ACS Surgery News

The American College of Surgeons (ACS) Committee on Trauma (COT) announced the 15 winners of the 38th annual Residents Trauma Papers Competition at its Annual Meeting, March 12–14, in Chicago, IL. Each winner received $500, with an additional $500 awarded to the second-place winners in each category, and an extra $1,000 awarded to the two first-place winners.

The competition is open to surgical residents and trauma fellows. Submissions describe original research in the area of trauma care and/or prevention in one of two categories: basic laboratory research or clinical investigation. The Eastern and Western States COTs, Region 7 (Iowa, Kansas, Missouri, and Nebraska) and the ACS are funding the competition.

Submissions begin at the state or provincial level, and winners are then judged at regional competitions. Each region is then eligible to submit two abstracts to a panel of COT judges, who make the final selection for presentation at the Scientific Session of the COT Annual Meeting. Leonard J. Weireter, MD, FACS, Norfolk, VA, Vice-Chair of the COT and Chair of the COT Regional Committees, moderated the session.

The 2015 competition winners are as follows:

• First Place, Basic Laboratory Research: Simone M. Langness, MD, University of California, San Diego, postgraduate year (PGY)-4 (COT Region 9): The Vagus Nerve Mediates the Neural Stem Cell Response to Intestinal Injury

• First Place, Clinical Investigation: Deepika Nehra, MD, Massachusetts General Hospital, Boston, PGY-7 (COT Region 10): Acute Rehabilitation after Trauma: Does It Really Matter?

• Second Place, Basic Laboratory Research: Michaela C. Kollisch-Singule, MD, State University of New York at Stony Brook Medical University, Syracuse, PGY-4 (COT Region 2): Impact of Chest Wall Recruitment in Prevention of Acute Respiratory Distress Syndrome

• Second Place, Clinical Investigation: Cherisse Berry, MD, University of Maryland, Baltimore, PGY-9 (COT Region 3): Prospective Evaluation of Post-Traumatic Vasospasm (PTV) and Post-Injury Functional Outcome Assessment: Is Cerebral Ischemia Going Unrecognized in TBI Patients?

Additional selected surgical residents and the papers they presented are as follows:

• Elizabeth King, MD, Boston University Medical Center, PGY-5 (COT Region 1): Valproic Acid Mitigates the Inflammatory Response in Murine Acute Lung Injury at the Expense of Bacterial Clearance

• Samuel W. Ross, MD, MPH, Carolinas Medical Center, Charlotte, NC, PGY-4 (COT Region 4): Hemodilution: Fact or Fiction? A Prospective, Randomized Control Trial to Quantify the Effect of Blood Loss and Crystalloid Resuscitation on Hemoglobin

• Ihab Halaweish, MD, University of Michigan, Ann Arbor, PGY-5 (COT Region 5): Early Resuscitation with Fresh Frozen Plasma for Traumatic Brain Injury Combined with Hemorrhagic Shock Improves Neurological Recovery

• Melody R. Saeman, MD, University of Texas Southwestern Medical School, Dallas, PGY-5 (COT Region 6): Alteration of the Circadian Network following Traumatic Brain Injury

• Haniee Chung, MD, Barnes Jewish Hospital, St. Louis, MO, PGY-5 (COT Region 7): The Problem of Age: The Role of the Immune Response to Severe Injury in the Elderly

• Hunter B. Moore, MD, University of Colorado, Denver, PGY-3 (COT Region 8): Hyperfibrinolysis Is Driven by Hemorrhagic Shock and Attenuated by Plasma Resuscitation: The Role of Plasma First Resuscitation in Critically Injured Patients

• Timothy J. Rice, MD, Hamilton General Hospital, ON (COT Region 12): A Randomized, Double-Blinded, Placebo-Controlled Pilot Trial on the Efficacy of Early Enoxaparin: The Optimal Timing of Thromboprophylaxis in a Traumatic Intracranial Hemorrhage Study

• Captain Jonathan J. Sexton, MD, Johns Hopkins Community Physicians Suburban Hospital, Bethesda, MD (COT Region 13): Administration of FTY720 during Tourniquet-Induced Hind Limb Ischemia-Reperfusion Injury Attenuates Morbidity and Mortality in a Rodent Model

• Eduardo Rissi Silva, MD, Hospital das Clinicas, Sao Paulo, Brazil (COT Region 14): Prospective Evaluation of a Protocol of Whole-Body CT Based Only in Mechanism of Injury in Major Trauma Patients

• Jacqueline van Laarhoven, MD, Ratboud University, Netherlands (COT Region 15): Associated Thoracic Injury in Patients with a Clavicle Fracture: An Analysis of 1478 Polytrauma Patients

• Felix Che-Lok Chow, MB, BS (HK), MHKICSBCS, University of Hong Kong, Queen Mary Hospital (COT Region 16): Clinical Parameters Predicting In-Hospital Mortality in Geriatric Patients following Severe Trauma: A 15-Year Experience

The American College of Surgeons (ACS) Committee on Trauma (COT) announced the 15 winners of the 38th annual Residents Trauma Papers Competition at its Annual Meeting, March 12–14, in Chicago, IL. Each winner received $500, with an additional $500 awarded to the second-place winners in each category, and an extra $1,000 awarded to the two first-place winners.

The competition is open to surgical residents and trauma fellows. Submissions describe original research in the area of trauma care and/or prevention in one of two categories: basic laboratory research or clinical investigation. The Eastern and Western States COTs, Region 7 (Iowa, Kansas, Missouri, and Nebraska) and the ACS are funding the competition.

Submissions begin at the state or provincial level, and winners are then judged at regional competitions. Each region is then eligible to submit two abstracts to a panel of COT judges, who make the final selection for presentation at the Scientific Session of the COT Annual Meeting. Leonard J. Weireter, MD, FACS, Norfolk, VA, Vice-Chair of the COT and Chair of the COT Regional Committees, moderated the session.

