American College of Surgeons: 2007 Board of Governors Survey Analyisis

Board of Governors

2007 American College of Surgeons Board of Governors Survey Analysis

Valerie W. Rusch, MD, FACS
October 7, 2007

Ninety percent of the College’s Governors (26 International, 13 Canadian, 201 United States) completed an electronic survey related to issues of concern to them and the Fellows they represent. The following issues are ranked by mean score.

2007 Board of Governors Survey Analyisis Slides (30K PDF)

Professional Liability/Malpractice/Tort Reform, Risk Management/Patient Safety: Overall, on a scale of 1S10, with 10 indicating most important, 90 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 8.46.

Eighty-one, 54, and 93 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: Surgeons in Chile have the same problem as those in the United States; important practice issues in this area were reported in Australia and New Zealand—New Zealand has a no-fault system but medical/legal problems are still an issue in surgical practice; the issue is starting to be a major concern in the Philippines; frequency and cost of litigation reportedly increasing annually in Ireland, with private practice in obstetric (ob) no longer viable due to hospital and physician insurance liabilities; patient safety is most important and professional liability/malpractice ranked lower on the scale in India; while it was noted to be very important issues to Japanese surgeons.
CANADA: risk management and patient safety issues are very popular right now; patient safety is a crucial issue.
UNITED STATES: conflicting data exists with some reports showing no real increase in amount of settlements as compared with other costs. ACS needs to study data that trial lawyers use and refute inaccuracies in order to help Fellows in this area; many observe that rises in liability insurance premiums are financially destroying their surgical practice, many surgeons are retiring early or relocating to other states; increasingly more important; surgeons are all paying exorbitant rates on liability premiums; litigation in many states has run rampant and is costly to our system in multiple ways; ACS needs to continue lobbying; there is still continued effort to modify the system to benefit the legal members; patient access dwindling; federal legislation needed to solve the problem; surgical practices are being acquired by hospitals because of liability insurance costs; some specialties leaving to practice in states with lower malpractice rates and less risk of high awards; good samaritan liability is still a concern; virtually every private practice surgeon says constant threat of lawsuit saps their enjoyment of practice of surgery; obviously an enormous issue in obstetrics/gynecology with worsening climate and decreasing reimbursement a combination that threatens all surgical specialties; very important issue to all surgeons, including those in academic centers; remains single most important barrier to our endeavors; surgeon retention very poor; premiums are slowing and progressively suffocating private practice of surgery. Membership is concerned that ACS has not been effective in bringing about change; senior surgeons cannot be part-time, junior surgeons must be in a group practice to cover expenses, and surgical specialists are leaving; biggest factor in surgery today—many feel only option is to retire early. If lawyers get liability limits overturned, premiums will rise again and push some surgeons out of medicine completely; unable to recruit partners, declining income, declining manpower, and older Fellows who might practice longer are retiring early or switching professions; it is harder to maintain and pay for private offices. Disillusion among physicians regarding ability of organized medicine to influence the government; visceral importance beyond economics; need help now—ACS needs to explore creative ways to finance malpractice tails for surgeons in high risk venues; critical problem with no relief in sight. Surgical specialties should have closed-claims reviews; need to demonstrate extreme expense that adds to overall health care; real crisis—doctor-owned liability insurer denying coverage to some surgeons; premiums represent huge part of overhead costs; situation remains very bad, particularly for bariatric surgeons; major concern in our state, particularly inaction on this issue; suits and severity up; impacts viability of practice and ability to attract young people into surgery; encourage all efforts to use closed-claims data as a means to educate Fellows.

Physician Reimbursement/Medicare/Medicaid: Overall, 92 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 8.37.

Sixty-two, 46, and 96 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: Medicare payments in private sector of Australia require continual negotiation with federal government; New Zealand has little government support but the state funds public hospitals to which university medical schools are attached; eight out of 10 patients have medical insurance but payments by insurance companies are too low; not as vital an issue in India—no fixed scale, hence depends on locale; reimbursement getting worse because economical resources of Japanese health insurance system are nearly exhausted by decrease of young people and increase of aged.
CANADA: fee-for-service remains the most common form of remuneration—fees are improving although not close to United States standards. In Nova Scotia, increasing number of doctors are accepting “alternative funding arrangements,” as a form of salary. The government seems interested but doctors concerned government would completely con-trol incomes. Physicians still practicing outside the system believe productivity will take a nosedive once salaries are introduced and exacerbate the wait-list problem.
UNITED STATES: Surgeons report it is hard to make ends meet with 40S50 percent overhead and continued significant discounted reimbursements from third-party payors— reimbursement is inadequate to cover fixed costs of providing care, uninsured patients, and patients seeking services of on-call physicians—lack of reimbursement by hospital for providing on-call services driving physicians away from general hospital staff practices and toward “boutique” specialty hospitals and outpatient surgical facilities; increasing intrusion reported private insurance companies requiring X-ray pre-certs, etc., as well as difficulty reaching a human in computerized phone system— all time intensive; community physicians are hurting financially and having difficulty attracting general surgeons; surgeons are limiting practices by eliminating procedures that reimbursement does not justify; reimbursements falling and practice costs rising to create tremendous financial pressure on physicians; we need to be very aggressive to the point of a national physicians strike if this and other major concerns are not dealt with in a fair way; we are not even keeping up with inflation; altruism dies quickly when one cannot pay bills, trauma centers are being closed; our young surgeons see this as a major problem and worry about being able to finance a practice in the next decade; more and more doctors will opt out of Medicare; refusal to treat patients already frequent with Medicaid; more regulations/more paper work/more hassles; important to strongly push for sustainable growth rate (SGR) reform; more young surgeons depending on hospitals to support them while others are turning to Kaiser systems; perception is American College of Surgeons (ACS) has not been ineffective in this area; avoiding fee decreases is really not progress— most surgeons expect an equitable return on their investment; Resource-Based Relative Value Scale (RBRVS) is not working and ACS has to find new and effective ways to change the reimbursement system; if current trend continues, one would predict the ACS will ultimately experience a decline in membership and relevancy; uphill battle and getting worse—surgeons expressed the desire that ACS use resources to especially help with the Medicare reimbursement issue; Medicare is a big issue and Medicaid is even worse; special interests still dominate as certain services take bigger piece of the pie at expense of others; precipitous downward spiral of access; lost our voluntary emergency room (ER) coverage; multiple surgeons leaving state or avoiding starting practice; rural areas are particularly hard hit; practicing surgeons are looking to ACS and beyond for significant initiatives to correct the problem. ACS leadership should not downplay this issue; it should be the main focus of the ACS and requires its best efforts—influencing a reduction for one year only is not an effective accomplishment.

