American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Spring 2013


Message from the Editor

Photo of Joshua A. Broghammer, MD, FACSIt is my great pleasure to assume the editorship of YFA e-News. First, many thanks to the previous editors, Juan Paramo, MD, FACS, and Ellen Farrohki, MD, FACS, for their dedication and hard work. My task as editor is two-fold: (1) maintain the high standards set by my predecessors and (2) bring in new ideas to keep YFA e-News fresh and exciting. We will continue our recent format changes. However, these changes can only work with your help. Two of our recurring columns, Surgeons in Their Spare Time and A Piece of My Mind, feature opportunities for guest writers. If you have a column you would like to submit on how surgeons should be spending their spare time or if there is an issue you would like to sound off on, please e-mail

YFA Membership Poll

In the last issue we asked readers to indicate how long they saw themselves practicing surgery. The results of the poll are in:

  • 51% say until you retire from professional work
  • 31% say until you have enough money to stop and then do what you really love
  • 20% say that you cannot imagine the day.

This edition's question is: What is the biggest threat to the sustainability of your surgical practice?

  • Disruption of work-life balance
  • Declining reimbursement
  • Increasing overhead
  • Governmental regulation
  • Increased patient volume

We will report the results in the next issue. As always, thank you for your time and I look forward to our exchanges.

Joshua A. Broghammer, MD, FACS
YFA e-News Editor
Assistant Professor of Urology
Kansas University Medical Center, Kansas City

Message from the YFA Chair

Photo of Laurel C. Soot, MD, FACSGreetings! I hope this finds you well. I have just returned from the Board of Regents meeting and have some exciting new changes to report from the American College of Surgeons (ACS).

  • 2013 Leadership and Advocacy Summit, April 14–16: Chapter leaders are encouraged to attend and I would encourage you as a Young Fellow to get involved with your chapter.
    • If your chapter is lacking a Young Fellow representative and you would like to get involved but do not know where to start, please contact me at or Rob Todd, YFA Chair-Elect, at, and we will help you make the necessary connections.
    • We need a YFA representative in every chapter!
  • Campaign for the Young Surgeon: Details are still forthcoming, but the ACS is dedicated to you and the growth of the Young Fellow constituency, which will continue to be a major focus.
  • New website development: Your comments, and many others, have been heard and are now in the hands of Lynn Kahn, Director, ACS Division of Integrated Communications, and her staff. The website will be completely redesigned, and will be mobile friendly. This large project should be completed by early 2014. Follow ACS on Facebook, Twitter, and YouTube for the latest news!
  • YFA Governing Council openings: Four positions on the YFA Governing Council will be open this year. Rob Todd will chair the Nominating Committee. If you are interested in obtaining more information about the application process, please contact Rob Todd at, or Peg Haar, ACS Staff Liaison at

Laurel C. Soot, MD, FACS
Chair, Governing Council
Associate Clinical Professor of Surgery
Oregon Health and Sciences University, Portland
The Oregon Clinic: Westside Surgical Specialists, Tualatin

Who We Are

At the 2012 Clinical Congress, the ACS welcomed a new set of initiates. Who are these new Fellows? A survey of the new 2012 initiates by KRC Research revealed some interesting facts about them:

  • Eight in 10 initiates are under of the age of 45, automatically making them Young Fellows.
  • Half have been in practice five years or less.
  • More than 23 specialties are represented.
  • Roughly one-third work at an academic practice, one-third in private practice, and one-third are hospital employees.
  • Nearly 20 percent live and work in a rural or small town.

Leadership Advice

Photo of Tyler Hughes, MD, FACSBecause I am writing to the Young Fellows, let me clue you in on something I had to learn. You think you are going to be a surgeon, but being a good surgeon means you will also be a leader. I stumbled into leadership, and I wish I had been more prepared. Leadership was a byproduct of wanting to be the very best surgeon I could be. The definition of a good surgeon includes being so involved in the profession that one's abilities in the operating room (OR) and ward become invaluable to your institution. (Don't expect your involvement to be terribly lucrative; this is value of an altogether different type.)

Development as a quality surgeon requires good judgment. To hone good judgment one has to be honest with oneself. Stepping out of your own skin and examining one's actions and decisions objectively is difficult, but it is essential if you hope to improve. The self-discovery process develops humility, which is a rare and precious quality that can be easily lost in the practice of surgery. I recommend reading Leadership and Self Deception: Getting Out of the Box by the Arbinger Institute.