The 2015 competition winners are as follows:

• First Place, Basic Laboratory Research: Simone M. Langness, MD, University of California, San Diego, postgraduate year (PGY)-4 (COT Region 9): The Vagus Nerve Mediates the Neural Stem Cell Response to Intestinal Injury

• First Place, Clinical Investigation: Deepika Nehra, MD, Massachusetts General Hospital, Boston, PGY-7 (COT Region 10): Acute Rehabilitation after Trauma: Does It Really Matter?

• Second Place, Basic Laboratory Research: Michaela C. Kollisch-Singule, MD, State University of New York at Stony Brook Medical University, Syracuse, PGY-4 (COT Region 2): Impact of Chest Wall Recruitment in Prevention of Acute Respiratory Distress Syndrome

• Second Place, Clinical Investigation: Cherisse Berry, MD, University of Maryland, Baltimore, PGY-9 (COT Region 3): Prospective Evaluation of Post-Traumatic Vasospasm (PTV) and Post-Injury Functional Outcome Assessment: Is Cerebral Ischemia Going Unrecognized in TBI Patients?

Additional selected surgical residents and the papers they presented are as follows:

• Elizabeth King, MD, Boston University Medical Center, PGY-5 (COT Region 1): Valproic Acid Mitigates the Inflammatory Response in Murine Acute Lung Injury at the Expense of Bacterial Clearance

• Samuel W. Ross, MD, MPH, Carolinas Medical Center, Charlotte, NC, PGY-4 (COT Region 4): Hemodilution: Fact or Fiction? A Prospective, Randomized Control Trial to Quantify the Effect of Blood Loss and Crystalloid Resuscitation on Hemoglobin

• Ihab Halaweish, MD, University of Michigan, Ann Arbor, PGY-5 (COT Region 5): Early Resuscitation with Fresh Frozen Plasma for Traumatic Brain Injury Combined with Hemorrhagic Shock Improves Neurological Recovery

• Melody R. Saeman, MD, University of Texas Southwestern Medical School, Dallas, PGY-5 (COT Region 6): Alteration of the Circadian Network following Traumatic Brain Injury

• Haniee Chung, MD, Barnes Jewish Hospital, St. Louis, MO, PGY-5 (COT Region 7): The Problem of Age: The Role of the Immune Response to Severe Injury in the Elderly

• Hunter B. Moore, MD, University of Colorado, Denver, PGY-3 (COT Region 8): Hyperfibrinolysis Is Driven by Hemorrhagic Shock and Attenuated by Plasma Resuscitation: The Role of Plasma First Resuscitation in Critically Injured Patients

• Timothy J. Rice, MD, Hamilton General Hospital, ON (COT Region 12): A Randomized, Double-Blinded, Placebo-Controlled Pilot Trial on the Efficacy of Early Enoxaparin: The Optimal Timing of Thromboprophylaxis in a Traumatic Intracranial Hemorrhage Study

• Captain Jonathan J. Sexton, MD, Johns Hopkins Community Physicians Suburban Hospital, Bethesda, MD (COT Region 13): Administration of FTY720 during Tourniquet-Induced Hind Limb Ischemia-Reperfusion Injury Attenuates Morbidity and Mortality in a Rodent Model

• Eduardo Rissi Silva, MD, Hospital das Clinicas, Sao Paulo, Brazil (COT Region 14): Prospective Evaluation of a Protocol of Whole-Body CT Based Only in Mechanism of Injury in Major Trauma Patients

• Jacqueline van Laarhoven, MD, Ratboud University, Netherlands (COT Region 15): Associated Thoracic Injury in Patients with a Clavicle Fracture: An Analysis of 1478 Polytrauma Patients

• Felix Che-Lok Chow, MB, BS (HK), MHKICSBCS, University of Hong Kong, Queen Mary Hospital (COT Region 16): Clinical Parameters Predicting In-Hospital Mortality in Geriatric Patients following Severe Trauma: A 15-Year Experience

The American College of Surgeons (ACS) Committee on Trauma (COT) announced the 15 winners of the 38th annual Residents Trauma Papers Competition at its Annual Meeting, March 12–14, in Chicago, IL. Each winner received $500, with an additional $500 awarded to the second-place winners in each category, and an extra $1,000 awarded to the two first-place winners.

The competition is open to surgical residents and trauma fellows. Submissions describe original research in the area of trauma care and/or prevention in one of two categories: basic laboratory research or clinical investigation. The Eastern and Western States COTs, Region 7 (Iowa, Kansas, Missouri, and Nebraska) and the ACS are funding the competition.

Submissions begin at the state or provincial level, and winners are then judged at regional competitions. Each region is then eligible to submit two abstracts to a panel of COT judges, who make the final selection for presentation at the Scientific Session of the COT Annual Meeting. Leonard J. Weireter, MD, FACS, Norfolk, VA, Vice-Chair of the COT and Chair of the COT Regional Committees, moderated the session.

The 2015 competition winners are as follows:

• First Place, Basic Laboratory Research: Simone M. Langness, MD, University of California, San Diego, postgraduate year (PGY)-4 (COT Region 9): The Vagus Nerve Mediates the Neural Stem Cell Response to Intestinal Injury

• First Place, Clinical Investigation: Deepika Nehra, MD, Massachusetts General Hospital, Boston, PGY-7 (COT Region 10): Acute Rehabilitation after Trauma: Does It Really Matter?