This issue deserves the best effort the ACS can produce; affecting recruitment and retention of qualified surgeons; the system will implode.

Health Care Reform and its Impact on Practice: Overall, 91 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 7.93.

Seventy-seven, 69, and 93 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: increase in management control, government pressures to ration services, and funding limitations both in Australia and New Zealand; reforms to date have created further stresses on training; varies from country to country and has low priority in most developing countries; Japanese government has tried various plans—American system of Diagnosis-related group (DRG) has been introduced and impacted practice in small hospitals more than we expected.
CANADA: so far health care has not extended to hospital-based surgical practice; reforms in Ontario are starting to have impact on practice, especially the newly initiated Wait Time Strategy.
UNITED STATES: the system is badly broken and how to fix it is not immediately evident; ACS needs to work against single-payor insurance in order to prevent rationing; driving practitioners out of clinical medicine and the more intelligent undergraduate students into other fields—add to this the constant erosion of the physician’s role in patient care by non-physicians; unfunded mandates from regulators of all types, archaic communications systems, and unrealistic expectation from the public; oversight and documentation becoming increasingly onerous; more bureaucracy leading to more paperwork; next generation of general surgeons will be employed by the hospitals; few want government to run things but everyone thinks the real bad actor in the current system is the insurance industry; it is essential to continue private medical practice otherwise we will have socialized medicine; we have more of a health crisis than a health care crisis except when the discussion focuses on covering the uninsured; it seems that the major change/ improvement should be in the provision of medicines; looking at universal care in California with physicians having to pay a tax on professional income; how will we pay and for what level of care are what we most need to discuss; rampant disillusionment exists amongst students, residents, and practicing surgeons.

Competency Measurement for the Practicing Surgeon: Overall, 80 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 7.19.

Eighty-one, 100, and 79 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: Chile has competency measurement for surgeons; Royal Australasian College of Surgeons (RACS) encourages competency reviews through the Department of Continuing Professional Development—this strategy is required in New Zealand for the annual practicing certificate issued by the Medical Council of New Zealand; under active discussion with advisory committee of Irish Medical Council— competency assurance will become mandatory for all doctors; the specialty board system has been revised in individual societies so as to improve the quality of medicine and the system for competency measurement for the practicing surgeon has been roughly established.
CANADA: reexamination is not in the picture as yet but validated complex continuing medical education (CME) and a compulsory basic competency assessment are being carried out now and this is an evolving process; with the abolition of mandatory retirement, this issue has become very high priority.
UNITED STATES: having just been an associate examiner for the American Board of Surgery (ABS), I am concerned as to how to measure the actual surgical competency of our new surgeons in the OR; we must make an effort to define; concerns about potential for abuse by competitors with agendas; some anxiety as many are still unaware of the importance and impact on their practice; if we don’t “they” will; much concern over how competency measurement will be implemented by Centers for Medicare & Medicaid Services (CMS) and others; practicing physicians worry about this strategy being used as a way to limit their practice; imperative that we pursue training and assessment tools that will allow us to include measurement of competence as part of our certification; very aware of the multitude of groups compiling quality data on hospitals and doctors—some of these databases are of value and some are abominations. There is a keen interest in getting the best data available—all databases suffer from the limitation of what can actually be objectively measured; info and programs are needed in order to prepare and educate; ACS must have a coherent position on this; most recognize this is important but are skeptical of the reporting documentation; competency measurement should be a function of the market place and not the ACS; measuring competence without first developing a strong base of education would be a sham exercise; many unknowns here—how to participate in hospitals not associated with ACS/(National Surgical Quality Improvement Program) NSQIP-type programs; surgeons and acute care are not well served by the models for physician measurement more adapted to chronic care; the measurement needs to be “real world,” reproducible, relevant, and run by surgeons, and not the government; concerns about how onerous this process may become; difficult if only one surgeon in community or two in two different clinics; difficult issue now with so much sub-specialization in surgery; small low-volume hospitals make the issue of competency even more difficult to assess—will become an issue as maintenance of certification (MOC) moves forward; how will this measurement be done in a responsible way so that it does not drive people from practice and worsen the manpower issue.

Graduate Medical Education: Overall, 80 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 7.18.

