slicense to practice medicine.

These results begin to clarify that opposition orreluctance to report errors is not likely due to de-ficiencies in the character, values, or competenceof individual surgeons, but rather due to the sys-tems-level variables and conditions that constitutecurrent medical care delivery systems. The wayin which medical care is provided, particularly inthe operating room, makes it unfair to assignblame to the surgeon only. By the time the sur-geon enters the operating room to remove a dis-eased limb, for example, many other decisions havebeen made, such as which limb to expose and howthe plan of care has been documented in the medi-cal chart. If the wrong limb is operated on, theentire system is at fault, not solely the individualsurgeon. Blaming and punishing the surgeon mostclosely associated with the error is not a substi-tute for analyzing the entire work flow, from pa-tient admission to discharge, to uncover proce-dures that should be modified and changed to pre-vent further similar incidents.

The current culture of blame and litigation alsoworks against the use of voluntary error report-ing. As several respondents indicated, until the le-gal system is changed to protect physicians’ rightsand hospital administrators’ rights to maintainprivate data on errors and near-misses, it is lesslikely that such data will be collected and analyzed.

Yet these data provide the best opportunity avail-able for addressing the system-wide weaknessesor latent errors that may pose greater recurringthreats to patient safety than singular incidentsof personal incompetence.

The analysis of trends in medical errors and ofrepeated mishaps, as well as the development ofprotocols and the implementation of standard pro-cedures, may lead to safer patient care. As one re-spondent said of the first scenario, “What ORdoesn’t count sponges? If your standard procedureis to count sponges, such mistakes cannot occur.”It is a sad fact that even though almost all institu-tions may now monitor OR equipment and mate-rials on a routine basis, sponges and instrumentscontinue to be left in surgical patients, even whenthe count was either reported as “correct” or thereport of “incorrect” was ignored. Factors such asthe critical shortage of nurses, temporary or floatpersonnel in high-risk areas such as the operat-ing or emergency room, and even cost pressuresmay be factors that influence the ability of com-mitted medical professionals to limit errors.

While overall these results support that sur-geons are motivated by professional values suchas responsibility, duty, and altruism, surgeonsmust be willing to identify colleagues who are care-less with patients, whether due to substance abuse,outdated skills, or indifference. Systems problemsin no way absolve from blame or censure individu-als who are negligent or incompetent.

Respondents had reservations about mandatoryreporting systems and about the development andimplementation of surgical protocols as ways toreduce the rates of adverse incidents. Both ap-proaches have limitations, some of which werehighlighted in comments from survey respondents.Mandatory reporting systems may expose indi-viduals to censure instead of being used to under-stand system-wide patterns. Surgeons may not bewilling to follow protocols, and protocols may beless useful in some surgical procedures or at somehospitals or surgical facilities than at others.

This pilot study methodology also has limita-tions that must be addressed before generalizingthese results to other populations. A response rateof 28 percent is acceptable for this type of “unoffi-cial” study; a study sponsored, for instance, by theAmerican College of Surgeons would no doubt en-courage a broader response. When cases similar

Dr. Roscoe is assistantprofessor, division ofmedical ethics andhumanities anddivision of geriatricmedicine, College ofMedicine, University ofSouth Florida, Tampa,FL.


17

to this were used at ethics colloquia at the Clini-cal Congress, a larger percentage of surgeons in-dicated they may have been tempted to concealthe finding of the sponge. The use of hypotheticalscenarios to elicit opinions about controversialsubjects was supported; the response rate was ac-ceptable and the resulting data yielded meaning-ful results.

This pilot survey of practicing surgeons was con-ducted to elicit their approach to two hypotheticalsituations in which error led to adverse conse-quences. Almost all surgeons believe that issues oferror need to be shared with patients and, to a some-what lesser degree, with the institution. A majorityof surgeons support more widespread use of proto-cols, particularly on the more common procedures.There is widespread concern about the legal conse-quences of mandatory reporting and the conflictbetween an ethical duty to address adverse eventsand the punitive consequences from reporting.

This study was supported by a pilot research grantfrom the Institute on Aging, University of SouthFlorida, Tampa, FL.

References

1. Thomas EJ, Studdert DM, Newhouse JP, et al:Costs of medical injuries in Utah and Colorado.Inquiry, 36:255-264, 1999.

2. Brennan TA, Leape LL, Laird NM, et al: Incidenceof adverse events and negligence in hospitalizedpatients: Results of the Harvard medical practicestudy I. N Engl J Med, 324:370-376, 1991.

3. Thomas EJ, Studdert DN, Burstin HR, et al: Inci-dence and types of adverse events and negligentcare in Utah and Colorado in 1992. Med Care (inpress).

4. Centers for Disease Control and Prevention:Deaths: Final data for 1997. Natl Vital Stat Rep,47:27, 1999.

5. Thomas EJ, Studdert DM, Brennan TA: The reli-ability of medical record review for estimating ad-verse event rates. Ann Int Med, 136:812-816, 2002.

6. Krizek TJ: Surgical error: Reflections on adverseevents. Bull Am Coll Surg, 85(7):18-22, 2000.

7. Andrews LB, Stocking C, Krizek T, et al: An alter-native strategy for studying adverse events inmedical care. Lancet, 349:309-313, 1997.

8. Krizek TJ: Surgical error: Ethical issues of adverseevents. Arch Surg, 135:1359-1366, 2000.

9. Reason J: Human error: Models and management.BMJ, 320:768-770, 2000.

10. Chassin MR, Becher EC: The wrong patient. AnnInt Med, 136:826-833, 2002.

Dr. Krizek is professorof surgery, medicine

(ethics), and courtesyprofessor of religious

studies, department ofreligious studies,

University of SouthFlorida, Tampa, FL. Heis a former Regent andFirst Vice-President of

the College.

11. Kohn LT, Corrigan JM, Donaldson MS (eds): ToErr Is Human: Building a Safer Health System.Committee on Quality of Health Care in America,Institute of Medicine. Washington, DC: NationalAcademy Press, 2000.

12. Bosk CL: Forgive and Remember: Managing Medi-cal Failure. Chicago, IL: University of ChicagoPress, 1989.

13. Krizek TJ: Ethics and Philosophy Lecture:Surgery...Is it an impairing profession? J Am CollSurg, 194(3):352-366, 2002.

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18

by Jon H. Sutton, State Affairs Associate,Division of Advocacy and Health Policy


18

For the past few years, the American Col-lege of Surgeons has been expanding itsadvocacy efforts to include greater in-

volvement in state legislative and regulatoryissues. Fellows and chapters have indicated inmembership surveys and during visits fromCollege leadership and staff that they wouldlike the College to be more supportive of theirefforts to advocate in their state legislatures.In fact, a 2001 survey of the chapters indicatedstrong support for the College’s developmentof advocacy resources for use by chapters, suchas sample letters to legislators, fact sheets, is-sue briefs, and so on.

This article highlights some of the advocacyresources the College has created so far to as-sist Fellows and chapters in their federal andstate advocacy efforts. Most are available foreasy access on the College Web site, primarilythe Division of Advocacy and Health Policy’shome page (http://www.facs.org/dept/hpa/index.html). Because this is an ongoing anddynamic process, it is important that sur-geons regularly visit this site to check onupdates to issues, publications, resource ma-terials, and so on. Web addresses for theother resources mentioned in this article arelisted in the box on page 19.

ACS offersadvocacy resources


19

Advocacy resourcesGrassroots advocacy sometimes seems to be a

confusing and frustrating effort. A lack of infor-mation about an issue, unfamiliarity with the“how-tos” of legislative advocacy, uncertaintyabout the effects of advocacy activities, and theidea of squeezing one more activity into an alreadybusy schedule can make grassroots lobbying anintimidating proposition. However, the followingInternet resources should help.

• Staff: The College has committed consider-able staff resources to its Division of Advocacy andHealth Policy. This Division is involved in numer-ous socioeconomic issues and activities. Its Webpage contains links to information for College-sponsored CPT coding workshops, practice man-agement courses, and the CPT coding hotline, aswell as a complete list of Division staff, includingcontact information and areas of responsibility.Calling a staff person in the Division is a good firststep toward learning more about an issue, gettingadvice on which legislators or government officialsto contact, and so on. The Washington Office,which handles all federal activity, can be contactedat 202/337-2701. Questions about state legislativeor regulatory issues should be directed to Chris-topher Gallagher, Manager, State Affairs, in theCollege’s Washington Office, or Jon Sutton, StateAffairs Associate, in the College’s Chicago Officeat 312/202-5358.

• Legislative Action Center (LAC): This simple,user-friendly Web-based advocacy tool is an excel-lent way for surgeons to advocate on their behalf.The LAC requires entry of a zip code, which helpsidentify federal legislators. It contains action alertson such issues as Medicare payment, trauma fund-ing, and federal tort reform, and provides sampleletters to legislators that can be sent by e-mail di-rectly from the action center. These letters are easyto modify to reflect a surgeon’s personal situationand the effect proposed legislation could have onhis or her patients. Also, the LAC convenientlylinks a surgeon to his local media outlets (news-papers, magazines, television and radio stations),so that surgeons can get the message out to thepublic and to patients, who can serve as effectiveadvocates on any issue.

While the Legislative Action Center currentlyis structured to address federal issues only, the Col-lege anticipates that a state legislative component

will be added by the end of this year. When thisnew service becomes available, chapters will beable to direct their members to action alerts forissues popping up in their state legislatures.