Leaders volunteer—and not solely because they are looking to advance their careers. The surgical leaders I have greatly admired did not get ahead because they reached for leadership. They followed their principles and dreams, which moved them into leadership positions and subsequent advancement. Sometimes these principles and dreams diverged from common thinking or an expedient path, which can be just as nerve racking as any surgical decision.

Every Fellow of the College I've met wants to be a good or great surgeon. If you are reading this, you are probably already on the path to leadership. It is best to prepare for the inevitable day when fate and ability put you into a leading role in your hospital, medical society, or the College. The ACS Leadership and Advocacy Summit is a great place to start. Being active in your state chapter, regional medical societies, and the College's advocacy division are great opportunities to practice and hone your skills.

Ten years ago I was just a country surgeon trying to do this job well. Putting a little extra of myself and my time into the roles at the hospital and the College has made me a better surgeon and a better person. Almost as good as saving a patient in the OR is the feeling of knowing that you can have a voice for our patients if you choose to accept your role as a leader. Like being on call, it can be a lot of work; but it is also an opportunity to experience the joy of making a difference and that is just plain fun.

Tyler Hughes, MD, FACS, is a community surgeon practicing in McPherson, KS. His leadership positions include membership on the ACS Board of Governors, Chair of the ACS Advisory Council for Rural Surgery, an at-large director of the American Board of Surgery, and the 2007 ACS Kansas Chapter President. Dr. Hughes was the 2012 recipient of the Practitioner of the Year award from the National Rural Health Association.

ACS Foundation: Young Fellows Leadership Circle

Photo of Suresh K. Agarwal Jr, MD, FACSOver its 100-year history, the ACS has been a leader in improving surgical care through quality programs and support of surgeons through scholarships, professional development, and research in best practices. This success was a result of the talent, time, and financial contributions of many ACS Fellows. Franklin Martin, MD, FACS, and the other College founders each made their own personal donations to establish ACS, providing priceless resources to thousands of surgeons and their patients over the last 100 years. Many other Fellows have since followed the founders' philanthropic examples:

"The ACS is moving ahead by championing surgeons, the profession of surgery, and quality in surgical care. We all need to fuel that engine."

—Andrew L. Warshaw, MD, FACS

"Philanthropic contributions—independent of the magnitude—are a wonderful experience, particularly when one knows the value with which the gift will be utilized in ensuring the highest quality of patient care for years to come—the sine qua non for which the American College of Surgeons stands."

—Richard A. Lynn, MD, FACS

"I've tried to give back for what I have been so richly given."

—Murray F. Brennan, MD, FACS

Now, it is our turn to give back. I ask that you join me in making your own financial contribution to ACS today. Your participation as a donor is more important than the amount of your gift and there has never been a better time to give. In honor of the 100th anniversary, the ACS Foundation is launching a new donor recognition program exclusively for ACS Young Fellows. The Young Fellows Leadership Circle gives you the opportunity to be a part of the College's philanthropic programs with a lower contribution. Please visit the ACS website for more information on how you can join the Young Fellows Leadership Circle today.

Thank you,

Suresh K. Agarwal Jr, MD, FACS
Committee Member, ACS Foundation
Young Fellows Association, Member
Associate Professor
University of Wisconsin School of Medicine and Public Health, Madison

A Piece of My Mind: Avoiding Peter

Photo of David Tom Cooke, MD, FACSIn 1969, educators and humorists Laurence J. Peter and Raymond Hull wrote The Peter Principle. In that book, the authors introduced the concept that employees are continually promoted until they reach a level that exceeds their competency and as a result are limited. Why should Young Fellows worry about the Peter Principle? Young Fellows run the gambit of relatively recent residency graduates who have passed their respective board examinations to individuals who take on more responsibility of management, personnel supervision, and strategic planning. The latter group includes new section and program heads, residency directors, or even running a grant-funded scientific lab that employs technicians, research residents, post-docs, and PhD students.

I would argue that traditional Accreditation Council for Graduate Medical Education (ACGME) surgical residencies do not prepare us for the previously mentioned endeavors. They are not a major part of the ACGME core competencies. Although as chief residents we do run a team, this training does not prepare us for management. Where in chief residency did we learn how to put together a business plan? If you want to start a robotics program at your hospital, you better have a business plan. If you want to be considered for section head when the position opens, you better submit to your chief or chair a strategic plan. How many physician assistants or nurse practitioners do you need to build your program? Your post-doc is just not working out. How do you approach that difficult conversation about termination? The reality is that unless your department allows you time to obtain a Masters of business administration or attend an executive education program, you will need to learn many of these skills on the job. Below is a list of resources that I have found helpful. They are in no way endorsements, just food for thought, and perhaps tools to avoid the Peter Principle.