Eighty-eight, 69, and 79 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: RACS is finding it increasingly difficult to provide training and accreditation on a pro bono basis to the high level expected; not enough centers for postgraduate courses in the surgical areas and a good number of doctors do not have access to them; impact of European Working Time Directive (EWTD), cost of medical care, and inadequate capacity in service are causes of major stress on postgraduate training; standards are falling as pool of teachers inadequate for increasing number of colleges; Japanese system of graduate medical education (GME) has been tremendously improved.
CANADA: long-term planning by the Royal College of Physicians and Surgeons of Canada (RCPSC) continues in an effort to address the need of our society to have access to well-trained surgeons.
UNITED STATES: how we train new surgeons is of vital importance; much higher level of concern expressed about this issue than in the past; surgical training experience is too spotty—residents are not learning how to take care of problems resulting from their actions; clinical ability of new graduates is of concern in view of the shorter work hours; our members are requesting some attention to “bread and butter” education—they desire practical and useful information to take to their practice; growing concern expressed about the quality and motivation of the medical students and resident candidates we are seeing; modernizing training to utilize currently understood adult education principles should be a priority; more teaching courses are needed; ACS should work with other surgical groups to increase resident work hours to 90 to100 hours per week; clinical ability of new graduates is of concern; 80-hour workweek seen as impairing surgical education; many are worried about cutbacks in this area; some programs are being deleted at community hospitals due to lack of faculty and marginal funding; with MOC coming more teaching courses are needed; adequate training, work hour rules, and number of trainees going into general surgery are a concern; residents have a “shift-work” mentality; we are letting industry dictate too much within our profession—current residents are learning about current procedural terminology (CPT) codes and reimbursable items rather than patients, and the depth of their experience is frighteningly poor—we need to maintain standards of practice experience; growing concerns that if Medicare cannot sustain funding for GME, how will such programs be funded; rural surgeons are finding it more difficult to recruit to their practices young surgeons finishing residency; need to ensure we train new surgeons with appropriate skills for the future.

Workforce Issues: Overall, 78 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 7.03.

Sixty-five, 69, and 79 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: workforce surveys in Australia and New Zealand show aging population, earlier retirement, less hours worked, and increased demand for services by the community; not uniformly distributed; inadequate capacity with numbers of consultants to implement European Working Time Directive (EWTD); of special importance in developing countries due to limited resources and vast patient population; workforce is another issue to be solved for Japanese surgeons because of decrease in medical graduates who want to become surgeons.
CANADA: Respondents report always having problems surrounding this issue; there are a number of International Medical Graduates (IMG) practicing with defined licenses. Assessment and licensure is difficult to obtain—some specialties are chronically short staffed—and there is no coherent strategy crossing all specialties regarding recruitment and retention; there is a considerable surgeon shortage with crisis looming, especially in rural settings.
UNITED STATES: Respondents expect we will have a significant shortage of generalists in the five basic surgical disciplines; many surgeons report having trouble recruiting others into their practices, especially in rural areas; this situation will become the most challenging public health issue in the next decade; some report it is difficult to hire new partners and continue the care provided, especially in rural areas; nursing shortages and specialty physician shortages are now a chronic problem; more and more residents and students are choosing practice areas related to quality of life; continuous meetings are being held on how to staff an ER as it has become the safety net for a large portion of our population; ER coverage is becoming critical; very important in Obstetrics/Gynecology. . many surgeons are cutting back on practice/retire early; more qualified students would go into medicine if restraints and constraints were not in place; our anesthesiologists are quite concerned about the penchant to openly advocate broadening the independent practice of physician extenders like certified registered nurse anesthetists (CRNA) and certified registered nurse practitioners (CRNP) to correct physician shortages; elements of workforce most critical to us are scope of practice implications for non-physician providers and their incursion into the practice of medicine; hospitals and hospital administrators commonly compound problems in this area—this has resulted in ineffective use of surgical manpower regardless of specialty; shortages in general surgery coverage will become apparent as specialization continues to expand; no general surgeons, no emergency surgical care, no rural surgical care; expectation of young surgeons often in conflict with older peers; significant maldistribution; we need to make practice desirable again; need to encourage medical schools to expand and state legislatures to increase funding to the schools.

Continuing Medical Education: Overall, 75 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 6.97.

Ninety-six, 85, and 71 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: University of Chile has postgraduate office in charge of continuing medical education (CME); CME within the Royal Australasian College of Surgeons (RACS) has become increasingly important—if requirements are not met, the surgeon’s name could be removed from the list of surgeons on the RACS Web site; most surgeons are in compliance, but it is not mandatory—a minimal grant is available annually to each consultant for CME; CME hours are not mandatory in India but most surgeons keep abreast for personal satisfaction and education; many training seminars have been carried out for the members of the individual societies and local or national medical association but definite credentialing system has not been established yet in Japan.
CANADA: The Royal College of Physicians and Surgeons of Canada (RCPSC) has an increasingly robust process for tracking this.
UNITED STATES: issue needs some re-thinking, especially for rural surgeons who cannot easily get away for courses due to economic and manpower issues—more online and onsite educational tools are needed; isolation of many smaller communities surgeons makes CME both more important and more difficult to obtain; it is difficult for the non-teaching hospital’s staff; excellent forums exist but the main problem is time to attend; increasingly expensive and some is good but a lot is not; surgeons would like more time to take advantage of CME but feel the pressures of maintaining a high volume practice put too many time constrictions on them; poorly-defined changes in CME accreditation requirements are an issue; travel is down and Web-based activity is up; new Fellows stated high priority to join for educational opportunities; this is an area where ACS can make an immediate concrete contribution; strive to make ACS CME materials free to Fellows; a well-organized system is in place to provide opportunity in the future to use telemedicine and Web-based learning, including simulation.

Credentialing for New Technology: Overall, 74 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 6.85.