• State issues database: This database providessurgeons and chapters with important informa-tion on proposed state legislation and regulation,including bill number and subject, legislative pro-visions, and bill status. The database is search-able by state, issue, legislative text, or date. Be-cause new bills are added on a regular basis, and

Web addressesWeb addressesWeb addressesWeb addressesWeb addresses

Division of Advocacy and Health Policywww.facs.org/dept/hpa/index.html

ACS Advocacy and Health Policy staffwww.facs.org/dept/hpa/staff.html

Legislative Action Centerhttp://capwiz.com/facs/home/

State issues databasehttp://web.facs.org/statelegislative/default.htm

Tips for communicating with legislatorswww.facs.org/dept/hpa/tips.html

State legislature Web siteswww.facs.org/dept/hpa/statesites.html

Publications on socioeconomic issueswww.facs.org/dept/hpa/pubs/pubs/html

ACS views on particular issuesh t t p : / / w w w. f a c s . o r g / d e p t / h p a / v i e w s /views.html.

Other resourceswww.facs.org/dept/hpa/otherres.html

Scope of practice action kitwww.facs.org/dept/hpa/scopeofpractice.html

Professional liability action kithttp://www.facs.org/dept/hpa/proliability.html


20

others are periodically updated, surgeons are en-couraged to regularly visit this database.

• Communicating with legislators: Critical tograssroots advocacy is effective communicationwith legislators and other government officials.Whether communication is conducted in writtenor oral form, it is important to understand andfollow a few simple “do’s and don’ts” for writingletters, talking with a legislator, or setting up ameeting. These tips are easily printed for sharingwith colleagues, who should be encouraged to con-tact their legislators when an action alert is sentout.

• State legislature Web sites: Each state legis-lature has a Web site that contains volumes of in-formation relating to bill status/history and text,pages for state senators and representatives, andlists of legislative committees and their hearingschedules. They can also serve as tools for identi-fying an individual’s elected officials, reviewingvoting information, and so on. Fellows should visittheir state’s Web site and become familiar withthe various features and information available.

• Publications on socioeconomic issues: It isimportant to know in advance of communicatingwith policymakers exactly what to say about anissue. To help surgeons understand socioeconomicissues, for many years, the College has publishedarticles, health policy briefs, and newslettershighlighting state and federal issues. By visitingthe link listed on page 19, surgeons can find theseitems in one convenient place. In addition, ACSviews on particular issues are available.

• Other Internet resources: Searching theInternet for anything may be a frustrating and time-consuming experience, with thousands of hits on anyone topic. To help narrow the focus, the College’sWeb site identifies some useful legislative Internetsites, as well as links to the legislative/governmen-tal relations pages of the national surgical specialtysocieties. All these items are found at the Web sitelisted above.

Chapter-focused resourcesOne issue that came to the College’s attention

earlier this year was that of single-degree oral sur-geons working to revise the definition of the prac-tice of dentistry to expand their scope-of-practiceinto cosmetic surgery of the head and neck. Toassist chapters in responding to these efforts (and

to provide them with a warning that this situa-tion could happen in their states), the College de-veloped and distributed a scope of practice actionkit. It provided a briefing on the issue and sugges-tions for advocacy activities, such as contactingstate dental boards to be placed on their meetingmailing list, working with state specialty andmedical societies, and communicating with statelegislators.

The College also developed a professional liabil-ity action kit to help chapters and Fellows dealwith the current malpractice insurance crisis. Fel-lows from around the country have noted prob-lems with rapidly increasing professional liabil-ity insurance premiums or with their ability topurchase insurance at any price. The kit details aseries of action steps, including writing legislators,governors, and insurance commissioners (withsample letters to follow) and working with statemedical and surgical specialty societies throughcoalitions. It also provides contact information forvarious groups, individuals, and entities. Finally,the kit contains some sample letters for use in con-tacting local media outlets (easily accessiblethrough the Legislative Action Center describedearlier in this article).

The professional liability action kit has its ownWeb page. Be sure to visit it and make use of itsmaterials when it comes time to push for tort re-form in your state.

Final thoughtsAdvocacy efforts need to begin now in order to

prepare for the 2003 state legislative sessions.Whether the issue is scope of practice, tort reform,Medicare payment, regulation of office-based sur-gery, or one of particular concern in a specific state,legislators and other government officials need toknow how these policies affect the practice of sur-gery and access to care. Visit the College Web siteto find out the latest on a particular issue and newaction alerts for the Legislative Action Center.Check your e-mail regularly, as this is often thefastest way to alert Fellows and chapters aboutcontacting legislators. �


21

Surgical residency is first and foremost an educa-tional experience based on direct patient care. Im-

plicit in a residency program is the principle that allpatient care provided by residents is safe and well su-pervised. Patients have a right to expect a healthy, alert,responsible, and responsive physician.

It is, therefore, inappropriate for teaching hospitalsto rely upon residents to perform tasks that are not di-rectly related to either education or patient care. Thesedemands threaten the educational system and are aprincipal reason for excessive work hours. It is essentialthat hospitals provide sufficient support personnel toperform these noneducational tasks. It is also essentialthat residents be provided with appropriate support andsupervision from faculty who exemplify professional-ism in all aspects of patient care and interpersonal in-teractions. Finally, there must be comfortable facilitiesin which residents may rest, eat, and study, as well asopportunities outside the work environment for personaldevelopment.

Quality patient care, now and in the future, is de-pendent on quality graduate education. It is critical thatthe work environment be monitored, modified, andoptimized in order to achieve this important goal.

Statement on residency work hours

In January 1994 the American College ofSurgeons published its recommendationsconcerning “Surgical Residencies and theEducational Environment” (Bull Am CollSurg, 79[1]89-93). The following statementaddresses the specific issue of residency workhours and the importance to patients of pro-fessionalism and continuity of care. It alsohighlights the need to improve working con-ditions and the educational environment forall surgical residents so that they can providecare of the highest quality to their patients.This statement was developed by the Candi-date and Associate Society of the AmericanCollege of Surgeons and was approved bythe Board of Regents at its June 2002 meet-ing.


21


22

In compliance...

...with HIPAA rulesby the Division of Advocacy and Health Policy

Since this series began, the U.S. Departmentof Health and Human Services has issued ad-ditional clarifications about the privacy pro-

visions of the Health Insurance Portability and Ac-countability Act (HIPAA). As originally proposed,the HIPAA privacy regulation would have requiredevery practice to develop and provide several formsto patients. The use of some of these forms, includ-ing the consent form, is now optional. This month’scolumn begins our look at the required documents.

Authorization formEach practice should develop a patient authori-

zation form. The form is not required to treat allpatients, but in some instances physicians mustrequest and receive authorization. The authoriza-tion process provides the patient with the oppor-tunity to ask questions, to negotiate how their in-formation will be used and disclosed, and ulti-mately to control whether these uses and disclo-sures will be made. A patient must sign the autho-rization form before a practice may use or discloseinformation for most purposes beyond treatment,payment, and health care operations.

According to HIPAA, payment means all the ac-tivities performed by a practice to obtain or pro-vide reimbursement for the provision of healthcare. Hence, payment includes determinations ofeligibility or coverage under a health plan, billing,claims management, collection activities, and re-lated health care data processing.

A practice does not need authorization to releasenecessary information to health plans and theiragents and business associates of the practice. Au-thorization is not required to disclose informationdirectly relevant to a family member or any otherperson identified by the patient, if that person isinvolved with the patient’s care or payment forhealth care, unless the patient has requested thatsuch disclosure not be made and you have agreed.

Authorization is not required if the patient isincapacitated or in an emergency situation and,in your professional judgment, the disclosure of theinformation is in the best interests of the patient.

Authorization does not apply if use or disclosureis required by law (that is: public health activities;reporting victims of abuse, neglect, or domesticviolence; reporting decedents and their organ, eye,or tissue donation; law enforcement purposes andjudicial and administrative proceedings; or effortsto avert a serious threat to health or safety). Au-thorization will be required for the disclosure ofany confidential information to life insurance com-panies, automobile insurance companies, or work-ers’ compensation carriers.

An authorization form must use plain languageand should include the patient’s name, date ofbirth, and identification number. Each authoriza-tion must specify the release under consideration,so the form should allot space for entering thatinformation. The form also should include the fol-lowing “core elements”:

• A description of the information to be usedor disclosed.

• Identification of the individuals authorizedto use or disclose the protected health information.

• Identification of who will receive protectedinformation.

• A description of each purpose of the use ordisclosure.

• An expiration date or event for the authori-zation.

• Any special privacy provisions included instate law. A good resource for links to state pri-vacy regulations can be found on the National As-sociation of Insurance Commissioners Web site(http://www.naic.org/1privacy).

• The patient’s signature and date or, if theform is signed by a personal representative, a de-scription of his or her authority to act for the pa-tient.

In addition, the authorization form is not validunless it contains the following information re-garding patient rights:

• The patient may revoke the authorization inwriting. This revocation may be accomplished ineither of two ways: (1) through a statement regard-

continued on page 33


23

Socioeconomictips of the month

Around the corner

October• 2003 ICD-9-CM code changes effective Oc-

tober 1. The 90-day implementation period dur-ing which Medicare will allow claims to be sub-mitted with the 2002 and the 2003 ICD-9-CM codeversions begins.

