Governors Survey Probes Telehealth, Microaggressions, Training, Private Practice

Editor’s note: The ACS Board of Governors (BoG) is the representative body of the ACS, and its members serve a critical role as liaisons between the Board of Regents and Fellows. The BoG conducts an annual survey of its domestic and international members in an effort to provide feedback to College leadership on matters of importance to surgeons.

This article provides an overview about matters related to current practice and training as a result of a 2021 survey. More in-depth results have been shared with ACS leadership, and discussions will continue on behalf of members to help shape the College’s priorities and efforts. The 2022 ACS Leadership Survey is being conducted this fall. Results will be reported in 2023.

The 2021 ACS BoG survey was conducted in July and August 2021 and had a 95% (277/292) response rate. Respondents were predominantly male (78.7%), White (71.5%), based in the US (79.1%), between the ages of 51 and 65 years old (65.7%), and in full-time academic practice (63.2%).

Survey questions focused on the use of telehealth, experiences regarding microaggressions and harassment, opinions on the surgical training paradigm in the US, and the status of surgical private practice.

Telehealth

The use of telemedicine has increased significantly since the start of the COVID-19 pandemic. Approximately 79% of Governors reported that they have used telemedicine (both audio and video) since the start of the pandemic; this finding was similar across age groups. In the outpatient setting, telemedicine was used more commonly for routine follow-up of simple operations or with known patients. In all categories, telemedicine was used least often for complicated postoperative patients (see Table 1). It also was less commonly used for managing inpatients, including intensive care unit (ICU) patients and rehabilitation patients; for other clinical activities, such as responding to patient inquiries or staff providing home health services; or in responding to requests from a colleague in the operating room (OR) (see Table 2).

Table 1.

During the previous 15 months, how often did you use telemedicine (both audio and video) for patient evaluation/management of outpatients?

Telemedicine use	Never	Rarely	Sometimes	Very Often	Always
Follow-up of known patients	2.29%	16.06%	47.71%	32.57%	1.38%
Simple, straightforward postop patients	8.72%	18.81%	43.58%	25.69%	3.21%
New outpatient referrals	28.44%	27.06%	32.57%	11.47%	0.46%
Complicated postop patients	53.67%	26.15%	16.51%	2.75%	0.92%

Table 2.

During the previous 15 months, how often did you use telemedicine (meaning both audio and video) for patient evaluation/management of other clinical activities?

Telemedicine use	Never	Rarely	Sometimes	Very Often	Always
Requests from the OR from a colleague	81.65%	12.39%	5.96%	0%	0%
ICU patients (including using an eICU model)	90.37%	4.13%	3.67%	1.38%	0.46%
Patient inquiries via your office telephone	46.79%	16.06%	29.82%	6.88%	0.46%
Patients receiving/staff providing home health services	61.47%	22.02%	14.68%	1.83%	0%
Extended care patients, inpatient rehab facility patients (either to see the patient or from their staff asking queries)	72.94%	15.60%	9.63%	1.83%	0%

Approximately 28% of respondents said that they restricted and/or were planning to restrict telemedicine use for certain types of patients. Additionally, 35% of respondents reported that they currently had and/or were planning to have a facet of their practices routinely conducted through telemedicine.

When asked which patients would be challenging to evaluate or communicate with using telemedicine, respondents identified new patients, those with complex and urgent/emergent needs, patients requiring a physical exam (especially anorectal, genital, breast, ear, or ophthalmologic), elderly individuals, and those who have language barriers.

Responses to questions about telehealth did not seem to differ significantly by age or gender; however, international respondents reported using telemedicine slightly more than their US and Canadian counterparts for patients in the inpatient, emergency department, ICU, and OR settings, as well as for patients in extended care and rehab facilities. Telehealth also was used for patient telephone calls to the office and patients receiving/staff providing home health services (see Figure 1).

Figure 1. Telemedicine Used for Extended Care, Inpatient Facility Rehab

A majority (58.8%) of Governors asserted that reimbursement should be the same for both in-person and telemedicine visits, while 35.4% noted reimbursement for in-person visits should be higher than for telemedicine visits, and 5.8% noted reimbursement for telemedicine visits should be higher than for in-person visits.

Respondents indicated strong support for the ACS to lobby for telemedicine coverage for established and new patient encounters by all public and private payer sources in the future. Additionally, many Governors said it was important for the ACS to better define optimal methods and clarify ethical concerns for telemedicine use (see Table 3).

Table 3.