Eighty-one, 92, and 72 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: funding; credentialing is undertaken by the boards of specialty surgery and there are nine of these which are responsible for training and also for the final RACS exam—within their training programs, modules for training and new technology are undertaken and credentialed from that board; there is no national policy; this is most important and can be well monitored by peer groups that are training and proctoring; entrusted to individual society—Japan Society of Endoscopic Surgery has established Endoscopic Surgical Skill Qualification System, which is somewhat of a self-assessment aimed at qualifying the surgeons who train the trainees.
CANADA: not enough attention is being paid to this issue; some rudimentary forms are required in some jurisdictions; in some specialties, there is increasing government oversight.
UNITED STATES: issue is a continuing problem as new technology applies to surgical practices; also need to address issue of crossover with other specialties; decisions should be left up to local institutions; issue needs to become more reasonable and less threaten-ing; the OR is not the place to learn new techniques—training beforehand is essential with appropriate documentation of said education. Malpractice lawyers are demanding in discovery appropriate certificates of training in any number of techniques; need to eliminate drive-by training programs; this issue impacts the cases surgeons can do; chief complaint is difficulty interrupting practice to adapt new techniques and practices; need uniform regulations with centers where surgeons can meet the requirements; learning new technology should be reviewed and regulated by each hospital with newer technology including robotics; most important committee in the hospital; training is left in part to specialty societies with little oversight; there must be developed methodology to validate the desirability of introducing the new technology to widespread availability—the same programs can be used for periodic recredentialing if that is desirable or for updating with additional skills for the same technology; ACS should be more vocal regarding its approval/disapproval of new technologies; we feel increased pressure from industry to endorse products whose value is uncertain—our own surgeons are being recruited to put pressure on the ACS and other societies to endorse prematurely; too often this issue is used by one group to gain a marketing advantage over another group—safety is paramount but access to new technology should not be controlled by the young lions; sometimes forced by the private sector and adequate validation is not always extensive enough; industry and entrepreneurs are developing expensive methods that may not be better than conventional ways of doing things but cost more—the system cannot currently afford all; isolated rural practitioners have great difficulty in timely, safe introduction of new technology.

Pay-for-Performance: Overall, 71 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 6.71.

Eighty-one, 38, and 70 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: not an issue.
CANADA: not an issue.
UNITED STATES: Pay-for-performance (P4P) may improve overall performance but may also increase cherry picking; a lot of work for minimal gain—time is money; just another method to withhold our money; how will it impact our practices and will it cost most by virtue of paper work alone; industry and government buzz words for controlling reimbursement; a major concern for everyone—data accuracy will be an issue—and few think this will be a fair process; we have no idea what this will lead to or where the Centers for Medicare & Medicaid Services (CMS) will go with it; most feel the proposed reimbursement is not worth the reporting effort required; surgeons want surgeons involved in making the rules; what will be the criteria for performance; most are concerned with honest reporting and clean interpretation of the data—a new stress seemingly out of our control; there are numerous traps being set with this movement—the measures that are commonly mentioned are all too often artificial and have nothing to do with true performance; well-intentioned but a bad idea; important to get rid of P4P; who decides whether our management of surgical patients and outcomes are good enough for maximum pay; concentration on easily measured variables that do not really measure quality; poorly-funded and not cost effective at present; this will not result in increased payments to practitioners; this proposal is largely a sham; this concept strikes me as vague and wrong—the argument that its coming is equivalent to the argument that since someone is about to put a bag on my head and suffocate me I might as well help; we need to expose the present sham of the current proposal—the criteria are not really related to quality but rather to who expends the fewest government dollars per CPT code and DRG. It has nothing to do with quality of patient care—pay for performance as it currently stands is hypocrisy; need info and advocacy to prevent government bureaucrats from running amok; concerns that CMS will use the surveillance as a fishing expedition; is the effort to participate worth the reward—does the process really increase performance or quality; we need to make this issue go away—there is no evidence-based rationale for any of this; ACS needs to stay highly engaged in the process—if we are to be burdened by this program, then appropriate criteria with appropriate reporting needs to include ACS input; P4P as currently envisioned has nothing to do with quality—more busy work with no likelihood of improving care for surgical patients; concerns about what this means for future reimbursement; surgeons need to formulate this activity—not the regulators; more, more, more paper work—good in theory but it will end up being more costly than it is worth. Ninety-nine percent of surgeons do the right thing and do not need to be analyzed to do the right thing; make surgeons remain involved in all the agencies that are so keen on creating measures to assess the quality of our work.

Medical Education and Research: Overall, 73 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 6.66.

Eighty-eight, 69, and 69 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: few educational programs include research; academic departments of surgery have receded in the hierarchy in medical schools and RACS continues to lob- by on their behalf; financial subsidy a big concern; important to some surgeons—more money becoming available in Ireland; research in India often duplicates that done in the West—research that does not target the ground reality of patient needs is unethical; funds are not always enough—more money is needed to achieve goals of Japanese government.
CANADA: only a few surgeons produce clinical studies and usually without institutional support—clinical work generally swamps these efforts after the first couple of years.
UNITED STATES—issue continues to be an important and underfunded area—striking how many articles in American medical journals are written by groups outside the United States; funding a priority; there is concern that too much research seems to be funded by the pharmaceutical industry and many colleagues are skeptical of some of the evidence— case in point, the continued lowering of “normal” cholesterol levels and the increased use of statins; research dollars and time to do research are becoming scarce; money is tight and taking time out to participate frequently leads to personal hardship; ACS should support National Institutes of Health (NIH) budget increase—must be supplemented as research is being diminished; among the academic surgeons, most have given up on funding from NIH—a bad sign for the future of surgical research; we need more and better research—surgery needs to define with much greater precision what research it supports; government support of research or lack thereof threatening to stifle new knowledge and innovation.