• Quarterly update to 2002 Medicare feeschedule effective October 1.

• Quarterly update to 2002 Correct CodingEdits effective October 1.

• ACS-sponsored basic coding workshop forsurgeons on October 8, during the Clinical Con-gress in San Francisco, CA. To register for PG25,go to http://www.facs.org/clincon2002/index.html.

• Health Insurance Portability and Account-ability Act (HIPAA) transaction compliance plansmust be submitted to CMS electronically or post-marked by October 15, 2002. To access and down-load the form or to file electronically go to http://www.cms.hhs.gov/hipaa/hipaa2/default.asp.

All specific references to CPT terminology and phraseologyare: CPT only © 2001 CPT American Medical Association. Allrights reserved.

In addition to understanding CPT and ICD-9-CM coding, surgeons and their staffs alsoshould be aware of the regulatory variables that

affect reimbursement. Most physicians are famil-iar with the Medicare correct coding initiative ed-its, which cause certain procedures to be incorpo-rated, or bundled, into other procedures and a de-crease in anticipated reimbursement.

Some other factors may affect acceptance of yourMedicare claims as well. In some cases, the Cen-ters for Medicare & Medicaid Services (CMS) is-sues a national coverage policy for a procedure.(To access the current Medicare national cover-age policies for medical procedures and diagnos-tic tests, go to http://www.hcfa.gov/pubforms/06_cim/ci00.htm.) If there is no CMS policy, Medi-care carriers may develop local medical reviewpolicies (LMRPs) to provide reporting standardsfor procedures. Both types of policies describe thecircumstances for Medicare coverage for specificmedical service procedures or devices.

A LMRP explains the clinical circumstancesunder which a service would be covered, correctlycoded, and considered medically reasonable andnecessary. The policy generally contains:

• A detailed description of the procedure.• Diagnoses and a list of the ICD-9-CM codes

that support the medical necessity for the proce-dure.

• Reasons why the carrier will consider theprocedure a covered service.

• Coding guidelines.• Documentation requirements.• National statutes and guidance that could af-

fect the carrier’s coverage policies.• Reasons for denial of a claim for the service.• Sources of the information (medical litera-

ture, the advice of local medical societies and medi-

cal consultants, and public comments) the carrierconsidered in developing the coverage determina-tion.

• All effective and revision dates and the ra-tionale for revising the policy.

All LMRPs may be viewed at http://www.lmrp.net. They are posted by carrier and canbe downloaded as zip files.

Application of LMRPsLMRPs only apply to claims that are submitted

to the carrier issuing the policy. A LMRP may notconflict with a Medicare national coverage deci-sion once that coverage decision is effective. How-

Understanding localmedical review policiesby the Division of Advocacy and Health Policy

continued on page 35


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Collegenews

On July 25, 2002, the surgicalcommunity lost a dear friendand colleague. C. James Carrico,MD, FACS, was one of thoseunique individuals who excelledin clinical care, investigativeskills, and administrative prow-ess. A visionary in his time, hewill long be remembered for hisunexcelled loyalty and dedica-tion to the American College ofSurgeons and his influence onsurgeons throughout the world.

The son of an educator, hefollowed in the footsteps of hisfather, who led the chemistrydepartment at his alma mater,North Texas State University.Jim’s leadership ability wassoon recognized and, upongraduation from The Univer-sity of Texas SouthwesternMedical School, he was selectedto receive the prestigious HoDin award as the outstandingsenior medical student.

During his residency, he wasunexpectedly thrust into his-tory as the first physician tocare for President John F.Kennedy at Parkland Memo-rial Hospital on that fatefulday in November 1963. True tohis character, he kept that inproper perspective, rarely dis-cussed, and never speculatedabout the circumstances sur-rounding the event.

Throughout his distinguishedcareer he was always able tobalance his professional inter-

ests and responsibilities withunparalleled love, devotion,and dedication to his lovelywife Sue and their three chil-dren.

Often seen as a serious indi-vidual, he had a sense of humorand a devilish side of his per-sonality that was youthful andrefreshing. He often said,“What we do is a serious busi-ness; however, we must nevertake ourselves too seriously.”He lived by that dictum andwas as comfortable in a pair ofjeans tromping around his be-loved home on Whidbey Islandas addressing a national audi-

ence in formal attire.His accomplishments are

well known. He was the con-summate educator who was of-ten called upon to lead manyorganizations, including theAmerican Board of Surgeryand the American Associationfor the Surgery of Trauma,which he did with diplomacyand grace. He had the enviousability to bring people togetherand achieve consensus whencompromise was difficult toaccomplish.

Despite his intense interest intrauma and critical care, he wasfirst a general surgeon andknowledgeable in all aspects ofthe specialty. He served as de-partment chair at the Univer-sity of Washington and his almamater, The University of TexasSouthwestern Medical School inDallas. Throughout his career,he championed the establishedprinciples and ideals that allowboth young and old surgeonsalike to be able to deliver thehighest quality of care to theirpatients. In his later years,much of his energy was directedtoward prevention of injury. Hesaw this as a major public healthissue, and weeks before his pass-ing was tenaciously lobbyingthis cause.

His work with the AmericanCollege of Surgeons was leg-endary. He served on 34 com-mittees, beginning with the Pre-

In memoriam

C. James Carrico: Farewell to a friendby Erwin R. Thal, MD, FACS, Dallas, TX

Dr. Carrico


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In accordance with Article I,Section 6, of the Bylaws, the An-nual Meeting of the AmericanCollege of Surgeons is called fortwo o’clock in the afternoon ofThursday, October 10, 2002, inthe Moscone Center, San Fran-cisco, CA.

This session constitutes theannual business meeting of theFellows, at which time Officers

OFFICIAL NOTICE

Annual Meeting of Fellows and Initiates,American College of Surgeons

and Governors will be elected,and reports from officials will bepresented. Items of general in-terest to the Fellows will also bepresented. Each Fellow is re-spectfully urged to be present.

John O. Gage, MD, FACSSecretary,

American College of SurgeonsAugust 9, 2002

and Postoperative Care Com-mittee in 1975, and his serviceculminated with chairing theBoard of Regents from 1999 to2001. Of all his accolades, be-coming the President-Elect ofthe College ranked as one of themost meaningful.

Jim was an inspiration to allwho knew him. The manner inwhich he faced his final battlewith cancer exemplified his posi-tive attitude and zest to con-tinue the work that was so im-portant to him.

Earlier this year, more than300 of his friends and col-leagues helped to establish theC. James Carrico, MD, Distin-guished Chair in Surgery forTrauma and Critical Care atthe University of Texas South-western Medical Center in Dal-las. This is only the second en-dowed chair in trauma in thenation and will allow hismemory to continue in perpe-tuity. This chair was a fittingtribute, honoring a person whohad unselfishly given so much

of himself and influenced somany in such a humble man-ner. He was an outstanding,teacher, mentor, clinician, in-vestigator, administrator,friend, and, above all, a de-voted son, husband, and father.

C. James Carrico has left anenviable legacy for which he willalways be remembered.

Farewell my friend.

The Pacific Vascular ResearchFoundation is accepting applica-tions for the 2003 Wylie ScholarAward in academic vascular sur-gery. The award was establishedby the foundation to honor thelegacy of Edwin J. Wylie by pro-viding support to outstandingvascular surgeon-scientists.

Purpose. The award is in-tended to enhance the careerdevelopment of academic vascu-lar surgeons with an establishedresearch program in vasculardisease. The award consists of agrant in the amount of $50,000per year for three years. Fund-ing for the second and thirdyears is subject to review of ac-ceptable progress reports. Thisthree-year award is nonrenew-able and may be used for re-search support, essential ex-penses, or other academic pur-poses at the discretion of thescholar and the medical institu-tion. The award may not be usedfor any indirect costs.

Eligibility. The candidate

must be a vascular surgeon whohas completed an accredited resi-dency in general surgery andwho holds a full-time appoint-ment at a medical school accred-ited by the Liaison Committeeon Medical Educators in the U.S.or the Committee for the Ac-creditation of Canadian MedicalSchools in Canada.

Applicants sought for Wylie Scholar Award

To apply. Applications are dueby February 1, 2003, for theaward to be granted July 1, 2003.Applications for the WylieScholar Award may be obtainedby contacting the Pacific Vascu-lar Research Foundation, 3627Sacramento St., San Francisco,CA 94118; tel. 415/771-3541, fax415/771-3902.

Dr. Thal is professor of surgery,University of Texas SouthwesternMedical School, Dallas, TX.


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Produced annually, the catalog reflects thediversity of publications the College developsto keep you, the busy practicing surgeon,informed about recent developments andcurrent standards that affect our dynamicprofession. With a broad range of topics—from trauma performance improvement tohealth policy issues—the catalog is a valuableresource for College members. And it isimmediately available through the College’sWeb site at:

http://www.facs.org/commerce/2002/catsplash.html

For immediate service, browse and order titlesonline and place your order by credit cardthrough a secured Web server. Or print outyour own paper copy of the catalog—and itscorresponding order form—and send in yourorder by mail or fax.

As new titles are added throughout theyear, the online catalog will be updated imme-diately. It’s fast, easy to browse, and alwaysup-to-date, the 2002-2003 Publications andServices Catalog.

