June 1, 2022
Approximately 700 individuals—220 in-person and 475 virtual attendees—participated in the American College of Surgeons (ACS) 2022 Leadership & Advocacy Summit, April 2−5, in Washington, DC. It was the first in-person summit that the College has hosted since COVID-19 struck the US in 2020.
Individuals still can register for the Leadership & Advocacy Summit on the ACS website to access the on-demand content available until July 5, 2022. Registrants can earn up to 4 AMA PRA Category 1 Credits™ for attending or viewing the Summit.
Speakers at the Leadership Summit offered insights on compelling topics, including second victim syndrome, surgeons as leaders, and diversity, equity, and inclusion (DEI) in surgery.
Haytham Kaafarani, MD, MPH, FACS, associate professor of surgery, Harvard Medical School, and a trauma surgeon at Massachusetts General Hospital (MGH), Boston, described his experience when he felt that he had failed a patient who died from a postoperative soft tissue infection after many operations to treat injuries the patient suffered following impalement by a forklift.
Dr. Kaafarani was haunted by this experience, second-guessing his clinical judgment. He was neither the first nor the last surgeon to wonder what he could have done differently. He pointed to a study of Boston physicians that showed that more than 81% of surgeons experience anxiety, depression, self-blame, embarrassment, and other negative emotions when a patient dies or experiences another adverse outcome.
“We all hide our grief and suffer in silence,” Dr. Kaafarani said. “If this is not about surgeon well-being, then what is?”
“So, how can we turn this around?” he asked. The one factor he and his colleagues found that can help someone who is dealing with second victim syndrome is peer support, especially from surgeons who have been in similar situations.
He outlined how the department of surgery at MGH selected peer supporters, noting that the peer support program at MGH has gone “extremely well,” with approximately 50 successful interventions occurring annually.
ACS Governor D. Rohan Jeyarajah, MD, FACS, moderated a well-received panel session on surgeon well-being. Tips and lessons learned came from ACS President Julie A. Freischlag, MD, FACS, DFSV, ACS Regent Douglas E. Wood, MD, FACS, FRCSEd, and Melanie A. Edwards, MD, FACS, a member of the ACS Women in Surgery Committee.
“Well-being is a real concern for surgeons at all stages, especially when you’re a leader,” Dr. Jeyarajah noted.
Dr. Edwards emphasized the importance of carving out time for well-being, even if it’s only 5 minutes a day for exercise.
In addition to exercise, Dr. Freischlag said it’s important to enjoy “mini pleasures,” such as going for a walk, checking out the sights in the vicinity, or leaving early from a meeting to engage in an activity that you enjoy.
Achieving work-life equilibrium plays a factor in surgeon wellness. Dr. Wood said that when his daughters were young, he made a point of “going to every soccer game, every parent-teacher conference, but there were also a lot of times when I was gone, and I felt guilty about that.” Often, it’s a matter of compromise and deciding when you need to be with your family rather than at a work-related event.
The Committee on Trauma (COT) and Commission on Cancer (CoC) both are celebrating 100 years of improving patient care in 2022.
John H. Armstrong, MD, FACS, FCCP, Chair of the Advocacy Pillar, and a member of the ACS COT Executive Committee, summarized the history of the COT. He noted that the COT grew out of the Committee on Fractures, created largely to ensure that injured patients would receive optimal care. Since then, the COT (formally established in 1949) has developed into a standard-setting and accreditation organization with the publication of Resources for Optimal Care of the Injured Patient, now in its seventh edition.
The COT also provides education to emergency medical services personnel and other trauma care professionals through the Advanced Trauma Life Support® program and to bystanders at the scene of incidents involving rapid blood loss through STOP THE BLEED®, Dr. Armstrong noted. COT leaders also have led the charge to improve motor vehicle safety and have created regional trauma systems.
“The COT created a culture of safety that puts the injured patient first,” Dr. Armstrong said. Spurring these innovations and activities, he said, is the COT constantly questioning, “What can we do better?”
Similarly, Timothy W. Mullett, MD, FACS, Chair of the CoC, provided an overview of the commission’s growth from the ACS Committee on Cancer to a standard-setting and accreditation body with more than 50 cancer-related organizations in partnership with the American Cancer Society. The CoC now accredits 1,500 cancer care facilities and issues 91 standards designed to ensure optimal care of cancer patients.