Trauma Care and Reimbursement: Overall, 73 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 6.60.

Sixty-two, 30, and 76 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: RACS coordinates trauma system in both countries and acute trauma is essentially managed in public government funded hospitals; trauma accidents are more frequent, medical attention is not well paid, and associations are trying to improve reimbursement; part of our general contract; with terrorist activity rampant in India, the management of mass trauma needs educating and is required irrespective of remuneration, which is unfair as it is very demanding and expensive care; no improvement in reimbursement and shortage of workforce—number of hospitals involved in trauma care decreasing in Japan.
CANADA: most trauma is handled by orthopedics as part of their practice—there are no pure trauma surgeons in our small province.
UNITED STATES: patients are being transported excessive distances for care that should be done expeditiously because there are no available surgeons in their area; trauma is leading cause of death under age 44; insufficient trauma funding threatening entire state; hospitals seem to be doing well but not doctors; no pay and high liability—hospitals get some relief but surgeons do not; liability issues should be reformed; lack of reimburse-ment and litigious nature of these cases is becoming a pertinent issue; with trauma centers being closed and the effects clearly seen, legislators cannot fathom the need for support; a major problem for hospitals and surgeons providing trauma care; unfunded mandates for trauma care and disaster preparedness a concern at trauma centers; no fee schedule can be based in anyway on Medicare rates; many have quit caring for trauma patients; with the growing number of uninsured, hospitals will simply have to pay stipends for coverage as we are at a breaking point for private practice physicians who simply cannot continue to provide free services and maintain a business practice; expanding number of patients and rapid decline of specialists are a growing concern; no malpractice help equals no rural trauma; creation of acute care surgery by trauma services to attempt to make a profit is not the solution as it reduces quality of care; so disruptive to one’s elective practice that no one wants to participate; trauma and emergency surgeons must be employed by hospitals as the reimbursement is not enough to sustain a private practice; due to ER abuse by patients using it as a clinic, the system is bogged down and inefficient; use of ER as a place of primary care and final common pathway for the seriously ill who wait until that is the only option; insurance companies not covering their insured for injury under the influence just further adds to the CEO’s robbery and worsens the unreimbursed care through the ER—hospitals need to reimburse for covering ER services; continued need for regionalization.

Peer Review Issues: Overall, 71 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 6.48.

Eighty-one, 85, and 69 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: peer review laws vary in Australia and New Zealand—peer review is encouraged at the hospital level with audit meetings and these are usually conducted with legal privilege; each hospital has a credentialing committee; will become important part of competency assessment; important but should never be permitted to degenerate into a witch hunt; not strictly performed in Japan.
CANADA: peer review is part of our newly introduced competency assessment for all doctors, including surgeons.
UNITED STATES: Need constructive peer review system; some mechanisms are in place but they need to be enhanced; challenge between insufficient or slow action versus witch hunt; difficult situation as lawyers are involved on both sides; important that we learn to police our own and are willing to do so in an objective manner; use peer review as a learning tool and not as a jury; should be done in an equitable way and not in a manner where individual prejudices can play a role; we are currently doing a poor job at peer review and do not have proper resources or training; increasingly the methodology is being utilized to serve purposes having little to do with competence and a great deal to do with personal issues; biggest issue here is inappropriate professional expert witness testimony; sham peer review is a fact of life for many Fellows; need independent reviewers—not local or in-hospital reviewers; roll into maintenance of certification (MOC).

Funding for Education Activities: Overall, 70 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 6.48.

Eighty-one, 62, and 69 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: we have a foundation for medical activities; RACS is looking at the possibility of developing a separately funded organization, which would derive funding from the trainees but also perhaps some governmental agencies—currently, all funding is from Fellows or trainees; we have postgraduate schools and most of them are government dependent; training grant, which is inadequate, given annually to each trainee; funds seem to be drying up in India; activities have been remarkably improved in Japan but funds are limited.
CANADA: only salaried surgeons have funded education—lobbies through our physician society have been unsuccessful. This is one argument for accepting the government’s alternative funding proposals.
UNITED STATES: funding from industry difficult even for excellent educational pro-grams; forever shrinking funding; not forthcoming from most institutions; increasingly more difficult to receive funding from any supporter or exhibitor; need to create new funding paradigms; government funding is drying up—need to find alternative sources of funding without compromising integrity; need more funding support from Washington; government and public scrutiny of corporate support for physician education places great stress on our members; many depend to a large part on volunteer faculty.

Relationships with Managed Care Organizations (MCOs): Overall, 64 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 6.25.

Sixty-nine, eight, and 64 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: not a major issue in Australia or New Zealand but some insurance companies are contracting with surgeons for specific procedures, which may well be a wedge to encourage managed care; not major players in health care in India; not going well for Japanese surgeons.
CANADA: not applicable.
UNITED STATES: too restricting for patient access and timely treatment. Payment schedule needs revision; insurance companies have too much money and power; state has passed prompt payment laws, which are routinely ignored—considering further regulatory efforts in this regard; list of out-of-network surgeons is growing and will continue to do so until there is change in reimbursement; insurance industry is seen as the enemy; fees will decrease as Medicare fees decrease thus decreasing doctors to provide services; many feel inept and need help to negotiate contracts; in most instances, it is managed cost not managed care, and there will have to be new methods of negotiating fair contracts and fees; solo surgeons and small surgical groups are concerned about their ability to negotiate fair compensation for their work with such organizations; surgeons feel helpless and isolated when dealing with health maintenance organization (HMO)—nearly every surgeon feels the need for an organized legal union, which can negotiate contracts with MCOs; managed care is really disguised fee-splitting; surgeons are still not experts in negotiating contracts—more help is needed, including a Web-based contract evaluation tool that uses CPT-based cost accounting; insurance industry is the main driving force behind the reduction in reimbursement for surgical services; they are killing us; resentment over inappropriate medical loss ratios; one-sided relationships.