Point your browser toThe 2002-2003

Publications and Services CatalogAmerican College of Surgeons

Now Online!Over 100 titlesthat reflectthe diversity ofsurgical practice

PUBLICATIONS&SERVICESAmerican College of Surgeons


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John E. Connolly, MD,FACS, and Sir RobertShields, MD, FACS (Hon)were recently named honoraryfellows of the Japanese Coun-cil for Medical Training. Dur-ing the same visit to Tokyo, theyboth served as guest speakers atthe annual meeting of the Ja-pan Hospital Association. Dr.Connolly is a thoracic surgeonand professor of surgery at theUniversity of California,Irvine, Medical Center, and Dr.Shields is a general surgeon inMerseyside, UK.

The American Association forHand Surgery recently pre-sented its clinician/teacher of theyear award to Michael E.Jabaley, MD, FACS, a plasticsurgeon. The award is pre-sented to individuals who havemade major teaching contribu-tions in the field of hand sur-gery. Dr. Jabaley was recog-nized for his more than 25years of service as a clinicalprofessor at the University ofMississippi School of Medicinein Jackson, MS.

Earlier this year, Steven T.Kmucha, MD, FACS, waselected chair of the CaliforniaMedical Association’s (CMA’s)President Forum and was re-elected chair of the CMA’s Com-mittee on Quality Care. Dr.Kmucha is a clinical instructorin otolaryngology at StanfordUniversity, in Stanford, CA.

In May 2002, PresidentGeorge W. Bush appointed

LaSalle D. Leffall, Jr., MD,FACS, to serve as chair of thePresident’s Cancer Panel. Thethree-member group overseesthe national cancer programand reports directly to thePresident. In addition to thisprestigious position, Dr.Leffall, a Past-President of theCollege, chairs the steeringcommittee of the National Dia-logue on Cancer and the SusanG. Komen Breast Cancer Foun-dation. Dr. Leffall is a profes-sor of surgery at Howard Uni-versity Hospital in Washing-ton, DC.

Fellows and facts

Balak R. Verma, MD, FACS,FRCS(C), recently received theFirst Millennium Award of“Himachal Ratan” (The Jewel ofHimachal) from the All IndiaConference of Intellectuals. The20-year-old organization wasfounded by Indira Gandhi,former prime minister of India,and the award honors individu-als who the group determineshave made exceptional contribu-tions in the areas of humanism,peace, and patriotism. Dr.Verma, a thoracic surgeon,works full-time as a medical mis-sionary in the Himalayas.

ACS Executive Director Thomas R. Russell, MD, FACS (left), congratulatesDonald J. Palmisano, MD, FACS, on becoming president-elect of theAmerican Medical Association during the organization’s annual meetingthis past June.


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The ACS Committee on Pa-tient Safety and ProfessionalLiability will sponsor two paneldiscussions during this year’sClinical Congress in San Fran-cisco, CA, that address liabilityand patient safety issues.

• Patient Safety: Medical Er-rors and Improving PatientSafety, will be held Tuesday, Oc-tober 8, from 8:00 to 10:00 am.Frank C. Spencer, MD, FACS,will serve as moderator.

Current experiences and newapproaches to patient safety willbe discussed. Emphasis will begiven to methods that any hos-pital can use, including: (1) thenew concept of the “clinical ex-pert” with adverse event com-mittees (other important com-ponents include decentraliza-tion of authority and continuingresponsibility); and (2) a concur-rent study of all patient deathsfor contributory adverse events.Specific topics will includewrong-site, wrong-patient, andwrong-procedure operations inboth inpatient and ambulatorysettings.

Topics and panelists are as fol-lows: Preventing Surgical Er-rors and Adverse Events UsingInformation Technology, DavidBates, MD, FACS, Boston, MA;Eliminate Medical Errors vs.Improve Patient Outcomes: CanWe Have It All?, William C.Nugent, MD, FACS, Lebanon,NH; and Building a PatientSafety Program in a UniversityHospital, Frank C. Spencer, MD,FACS, New York, NY.

• The Surgeon and the Law:Patient Confidentiality—Sur-geon, Patient, and GovernmentPerspective, will be held Tues-day, October 8, from 1:30 to 4:30pm. John M. Daly, MD, FACS,will serve as moderator.

Patient confidentiality isdeemed to be a hallmark of theHippocratic Oath. Yet, rules ofconfidentiality and their appli-cations are changing by directgovernment action. Rules applynot only to physicians but topharmacies, HMOs, hospitals,and multiple health care provid-ers. The symposium will addressthese changing rules and the re-quirements for surgeons’ adher-ence. Penalties for nonadher-ence to these new rules are se-vere and far-reaching. Thus,knowledge of this changing en-

vironment is critical to all prac-ticing surgeons and surgicalresidents.

Topics and panelists for thissession are as follows: The NewPeer Review Dilemma: Confi-dentiality vs. Disclosure, F. DeanGriffen, MD, FACS, Shreveport,LA; Health Insurance Portabil-ity and Accountability Act(HIPAA) Privacy Rule: Over-view, Ira Pollack, San Francisco,CA; Practical Applications ofConfidentiality in the Phy-sician’s Office, JacquelineDarrah, MA, JD, Chicago, IL;Health Privacy in the States,Jon Sutton, MBA, Chicago, IL;and The Surgeon’s Perspectiveon the Legal Issues, A. CraigEddy, MD, JD, LLM, FACS,Missoula, MT.

Liability and patient safety issuesto be addressed at Congress

Dr. Spencer Dr. Daly


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The American College of Sur-geons and 14 surgical specialtyorganizations recently under-took a process to update a studyon the need for a physician as anassistant at surgery for all pro-cedures listed in the “Surgery”section of the American MedicalAssociation’s Current Proce-dural Terminology (CPT™)2002.

Each organization was asked

to review procedure codes appli-cable to their specialty and de-termine whether the operationrequires the use of a physicianas an assistant at surgery: (1)almost always, (2) almost never,or (3) some of the time.

The report, Physicians As As-sistants at Surgery: 2002 Study,is widely used by third-partypayors to determine which pro-cedures require the use of a phy-

sician assistant. This is thefourth edition of the study, whichwas first conducted in 1994. Fora downloadable copy of the 2002document, go to http://www.f a c s . o r g / d e p t / h p a / p u b s /pubs.html. A hard copy of thedocument may be requested bycontacting [email protected] or by calling 312/202-5474.

Report on physicians as assistantsat surgery available

Change your address online!

At this year’s Clinical Con-gress, the textbook ACS Sur-gery—an official College publi-cation—celebrates the launch ofits electronic newsletter, What’sNew in ACS Surgery. This con-venient newsletter highlightskey recommendations from thelatest updates to ACS Surgery.Plus, What’s New features amonthly column on a variety oftopics from today’s leading sur-

geons. The newsletter also in-cludes a free e-mail alert serviceto electronically “tap readers onthe shoulder” when new infor-mation is available online.

Sign up for this service atwww.acssurgery.com. Just clickon the link “FREE by e-mail”under What’s New in ACS Sur-gery. Or sign up at the Congressat the ACS Surgery booth,#1800.

While visiting the booth, takeadvantage of special ClinicalCongress savings. ACS Fellows,Associates, and Candidates cansubscribe to ACS Surgery at adiscounted member price. Foradditional savings, pick up anACS Surgery savings coupon,available with the Clinical Con-gress Program Book, andpresent it at booth #1800.

New service, Congress savingsavailable from ACS Surgery

Just visit www.facs.organd go to the “Members Only” tab


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ing the right to revoke and providing instructionson how to exercise such a right; or (2) by includinga reference to the practice’s privacy notice, if thisinformation is included in the privacy notice.

• The provider may not condition the patient’streatment on obtaining the authorization exceptfor a research-related treatment or if the purposeof creating the information is for disclosure to athird party, such as a life insurance examination.

• The patient must be made aware that thereis a potential that the health information may nolonger be protected by the privacy rule once it isdisclosed by the practice.

Practices that receive an authorization are re-quired to provide the individual with a copy of thesigned authorization form. You also need to recordthat you received the authorization and retain acopy of the form in the patient’s file.

Next month, we’ll look at the components of the“notice of privacy practices” that will need to beprovided to all patients.

Tip for privacy officerHIPAA requires practices to have contingency

plans to ensure confidential data are available fol-lowing any kind of disaster (floods, fires, and soon) or interruption (such as computer, transmis-sion, and related events). Each practice needs toevaluate where confidential information is kept.Is patient information kept in paper files or in spe-cific software programs? You also need to deter-mine which systems are critical to the operationof the practice. If the computer system is down, doyou have access to necessary information so thatpatients can be treated? If you use the fax machineto order tests and get test results, how will the prac-tice perform those tasks if the fax is broken?

ACS guidance on HIPAA issues is based on informa-tion contained in the “Small Practice ImplementationGuide” version 1.2 (http://snip.wedi.org/public/articles/index.cfm?Cat=17), © 2001, The Workgroup on Elec-tronic Data Interchange.

IN COMPLIANCE, from page 22

�


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ever, a contractor may develop a LMRP thatsupplements a national coverage decision.

Before policies are implemented, they are pub-lished in draft form for public comment and arepresented to the Medicare Carrier Advisory Com-mittees for their review. You may view draftLMRPs on your carrier Web site or at http://www.draftlmrp.net.

Although LMRPs apply primarily to the Medi-care program, some private payors have developed

and published LMRPs for their plans. You maywant to contact all your local practice contractsto find out if they have medical review policiesavailable for their providers.