• Second Place, Basic Laboratory Research: Michaela C. Kollisch-Singule, MD, State University of New York at Stony Brook Medical University, Syracuse, PGY-4 (COT Region 2): Impact of Chest Wall Recruitment in Prevention of Acute Respiratory Distress Syndrome

• Second Place, Clinical Investigation: Cherisse Berry, MD, University of Maryland, Baltimore, PGY-9 (COT Region 3): Prospective Evaluation of Post-Traumatic Vasospasm (PTV) and Post-Injury Functional Outcome Assessment: Is Cerebral Ischemia Going Unrecognized in TBI Patients?

Additional selected surgical residents and the papers they presented are as follows:

• Elizabeth King, MD, Boston University Medical Center, PGY-5 (COT Region 1): Valproic Acid Mitigates the Inflammatory Response in Murine Acute Lung Injury at the Expense of Bacterial Clearance

• Samuel W. Ross, MD, MPH, Carolinas Medical Center, Charlotte, NC, PGY-4 (COT Region 4): Hemodilution: Fact or Fiction? A Prospective, Randomized Control Trial to Quantify the Effect of Blood Loss and Crystalloid Resuscitation on Hemoglobin

• Ihab Halaweish, MD, University of Michigan, Ann Arbor, PGY-5 (COT Region 5): Early Resuscitation with Fresh Frozen Plasma for Traumatic Brain Injury Combined with Hemorrhagic Shock Improves Neurological Recovery

• Melody R. Saeman, MD, University of Texas Southwestern Medical School, Dallas, PGY-5 (COT Region 6): Alteration of the Circadian Network following Traumatic Brain Injury

• Haniee Chung, MD, Barnes Jewish Hospital, St. Louis, MO, PGY-5 (COT Region 7): The Problem of Age: The Role of the Immune Response to Severe Injury in the Elderly

• Hunter B. Moore, MD, University of Colorado, Denver, PGY-3 (COT Region 8): Hyperfibrinolysis Is Driven by Hemorrhagic Shock and Attenuated by Plasma Resuscitation: The Role of Plasma First Resuscitation in Critically Injured Patients

• Timothy J. Rice, MD, Hamilton General Hospital, ON (COT Region 12): A Randomized, Double-Blinded, Placebo-Controlled Pilot Trial on the Efficacy of Early Enoxaparin: The Optimal Timing of Thromboprophylaxis in a Traumatic Intracranial Hemorrhage Study

• Captain Jonathan J. Sexton, MD, Johns Hopkins Community Physicians Suburban Hospital, Bethesda, MD (COT Region 13): Administration of FTY720 during Tourniquet-Induced Hind Limb Ischemia-Reperfusion Injury Attenuates Morbidity and Mortality in a Rodent Model

• Eduardo Rissi Silva, MD, Hospital das Clinicas, Sao Paulo, Brazil (COT Region 14): Prospective Evaluation of a Protocol of Whole-Body CT Based Only in Mechanism of Injury in Major Trauma Patients

• Jacqueline van Laarhoven, MD, Ratboud University, Netherlands (COT Region 15): Associated Thoracic Injury in Patients with a Clavicle Fracture: An Analysis of 1478 Polytrauma Patients

• Felix Che-Lok Chow, MB, BS (HK), MHKICSBCS, University of Hong Kong, Queen Mary Hospital (COT Region 16): Clinical Parameters Predicting In-Hospital Mortality in Geriatric Patients following Severe Trauma: A 15-Year Experience

The House Committee on Energy and Commerce Subcommittee on Health Thursday, May 14, reviewed and passed a draft of legislation known as the 21st Century Cures Initiative.

The full committee will consider this third draft of the proposed legislation in the near future.

The 21st Century Cures Initiative was created to more quickly bring medical treatments and cures to the American public without being overburdened by government regulations.

The American College of Surgeons (ACS) will submit a letter to the committee providing input on the bill. More information on the 21st Century Cures Initiative is on the Energy & Commerce Committee website at http://
energycommerce.house.gov/cures.

The House Committee on Energy and Commerce Subcommittee on Health Thursday, May 14, reviewed and passed a draft of legislation known as the 21st Century Cures Initiative.

The full committee will consider this third draft of the proposed legislation in the near future.

The 21st Century Cures Initiative was created to more quickly bring medical treatments and cures to the American public without being overburdened by government regulations.

The American College of Surgeons (ACS) will submit a letter to the committee providing input on the bill. More information on the 21st Century Cures Initiative is on the Energy & Commerce Committee website at http://
energycommerce.house.gov/cures.

The House Committee on Energy and Commerce Subcommittee on Health Thursday, May 14, reviewed and passed a draft of legislation known as the 21st Century Cures Initiative.

The full committee will consider this third draft of the proposed legislation in the near future.

The 21st Century Cures Initiative was created to more quickly bring medical treatments and cures to the American public without being overburdened by government regulations.

The American College of Surgeons (ACS) will submit a letter to the committee providing input on the bill. More information on the 21st Century Cures Initiative is on the Energy & Commerce Committee website at http://
energycommerce.house.gov/cures.

The American College of Surgeons Professional Association Political Action Committee (ACSPA-SurgeonsPAC) launched its first peer-to-peer membership campaign on May 26. The six-week “PAC Captain” campaign will promote the ACSPA-SurgeonsPAC to a broad College audience. More than 40 surgeons from across the country will serve as PAC Captains. These strong supporters of ACSPA-SurgeonsPAC are the College’s most valuable resource for advancing the surgical profession through political involvement. The Captains will work to increase the PAC’s membership base throughout the 2015-2016 election cycle. For more information, contact Katie Oehmen, PAC Associate, at 202-672-1503 or koehmen@facs.org.

