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Bulletin

Presidential Address: #SurgeonsSowingHope: Enhanced postoperative recovery and elevated healing

Julie A. Freischlag, MD, FACS, FRCSEd(Hon), DFSVS, identified lessons learned from enhanced postoperative recovery and how this approach may be applied to challenges raised by the pandemic in her Presidential Address at Clinical Congress 2021.

Julie A. Freischlag, MD, FACS

December 3, 2021

Editor’s note: The following is an edited version of the Presidential Address that Dr. Freischlag delivered at Convocation at the virtual Clinical Congress 2021. The presentation has been modified to conform with Bulletin style.

It is an incredible honor to be here for the American College of Surgeons (ACS) Convocation as the incoming President.

The ACS has been such an important part of my life for more than 30 years, and I couldn’t be prouder to welcome all of you—Initiates, Honorary Fellows, Officers, and returning members—into its Fellowship. Congratulations on your amazing achievement. You are joining ranks with a vibrant, diverse community of surgeons who will inspire and support your continued growth and leadership.

Today, I also have the privilege to take my next exciting step in the College and to thank the 2020−2021 President and my dear friend J. Wayne Meredith, MD, FACS, MCCM, for his leadership. Under his direction, the College has accomplished a great deal, developing guidelines for patient triage and management, recommendations for maintaining essential surgery, and wellness resources to guide us through the pandemic. The College also made the very important call for all health care employers to require the coronavirus 2019 (COVID-19) vaccine—a critical step in the continued fight against COVID-19.

Dr. Freischlag, left, with Dr. Meredith
Dr. Freischlag, left, with Dr. Meredith

Dr. Meredith has been instrumental, along with L. Scott Levin, MD, FACS, immediate Past-Chair of the ACS Board of Regents; ACS Regent Timothy J. Eberlein, MD, FACS; and others, in starting the Task Force on Racial Issues and the Regents Committee on Anti-Racism, which will carry on its important work during my presidency and beyond. Grants have been established to advance the diversity of our specialty and increase inclusion and equity.

Dr. Meredith’s contributions and service have been truly remarkable, and I hope you will join me in thanking and celebrating him.

#SurgeonsSowingHope

Today’s address is about recovery—a word we have heard often over the past 18 months in our surgical circles and beyond. I’ll talk about enhanced postoperative recovery after surgery and how lessons learned from this approach can be applied as we step closer to the other side of the pandemic.

I titled my talk “#SurgeonsSowingHope” as a charge for our surgical community: to enhance recovery, elevate healing, and spread hope for our patients, our communities, our teams, and ourselves. I encourage all of us to share the many ways we are sowing hope with this hashtag on social media. It always is inspiring to see the wonderful works of our fellow surgeons in action. My plan throughout the year is to invite many of our leaders at the College to post a one-minute podcast, video, or social media message with this hashtag so that we can share enhanced recovery thoughts as we go forward, beyond the pandemic.

The poet Emily Dickinson wrote:

Hope is the thing with feathers

That perches in the soul,

And sings the tune without the words,

And never stops at all….

A physical therapist, who also happens to be an artist, drew the picture that appears here and on the cover of this issue of the Bulletin, which shows the first rib removed for thoracic outlet syndrome, which is my area of vascular surgery expertise. To me, the words in this poem describe the delicate and fleeting nature of hope. But hope also never stops singing. It overcomes even the most difficult circumstances and challenges. Hope endures.

Uncaged by Jordan Spennato: www.spennatojm.weebly.com [spennatojm.weebly.com]
Uncaged by Jordan Spennato: www.spennatojm.weebly.com [spennatojm.weebly.com]

Hope for improved health is a driver behind enhanced recovery after surgery. “Enhance,” in its various forms, means to improve the quality or strength of, to make better and to educate and enlighten. Its very essence is captured by this approach to patient care, which aims to medically optimize the health and safety of patients before surgery—on day one—and throughout the continuum of care.