Harvard Business Review (HBR): This is a general management periodical that is published 10 times year. It is published by Harvard Business Publishing and is a great resource to learn both the basics and the most current and innovative concepts in management. It is often referred to as a "Poor Man's MBA."

Switch: How to Change Things When Change Is Hard, by Chip Heath and Dan Heath: This book enhances understanding of strategic planning, especially in environments that are not used to change.

Business Model Generation: A Handbook for Visionaries, Game Changers, and Challengers, by Alexander Osterwalder and Yves Pigneur: This is a straightforward book that defines and explains multiple business models types, while using easy-to-understand language and graphics.

Getting to Yes: Negotiating Agreement Without Giving In, by Roger Fisher, William L. Ury, and Bruce Patton: Surgeons have been falsely stereotyped as people who get their way by yelling at people. Screaming at other people will not produce results on Capitol Hill and it will not work anywhere else in the real world. This book introduces the reader to the nuances of negotiation.

These are just a few resources, and there are a myriad of helpful sources of information out there. Happy learning!

David Tom Cooke, MD, FACS
Assistant Professor
Section Head of General Thoracic Surgery
Division of Cardiothoracic Surgery
University of California, Davis Medical Center, Sacramento

Times May Change but Our Mission Remains

Photo of Ellen T. FarrokhiIn this new century, as the ACS looks back at 100 years of surgery and begins looking toward the next 100 years, it is important to survey the landscape and evaluate where we have been and where we need to go. Among the many changes this century has brought, there has been a shift in ideology for the surgical profession. Many of us have changed from being the employer to being employed.

A story about my grandfather illustrates this topography shift. He practiced medicine in the early part of the 20th century and practiced in a very different way than we do today. He was a solo practitioner.

One of my grandfather's rotations was in the Appalachian Mountains, a rural area in the eastern part of the U.S. He rode a donkey to see his patients and performed procedures, such as appendectomies and delivering babies. He was rumored to have treated both the Hatfields and the McCoys.

I have a letter my grandfather wrote to my grandmother when he was serving in the mountains. He wrote that he was tired and had delivered a premature baby and was uncertain if the infant would survive. He described in detail a makeshift incubator he made to try to keep the baby alive. His efforts reflect what one-to-one delivery of care, and some would say health care, was like in the early 20th century. For my grandfather, there was simply a patient who had a disease, and his job was to try and relieve the suffering. Patient and doctor worked together and health was their priority.

My grandfather was often paid with furniture, chickens, and fabric for his services. But as his practice continued, he had to negotiate for payment. Chickens and furniture was not how he made his living; it was a fee for service.

pyramidIn the latter part of the 20th century, providing surgical care was no longer about riding your donkey directly to a patient's home and putting your ungloved hand on them. Doctors did not have time to sit at their patients' bedside as they died. Copay became the act of initiation of care and because blood-borne illness became prevalent, we no longer feel the touch of flesh to flesh. That manner of examination has given way to universal precautions. And so the pyramid changed. Later in the 20th century, you still have a patient who has a disease and you are still the doctor, but in order to get to health you have to negotiate the payment.

My grandfather has since retired, but those of us who continue to practice find ourselves in the middle of another transition, which involves a new barrier. As accountable care organizations or "big medicine" come into existence, the hospital will have to negotiate with the payer for a lump sum and then spend it on their patient population in a disease-specific manner. The organization that you belong to and employs you, is going to prioritize who gets what piece of the pie by deciding what procedures and tests can be performed. Health is still at the top of the pyramid, but our role has changed. In order to rise to that occasion and meet the demands of the future, we will have to continue to deliver the things that we do as surgeons, but we will have to enhance our stewardship of resources and quality.

pyramidThere are many people at this table now discussing and planning how we need to deliver health to the patients we serve. We must become leaders in quality health care delivery and resource stewardship.

Our mission remains unchanged and is still based in service. We serve the sick; those are the people we treat. We teach the young; whether it is the residents or the new partner, we have to invest in the next generation. Ultimately, when we do these things right and focus on quality, we advance our field.

So by serving the sick, teaching the young, and advancing the field we get ready for the next 100 years of surgery.

Ellen T. Farrokhi, MD, FACS
Foundation of Healthcare Quality
Vascular Surgery
Providence Regional Medical Center, Everett, WA