The American College of Surgeons Professional Association Political Action Committee (ACSPA-SurgeonsPAC) launched its first peer-to-peer membership campaign on May 26. The six-week “PAC Captain” campaign will promote the ACSPA-SurgeonsPAC to a broad College audience. More than 40 surgeons from across the country will serve as PAC Captains. These strong supporters of ACSPA-SurgeonsPAC are the College’s most valuable resource for advancing the surgical profession through political involvement. The Captains will work to increase the PAC’s membership base throughout the 2015-2016 election cycle. For more information, contact Katie Oehmen, PAC Associate, at 202-672-1503 or koehmen@facs.org.

The American College of Surgeons Professional Association Political Action Committee (ACSPA-SurgeonsPAC) launched its first peer-to-peer membership campaign on May 26. The six-week “PAC Captain” campaign will promote the ACSPA-SurgeonsPAC to a broad College audience. More than 40 surgeons from across the country will serve as PAC Captains. These strong supporters of ACSPA-SurgeonsPAC are the College’s most valuable resource for advancing the surgical profession through political involvement. The Captains will work to increase the PAC’s membership base throughout the 2015-2016 election cycle. For more information, contact Katie Oehmen, PAC Associate, at 202-672-1503 or koehmen@facs.org.

The American Board of Surgery (ABS) was founded in 1937 by the leading surgical organizations of the time in recognition of the need to differentiate formally trained surgeons from other doctors who were performing operations without formal training.

At its onset, the ABS acknowledged that it had a dual purpose: to protect the public and improve the specialty of surgery. Eligibility criteria for certification were defined – graduation from an approved medical school, the requisite duration of surgical training, a list of operations performed, high ethical standards – and passing an examination became a differentiating requirement.

Over the nearly eight decades since its founding, the ABS has retained its position as the premier certifying body for surgeons in the United States. Its mission statement, “to serve the public and the specialty of surgery by providing leadership in surgical education and practice, by promoting excellence through rigorous evaluation and examination, and by promoting the highest standards for professionalism, lifelong learning, and the continuous certification of surgeons in practice,” embodies the elements of the Maintenance of Certification (MOC) Program. Setting standards for board certification is a privilege of self-regulation that has been granted to our profession by the American public. In return, we must demonstrate our commitment to serve the best interests of the public through our processes and requirements.

ABS certification is based upon education, evaluation, and assessment. Appropriate undergraduate medical education, accredited surgical training, broad operative experience, and high ethical standing continue as essential requirements of ABS certification. For the first four decades of its existence, once ABS certification was achieved, it was valid for a surgeon’s entire professional career. This changed as the ABS Directors recognized the rapid evolution of surgical practice and believed it was necessary for diplomates to demonstrate that they were up to date with advances in medical knowledge and patient care. In 1976, the ABS adopted time-limited certification and required its diplomates to “recertify” by passing an examination every 10 years. In 2000, a requirement for its diplomates to complete 100 hours of continuing medical education (CME) credits in the 2 years prior to applying for the recertification exam (60 in Category I and 40 in Category II) was implemented. This requirement has been modified since; however, the basic rationale for its adoption remains relevant.

In 2005, the American Board of Medical Specialties (ABMS), which establishes standards for its 24 member boards, introduced MOC and proposed standards based on the six competencies jointly developed by the Accreditation Council on Graduate Medical Education and the ABMS. These competencies – patient care, medical knowledge, professionalism, interpersonal communication skills, practice-based learning and improvement, and systems-based practice – were the basis for the four parts of MOC: professional standing, lifelong learning and self-assessment, cognitive expertise, and evaluation of performance in practice. The development of MOC was further recognition that board certification needed to become a more continuous process as the pace of change in medicine had accelerated beyond any seen previously.

Boards and their diplomates have the responsibility to demonstrate to the public and their peers an enduring commitment to maintain standards for the profession, participate in lifelong education, possess medical knowledge relevant to the specialty, and improve their performance in practice. All surgeons certified or recertified beginning July 2005 have been enrolled in ABS MOC. A decade later, 95% of ABS diplomates with time-limited certificates are enrolled in the ABS MOC program and more than 90% are actively participating.

Although the ABMS established general requirements for MOC that its member boards must meet, each board is allowed to develop its own requirements. The foundations of the ABS MOC program were established before the term “maintenance of certification” was used. Professional standards have been a requirement for ABS certification since its beginning and exam requirements have been in place for more than a generation. All diplomates must fulfill the professional standing requirements to have a valid unrestricted state medical license, have hospital or ambulatory surgery center privileges if clinically active, and have references from the chief of surgery and the chair of the credentials committee where they practice.

The ABS MOC program is meant to be practice relevant. This allows surgeons to satisfy the requirements by completing CME that they choose and by participating in performance assessment activities in a way that best applies to their practices. The requirement that two-thirds of the CME hours earned be self-assessment demonstrates a greater level of engagement of the learner and shows that knowledge acquisition is achieved at the conclusion of the activity. The addition of a practice performance improvement activity requirement has generated the most controversy and misunderstanding. To meet this requirement, diplomates are asked to assess some aspect of their practice and seek to improve that. This can be done in conjunction with a hospital through participation in a national, regional, or state registry that tracks patient outcomes, or by participating in a hospital-based quality improvement activity. Some diplomates have developed performance improvement activities within their offices by focusing on a specific area for evaluation, defining measures and goals for improvement, analyzing results and making changes when appropriate, and then reassessing to develop an action plan for improvement.

Regardless of what you choose, the ABS asks only that you attest to your participation and does not collect, review, or otherwise scrutinize your results.

The ABS MOC program extends over a 10-year period. Requirements for the first 9 years are organized in identical 3-year reporting cycles running from Jan. 1 to Dec. 31. By the end of each 3-year cycle, diplomates are required to submit information on how they are meeting MOC requirements through an individualized secure login on the ABS website (www.absurgery.org). Successful completion of an MOC exam continues to be required every 10 years; however the exam may be taken in years 8 and 9 of the 10-year cycle.