Hospital Privileging Issues: Overall, 59 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 5.98.

Fifty-eight, 23, and 59 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: the main problem is for those surgeons who have trained overseas— these surgeons are assessed by RACS, which then is in a position to advise the registering authorities as to the competence of the surgeon and whether they should be vocationally registered to practice in their specialty. There have been some problems where this process has not been undertaken and hospital privileges have been accorded to surgeons who are clearly not of a satisfactory standard; in our area, there are different levels of hospitals and the levels are related to the level of patient care; only large hospitals in India implement procedure-based privileges; the problem inherent with this issue is that it has been frequently changed with pressure from Japanese government and Japan Medical Association.
CANADA: Canadian situation is quite different; needs improvement in all districts.
UNITED STATES: surgeons need to demonstrate competency in overlapping areas if turf wars are to be avoided—ACS and ABS should be at the forefront of providing fellowship and residency training guidelines in these areas of potential contention; all politics are local, at least to some degree—it would be nice to have global rules, which could counter-balance the local politics; not always the right people make the call; should not be a problem if done honestly; significant antagonism between physicians and hospitals surrounding physician-owned ventures; with the hospitalist movement there is a trend toward giving privileges only to hospital-based physicians—this further separates the patient and surgeon from the patient’s primary care physician; younger surgeons should not be barred from privileges by senior surgeons on the hospital staff—a trend in some institutions; economic privileging is a reality and it is becoming increasingly dishonest and often involves ACS members on either or both sides; need to develop national guidelines rather than have hospitals flail among their own personal and economic prejudices; ACS needs to be a strong advocate for general surgeons or the scope of general surgery will continue to shrink.

Medical School Issues: Overall, 53 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 5.66.

Seventy-seven, 31, and 50 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: RACS is concerned about the reduction in surgical teaching to undergraduate medical students; an admission test is the measure taken to filter good from bad/poor performance schools; the big problem is limited funds provided by government.
CANADA: not affecting areas outside Halifax very much.
UNITED STATES: we must attract the best and brightest medical students to consider surgical careers—to that end, we must be exemplary teachers and role models; we need to increase the number of entering students; continuing trend of increased non-compensated demands of clinicians’ time with increased expectations of clinical productivity; increasing difficulty getting clinical faculty to participate because of financial hardship; need to increase the number of medical graduates; ACS should support more medical students to enter the workforce ASAP; push for less quotas and more quality of education of the enrollee; dismayed to learn that many medical school deans encourage their students to take extra curricular study courses, eg, “Kaplan,” so they can score higher on parts one and two of their boards—this undermines our process in evaluating students for surgical residency positions; we have a stake in that inadequate numbers of graduates, inadequate exposure to surgery, and increasing emphasis on life issues work to the detriment of surgery; surgery needs to be in the forefront of choices students can make and not hidden until they are finished or nearly finished with medical school; surgery will have to make itself known to medical students in a positive way if we are to solve workforce issues; we need more involvement of ACS in years one and two of medical school to pique the interest of medical students in surgery—maybe statewide conferences, combined meetings for students, etc., sponsored by the ACS with local surgeons and national surgeon speakers.

International Fellows’ Access to ACS: Overall, 40 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 5.11.

Ninety-two, 23, and 33 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: good.
CANADA: not applicable.
UNITED STATES: almost every hospital I have been in in a third-world country has Internet access; the programs and opportunities have an impact far beyond our shores.

Assistants at Surgery: Overall, 45 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 5.08.

Seventy-seven, 38, and 40 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: we are assisted by residents and interns; in Australia, there is Medicare payment for assistants, and in New Zealand, their remuneration is paid directly from the surgeon or by the hospital employing them; concerns about availability of skilled assistants after EWTD, particularly in smaller hospitals; fundamental for resident education—all assistance in India is residents’ responsibility; Japanese system for assistants at surgery has not been established yet.
CANADA: respondents report no problem finding physician assistants (PA) for the OR but there is a need for physician extenders for ward work, ER contacts, and admissions/ discharges—the main roadblock is lack of funded positions.
UNITED STATES: will assistants fill the void from shortage of surgeons; competence is important; lack of compensation for those doing more complex interventions may make it difficult to find help; poorly-trained individuals are dangerous and inefficient; shortage of assistants; reimbursements are so low that most use PAs or nurse practitioners (NP) if they do not have residents; with the ever-expanding range of complex surgical procedures, it is critical for surgeons to be able to work together on these hard cases; concern revolves around scope of practice issues and reimbursement for surgical assistants; difficult to obtain since reimbursement vanished; with dwindling numbers of previously thought to be qualified individuals available for assisting, the ACS needs to rethink and reevaluate previous espoused positions; concern regarding availability and compensation in rural areas; some worry that Medicare will take the assistant’s fee out of the surgeon’s fee; safety requires having capable assistants but payment for their services has to be assured; this is a double-edged sword as surgeons are delegating more and more to others.

Credentialing of International Applicants: Overall, 40 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 4.92.

Eighty-five, 62, and 32 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: RACS has been given the responsibility to assess international applicants in Australia and New Zealand. It utilizes specialty groups to assess the applicants and then advises the medical board; there is no one standard of practice among countries; new legislation will likely require all surgeons to be specialists and this will require validated evidence of training and knowledge.
CANADA: an increasingly important item in our province—we have virtually no access to university assessment programs for these doctors with no Canadian experience and whose training is not recognized by the RCPSC; high visibility but not much controversy.
UNITED STATES: our credentials verification office sometimes has trouble validating or even obtaining proper source documents.