Brothers by Peter Freischlag, the author’s brother: https://www.bigmoosestudios.net/
Brothers by Peter Freischlag, the author’s brother: https://www.bigmoosestudios.net/

Benefits of enhanced recovery after surgery

Enhanced recovery after surgery has proven benefits. It is associated with improved patient outcomes and safety, reduced hospital stays and readmissions, shorter recovery times, and lower costs. Through a combination of evidence-based guidelines based on patient education and engagement, multidisciplinary teamwork, screening tools, nurse navigation, and patient champions, the whole patient is supported throughout the surgical journey and beyond, through recovery.

Two recent studies from the Journal of Vascular Surgery quantified some of the benefits.

The first examined implementation of an enhanced recovery bundle in 57 patients with lower extremity bypass. Patients in the enhanced recovery program had decreased length of stay of eight versus 11 days when compared with patients who were not in the program. In addition, variable costs declined from about $18,000 to $13,000.1

Enhanced recovery is a theme we can apply on an even larger scale as we begin to emerge from the pandemic. Many of the same principles that underlie this approach to optimization—collaboration, compassion, inclusion, engagement, and innovation—can guide us as we heal, recover, and lead moving forward.

The second study examined patients undergoing abdominal aortic aneurysm repair with an enhanced recovery program, in comparison with patients undergoing endovascular aneurysm repair, or standard open repair. The protocol was associated with a reduced time to discharge, with a mean time to discharge of five days in the enhanced recovery group and 8.4 days in the open repair group. There also were improved postoperative outcomes like early ambulation and feeding.2

Both of these studies have what I consider the most important element of enhanced care: a multidisciplinary team at the core.

Enhanced recovery is a theme we can apply on an even larger scale as we begin to emerge from the pandemic. Many of the same principles that underlie this approach to optimization—collaboration, compassion, inclusion, engagement, and innovation—can guide us as we heal, recover, and lead moving forward.

I frequently say, “What has COVID-19 done for me, or us, lately?” Even though the list is not long, it has enabled us to enhance communication, just as we are doing today with this virtual meeting. It also has allowed us to use telehealth for our patients and made us more flexible in how and where we work.

Dr. Freischlag in surgery
Dr. Freischlag in surgery

Resilience

I want to talk a bit with you about my experience as a leader.

When I was seven, my grandfather told me, “Julie, there are going to be people who say you can’t do things in your life. When they say you can’t, show them you can.”

Several times during my career, I have been told “no,” but this advice to be resilient became my motto—“Yes, I can”—which has grown to, “Yes, WE can.”

For 11 years, I was the only woman chair of a department at Johns Hopkins Hospital in Baltimore, MD. You’ll see me in red in the photo. I wore black for a year in an attempt to blend in before deciding to show my true colors and self. Those were some of the most transformative years of my career, during which I learned about myself as a leader and the importance of building connections, culture, and teams based on trust, openness, inclusion, and opportunity.

Department chairs at Johns Hopkins Hospital, 2012 (photo courtesy of Johns Hopkins Medicine)
Department chairs at Johns Hopkins Hospital, 2012 (photo courtesy of Johns Hopkins Medicine)

In 2012, I also was elected to serve as the first woman Chair of the College’s Board of Regents. We have made great strides in diversity since then. Today, 18 percent of our members of the ACS are women. Almost 12 percent of our Fellows are women, 34 percent of Associate Fellows are women, 43 percent of Resident Members are women, and 47 percent of Medical Student Members are women. And today, we welcome an Initiate class in which 27 percent are women.

As leaders and surgeons, COVID-19 has brought a storm of challenges we never could have imagined—from delays in elective procedures to redeployment of staff, financial strain, and new safety practices. There also have been silver linings where we have seen the most amazing acts of bravery and teams come together stronger than ever.

Some of the words that come to mind when I think of what I’ve experienced and seen in others are transformation, compassion, courage, strength, purpose, and determination; but there are so many more. What are your words, and how can we live these out in our daily practices as we lead through COVID-19?

COVID-19’s effects on surgery

To look forward, let’s take a quick look back at the past year.