ABS MOC is a surgeon-defined, national standard that formally documents many of the activities surgeons already do to stay current in their field. Participating in the ABS MOC program demonstrates your commitment to remain current in your area of practice and to strive to improve what you do.

Since its beginning, the ABS has exercised its duty to develop, promote, and refine standards for certification in surgery. Just like changes in medical practice, MOC will evolve over time to reflect new standards and best practices. The ABS Board of Directors is focused on how ABS MOC can be an even more meaningful process for surgeons without increasing the already substantial administrative burden everyone faces. We are following the progress of innovative programs being piloted by other boards and organizations involved in quality improvement. The ABS recognizes that MOC requirements established or changed will affect roughly 30,000 surgeons who practice in a wide variety of environments. We encourage our diplomates to provide ideas to improve the program as we continue to develop ABS MOC, while at the same time staying mindful of our duty to the public.

For more information, please see the MOC Requirements page on the ABS website.

Dr. Malangoni is Associate Executive Director, American Board of Surgery, Philadelphia. Dr. Lewis is Executive Director, American Board of Surgery, Philadelphia.

The American Board of Surgery (ABS) was founded in 1937 by the leading surgical organizations of the time in recognition of the need to differentiate formally trained surgeons from other doctors who were performing operations without formal training.

At its onset, the ABS acknowledged that it had a dual purpose: to protect the public and improve the specialty of surgery. Eligibility criteria for certification were defined – graduation from an approved medical school, the requisite duration of surgical training, a list of operations performed, high ethical standards – and passing an examination became a differentiating requirement.

Over the nearly eight decades since its founding, the ABS has retained its position as the premier certifying body for surgeons in the United States. Its mission statement, “to serve the public and the specialty of surgery by providing leadership in surgical education and practice, by promoting excellence through rigorous evaluation and examination, and by promoting the highest standards for professionalism, lifelong learning, and the continuous certification of surgeons in practice,” embodies the elements of the Maintenance of Certification (MOC) Program. Setting standards for board certification is a privilege of self-regulation that has been granted to our profession by the American public. In return, we must demonstrate our commitment to serve the best interests of the public through our processes and requirements.

ABS certification is based upon education, evaluation, and assessment. Appropriate undergraduate medical education, accredited surgical training, broad operative experience, and high ethical standing continue as essential requirements of ABS certification. For the first four decades of its existence, once ABS certification was achieved, it was valid for a surgeon’s entire professional career. This changed as the ABS Directors recognized the rapid evolution of surgical practice and believed it was necessary for diplomates to demonstrate that they were up to date with advances in medical knowledge and patient care. In 1976, the ABS adopted time-limited certification and required its diplomates to “recertify” by passing an examination every 10 years. In 2000, a requirement for its diplomates to complete 100 hours of continuing medical education (CME) credits in the 2 years prior to applying for the recertification exam (60 in Category I and 40 in Category II) was implemented. This requirement has been modified since; however, the basic rationale for its adoption remains relevant.

In 2005, the American Board of Medical Specialties (ABMS), which establishes standards for its 24 member boards, introduced MOC and proposed standards based on the six competencies jointly developed by the Accreditation Council on Graduate Medical Education and the ABMS. These competencies – patient care, medical knowledge, professionalism, interpersonal communication skills, practice-based learning and improvement, and systems-based practice – were the basis for the four parts of MOC: professional standing, lifelong learning and self-assessment, cognitive expertise, and evaluation of performance in practice. The development of MOC was further recognition that board certification needed to become a more continuous process as the pace of change in medicine had accelerated beyond any seen previously.

Boards and their diplomates have the responsibility to demonstrate to the public and their peers an enduring commitment to maintain standards for the profession, participate in lifelong education, possess medical knowledge relevant to the specialty, and improve their performance in practice. All surgeons certified or recertified beginning July 2005 have been enrolled in ABS MOC. A decade later, 95% of ABS diplomates with time-limited certificates are enrolled in the ABS MOC program and more than 90% are actively participating.

Although the ABMS established general requirements for MOC that its member boards must meet, each board is allowed to develop its own requirements. The foundations of the ABS MOC program were established before the term “maintenance of certification” was used. Professional standards have been a requirement for ABS certification since its beginning and exam requirements have been in place for more than a generation. All diplomates must fulfill the professional standing requirements to have a valid unrestricted state medical license, have hospital or ambulatory surgery center privileges if clinically active, and have references from the chief of surgery and the chair of the credentials committee where they practice.

The ABS MOC program is meant to be practice relevant. This allows surgeons to satisfy the requirements by completing CME that they choose and by participating in performance assessment activities in a way that best applies to their practices. The requirement that two-thirds of the CME hours earned be self-assessment demonstrates a greater level of engagement of the learner and shows that knowledge acquisition is achieved at the conclusion of the activity. The addition of a practice performance improvement activity requirement has generated the most controversy and misunderstanding. To meet this requirement, diplomates are asked to assess some aspect of their practice and seek to improve that. This can be done in conjunction with a hospital through participation in a national, regional, or state registry that tracks patient outcomes, or by participating in a hospital-based quality improvement activity. Some diplomates have developed performance improvement activities within their offices by focusing on a specific area for evaluation, defining measures and goals for improvement, analyzing results and making changes when appropriate, and then reassessing to develop an action plan for improvement.

Regardless of what you choose, the ABS asks only that you attest to your participation and does not collect, review, or otherwise scrutinize your results.

The ABS MOC program extends over a 10-year period. Requirements for the first 9 years are organized in identical 3-year reporting cycles running from Jan. 1 to Dec. 31. By the end of each 3-year cycle, diplomates are required to submit information on how they are meeting MOC requirements through an individualized secure login on the ABS website (www.absurgery.org). Successful completion of an MOC exam continues to be required every 10 years; however the exam may be taken in years 8 and 9 of the 10-year cycle.