International Fellows’ Ability to Attend ACS Clinical Congress: Overall, 37 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 4.78.

Ninety-two, 23, and 29 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: difficult because it is expensive; clearly a financial disincentive for Fellows of Australia and New Zealand but there is a tendency to be more aware of the importance of meetings such as the Clinical Congress; a must for updating and comparing surgical practice; usually good attendance from Ireland. The Surgical Forum book was well regarded and trainees miss it; cost of travel and accommodations make it difficult for surgeons from India to attend; difficult to push Japanese members to attend but advise them to participate as much as possible.
CANADA: not applicable.
UNITED STATES: exchange of ideas and issues is important—keeping surgical standards uniformly high; a very good way to promote exchange of ideas; good for the meeting.

ACS Support of Young International Surgeons Training in United States: Overall, 36 percent of the total number of respondents ranked the importance of this issue at 6 or above, which resulted in a mean score of 4.78.

Eighty-one, 15, and 30 percent of the International, Canadian, and United States respondents, respectively, scored this issue at 6 or above.

Comments related to this issue are as follows.

INTERNATIONAL: Australia and New Zealand surgeons are keen on spending time in United States residency programs to further their training in some of the important units; there is a clear need for more scholarships and increased funds.
CANADA: not applicable.
UNITED STATES: this could be an area that ACS could investigate; most see this as a vital activity for the exchange of ideas.

Other Issues of Concern: Overall, 48 percent of the total number of respondents ranked the importance of other issues at 6 or above, which resulted in a mean score of 5.45.

Twenty-seven, zero, and 19 percent of the International, Canadian, and Unites States respondents, respectively, scored other issues at 6 or above.

Concerns/recommendations regarding these issues are as follows.

INTERNATIONAL: cost of continuing education and transfer of technology could be bilateral benefit.
CANADA: access to adequate OR time, lack of anesthesia, lack of OR nurses, lack of recovery space, wait lists getting longer, and difficulty booking urgent cases causing on-call surgeon to work on cases all night when they could have been done much sooner had OR been available—another reason to retire early.
UNITED STATES: centers of excellence; national regionalization and leveling of trauma care with tort reform and malpractice relief for all who work in ER; leadership training to move surgeons into administrative positions; replacement of retiring rural surgeon/ decreasing rural surgeon workforce—need to commit energy to ensure viability—and new training requirements making it more difficult to obtain well-rounded surgeons able to practice in rural communities; coping with increased new technologies, demands on time, and administrative/bureaucratic activities leaving many physicians more distressed than ever; economic credentialing by hospitals; funding mechanism and training for young surgical investigator, and promotion of surgeon-scientists; have to get more participation in political action committee (PAC); disaster preparedness at hospital level/role of surgeon; unification of surgical disciplines behind common interests and goals; loss of surgeons’ place in society; contract negotiations—every practice needs an MBA to keep government and insurance companies from pulling their next fast one; NSQIP and basic ethical issues need to be reexamined—too many rules/not enough principles; access to volunteer programs; expanding scope of practice of non-physician providers; “physician order” portion of electronic medical record is strongly opposed by virtually all members in state; low morale among surgeons/a lot of unhappiness; inadequate numbers of hospital beds and nurses; post-surgical CME programs would be of value to senior surgeons; advocacy for surgeons—ACS has been too reserved on issues involving practice of surgery. ACS seen as grand club of senior people who have matriculated out of fray of today’s practice of surgery, and ACS needs to be more visible and an advocate for real-world surgical issues; development of a national research agenda that all could contribute to would allow more rapid accrual of data and hopefully provide answers to significant clinical problems.

The following concerns/recommendations were extracted from the “narrative” section of the B/G surveys and are not necessarily related to any of the previous issues.