Because local medical review policies containprocedures, the diagnoses for which a carrier be-lieves the procedures are appropriate, and docu-mentation requirements for the procedures, theyrepresent a good teaching tool for surgeons andtheir staffs.

SOCIOECONOMIC TIPS, from page 23

The speakers will be Ajit K. Sachdeva, MD, FACS, FRCSC, Director of the College’s Division of Education,

and Michael E. Whitcomb, MD, Senior Vice-President for Medical Education and Director, Division

of Medical Education, Association of American Medical Colleges. Dr. Whitcomb is also Editor-in-

Chief of Academic Medicine, the leading journal devoted to issues relevant to academic medicine.

There will be an open-microphone discussion following their presentations.

For more information about this event or the CAS-ACS, contact Peg Haar at the ACS via email at

[email protected] or via telephone 312/202-5312.

CAS SymposiumClinical Congress

2002

The Candidate and Associate Society of the American College of Surgeons(CAS-ACS) invites all residents, residency program directors, and Associate

Fellows to attend a symposium on professionalism and how it is taught inthe medical environment during the Clinical Congress in San Francisco. The symposium

will be held Sunday, October 6, 2002, from 2 to 5 pm.

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Highlightsof the ACSPABoard of Directorsand the ACSBoard of Regentsmeeting

June 7-8, 2002

by Paul E. Collicott, MD, FACS,Director,Division of Member Services

American College of Surgeons Profes-sional Association (ACSPA)

Steps have been taken to implement thebusiness plan to establish the 501(c)(6) cor-poration. Corporate papers—including aBoard of Directors slate and Bylaws—to es-tablish the entity have been filed with the stateof Illinois. A budget has been approved, andadditional staffing has been taken into ac-count.

The Officers of the ACSPA Board of Direc-tors (B/D) are: R. Scott Jones, MD, FACS,Charlottesville, VA, President; Edward R.Laws, MD, FACS, Charlottesville, VA, Chair;John O. Gage, MD, FACS, Pensacola, FL, Sec-retary; John L. Cameron, MD, FACS, Balti-more, MD, Treasurer; Thomas R. Russell, MD,FACS, Chicago, IL, Executive Director; andGay L. Vincent, Chicago, IL, Comptroller.

The members of the ACSPA Board of Direc-tors (B/D) are (all MD, FACS): Barbara L. Bass,Baltimore, MD; L.D. Britt, Norfolk, VA; Will-iam H. Coles, New Orleans, LA; Paul E.Collicott, Chicago, IL; Edward M. CopelandIII, Gainesville, FL; A. Brent Eastman, LaJolla, CA; Richard J. Finley, Vancouver, BC;Josef E. Fischer, Boston, MA; Alden H.Harken, Denver, CO; Gerald B. Healy, Boston,MA; Margaret F. Longo, Hot Springs, AR; JackW. McAninch, San Francisco, CA; Mary H.McGrath, Maywood, IL; Jonathan L. Meakins,Montreal, PQ; John T. Preskitt, Dallas, TX;Ronald E. Rosenthal, Wayland, MA; andMaurice J. Webb, Rochester, MN.

Educating the Fellowship began with a coverstory in the April 2002 Bulletin, which fea-tured the new ACSPA logo developed in-house.Additional outreach efforts are planned forlater in the year, including a membership mail-ing in the early fall. In addition to dedicatedWeb pages, educational material will be avail-able at the ACS Resource Center during theClinical Congress.

The ACS Executive Staff has been briefedby counsel on some of the issues and opportu-nities that the new corporation presents. Onesuch opportunity is the initiation of a Politi-


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cal Action Committee (PAC). The ACSPA B/Dapproved the creation of a PAC. The B/D alsoconsented that the PAC should be separatelyincorporated. The PAC’s function will be tofurther the interests of all surgical specialistsand their patients.

The ACSPA B/D also approved the estab-lishment of a PAC Board to govern the PAC’sgeneral operations and set its goals and pri-orities. The appointed Board members—allMD, FACS—are: Andrew L. Warshaw, Bos-ton, MA, Chair; Gary M. Bloomgarden, NewHaven, CT; Bruce D. Browner, Farmington,CT; James K. Elsey, Thomaston, GA; JosefE. Fischer, Boston, MA; Jean Hausheer, In-dependence, MO; Jack W. McAninch, SanFrancisco, CA; Stephen D. McBride, Las Ve-gas, NV; Joseph S. McLaughlin, Baltimore,MD; Constantine A. Michas, Fresno, CA;Farouk N. Obeid, Detroit, MI; Richard T.Perry, Phoenix, AZ; Thomas V. Whalen, NewBrunswick, NJ; Daryl D. Wier, Winter Park,FL; Mitchell L. Willens, Tyler, TX; and PaulI. Wills, Fort Smith, AR.

American College of Surgeons (ACS)

Comptroller’s OfficeThe Regents approved the 2003 budget as

presented. There is a projected $1.6 millionbudget deficit prior to the projected incomefrom investment activities.

Ad Hoc Committee to Review theStructure, Composition, and Termsof the Board of Regents

The formation of this committee was an-nounced at the February 2002 meeting of theBoard of Regents. W. Gerald Austen, Chair,Barbara L. Bass, David G. Murray, J. PatrickO’Leary, Frank C. Spencer, and L. WilliamTraverso—all MD, FACS—are the membersof this committee. The committee has held twoconference calls, with a third call scheduledfor July. Dr. Austen will report on thecommittee’s deliberations and recommenda-tions at the Board of Regents’ October meet-ing.

Executive Committeeof the Board of Regents

The committee held its interim meetingApril 15 in conjunction with the College’sSpring Meeting. One of the many agenda itemswas the proposal for an in-house travel agent.With such an operation, the College could re-alize a significant cost savings and deliver ahigher level of service to its members. All trav-elers who would be reimbursed by the Collegewould be requested to use the ACS agent andcomply with a travel policy that would be de-veloped and administered by ACS staff. Thepolicy would be sensitive to the needs of thetraveler, as well as convenient for the travelerto use. The establishment of this operation wasapproved.

Joint Commission on Accreditationof Healthcare Organizations (JCAHO)

Robert B. Smith III, MD, FACS, one of thethree ACS-appointed commissioners, reportedon the March 1-2 meeting of the JCAHO Boardof Commissioners (BOC). The following is abrief list of activities that were addressed dur-ing the meeting:

• Patient safety, especially wrong-site sur-gery, is a strong emphasis of JCAHO.

• Core measures as indicators of clinicaloutcomes are on schedule in their developmentand implementation.

• JCAHO is moving forward with the cre-ation of ICU measure sets.

• The JCAHO is eager to enhance relation-ships with practicing physicians.

• It was reported that there has been someexodus of hospitals from JCAHO to “alterna-tive accreditors.” This trend is believed to beminimal, but a wake-up call nonetheless.

• Specific disease management certifica-tion by JCAHO has officially begun.

• Attention was given to ways to improvethe BOC engagement with the home care field.The decision was made to have a home carerepresentative present at the board meetingsto serve as a resource and to have one com-missioner responsible for providing liaisonwith that industry.


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• The board voted to modify agreementswith nine cooperative accreditation agencies,including the ACS Commission on Cancer.

• The board was informed that its execu-tive committee had chosen not to submit anapplication for JCAHO to compete for a PROrole in the state of Illinois.

• The board voted to change responsibil-ity for scoring sentinel event alerts over to aparallel system of “patient safety goals.”

• The JCAHO plans to convene a NationalSymposium on Patient Safety in the fall.

Charter on Medical ProfessionalismThe Regents endorsed the Charter developed

by the American Board of Internal Medicine(ABIM) Foundation, the American College ofPhysicians-American Society of InternalMedicine (ACP-ASIM) Foundation, and theEuropean Federation of Internal Medicine. Inaddition to asking societies for endorsement,ACP-ASIM is also asking medical schools toconsider adopting its principles in their cur-riculum. Packets of information on the Char-ter are available through the offices of theABIM and the ACP-ASIM.

CommunicationsThe 2002-2003 edition of the College’s

Publications & Services Catalog was postedon the College’s Web site in early April. Theonline Catalog is the only version availablethis year.

The Northern California Chapter cameonline in early May, bringing the known num-ber of chapters with Web sites to 36. A newoptional program is being rolled out to inter-ested chapters; template-driven software en-ables users to cut and paste text from a wordprocessing file into designated text fields. Thenew program does not require the user toknow HTML coding.

Since the deferral of action on an ACSBranding/Marketing-Advertising program,the College held a meeting of a working groupon communications issues in conjunction withthe Board meeting. Richard J. Finley, MD,FACS, served as the chair of the working

group, which submitted the following recom-mendations to the Board:

• Create a rapid-response team to developpolicies and training for ACS leaders in theareas of public image, patient advisory, andhealth care policy for the purpose of address-ing issues that are in need of a response fromthe College within 24 hours.

• Develop a public relations business plan.• Develop a task force to address relation-

ships with specialties and particularly focuson common education and health care policyissues.

• Support the educational programs thatare being addressed by the Division of Educa-tion.

• Create and implement a timetable thatwill build value into the Web site and comple-ment the existing educational programs.

• Develop a personalized electronic rela-tionship with the Fellows that can be interac-tive.