ABS MOC is a surgeon-defined, national standard that formally documents many of the activities surgeons already do to stay current in their field. Participating in the ABS MOC program demonstrates your commitment to remain current in your area of practice and to strive to improve what you do.

Since its beginning, the ABS has exercised its duty to develop, promote, and refine standards for certification in surgery. Just like changes in medical practice, MOC will evolve over time to reflect new standards and best practices. The ABS Board of Directors is focused on how ABS MOC can be an even more meaningful process for surgeons without increasing the already substantial administrative burden everyone faces. We are following the progress of innovative programs being piloted by other boards and organizations involved in quality improvement. The ABS recognizes that MOC requirements established or changed will affect roughly 30,000 surgeons who practice in a wide variety of environments. We encourage our diplomates to provide ideas to improve the program as we continue to develop ABS MOC, while at the same time staying mindful of our duty to the public.

For more information, please see the MOC Requirements page on the ABS website.

Dr. Malangoni is Associate Executive Director, American Board of Surgery, Philadelphia. Dr. Lewis is Executive Director, American Board of Surgery, Philadelphia.

The American Board of Surgery (ABS) was founded in 1937 by the leading surgical organizations of the time in recognition of the need to differentiate formally trained surgeons from other doctors who were performing operations without formal training.

At its onset, the ABS acknowledged that it had a dual purpose: to protect the public and improve the specialty of surgery. Eligibility criteria for certification were defined – graduation from an approved medical school, the requisite duration of surgical training, a list of operations performed, high ethical standards – and passing an examination became a differentiating requirement.

Over the nearly eight decades since its founding, the ABS has retained its position as the premier certifying body for surgeons in the United States. Its mission statement, “to serve the public and the specialty of surgery by providing leadership in surgical education and practice, by promoting excellence through rigorous evaluation and examination, and by promoting the highest standards for professionalism, lifelong learning, and the continuous certification of surgeons in practice,” embodies the elements of the Maintenance of Certification (MOC) Program. Setting standards for board certification is a privilege of self-regulation that has been granted to our profession by the American public. In return, we must demonstrate our commitment to serve the best interests of the public through our processes and requirements.

ABS certification is based upon education, evaluation, and assessment. Appropriate undergraduate medical education, accredited surgical training, broad operative experience, and high ethical standing continue as essential requirements of ABS certification. For the first four decades of its existence, once ABS certification was achieved, it was valid for a surgeon’s entire professional career. This changed as the ABS Directors recognized the rapid evolution of surgical practice and believed it was necessary for diplomates to demonstrate that they were up to date with advances in medical knowledge and patient care. In 1976, the ABS adopted time-limited certification and required its diplomates to “recertify” by passing an examination every 10 years. In 2000, a requirement for its diplomates to complete 100 hours of continuing medical education (CME) credits in the 2 years prior to applying for the recertification exam (60 in Category I and 40 in Category II) was implemented. This requirement has been modified since; however, the basic rationale for its adoption remains relevant.

In 2005, the American Board of Medical Specialties (ABMS), which establishes standards for its 24 member boards, introduced MOC and proposed standards based on the six competencies jointly developed by the Accreditation Council on Graduate Medical Education and the ABMS. These competencies – patient care, medical knowledge, professionalism, interpersonal communication skills, practice-based learning and improvement, and systems-based practice – were the basis for the four parts of MOC: professional standing, lifelong learning and self-assessment, cognitive expertise, and evaluation of performance in practice. The development of MOC was further recognition that board certification needed to become a more continuous process as the pace of change in medicine had accelerated beyond any seen previously.

Boards and their diplomates have the responsibility to demonstrate to the public and their peers an enduring commitment to maintain standards for the profession, participate in lifelong education, possess medical knowledge relevant to the specialty, and improve their performance in practice. All surgeons certified or recertified beginning July 2005 have been enrolled in ABS MOC. A decade later, 95% of ABS diplomates with time-limited certificates are enrolled in the ABS MOC program and more than 90% are actively participating.

Although the ABMS established general requirements for MOC that its member boards must meet, each board is allowed to develop its own requirements. The foundations of the ABS MOC program were established before the term “maintenance of certification” was used. Professional standards have been a requirement for ABS certification since its beginning and exam requirements have been in place for more than a generation. All diplomates must fulfill the professional standing requirements to have a valid unrestricted state medical license, have hospital or ambulatory surgery center privileges if clinically active, and have references from the chief of surgery and the chair of the credentials committee where they practice.

The ABS MOC program is meant to be practice relevant. This allows surgeons to satisfy the requirements by completing CME that they choose and by participating in performance assessment activities in a way that best applies to their practices. The requirement that two-thirds of the CME hours earned be self-assessment demonstrates a greater level of engagement of the learner and shows that knowledge acquisition is achieved at the conclusion of the activity. The addition of a practice performance improvement activity requirement has generated the most controversy and misunderstanding. To meet this requirement, diplomates are asked to assess some aspect of their practice and seek to improve that. This can be done in conjunction with a hospital through participation in a national, regional, or state registry that tracks patient outcomes, or by participating in a hospital-based quality improvement activity. Some diplomates have developed performance improvement activities within their offices by focusing on a specific area for evaluation, defining measures and goals for improvement, analyzing results and making changes when appropriate, and then reassessing to develop an action plan for improvement.

Regardless of what you choose, the ABS asks only that you attest to your participation and does not collect, review, or otherwise scrutinize your results.

The ABS MOC program extends over a 10-year period. Requirements for the first 9 years are organized in identical 3-year reporting cycles running from Jan. 1 to Dec. 31. By the end of each 3-year cycle, diplomates are required to submit information on how they are meeting MOC requirements through an individualized secure login on the ABS website (www.absurgery.org). Successful completion of an MOC exam continues to be required every 10 years; however the exam may be taken in years 8 and 9 of the 10-year cycle.