INTERNATIONAL: ACS can play vital role in improving overall surgical care in third-world countries—real need for Advanced Trauma Life Support^® (ATLS^®), standardized protocol in trauma, surgical oncology, minimally invasive surgery, standardization of patient care, peer review, and Morbidity and Mortality (M&M); ACS Fellowship process should be more stringent—many Fellows who were not trained in United States are very casual in writing letters of recommendation for some surgeons who do not deserve to be Fellows; continuity of care for the surgical patient has become more difficult with responsibility shifted from surgeon to surgical team—there are considerable professional, medical, and legal difficulties; ACS has had very limited activity in building bridges with major international surgical societies while it has a great deal to offer these societies, and it is very possible these societies have something to offer ACS; would request that ACS make a rule that Fellows participate in Clinical Congress and chapter meetings at least once every three years.
CANADA: ACS needs to remain the force in establishing evidence-based best practices for general surgeons and should be invested in developing resources for general surgeons at community level where majority of care is provided; ACS represents general surgery but not all other specialties even though all share the same resources. ACS is still great organization but in Canada it is not appealing enough and should show more interest; is there an opportunity for ACS to develop leadership role in development, promulgation, and postgraduate training in evidence-based guidelines—not standards—for the investigation, management, and prevention of common surgical diseases; patients’ accessibility to latest techniques, equipment, and modalities severely limited by their insurance— patients must be made aware of who is allowed to make decisions. Availability to patients of checklist of important questions to ask when seeking insurance coverage would be of most help and would help secure ACS as patient advocate institution; ACS sets high standards for care of surgical patient but the care is not available to a large number of United States citizens who do not have insurance or private funds; ACS should be a leader in doing studies on common surgical problems—many day-to-day problems could be resolved quickly if ACS led trials that involved tens of thousands of patients.
UNITED STATES: value of ACS not fully apparent to clinical subspecialists—current ACS conferences are not coordinated well enough with other important societies and appear to be redundant or lack focus; technology is rapidly expanding and for small town rural surgeons our role in good patient care is becoming more difficult to define; important for ACS to expand its goals and be more proactive by bringing all surgical specialties under one roof; ACS needs to continue to align itself with quality and safety for the surgical patient; ACS is at critical juncture for the relationship with practicing surgeons—they feel the ACS does not represent their interests satisfactorily; ACS needs to create links among all practicing surgeons, surgical specialties, and generations of surgeons—without the ACS the care of the surgical patient will suffer; greatest role for ACS is to represent surgeons politically in Washington, DC—we need to be involved in health policy reform and change; ACS has to be viewed as the professional society representing surgery; there is still a sense that control of patient care has been commandeered by others; would like to see ACS support the importance of private practice; implore the leadership to realize that change will come from the grassroots movements that are a function of the surgeons in community practice who see members of their community on a regularly recurring basis; perceived inability to present a uniform effective front to government bodies; keeping young surgeons of all specialties aware of ACS; would like to see increased efforts to make ACS more visible to our patients; never has the role of ACS as surgical patient advocate been more critical—ACS must not only advocate for patients but for the health and support of its Fellows as well; ACS must be perceived by public and government as more than a voice for surgeons—it must be the advocate for the surgical patient; it is essential that ACS provide advocacy for surgeons; ACS should recommend and publicize timing of antibiotic prophylaxis, beta blocker therapy, deep venous thrombosis (DVT) prophylaxis, and so forth; post-marketing studies have not been done for most drugs but ACS is in unique position to assess adverse events associated with them; ACS should take leadership role in training and enabling surgeons to take a systems-based approach to practice; regarding health care reform, ACS should sponsor nationwide conference, including major health care players as well as patient representatives; resident graduates are increasingly pursuing fellowships and aligning more with their specialty societies—membership in national organizations more difficult than ever to stimulate; definition of general surgery has changed and therefore, need to respond with changes in the surgical curriculum. ACS should take leadership role in redefining general surgery and attendant changes in education and recertification; concern that surgical specialists are not equally available to attend Clinical Congress—in some cases, (plastic surgery) meetings of specialty organizations directly conflict with ACS meetings; need ACS to help set us apart from those who are not ACS members. Public has no concept of what FACS means—ACS needs to brand us so public knows what FACS is all about; concerned about ethical practice in medicine and surgery and not turning our wonderful profession into just another business; our public image does not recognize all the free care that is provided to Americans and those who come to America to receive care; an example of impact of legal system on health care and medical education is the declining autopsy rate in United States—we have lost one of our most valuable educational tools due to fear of reprisal; partner with our RN colleagues to lobby for better care in our ORs; ACS must figure out a way to effectively serve as umbrella for all surgical specialties as poor representation is poor prognosticator for continued health of organization; initiatives by Committee on Trauma (COT) for Alcohol and Alcohol Problems Science Database (ETOH) training and reporting will be costly. If we report each ETOH use, we do not receive compensation for care—state laws and regulations allow insurance companies to defer payment and place the burden for payment on the patient, who may or may not have been driving. This requires national attention; what is the role of the ACS in the care of the surgical practice; ACS emphasizes preventing payment cuts as a way to maintain quality of care. We should emphasize that we are an organization committed to eliminating wasteful/harmful medical practices—we should be advocates and drivers of reducing the cost of care; ACS has increased its relevance and measurable service to its Fellows but needs to be vocal in its support of other surgical societies and their education, advocacy, and research efforts—there needs to be great care in avoiding the appearance of competing head-to-head with component societies’ services and specialty specific work; keeping surgery together has to be a major priority; need to coordinate our PAC activities with other affiliations—together we are stronger; ACS needs to promote the profession of surgery; improve morale by letting the world know of our relative value, personal dedication, and the importance of having a surgeon who personally cares; private practice general surgery is dying—fragmentation, low reimbursement, and emphasis on “centers of excellence” defined by numbers is causing a shortage of qualified and willing young surgeons to choose community or rural surgery as a career; most general surgeons are apprehensive about the future of the profession. The idea of acute care surgeons potentially solves many on-call issues but will there be enough quality resident graduates willing to work all night and do this their whole lives? What will happen in small towns where a general-general surgeon is what is really needed— will we be training any more general-general surgeons; the care of the practicing surgeon is a worry; two of five candidates for Fellowship interviewed last week stated their main reason for seeking “FACS” was to become involved in an organization that can represent surgery and the care of the surgical patient; ACS is most able to represent the views of surgeons in America; ACS needs to become a more effective advocate for all practicing surgeons and surgical patients; we will have the difficult task of controlling many health care providers doing surgical procedures where proper oversight is lacking and their training is far from adequate—it is necessary that office-based procedures are properly monitored; ACS must represent the interest of its Fellows—not the leadership’s interest to the Fellows; ACS is not espousing “good” surgery to the public—ACS must not be known as a group of austere, robe wearing, senior surgeons who have worked their way to a comfortable position regardless of what happens to the profession; for those who are not in an academic or other large organization, surgery is becoming less and less attractive— many surgeons in middle and lower socioeconomic areas are relocating; the best and brightest in our upcoming generations will have no interest in pursuing this noble profession—ACS is the only entity in United States with sufficient size, energy, and vision to head off this catastrophe.

Online December 5, 2007

Board of Governors

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by the American College of Surgeons, Chicago, IL 60611-3211