Indicate Level of Importance for Advocacy Efforts, Other Topics

	Not at all important	Slightly important	Moderately important	Quite important	Essential
How important is it for the ACS to lobby for telemedicine (audio and video) of established patient encounters to be covered by all public and private payer sources in the future?	3.25%	12.64%	21.30%	31.41%	31.41%
How important is it for the ACS to lobby for telemedicine (audio and video) involving new patient encounters to be covered by all public and private payer sources in the future?	8.66%	13.00%	27.80%	21.66%	28.88%
How important is it for the ACS to better define optimal methods for using telemedicine (including audio and video)?	2.89%	11.55%	31.41%	26.71%	27.44%
How important is if for the ACS to better clarify ethical concerns for using telemedicine (including audio and video)?	6.14%	13.00%	27.44%	24.19%	29.24%

DEI

The survey found that some of the more common challenges faced by surgeons related to diversity, equity, and inclusion (DEI) included harassment and microaggressions. While many traits, behaviors, and actions can be the target of harassment and/or microaggressions, this survey focused on gender and race.

Gender-based harassment was defined explicitly as “…verbal and non-verbal behaviors that convey hostility, objectification, exclusion, or second-class status based on gender.” The questions referred to the respondents’ experiences over the past year.

Men were more likely to report having witnessed harassment based on gender than having experienced it, but women reported very similar rates of experiencing and witnessing gender-based harassment. A majority of men (79.8%) reported “never” experiencing harassment based on their gender compared to only 26.3% of women, and approximately 14% of women reported experiencing gender-based harassment “very often” or “always” compared to only 0.5% of men (see Table 4).

Table 4. Gender-Based Harassment

In the past year, how often have you experienced harassment due to your gender?

Gender	Never	Rarely	Sometimes	Very Often	Always
Male	79.82%	15.14%	4.59%	0.46%	0%
Female	26.32%	28.07%	31.58%	10.53%	3.51%
Prefer not to answer	0%	100%	0%	0%	0%
Total	68.48%	18.12%	10.14%	2.54%	0.72%

In the past year, how often have you witnessed harassment based on gender?

Gender	Never	Rarely	Sometimes	Very Often	Always
Male	41.28%	37.61%	19.72%	1.38%	0%
Female	21.05%	28.07%	35.09%	12.28%	3.51%
Prefer not to answer	0%	100%	0%	0%	0%
Total	36.96%	35.87%	22.83%	3.62%	0.72%

In this survey, microaggressions were defined explicitly as “…subtle snubs, slights, and insults directed towards minorities, women, and other stigmatized groups that implicitly communicate hostility.”

Men were more likely to have witnessed microaggressions based on gender than experienced them, but women reported very similar rates of experiencing and witnessing microaggressions (see Table 5). A majority of men (68.8%) reported “never” experiencing microaggressions based on their gender, whereas only 15.8% of women reported never experiencing them. Approximately 26.3% of women reported experiencing microaggressions “very often” or “always” compared to only 1.4% of men.

Table 5. Gender-based microagressions

In the past year, how often have you experienced microaggressions due to your gender?

Gender	Never	Rarely	Sometimes	Very Often	Always
Male	68.81%	19.27%	10.55%	1.38%	0%
Female	15.79%	15.79%	42.11%	21.05%	5.26%
Prefer not to answer	0%	0%	100%	0%	0%
Total	57.61%	18.48%	17.39%	5.43%	1.09%

In the past year, how often have you witnessed microaggressions based on gender?

Gender	Never	Rarely	Sometimes	Very Often	Always
Male	31.19%	41.74%	23.85%	3.21%	0%
Female	10.53%	15.79%	42.11%	26.32%	5.26%
Prefer not to answer	0%	0%	100%	0%	0%
Total	26.81%	36.23%	27.90%	7.97%	1.09%

Both genders were more likely to have witnessed than experienced racism (defined in this study as “…prejudice against someone because of their race, when those views are reinforced by systems of power”) and microaggressions due to race. With most respondents identifying as White, this result is not unexpected.

A majority of men (65.6%) reported “never” experiencing microaggressions based on their race, whereas only 17.5% of women did. A similar percentage of men (3.2%) and women (3.5%) reported experiencing microaggressions due to their race “very often” or “always.”

When analyzing by race, however, only 14.3% of Black Governors reported “never” experiencing microaggressions based on their race, and 35.7% reported experiencing microaggressions based on race “very often” or “always.” A higher rate of Black respondents reported experiencing microaggressions based on race “very often” or “always” in the past year (see Table 6).

In fact, 42.9% of Black respondents reported that over the past year they had witnessed microaggressions based on race “very often” and only 7.1% indicated that they “never” did (see Table 6). Similar responses were given for those regarding microaggressions based on race.