ABS MOC is a surgeon-defined, national standard that formally documents many of the activities surgeons already do to stay current in their field. Participating in the ABS MOC program demonstrates your commitment to remain current in your area of practice and to strive to improve what you do.

Since its beginning, the ABS has exercised its duty to develop, promote, and refine standards for certification in surgery. Just like changes in medical practice, MOC will evolve over time to reflect new standards and best practices. The ABS Board of Directors is focused on how ABS MOC can be an even more meaningful process for surgeons without increasing the already substantial administrative burden everyone faces. We are following the progress of innovative programs being piloted by other boards and organizations involved in quality improvement. The ABS recognizes that MOC requirements established or changed will affect roughly 30,000 surgeons who practice in a wide variety of environments. We encourage our diplomates to provide ideas to improve the program as we continue to develop ABS MOC, while at the same time staying mindful of our duty to the public.

For more information, please see the MOC Requirements page on the ABS website.

Dr. Malangoni is Associate Executive Director, American Board of Surgery, Philadelphia. Dr. Lewis is Executive Director, American Board of Surgery, Philadelphia.

Over 100 years ago, Dr. William S. Halsted wrote: “Every important hospital should have on its resident staff of surgeons at least one who is well and able to deal with any emergency that may arise” (Bull. Johns Hopkins Hosp. 1904;15:267-75). Today, acute care surgeons fulfill that role because, as general surgeons with expertise in trauma, surgical critical care, and emergency general surgery, they provide 24/7 comprehensive care for patients with acute surgical disorders. In less than 10 years, the term “acute care surgery” has become established in the lexicon of surgical practices, training fellowships, and hospital services worldwide. The American Association for the Surgery of Trauma (AAST) Acute Care Surgery fellowship program has grown from infancy to adolescence or perhaps near mature status with 19 approved programs, 59 graduates, and a substantial case log database. These achievements have been brought about in a rapid fashion because of an emphasis on patients and their needs, and a focus on value, i.e., quality care as a cost-efficient means. Emergency Quality Improvement Program (EQIP) is being developed to ensure that patients with time-sensitive general surgical disorders receive the best care in an expeditious manner (J. Trauma Acute Care Surg. 2014;76:884-7). The purpose of this article is to present an overview of the development of acute care surgery. Future articles will cover fellowship training programs and the initiation of quality measures to characterize and validate best practices.

Grace S. Rozycki, M.D., FACS, is the Willis D. Gatch Professor of Surgery; associate chair, department of surgery, Indiana University; and chief of surgery, IUH-Methodist Hospital, Indianapolis.

Gregory J. Jurkovich, M.D., FACS, is chief of surgery, Denver Health Medical Center.

EMERGENCE OF ACUTE CARE SURGERY

Over the last 15 years it has been recognized that there has been an insufficient number of physicians participating in emergency call panels [1]. From 1993 to 2003, there was a 26% increase in the number of patients receiving care in emergency rooms across the country despite a concurrent decrease in the total number of hospitals (703 fewer), hospital beds (198,000 fewer), and emergency departments (425 fewer) [2,3]. In 2005, nearly half of all hospital emergency departments reported that they were routinely at or beyond capacity resulting in ambulance diversion [4]. This is a more severe problem for major teaching institutions, with 79% of their emergency rooms at or over capacity [5]. The Institute of Medicine highlighted this crisis in a report entitled “Hospital Based Emergency Care at the Breaking Point” [3]. Central among the issues discussed in the Institute of Medicine report included the boarding of non-funded and under-funded patients in the nation’s shrinking number of emergency departments, as well as the problem of minimal surge capacity [3]. Further exacerbating issues with access to care are workforce shortages that exist across a range of medical disciplines, but are generally more significant for surgical disciplines. The American Association of Medical Colleges estimates that a 35% increase in the number of surgeons will be necessary to meet clinical demands by 2025 [6]. An aging surgical workforce and increasing surgical sub-specialization driven in part by technological advances have compounded these shortages [1]. As a result, there are fewer general surgeons available to take emergency department call, and to care for patients with time-sensitive general surgical conditions. A survey conducted by the American College of Emergency Physicians in 2005 demonstrated that nearly 75% of emergency department medical directors believed that they had inadequate on-call surgical specialist coverage, up from 66% in 2004 [7].

At the center of these issues, described as “the perfect storm,” is the patient [8]. Just as the needs of the injured patient drove the development of the field of trauma surgery, so did the needs of the emergency general surgery patient drive the development of the acute care surgery paradigm [8]. In response to this crisis the AAST took the lead to develop a response to the patient’s need for access to high quality and timely care for surgical emergencies [9, 10]. In response, and after extensive discussions and deliberations, the AAST developed a training paradigm and a fellowship program in the specialty of acute care surgery [9]. This fellowship-training model follows core general surgery residency requirements, incorporates the Accreditation Council of Graduate Medical Education–approved Surgical Critical Care Fellowship, and is designed to produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and time-sensitive general surgery. Unlike most specialty training, this paradigm strives to create a broad-based surgical specialist, specifically trained in the treatment of acute surgical disease across a wide array of anatomic regions.