“The CoC is not sitting on 100 years of laurels,” Dr. Mullett noted. The CoC promulgates operative standards and staging guidelines. Many of these standards and guidelines are based on data monitored through the National Cancer Database and submitted by the CoC-accredited cancer program.
Advancements and enhancements, such as the introduction of synoptic reporting, are ongoing.
The CoC and the ACS National Accreditation Program for Breast Centers also recently launched the Just ASK study to increase and improve the integration of smoking assessment as a standard of care.
Marion C. W. Henry, MD, MPH, FACS, FAAP, professor of surgery, pediatric surgery, University of Chicago, IL, said her journey into advocacy began in December 2012, around the time of the massacre at a Connecticut school. “I dropped my son at school that day and went to work. I was lucky. I picked up my son from school, and we went home that afternoon—something the parents of 20 students at Sandy Hook Elementary School could not do that day,” she said.
As she saw the number of mass shootings rise, including one on the East Coast Navy Base where she worked, alongside daily death tolls from firearm violence, she knew it was time to get involved. After leaving the Navy, Dr. Henry began to speak out on healthcare issues as a private citizen. Soon thereafter, then-president of the American Pediatric Surgical Association (APSA) and ACS Second Vice-President-Elect Mary E. Fallat, MD, FACS, asked her to serve as vice-chair of the organization’s health policy and advocacy committee.
“Both APSA and the ACS have outstanding resources to help you get involved,” Dr. Henry said, including the opportunity to participate in the Health Policy and Leadership Program at Brandeis University in Boston, MA.
She also found mentors at the ACS, APSA, and American Academy of Pediatrics who helped her get involved at the state and federal levels.
Dr. Henry said it is important that surgeons learn early in their careers about the importance of advocacy. She proposed a new “quadripartite mission of academia,” which includes not only the traditional elements of education, clinical care, and research, but also social accountability.
“Most surgeons assume that they become a leader when they get a title, and that means when you become a director, a chief, a chair, and so forth. But the truth is every healthcare organization depends on the leadership of every healthcare professional every day,” said Jon A. Chillingerian, PhD, a professor at Brandeis University and adjunct professor of public health and community medicine at Tufts University School of Medicine, Boston.
“Leaders can never see themselves clearly until they see themselves through the eyes of others,” Dr. Chillingerian said. With that thought in mind, he asked surgeon leaders to self-evaluate and seek out anonymous assessments from their peers. He found that surgeons generally rated themselves in the 50th percentile on a scale of leadership qualities, whereas their colleagues generally ranked them in the 70th percentile. “So, surgeons are actually better leaders than they think they are,” he noted.
Leaders from three ACS chapters shared their success stories:
Bonnie Simpson Mason, MD, FAAOS, Medical Director, ACS Office of DEI, noted that DEI is not always a welcome topic of conversation, but communication is key to reducing the disparities in healthcare and the surgical workforce.
She emphasized cultural humility—acknowledging that surgeons of different backgrounds, races, ethnicities, and genders do not have shared experiences.
“We need everyone to approach this work with a lens of curiosity—like the one we had our first year of medical school,” Dr. Mason said. “The work starts with us, especially those of us who are leaders.”
Efforts to improve DEI are not competitive in nature. “We need to create a safe, trauma-free space where there is no judgment. We can have these conversations without confrontation. We don’t have to agree,” but we do need to be respectful, she said.
ACS Executive Director Patricia L. Turner, MD, MBA, FACS, outlined her vision for the College moving forward.
“Our motto is ‘To Heal All with Skill and Trust,’” Dr. Turner said. Implicit in this statement is inclusivity and advocacy. “We cannot heal all if we don’t have all surgeons at the table in the College. That means all specialties, that means all practice patterns, that means all ages,” she noted.
The ACS motto also implies that its members are skillful. Hence, the College needs to be mindful of providing training and educational opportunities to help surgeons attain, maintain, and enhance the skills they need to provide optimal care, she noted.
“This notion of trust is incredibly important,” Dr. Turner said. “The public, our patients, place their trust in us in a way that is different from any other physician.”
“Part of our strategy moving forward will be to enhance communication and be sure we are sharing all that we do and ensuring that we can support our surgeons and support the patients of those surgeons,” Dr. Turner said.