According to the ACS, 52 percent of surgeons reported experiencing burnout.3 Delays in care affected each of us and had far-reaching implications. A Centers for Disease Control and Prevention study reported that, by June 30, 2020, 41 percent of adults in the U.S. delayed or avoided medical care.4 In addition, a study presented at the annual meeting of the Society of Thoracic Surgeons cited a 53 percent drop in adult cardiac operations nationwide and a 65 percent decline in elective procedures.5

And most importantly, the pandemic showed us the devastating impact of long-standing health disparities in our underserved communities. COVID-19’s disproportionate effect on communities of color is staggering, with one study reporting that more than one-third of COVID-19 deaths have been among Blacks/African Americans.6 We know we can—and must—do so much better.

How do we begin to recover and also ensure that we improve along the way?

I want to go back to the values that frame enhanced recovery after surgery—compassion, collaboration, inclusion, engagement, and innovation—and share how we’re putting these into action with our surgical teams and patients.

Adapt and innovate

The pandemic created a paradigm shift, pushing us to innovate quickly. Telehealth emerged as a safe, convenient, and lower-cost alternative to in-person visits, while still allowing us to engage with and include patients in our care.

Anthony Atala, MD, FACS, director of the Wake Forest Institute for Regenerative Medicine, Winston-Salem, NC, and an ACS Regent, created a tool kit for rapid integration of an outpatient telemedicine program during the pandemic, the findings of which he and colleagues described in an article in the Journal of the American College of Surgeons. These elements include provider and staff training, patient education, engagement and participation, coding and billing integration, information technology support, an electronic health record system, audiovisual platforms, and hardware investment.7

Telehealth provides enhanced benefits, but it also poses barriers for underserved communities that may not have access to an Internet connection. Recognizing this limitation, our hospital launched a Hospitalist at Home program last December. By combining telehealth technology with in-home visits from paramedics, we reached more than 500 patients in our region within the first seven months of the program. This is just one way we are enhancing care with innovation.

Elevate equity and inclusion

With enhanced recovery comes the incredible opportunity to be ambassadors and advocates for equity and inclusion. Every patient, regardless of background, race, gender, or ethnicity, deserves access to equitable care and treatment, and we have seen this more than ever during the pandemic.

Across our health care system, we are focusing on enhancing equity and creating a vibrant, rich tapestry of perspectives, voices, backgrounds, beliefs, and talents that reflect our community.

Similar to the ACS, another major initiative we started at our hospital during the pandemic was a Racial Equity Task Force, which brings together leaders, staff, students, and community members focused on positive change. Together, we are examining our data trends, hiring and retention practices, community outreach, staff support, educational opportunities, and culture to ensure that everyone has a seat at the table, that all voices are heard, and that we are best caring for our community.

Make a compassionate connection

At the heart of enhanced caring is compassion. In the book Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference, authors Stephen Trzeciak, MD, MPH, and Anthony Mazzarelli, MD, JD, MBE, define compassion as “the emotional response to another’s pain or suffering, involving an authentic desire to help.”8 Through an expansive literature review, they describe the importance of compassion in health care and its many benefits, including improved patient outcomes, reduced costs, time savings, and lower levels of physician burnout.

They share research that indicates more than half of physicians believe they do not have time for compassion; however, they also cite research that shows it takes only 40 seconds to create a meaningful connection with a patient. This finding made me pause and think, what can I do in just 40 seconds to make a compassionate connection and difference?

For me, it is treating patients how I would want my own family treated: Asking, “How do you feel, and what are you hoping for?” and making sure I communicate that “together, we are one team focused on your health and recovery.” My son calls that “mom-directed care.” Everyone deserves this kind of care.

Celebrate victories and teamwork

Over the past year, we have seen the difference that commitment and compassion make when they are enhanced. We created a Victory Lane (see photo), which is on the walkway our employees use every day as they arrive at the hospital. Each yellow ribbon represents a patient who received COVID-19 care at our hospital and returned home. Today, this walkway is completely filled with ribbons, as more than 3,000 patients with COVID-19 have been discharged across our health care system. This picture reflects the amazing opportunity that we each have to make a life-changing difference.