Table 6. Race-Based Microagressions

In the past year, how often have you experienced microaggressions due to your race?

Race	Never	Rarely	Sometimes	Very often	Always
American Indian or Alaska Native	50.00%	50.00%	0%	0%	0%
Asian	34.04%	29.79%	29.79%	6.38%	0%
Black or African American	14.29%	21.43%	28.57%	35.71%	0%
Native Hawaiian or other Pacific Islander	0%	100%	0%	0%	0%
White	72.73%	18.18%	9.09%	0%	0%
Prefer not to answer	52.94%	23.53%	17.65%	5.88%	0%
Total	62.09%	20.94%	13.72%	3.25%	0%

In the past year, how often have you witnessed microaggressions due to race?

Race	Never	Rarely	Sometimes	Very often	Always
American Indian or Alaska Native	50.00%	50.00%	0.00%	0.00%	0%
Asian	21.28%	27.66%	40.43%	10.64%	0%
Black or African American	7.14%	21.43%	28.57%	42.86%	0%
Native Hawaiian or other Pacific Islander	0%	100%	0%	0%	0%
White	38.38%	32.83%	25.76%	2.02%	1.01%
Prefer not to answer	17.65%	29.41%	47.06%	5.88%	0%
Total	32.85%	31.77%	28.88%	5.78%	0.72%

Importantly, Asian and Black respondents were more likely to report having “very often” experienced or witnessed microaggressions based on gender than did other racial groups (see Table 7). An attempt to further analyze the responses in the context of intersectionality was limited by the very small numbers of respondents in some of the intersections of gender and race.

Age did not seem to have a significant correlation with experience or witnessing of racism, gender-based harassment, or microaggressions based on gender or race.

Overall, microaggressions based on gender and race, gender-based harassment, and racism were reported as being witnessed more often than experienced, but all of these behaviors are occurring at rates higher than desired. Respondents indicated the ACS could reduce gender-based inequities and racism in surgery by promoting increased awareness and education, as well as transparency.

Table 7. Gender-based microagressions, breakdown by race

In the past year, how often have you experienced microaggressions due to your gender?

Race	Never	Rarely	Sometimes	Very often	Always
American Indian or Alaska Native	50.00%	50.00%	0%	0%	0%
Asian	48.94%	23.40%	17.02%	10.64%	0%
Black or African American	28.57%	14.29%	42.86%	14.29%	0%
Native Hawaiian or other Pacific Islander	100%	0%	0%	0%	0%
White	61.62%	18.18%	14.65%	4.04%	1.52%
Prefer not to answer	47.06%	11.76%	35.29%	5.88%	0.00%
Total	57.40%	18.41%	17.69%	5.42%	1.08%

In the past year, how often have you witnessed microaggressions based on gender?

Race	Never	Rarely	Sometimes	Very often	Always
American Indian or Alaska Native	50.00%	50.00%	0.00%	0.00%	0.00%
Asian	23.40%	21.28%	42.55%	12.77%	0.00%
Black or African American	0%	35.71%	28.57%	35.71%	0.00%
Native Hawaiian or other Pacific Islander	100%	0%	0%	0%	0%
White	28.79%	39.90%	24.24%	5.56%	1.52%
Prefer not to answer	23.53%	35.29%	35.29%	5.88%	0.00%
Total	26.71%	36.46%	27.80%	7.94%	1.08%

Surgical Training

Over the past several years, a resurgence in discussion about surgical training paradigms in the US has occurred. Concerns have included:

Depth and breadth of experiences in medical school (especially in the fourth year)
Impact of duty-hour restrictions on surgical residents
Decrease in resident autonomy during training
Best incorporation of new techniques and technologies into practice once surgeons have completed their formal training

As a result, the survey included questions about surgical training in medical schools, residency, and practice. Approximately 55% of Governors indicated that medical schools should require a surgical readiness rotation before advancing to a surgical residency. Approximately 18% “disagreed,” and approximately 27% were “unsure.”

Respondents younger than 51 years old were more likely to support such a requirement than those aged 51 and older. Of the 54 respondents younger than age 51, 36 (67%) favored such a requirement, seven (13%) opposed it, and 11 (20%) were unsure. Among the 223 respondents ages 51 and older, 116 (52%) reported being in favor of such a requirement, 42 (19%) were opposed, and 65 (29%) were unsure.