The College needs to communicate with legislators, policymakers, the media, and the public “writ large” that this organization is a trustworthy source of information “on all things surgical,” she added.
The Advocacy Summit kicked off with a Keynote Dinner, during which Washington Post associate editor Bob Woodward shared his views on the political climate. Another political journalist, Jake Sherman, founder of Punchbowl News, spoke at a luncheon sponsored by the ACS Professional Association Political Action Committee—ACSPA-SurgeonsPAC.
As Matt Coffron, MA, Chief, Health Policy Development, Division of Advocacy and Health Policy (DAHP), noted, “All laws are flawed,” and the Medicare Access and CHIP Reauthorization Act (MACRA) is no different.
The law was passed with the intention of replacing the sustainable growth rate Medicare physician payment mechanism with the Quality Payment Program (QPP)—a value-based system. The plan was that initially most physicians would be paid using the Merit-based Incentive Payment System (MIPS), but ultimately would move into Alternative Payment Models (APMs).
The law provided opportunities for specialty organizations to develop APMs and to accurately value the work that specialists do. Since implementation began in 2016, the Physician-Focused Payment Technical Advisory Committee (PTAC), which advises the Administration on implementation of APMs, has received 39 specialty proposals for APMs, including recommendations from the College, Mr. Coffron said.
However, the Centers for Medicare & Medicaid Services (CMS) has yet to test these proposed APMs.
CMS and the ACS “have completely different perspectives on quality,” Mr. Coffron said.
Jill Sage, MPH, Chief, Quality Affairs, ACS DAHP, said, “The ACS understands quality. The ACS was built on quality.”
The ACS maintains that “quality is a program—not a measure,” she added. Although CMS agrees with the College’s perspective, “they don’t really know how to disrupt the payment system that they have created over the decades,” Ms. Sage added.
Furthermore, “Defining value remains incomplete,” she noted. The ACS has asserted that value is more than weighing quality against costs and that it must account for what matters most to the individual patient, Ms. Sage said.
Vinita Mujumdar, JD, Chief, Regulatory Affairs, DAHP, spoke about short-term fixes to the Medicare physician fee schedule (MPFS). Without these changes, surgeons will once again face the threat of significant payment reductions starting in January 2023.
More specifically, Mujumdar said, the College is asking Congress to hold hearings on the projected payment cuts in 2023. The goal is to “immediately reverse all reductions in the Medicare physician fee schedule caused by PAYGO [a budget rule requiring offsets for tax cuts and mandatory spending increases], sequestration, and budget neutrality adjustments to the conversion factor,” she said.
The College also is asking that the updates to evaluation and management (E/M) codes for in-office visits be applied to the E/M portion of global surgery codes, Mujumdar said.
In addition, the ACS is asking that physician payment updates “reflect medical inflation and increased practice costs,” among other requests, she said.
During his presentation on the COT at the Leadership Summit, Dr. Armstrong said, “It is time to establish a national trauma system.”
Building on this proposition, Robert Kadlec, MD, Senior Counsel for the Senate Committee on Health, Education, Labor and Pensions, said, “Clearly, the ACS has been a leading voice in this kind of movement.”
Noting that the COVID-19 pandemic, the war in Ukraine, and North Korea’s missile development efforts have rendered the US’s previous emergency response system archaic, Dr. Kadlec called for change. “We need an operational component that can stitch together” federal and private sector capabilities to respond to healthcare crises—regionally and nationally, he said.
Eileen M. Bulger, MD, FACS, Medical Director, ACS Trauma Programs, described the COT’s efforts to establish such a system, known as the national trauma and emergency preparedness system (NTEPS).
“COVID really highlighted the problems we have in dealing with national trauma capacity,” Dr. Bulger said.
“We think there is broad variability in quality, continuity, and access to care,” she said. “Can we come together now and harness the lessons we learned from COVID to develop a system that meets these needs?”
A multidisciplinary group has united to develop five constructs that are essential to NTEPS, Dr. Bulger noted, including:
“Our systems often don’t know what they don’t have until they need it,” Dr. Bulger said. "Perhaps this is the time to move the needle forward on our trauma healthcare systems.”