The Regents approved the formation of arapid-response team. Its members are ACSFellows Ira Kodner, Chair; Dr. Finley; Dr.Fischer; Dr. Healy; Dr. McAninch; Dr. Russell;Linn Meyer, ACS Director of Communica-tions; and Cynthia Brown, ACS Director of theDivision of Advocacy and Health Policy.

Journal of the American Collegeof Surgeons (JACS)

Editorial preparations for 2005, the centen-nial year for JACS, have begun. In keepingwith the goals of an educational ACS grant,“Educating Surgeons in Patient Safety,” JACShas published a call for submissions that re-quests manuscripts about patient safety issues.The call will continue to run as space allows.JACS welcomes individual advertisementsabout ACS programs and will publish themwithout charge; all ACS Directors have beenurged to send material to the JACS editorialoffice.

An attempt to move the publication’s con-tent to a “new technology” Web site has stalleddue to problems with the new site. ElsevierScience, the Web site’s manager, is reworking


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Highlights, continued


39

its platform and were to have the revitalizedWeb site up by August 2002.

Simulators in surgical educationIn an effort to gain insight into the value of

simulators in medical education, the Collegesponsored a two-day symposium on the poten-tial utilization of simulators in surgical edu-cation. A cross section of individuals includ-ing surgeons, educators, engineers, and ex-perts in educational testing participated inthis discussion. The group concluded that theoverwhelming need facing all surgeons is toimprove patient safety and that simulationcan play a major role in advancing that aim.It was the conclusion of meeting attendees thatsimulators can be used well into the future toteach, refine, and test surgical skills. Assess-ment techniques may be developed to validatethese skills and to relate them to patient out-comes with a high level of certainty. In addi-tion, simulators may be joined with techniquesthat assess judgment and decision-makingskills.

Development ProgramDuring the calendar year beginning Janu-

ary 1, 2002, the College received 1,002 giftstotaling $277,692. Both the number of giftsand the amounts contributed have increasedin comparison to the same period last year.

The Regents approved a list of gift opportu-nities for 2002-2003. Some of the opportuni-ties include support for:

• The Chapter Young Surgeon’s TravelingAward.

• The Annual Fund, the Scholarship En-dowment Fund.

• The International Guest ScholarshipFund.

• The Owen Wangensteen Fund for Sur-gical Research.

• The Loyal and Edith Davis Cancer Fund.• An endowment fund for trauma educa-

tion in resource-challenged countries.• The Clinical Congress orientation pro-

gram for female and minority students.• Publication of the Patient Safety Manual.

• The new President’s reception for thenew Fellows during the Clinical Congress.

The committee reviewed progress to date inimplementing the approved business plan forexpansion of the Development Program. Therole of the surgeon who will serve as the Di-rector for Development continues to be dis-cussed and reviewed by the committee.

The 2002 Fellows Leadership Society lun-cheon will take place October 7 in San Fran-cisco, CA. In addition to the Distinguished Phi-lanthropist Award presentation, the luncheonwill feature the introduction of the new Fel-lows Leadership Society life members as wellas additional major donors.

Division of Advocacy and Health PolicyMs. Brown presented an overview of College

activities in the legislative arena. A review ofthe College’s efforts to support Health Insur-ance Portability and Accountability Act(HIPAA) compliance was presented. In addi-tion to a new Bulletin column entitled “Incompliance,” which premiered in May, devel-opment has begun on a Web page to link Fel-lows with primary source materials to aid intheir understanding of the regulations.

The status of the development of new prac-tice management courses was reported. Theinitial course is scheduled to take place in Julyin Chicago, IL, and September in Miami, FL.A report on the courses will be presented tothe General Surgery Coding and Reimburse-ment Committee at its October meeting. Thecommittee will determine whether it will rec-ommend that the course be incorporated intothe 2003 schedule of educational meetings.

The College has launched a nationwidegrassroots campaign encouraging surgeons towrite their members of Congress, asking themto support the Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of2002 (H.R. 4600). Modeled closely afterCalifornia’s liability reforms, this bill wouldplace a $250,000 cap on noneconomic dam-ages, impose a three-year statute of limita-tions, require proportional damages amongdefendants, modify the collateral source rule,


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allow for periodic payments of future damages,and limit attorneys’ fees.

Dr. Russell testified before the House En-ergy and Commerce Subcommittee on Healthon February 14. He reiterated the College’ssupport for the Medicare Payment AdvisoryCommission’s (MedPAC’s) recommendationsand strongly questioned the Centers for Medi-care & Medicaid Services (CMS) estimatesabout the 10-year cost of implementing thecommission’s plans.

In March, Dr. Russell joined with the CEOsof the major professional organizations whosemembers are reimbursed under the Medicarephysician fee schedule for a meeting with BillNovelli, CEO of AARP (formerly the Ameri-can Association of Retired Persons). Thegroups tried to find common ground on thepatient access problems that have started toemerge as a result of continued physician pay-ment reductions.

The College continues to pressure Congressto immediately address both the 5.4 percentnegative 2002 payment update and the prob-lematic sustainable growth rate formula. Inaddition, the College participated in a May 13,2002, press conference during which TerryColeman, the former chief counsel of theHealth Care Financing Administration (nowknown as CMS), presented a legal analysisconfirming that the agency is allowed by lawto correct erroneous figures used in calcula-tions to determine professional payments un-der the Medicare program. Mr. Coleman’sanalysis also questioned CMS’s decision toinclude drug costs in the calculation it uses todetermine the amount Medicare spends forprofessional services. The analysis was fundedthrough specialty society contributions madeto the AMA-led coalition effort.

The AMA’s work group on evaluation andmanagement codes held a public meeting onMay 17 to hear testimony on revising the visitcoding system. The College was one of ninesurgical societies identified in advance to tes-tify and presented a coding proposal based onthe patient’s presenting problem. The docu-mentation required under such a coding sys-

tem would be reduced markedly; the numberof codes would remain the same.

The College drafted a letter that wascosigned by more than 40 medical and surgi-cal societies, nonphysician groups, and others,which provided information to MedPAC on theuse of first assistants and outlined the prob-lems with proposals for bundling these ser-vices. At the MedPAC meeting on April 25,2002, commissioners dropped the recommen-dations for bundling the assistant at surgerypayments.

Last December, the Department of Healthand Human Services (HHS) announced thatit had appointed an Advisory Committee onRegulatory Reform to recommend stream-lining requirements set by the Food andDrug Administration and CMS. The commit-tee requested written comments on regula-tory burdens and will hold four public hear-ings to gather more information before mak-ing its recommendations. In his letter to thecommittee, Dr. Russell requested that minormodifications be made to two Medicare regu-latory requirements that are especially bur-densome to surgeons. One is to clarifywhether it is necessary for the surgeon toobtain an advanced beneficiary notice fromthe patient when he or she is being referredto another physician for a face-to-face ser-vice. The second issue relates to the 23 na-tional coverage decisions on clinical labora-tory tests that will become effective thisNovember. The College requested that thecoverage decisions be clarified to indicatethat the preoperative testing is recognizedwherever it is appropriate.

In February, the HHS Office of Civil Rightsrepublished its policy guidance on personswith limited English proficiency that clarifiesthe legal obligation health care providers havein providing oral and written language assis-tance to these patients. The College submit-ted brief comments that raised concerns aboutthe financial burden that the requirementsplace on physicians. The comments acknowl-edge the importance of meaningful communi-cation between health care professionals and


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their patients, but pointed to the financial andlogistical difficulties of providing professionalinterpretation services for patients who lackproficiency in English, without any mecha-nism to reimburse physicians for the cost ofthese services.

The College is gathering signatures frommembers of Congress on a letter of supportfor increased funding for state trauma caresystem planning and development grants out-lined by Title XII (Trauma Services) of thePublic Health Service Act. Thus far, 134 rep-resentatives and 45 senators have signed thisyear’s letter to House and Senate appropria-tors. The College also is working with the keycommittees to reauthorize Title XII. In addi-tion, the College is working at the state levelto secure a governors’ sign-on letter that willbe sent to Senate HELP Committee Chair TedKennedy (D-MA) and House Energy and Com-merce Committee Chair Billy Tauzin (R-LA),urging reauthorization of Title XII.

The College continues to focus on the Emer-gency Medical Treatment and Active LaborAct (EMTALA) and physician on-call issues.The College is a member of an EMTALA taskforce, which continues efforts to reform thestatute.

At the direction of the Board of Regents, theCollege joined the National Quality Forum toensure that surgeons were active participantsin the development and implementation ofproposed clinical quality and outcomes mea-sures that would be shared throughout thenation.

The College’s Health Policy Steering Com-mittee (HPSC) reviewed its subcommittee’sdraft position statement regarding surgery’sresponse to the current nursing shortage.The HPSC suggested minimal changes to thedraft. The HPSC also offered feedback on aCollege response to the Accreditation Coun-cil of Graduate Medical Education’s(ACGME) preliminary report on residentduty hours. The committee believed thatsurgery needs maximum flexibility in termsof hours, emphasizing that residency is aneducation, not a job, and that greater em-

phasis should be placed on adequate super-vision, backup systems, and the need tomonitor and limit moonlighting.

The 2002 annual meeting of the AmericanMedical Association (AMA) House of Delegateswas held June 15-20 in Chicago, IL. As a re-sult of the biannual balloting process, theCollege’s delegation has been reduced fromfive to four. The College was represented atthe June meeting by four delegates and twoalternates—all MD, FACS—LaMar S.McGinnis, Jr., Charles Logan, Richard Reiling,Amilu Rothhammer, Dr. Russell, and ThomasWhalen. Chad Rubin, MD, FACS, will continuehis service as the College’s representative tothe AMA Young Physicians Section.