The survey included questions regarding which areas should be covered in a “surgical readiness rotation” (see Table 8) and made an open-ended inquiry as to what other topics should be included in the rotation. The areas that most respondents noted should be part of this educational experience included sterile technique (94%), suturing (90%), knot tying (89%), and identification and initial treatment of shock (89%).

Table 8.

What Should a Surgical Readiness Rotation Include?

Starting IVs	76.32%
Placing NG tubes	82.89%
Placing Foley catheters	80.92%
Identification and initial treatment of shock	89.47%
Identification and initial treatment of pulmonary embolus	69.08%
Identification and initial treatment of sepsis	82.89%
Identification and initial treatment of ACS/MI	65.13%
Knot tying	89.47%
Suturing	90.13%
Sterile technique	94.08%
Other (please specify)	26.32%

ACS Practice Protection Committee Resources

The ACS Practice Protection Committee is dedicated to the success of practicing Fellows, whether in independent surgical practice or employed practice. The committee directs its efforts toward providing timely information, practical suggestions, and other educational resources to assist Fellows in making well-informed business, professional, and financial decisions. Resources include the following, as well as:

ACS Employed Surgeon Handbook
ACS Private Practice Surgeon Handbook
Commercial Insurance Coverage for Telehealth Services
Economic Survival Strategies in the COVID World
Financial Resources Available to Assist Surgeons
Interviews
Resource Library
Webinars

When asked about the ACS, the Association of Program Directors in Surgery, and the Association for Surgical Education Resident Prep Curriculum, most (67%) reported that they were unaware of it:

38% were unaware but interested in knowing more
29% were unaware and not interested in knowing more
17% were aware of the program and had used it
13% were aware of the program and indicated that they may use it in the future
4% were aware of the program but had no plans to use it

Surgical training is a process of lifelong learning that starts in medical school and continues throughout a physician’s practice. The surgical training paradigms change and evolve over time, and responses in this survey are consistent with much of the current literature.

Ongoing discussions regarding surgical residency training, the optimal degree of flexibility, and the idea of competency-based education and promotion undoubtedly will continue. This BoG survey reflects a broad spectrum of opinions and, at this time, it is recommended that the ACS act as a facilitator for these ongoing discussions rather than advocating for a single approach.

Private Practice

As the healthcare environment has evolved with time, the models for physician employment also have evolved. A large percentage (41%) of respondents were currently or had previously been in private practice, and most (71%) of them indicated that they would choose private practice again. A significantly lower percentage (14.9%) currently in full-time academic practice responded that they would choose private practice again.

A wide variety of barriers were reported for starting or joining a private practice, including specialty or practice focus, needed business skills, the challenge of building a reputation and developing referral sources, and the overall financial risks.

Neary half (47.3%) of respondents indicated that the ACS should advocate for a revision of the Stark Law* to allow for more support of private practices, while 13.4% didn’t agree, and 39.4% were unsure. The distribution of responses to this question changed somewhat when analyzed by practice type; fewer full-time academic surgeons supporting ACS advocacy for the Stark Law revision.

Respondents indicated that if the Stark Law were revised, hospital-provided electronic health record (EHR) systems would be the most beneficial to sustaining a private practice. It is important to note that in 2020, the Centers for Medicare & Medicaid Services and the Office of Inspector General released final rules amending the regulations to the Stark Law and the Medicare and State Health Care Programs: Fraud and Abuse; Revisions to Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements that facilitated the donations of EHR and cybersecurity technology.

More than 78% of respondents said that it was moderately important to essential for the ACS to develop programs/resources to help sustain surgical private practices. They indicated that the ACS programs/resources related to business and management education and coding support were the most valuable to those in private practice (see Figure 2).

Figure 2. Which of the following ACS programs/resources do you think would be valuable to those in private practice?

Survey respondents indicated that it is critical for the ACS to continue assessing and understanding the models of surgical practice and support surgeons in the type of practice best suited to meet their needs and the needs of their patients. The ACS offers many resources across several specialties and is receptive to feedback from Fellows regarding strategies to optimize the utility of these efforts.

*The Stark Law (42 USC 1395nn) is the physician self-referral law which (1) prohibits a physician from making referrals for designated health services payable by Medicare to an entity with which they have a financial relationship; (2) prohibits the entity from presenting claims to Medicare (or billing another individual, entity, or third party payer) for those referred services; and (3) establishes specific exceptions and grants the authority to create regulatory exceptions for financial relationships that do not pose a risk of program or patient abuse.

Dr. Danielle Katz is associate professor, Department of Orthopaedic Surgery, and associate dean of graduate medical education, State University of New York Upstate Medical University, Syracuse. She is the Vice-Chair of the BoG Survey Workgroup.