Charles D. Mabry, MD, FACS, a former ACS Regent and Chair of the ACS Health Policy Advisory Council, explained that hospitals are paid under Medicare Part A, whereas physicians are paid under Part B. Medicare Part A is funded through income taxes, and payment is based on diagnostic-related groups, whereas Medicare Part B has a budget, and payment is based on the resource-based relative value scale (RBRVS).
“While we can all wring our hands about the increased expenses of Medicare, unfortunately physicians are not the ones driving the boat,” Dr. Mabry said. Reimbursement to physicians has dropped by approximately 4% of total Medicare spending, and surgeons are bearing the brunt.
Part A gets a mandatory update every year. On the other hand, physician payment updates are tied to overall expenditure, so surgeons are not getting annual payment increases.
Margaret C. Tracci, MD, JD, FACS, explained that payment increases have not kept pace with inflation. “We all feel that we are doing work that we’re not compensated for,” she said. Moreover, inflation has outpaced surgeon payment by up to 30% over previous decades.
Surgeons bring “tremendous value to the healthcare system, largely unseen,” Dr. Tracci said.
Patrick V. Bailey, MD, MLS, FACS, Medical Director, ACS Advocacy, provided an overview of the No Surprises Act, which took effect at the beginning of this year. The legislation is designed to protect patients from unexpected and often costly medical bills. The legislation also calls for establishing an independent dispute resolution (IDR) process to resolve disputes between payers and providers, he said.
These provisions are intended to take patients out of the middle of these disagreements, Dr. Bailey said.
Robert Jasak, JD, vice-president, coverage and payment policy, Hart Health Strategies, Washington, DC, explained that the legislation includes other provisions intended to better inform patients about what charges to expect and their rights under the law. For instance, providers must post disclosures in their offices and on their websites, provide patients with a notice of their rights under the law, and must offer good faith estimates of how much patients will be billed.
If a patient requires emergency care or seeks nonemergency care from out-of-network physicians at in-network facilities, “providers cannot balance bill the patient for those services,” Jasak said.
For uninsured and self-pay patients, surgeons must reach out to all providers and facilities that will be involved in delivering care and provide a comprehensive good faith estimate of total charges, he said.
Katy Johnson, JD, senior counsel, health policy, American Benefits Council, said health plans must make an “initial payment amount” to providers within 30 days of service. If the plan disputes the claim, it goes to IDR. Arbitrators are to look at the qualifying payment amount (QPA), training and experience of the provider, and whether the procedure is done at a teaching hospital, Johnson said.
The federal agencies involved in issuing guidance on implementation of the law have said IDR arbitrators should select reimbursement amounts that are closest to the QPA. The agencies also issued the final rules without issuing proposed regulations. Further complicating matters, Johnson said, is the fact that the federal regulations apply only in states without surprise billing legislation already in place.
The number of non-White physicians working in the US is strikingly small, according to Sandra E. Ford, MD, MBA, a pediatrician and Special Assistant to the President for Public Health. Yet, “studies have shown that having a clinician who looks like you or shares your culture and speaks your language increases your trust.”
The White House is very much engaged in ensuring we have equity across the board,” she said.
Equal acces to healthcare also is a priority for the College. Dr. Turner noted that Dr. Martin Luther King Jr. once said, “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.”
Thus, she said, “It is fairly obvious that we should achieve equity, but how do we do that?” Dr. Turner noted that the College secured a grant from the National Institutes of Health to determine how the nation can address disparities in healthcare.
In addition, 2020−2021 ACS President J. Wayne Meredith, MD, FACS, formed a Regental Anti-Racism Task Force. This body offered recommendations on how the College can improve DEI in the surgical workforce and within the ACS, Dr. Turner noted. Subsequently, the Regents Committee on Anti-Racism was appointed to ensure the recommendations were implemented and woven into the fabric of the College’s work.
For insights on how the College and other surgical societies could implement these recommendations, the ACS hosted a DEI and Anti-Racism Summit, established a new Pillar within the Board of Governors and other ACS committees to explore opportunities, and created the Office of DEI led by Dr. Mason and Cie Armstead, MPA, DBA.
Advocacy Summit participants engaged in more than 150 virtual visits with lawmakers and their senior staff April 5. ACS DAHP staff briefed attendees on key congressional “asks” to discuss in these briefings:
The next Leadership & Advocacy Summit will take place April 15−18, 2023, in Washington, DC.