The College is submitting a resolution tothe House of Delegates and the Young Phy-sicians Section calling on the AMA, in col-laboration with the specialty societies, to ad-vocate that Medicare and other payors re-imburse all appropriately trained physiciansregardless of specialty for performing diag-nostic sonography in situations with definedclinical indications.

Division of EducationAjit K. Sachdeva, MD, FACS, FRCSC, Direc-

tor, Division of Education, gave a status re-port that included the mission, vision, andgoals of the division. The Regents approvedrevisions to the ACS Statement on the Use ofAnimals in Research. The revisions are basedon recent changes to the Federal Animal Wel-fare Act, Regulations, and Standards with re-spect to the classification of and emphasis onthe animal’s level of pain and distress. The U.S.Department of Agriculture has also added“teaching” and “education” to the Act and nolonger includes these items under the realmof “research.”

Planning for the Clinical Congress in SanFrancisco, CA, is progressing well. The expe-riential, skills-oriented courses have beenseparated from the didactic courses in the pro-gram listings as a first step toward greater edu-cational distinction between these two typesof courses.


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A review course in urology will be piloted atthe Clinical Congress. Plans are under way toproduce specialty-specific informational bro-chures with the help of the chairs of the re-spective advisory councils to target membersof various surgery specialties. A major changein the medical student program is planned,and an open invitation will be sent to all medi-cal schools across the country inviting eachschool to send students to the Clinical Con-gress.

Steps are under way to establish a uniquecharacter for future Spring Meetings, withgreater emphasis on practice-related topicsand experiential courses that focus on the ac-quisition and maintenance of skills. In addi-tion, beginning in 2003, the Spring Meetingwill begin on Saturday and conclude on Tues-day. This modification will take the surgeonaway from practice one less weekday.

The American Board of Surgery (ABS) wasinvited to the College to participate in an ex-amination content review process to evaluatethe match between items of the last recertifi-cation examination of the ABS and the Surgi-cal Education and Self-Assessment Program(SESAP) 11. The board has appointed a liai-son to work with the SESAP Committee andthe division to strengthen the collaborationbetween the ABS and the College.

The opening session of the 2002 SpringMeeting was videotaped for Web-casting. Thenumber of times the program has been ac-cessed attests to its very positive reception. Op-portunities for Web-casting of other educa-tional programs are being pursued. Opportu-nities to offer CME credits for participationin international-based educational programswill also be explored.

The ninth Surgeons As Educators Workshopwas offered February 23-March 1, 2002. Thecourse was very well received. Summativeevaluations for the participants were ex-tremely laudatory. The comments from theattendees were also overwhelmingly positive,and planning for the 2003 workshop has be-gun.

A graduate student has been identified to

serve as assistant editor to create a “Manualfor Residents” and a “Manual for Instructors”from the publication, Ethics Curriculum forSurgical Residents. The student will workclosely with the authors of various chaptersand the division to accomplish this task. Thecurriculum will then be ready for pilot-test-ing at a number of different institutions. On-going educational support for the instructorsduring pilot-testing and implementation ofthis curriculum will be provided through thedivision.

The Committee for the Forum on Funda-mental Surgical Problems held a retreat Feb-ruary 7 to address concerns relevant to its fu-ture. The charge was to perform an analysis,develop objectives and goals, and recommendsteps that could lead to the Forum’s reinvigo-ration. Several of these steps have been initi-ated, including:

• Publishing all the accepted abstracts ina September supplement of JACS.

• Highlighting the individual to whom theForum is dedicated annually in the JACSsupplement with the individual’s picture andbiosketch.

• Sending the supplement to the entireFellowship as a regular issue of JACS.

• Distributing the supplement to all at-tendees of the Clinical Congress at the regis-tration desk.

• Providing a special gift to the individualto whom the Forum is dedicated at the time ofthe Clinical Congress.

The Society of American GastrointestinalEndoscopic Surgeons (SAGES) was repre-sented at the Regents’ meeting by Jeffrey H.Peters, MD, FACS, who presented a programoverview of SAGES’ “Fundamentals ofLaparoscopic Surgery” course. ACS/SAGES’administration of this program will be broughtback to the Regents at their October meeting.

The Council of Medical Specialty Societies(CMSS) approved a statement relating to resi-dent duty hours at its meeting on March 23.In summary, the CMSS endorses efforts tolimit the work hours of residents in a respon-sible way—residents must be properly super-


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vised and not overworked while, at the sametime, properly educated and trained. Be-cause not all specialties are the same, rec-ognition must be given to differences intraining requirements. The statement alsoindicated that the CMSS endorses the cur-rent attempts of the ACGME and its mem-ber organizations to set appropriate limitson resident work hours, that the CMSS en-dorses the concept of limiting the time-on-task responsibilities of residents and for pro-viding adequate rest periods. The CMSS doesnot support the imposition of federal or statemandates to set limits on work hours.

Division of Member ServicesDr. Collicott gave a status report on the

activities of the division. Currently, he isworking with Philip T. Siegert, MD, FACS,on the Ambulatory Surgery in the Office Set-ting Consensus Project under the aegis ofthe National Patient Safety Foundation.This project deals with the prevention of un-necessary deaths related to office-based sur-gery.

The Executive Committee of the Board ofGovernors has proposed a reorganization ofthe Governors’ committees. This committeealso suggested that the Governors’ commit-tees have mission statements to better re-flect the current issues under considerationby their board.

The New Governors’ Orientation occurredin conjunction with the College’s SpringMeeting in San Diego, CA. The orientationwill not be held in 2003.

The Nominating Committees of the Fel-lows and the Board of Governors have sub-mitted their final slate of nominees for thepending vacancies on the Board of Regents,for ACS Officers, and Executive Committeemembers of the Board of Governors. Thenames of the nominees remain confidentialuntil they are announced October 9 and 10during the Clinical Congress.

Dr. Collicott and Ms. Vincent, along withconsultants, have met several times withprofessional liability insurance companies to

address the malpractice crisis in the U.S.today. The problem is not necessarily the in-surance companies, but rather the lawswithin the states regarding the tort system.This situation again emphasizes the need fortort reform at all levels in the U.S. The Col-lege is currently pursuing an insurance pro-gram that it could endorse and that couldprovide a unique product for its members.Proposals for a sponsored professional liabil-ity program have been submitted and areunder consideration.

In December 2000, the College began toinvestigate a surgery resident loan program.Initial examination revealed several nega-tive factors, one of which was that the Col-lege did not have enough information aboutresidents’ loans or their net debt need or rateto determine the needs of its residents andhow to address these needs. Development ofa survey document on debt management is-sues was initiated but not finalized, and ul-timately the surgery resident loan programwas removed from the College’s priority list.In April, the College received a proposal fora resident assistance loan program, and asa result is in the process of reviewing thestatus of the first program and what infor-mation is needed to move forward at thistime.

In the area of membership recruitment:• Mailings were sent to all chairs of de-

partments of surgery and to all surgical pro-gram directors to enlist their support in resi-dent and junior staff management.

• The ACS application form has beenshortened and the application processstreamlined; the forms can be downloadedfrom the College’s Web site.

• The membership categories “DuesFully Paid” and “Age Limit” have been com-bined and renamed “Senior,” and a categoryof “Inactive” has been created for those in-dividuals that the College is unable to con-tact and who are unresponsive to mail; allACS mailings to this latter group will beeliminated.

An in-house committee was formed to ana-


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lyze and follow up on the membership sur-vey conducted in 2001 as a part of the stra-tegic planning process. This survey was anoutgrowth of the recommendations of theRegental task force on membership andmember benefits. The survey was sent to themembers of the Board of Regents, all Gov-ernors, Advisory Council members, generalsurgery program directors, chapter officers,and standing committee members and se-lected Fellows. The committee held five sepa-rate meetings to discuss the report, to evalu-ate its validity, and to make comments, sug-gestions, and recommendations. The com-mittee noted that the membership in the Col-lege accounts for only about 22 percent ofall American Board of Medical Specialty(surgical) certificate holders. Following aresome of the recommendations made by thecommittee in response to various observa-tions:

• Meet the needs of all members, both aca-demic and community-based.

• Use passwords rather than membershipnumbers to access “Members Only” side of theWeb site.

• Continue to provide more online servicesfor all ACS members.

• Provide online access to personal atten-dance records at College-sponsored programs.

• Consider major changes in the SpringMeeting format with more “hands-on”courses.

• Continue to review and revise online pa-tient information brochures.

• Develop a State Legislative Action Cen-ter similar to the Federal Action Center.

• Improve the maintenance of the JobBank.

• Continue to build on efforts to encour-age chapter advocacy activity including butnot limited to regular College leadership/staffparticipation in chapter meetings and devel-opment of advocacy action kits relating to spe-cific state legislative issues.

• Consider discount of membership duespaid electronically.

• Increase electronic publications.

Candidate and Associate Society,American College of Surgeons (CAS-ACS)

The Regents approved the Statement onResidency Work Hours drafted by the CAS-ACS. The statement is consistent with recom-mendations published by the ACS in 1994 con-cerning Surgical Residencies and the Educa-tional Environment. The statement appearson page 21 of this issue of the Bulletin.