Victory Lane at Atrium Health Wake Forest Baptist
Victory Lane at Atrium Health Wake Forest Baptist

I believe that part of enhancing recovery means taking the time to say thank you and celebrating the incredible work and sacrifices our health care heroes have made. This can take the form of a recognition like Victory Lane or smaller gestures like stopping to ask a teammate how their day is going and if you can help in any way.

Lastly, enhanced care and recovery take true teamwork based on communication, trust, transparency, and opportunity. When we provide opportunity and empower others, our teams become stronger, and together we go further.

Enhance recovery: #SurgeonsSowingHope

As you move forward through the pandemic and support your teams, I encourage you to care for yourselves, too. Surgery is a rewarding but demanding profession, and as a recent New York Times article noted, we need to find ways to flourish.9 This can take many forms: making new connections, celebrating small wins, doing good deeds, and practicing gratitude. It is so true that when we better care for ourselves, we better care for others, too.

One of the ways to enhance recovery as you enter into the next part of your career as a new Fellow of the ACS is to be involved and have your friends and colleagues become members. My friendships over the years with other members have always sustained me, but even more so during the pandemic. Even virtual connections have been essential to me, and I cannot wait until we are back safely meeting in person again.

Today marks an incredible accomplishment for each of you, and I encourage you to get involved and engaged with this amazing organization and network of people, who will become your friends, advocates, and closest professional collaborators.

Together, as surgeons, we have an exciting opportunity to elevate healing, enhance recovery, and spread hope.

Together, as surgeons, we have an exciting opportunity to elevate healing, enhance recovery, and spread hope. My charge for each of us is to lead with compassion, collaboration, inclusion, and innovation.

I cannot wait to see the many ways we enhance care and uplift recovery as #SurgeonsSowingHope.

Thank you for having me here today. It is an honor and privilege to lead with you, and I look forward to all we will accomplish together with the American College of Surgeons.


References

  1. Witcher A, Axley J, Novak Z, et al. Implementation of an enhanced recovery program for lower extremity bypass. J Vasc Surg. 2021;73(2):554-563.
  2. Giacomelli E, Dorigo W, Campolmi M, et al. A pilot study of the enhanced recovery after surgery protocol in aortic surgery. J Vasc Surg. 2021;74(1):90-96.e2.
  3. American College of Surgeons. COVID-19 induced a second crisis: The mental health pandemic. Bulletin: ACS COVID-19 Newsletter. May 8, 2020. Available at: https://www.facs.org/covid-19/archives/newsletter/050820/well-being. Accessed October 13, 2021.
  4. Czeisler MÉ, Marynak K, Clarke KE, et al. Delay or avoidance of medical care because of COVID-19–related concerns—United States, June 2020. Morb Mortal Wkly Rep. 2020;69(36):1250-1257.
  5. Nguyen TC, Thourani VH, Nissen AP, et al. The effect of COVID-19 on adult cardiac surgery in the United States in 717,103 patients. Ann Thorac Surg. 2021;S0003-4975(21)01310-2.
  6. Holmes L Jr, Enwere M, Williams J, et al. Black-white risk differentials in COVID-19 (SARS-COV2) transmission, mortality and case fatality in the United States: Translational epidemiologic perspective and challenges. Int J Environ Res Public Health. 2020;17(12):4322.
  7. Smith WR, Atala AJ, Terlecki RP, Kelly EE, Matthews CA. Implementation guide for rapid integration of an outpatient telemedicine program during the COVID-19 pandemic. J Am Coll Surg. 2020;231(2):216-222.e2.
  8. Trzeciak S, Mazzarelli A. Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference. Pensacola, FL. Studer Group; 2019.
  9. Blum D. The other side of languishing is flourishing. Here’s how to get there. New York Times. May 4, 2021 (updated May 6, 2021). Available at: https://www.nytimes.com/2021/05/04/well/mind/flourishing-languishing.html. Accessed October 13, 2021.