Committee on Diversity IssuesThe Regents approved the following mission

statement: “To study the educational and pro-fessional needs of underrepresented surgeons,and to seek relevancy and support by theAmerican College of Surgeons through mis-sion, policies, and programs.”

The Regents also approved the followingACS Fellows as members of the Committee onDiversity Issues: Myriam Curet, Chair; JuanCendan; Edward Cornwell III; Fernando Diaz;Margaret Dunn; Joseph Espat; Debra Ford;Karen Johnston; William Pearce; and SylviaRamos.

Advisory Councils forthe Surgical Specialties

The Regents approved the deletion of theStatement of the Advisory Council for Gen-eral Surgery to the Board of Regents of theAmerican College of Surgeons and approveda revised statement as recommended by theAdvisory Council for General Surgery. Therevised statement includes revisions to the textaddressing training and skills.

Nine of the 12 advisory councils have heldtheir interim meetings. The main topics ofdiscussion were resident duty hours, profes-sional liability, Medicare reform, and theSurgical Forum. The advisory councils havebeen supportive of the ACGME workgroup’srecommendations. The advisory councilscontinue to propose educational program-ming for the Clinical Congress. Also, theAdvisory Council for General Surgery is ac-tively working with the American Board ofSurgery on the development of the mainte-nance of certification process established by


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the surgical boards. The Advisory Council forGeneral Surgery agrees that the link betweenthe ACS and the surgical boards is importantand that specific ACS educational programsdeveloped and offered should properly iden-tify and acknowledge the maintenance of cer-tification efforts.

ChaptersNumerous chapter meetings have been held

both domestically and internationally sinceFebruary 2002, many of them celebrating their50th anniversary. The College expresses itsgratitude to the Officers, Regents, and Gover-nors who donated their time and energy to rep-resent the ACS and contributed to makingthose meetings successful.

The Chapter Leadership Conference wascombined with the Young Surgeons Meetingat the College headquarters in May. Approxi-mately 125 individuals attended. The possi-bility of holding the meeting in Washington,DC, is being examined for 2003.

In cooperation with the Division of Educa-tion, an off-site ultrasound course will be pi-loted immediately before the ConnecticutChapter’s annual meeting. Also, in conjunc-tion with the Division of Advocacy and HealthPolicy, a practice management seminar is be-ing planned for availability to the chapters inthe future.

The Chapter Web Site Management Pro-gram is undergoing a revision to make it easierfor chapters to maintain and update their re-spective Web sites. The College used the samecontractor for this project that it uses for itsown Web site.

An Advanced Trauma Life Support® intro-ductory program was presented in Colum-bia, SC, in preparation for introducing thecourse into Germany and Hungary. This pro-gram provides an excellent tool for memberrecruitment internationally.

The Australia and New Zealand Chapter ofthe ACS Travelling Fellowship was awardedthis year to Christopher R. Forrest, MD, FACS.Mark D. Duncan, MD, FACS, is the designatedalternate. The purpose of this Fellowship is to

encourage international exchange of surgicalscientific information.

The Nizar N. Oweida, MD, FACS, Scholar-ship of the American College of Surgeons wasawarded to Caren E. Gaines Wilkie, MD,FACS. John M. McBee, MD, FACS, is the des-ignated alternate. The Oweida Scholarshipprovides an award of $5,000 to subsidize theparticipation of a young rural-based Fellow orAssociate Fellow in attendance at the annualClinical Congress.

The Regents approved a new exchange pro-gram, the ACS/Japan Traveler Exchange,sponsored jointly by the College, the JapanSurgical Society, and the ACS Japan Chapter.The financial support is for ACS travelers fora three-year period. The Japan Surgical Soci-ety and the ACS Japan Chapter will be respon-sible for support of the Japanese travelers dur-ing this time period. The first ACS travelerwill attend the annual meeting of the JapanSurgical Society in April 2003.

Division of Researchand Optimal Patient Care

The Office of Evidence-Based Surgery, Can-cer, and Trauma function under this division.Margaret M. Mooney, MD, former Interim Di-rector of the Office of Evidence-Based Surgery,left the College to accept a position with theCancer Therapy Evaluation Program of theNational Cancer Institute. A search is underway for a new director for this office.

The Agency for Healthcare Research andQuality’s first annual Patient Safety ResearchConference for all patient safety grantees tookplace February 7-8. Representatives from theACS attended to present the progress to dateon both the Patient Safety in Surgery Studyand the Resident Work Conditions Study.

The Surgeons Palliative Care Workgroup issupported by a grant from the Robert WoodJohnson Foundation. The primary focus of the21-person workgroup is to raise the awarenessof practicing surgeons to the various roles andresponsibilities that they can assume in assist-ing patients with serious, life-threatening con-ditions.


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The Young Surgical Investigators Confer-ence took place March 8-10 and was attendedby approximately 110 participants. The courseevaluations were all very positive and indicateda successful meeting. The next conference isbeing planned for the spring of 2004 and willbe chaired by Colleen Brophy, MD, FACS.

Following approval by the Board of Regents,the Surgical Research Committee has taken onthe responsibility for oversight of the effortsof the Office of Evidence-Based Surgery. TheOffice of Evidence-Based Surgery now alsoprovides staff support to the newly formedCommittee on Perioperative Care, formerly theCommittee on Processes of Surgical Care. TheRegents approved the new name of this com-mittee along with a relative document thatstates the organization, objectives, and activi-ties of the committee.

The Commission on Cancer has embarkedon a proactive evaluation and revision of thecurrent cancer program standards. Concernswere identified with the current standards, andchanges were recommended. July 1, 2003, isthe projected time line for implementation ofthe recommendations.

The Committee on Trauma (COT) held itsannual meeting April 11-13. The COT’s com-plete annual report will be forthcoming thissummer. The 24th Annual Residents TraumaPapers Competition was held during the COTmeeting. Twelve regions submitted winningpapers, and awards were presented in the ba-sic science category and the clinical researchcategory. A special session was undertakenwith the COT chair, in anticipation of thechange in the COT leadership, to create a stra-tegic planning process for the NationalTrauma Data Bank™, the design of the Officeof Evidence-Based Surgery—with an empha-sis on guidelines and clinical trials, and the de-velopment of a committee on disaster manage-ment. J. Wayne Meredith, MD, FACS, and Gre-gory J. Jurkovich, MD, FACS, were namedChair and Vice-Chair, respectively, of the COT.

The Regents approved “Withholding or Ter-mination of Resuscitation in Prehospital Trau-matic Cardiopulmonary Arrest,” a proposed

joint position statement (and publication of thesame) of The National Association of Emer-gency Medical System Physicians and the ACSCommittee on Trauma. The need for consen-sus on withholding or termination of resusci-tation has been an issue and continues to con-sume resources and expose health care work-ers to potential injury. The document is evi-dence-based and will create guidelines to al-low paramedics to terminate resuscitation.


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They fit not only in your pocket, but intoyour busy schedule as well. You can take the2002 Syllabi Select courses wherever you haveaccess to a computer ... at home, at work, oreven on the road.

Syllabi Select is a CD-ROM containing14 postgraduate course syllabi from the 2002Clinical Congress. These syllabi—selected andpackaged for your convenience—canbe purchased during Clinical Congress at thepublications booth, North Hall.

After Clinical Congress, Syllabi Select will beavailable by calling 312/202-5474or through the College’s Web site athttp://secure.telusys.net/commerce/current.html

The 2002 Syllabi Select CD-ROM is priced at $75.There is an additional $12 shipping and handling chargefor international orders.

PG 15: Endocrine Surgery

PG 16: Diseases of the Liver, BiliaryTract, and Pancreas

PG 17: Vascular Surgery: Technical TipsThat Enhance Surgical andEndovascular Outcomes

PG 18: Thoracic Surgery

PG 19: Gastrointestinal Disease

PG 20: Minimal Access Surgery

PG 21: Essential Technical Elements inTrauma

PG 22: Cardiac Surgery

PG 24: Colon and Rectal Surgery

PG 26: Surgical Infection and Antibiotics

PG 27: Breast Disease

PG 28: Plastic Surgery: Management ofDevastating Defects of theAbdomen and Perineum

PG 29: Pediatric Surgery: EsophagealDisorders and Anomalies inInfancy and Childhood

PG 30: A Surgeon’s Personal Guideto Risk Management andTrial Participation

Fourteen Big CoursesThat Fit In Your Pocket

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Collective Reviews:

•Endovascular Therapies: An Update on Aortic Aneurysm Repair

and Carotid Endarterectomy

•Neurofibromatosis: Implications for the General Surgeon

Education:

•Effects of Limited Work Hours on Surgical Training

Original Scientific Articles:

•Life-Sustaining Capacity of Human Polymerized Hemoglobin when Red Cells

Might Be Unavailable

•Condordance and Validation Study of Sentinel Lymph Node Biopsy for Breast

Cancer Using Subareolar Injection of Blue Dye and Technetium 99m Sulfur Colloid

•Intraoperative Parasympathetic Nerve Stimulation with Tumescence Monitoring

During Total Mesorectal Excision for Rectal Cancer

•Anorectal Dysfunction after Surgical Treatment for Cervical Cancer

The October issue of the Journalof the American College of Surgeonswill feature:

ext month in JACSN

september 2002 reporting medical errors: variables in the

Documents