Although often used interchangeably, “emergency general surgery” and “acute care surgery” have different meanings, especially relative to the acute care surgery training paradigm. Whereas emergency general surgery refers to acute general surgical disorders, acute care surgery includes surgical critical care and the surgical management of acutely ill patients with a variety of conditions including trauma, burns, surgical critical care, or an acute general surgical condition. The challenges in caring for these patients include around-the-clock readiness for the provision of comprehensive care, the often constrained time for preoperative optimization of the patient, and the greater potential for intraoperative and postoperative complications due to the emergent nature of care. In managing these patients, acute care surgeons are fulfilling a huge patient care demand as the number of patients with acute surgical disorders is on the rise [4, 5]. And, each year, fewer general surgeons are available to participate in emergency room call to care for these patients. The general surgery workforce continues to shrink as each year more general surgeons retire and only about 25% of general surgery resident graduates choose to practice general surgery [11,12]. Hence, there is an increasing gap between the supply of general surgeons and the increasing numbers of patients with acute general surgical disorders. Another factor that contributes to the gap in supply and demand is the growing emphasis on minimally invasive techniques that have encouraged subspecialization. Minimally invasive surgery has also altered the operative experience of residents so that many general surgery graduates no longer feel comfortable taking care of patients with a broad range of general surgical conditions, especially those that are complex and time sensitive [9]. All of these factors support the continuous growing need for the well-trained acute care surgeon.

References

1. A growing crisis in patient access to emergency surgical care.

Bull. Am. Coll. Surg. 2006;91:8-19

2. McCaig LF, Burt CW. National hospital ambulatory medical care survey: 2003 Emergency Department Summary. National Center for Health Statistics, Centers for Disease Control and Prevention. Department of Health and Human Services. Available at

http://www.cdc.gov/nchs/data/ad/ad358.pdf , accessed December 11, 2009.

3. “Hospital Based Emergency Care at the Breaking Point.” Institute of Medicine, Committee on the Future of Emergency Care in the U.S. Health System. Hospital Based Emergency Care at the Breaking Point. Washington, DC: National Academy Press, 2006.

4. Kellermann A. Crisis in the emergency department.

N. Engl. J. Med. 2006; 355:1300-3

5. American Hospital Association. Hospital Statistics 2006. Health Forum LLC, 2006.

6. https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf


7. On-call specialist coverage in U.S. Emergency Departments. American College of Emergency Physicians Survey of Emergency Department Directors. April 2006. Available online at http://www.acep.org/workarea/DownloadAsset.aspx?id=33266

8. Rotondo MF. At the center of the “perfect storm”: the patient.

Surgery 2007; 141:291-2.

9. Jurkovich GJ et al: Acute care surgery: trauma, critical care, and emergency surgery. A report from the Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.

J. Trauma 2005;58:614-6

10. Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD: Acute care surgery: Eraritjaritjaka.

J Am Coll Surg. 2006 Apr; 202(4):698-701 Epub 2006 Feb 21.

11. Fraher EP, Knapton A, Sheldon GF, Meyer A, Ricketts TC. Projecting surgeon supply using a dynamic model.

Ann. Surg. 2013;257:867-72.

12. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery.

J Am. Coll. Surg. 2008;206:782-8

Dr. Davis is professor of surgery, Vice Chairman of Clinical Affairs, chief of the Section of Trauma, Surgical Critical Care and Surgical Emergencies,Yale University School of Medicine; Trauma Medical Director and Surgical Director, Quality and Performance Improvement, Yale–New Haven Hospital, New Haven, Conn. Dr. Jurkovich is chief of surgery, Denver Health Medical Center.

Over 100 years ago, Dr. William S. Halsted wrote: “Every important hospital should have on its resident staff of surgeons at least one who is well and able to deal with any emergency that may arise” (Bull. Johns Hopkins Hosp. 1904;15:267-75). Today, acute care surgeons fulfill that role because, as general surgeons with expertise in trauma, surgical critical care, and emergency general surgery, they provide 24/7 comprehensive care for patients with acute surgical disorders. In less than 10 years, the term “acute care surgery” has become established in the lexicon of surgical practices, training fellowships, and hospital services worldwide. The American Association for the Surgery of Trauma (AAST) Acute Care Surgery fellowship program has grown from infancy to adolescence or perhaps near mature status with 19 approved programs, 59 graduates, and a substantial case log database. These achievements have been brought about in a rapid fashion because of an emphasis on patients and their needs, and a focus on value, i.e., quality care as a cost-efficient means. Emergency Quality Improvement Program (EQIP) is being developed to ensure that patients with time-sensitive general surgical disorders receive the best care in an expeditious manner (J. Trauma Acute Care Surg. 2014;76:884-7). The purpose of this article is to present an overview of the development of acute care surgery. Future articles will cover fellowship training programs and the initiation of quality measures to characterize and validate best practices.

Grace S. Rozycki, M.D., FACS, is the Willis D. Gatch Professor of Surgery; associate chair, department of surgery, Indiana University; and chief of surgery, IUH-Methodist Hospital, Indianapolis.

Gregory J. Jurkovich, M.D., FACS, is chief of surgery, Denver Health Medical Center.

EMERGENCE OF ACUTE CARE SURGERY

Over the last 15 years it has been recognized that there has been an insufficient number of physicians participating in emergency call panels [1]. From 1993 to 2003, there was a 26% increase in the number of patients receiving care in emergency rooms across the country despite a concurrent decrease in the total number of hospitals (703 fewer), hospital beds (198,000 fewer), and emergency departments (425 fewer) [2,3]. In 2005, nearly half of all hospital emergency departments reported that they were routinely at or beyond capacity resulting in ambulance diversion [4]. This is a more severe problem for major teaching institutions, with 79% of their emergency rooms at or over capacity [5]. The Institute of Medicine highlighted this crisis in a report entitled “Hospital Based Emergency Care at the Breaking Point” [3]. Central among the issues discussed in the Institute of Medicine report included the boarding of non-funded and under-funded patients in the nation’s shrinking number of emergency departments, as well as the problem of minimal surge capacity [3]. Further exacerbating issues with access to care are workforce shortages that exist across a range of medical disciplines, but are generally more significant for surgical disciplines. The American Association of Medical Colleges estimates that a 35% increase in the number of surgeons will be necessary to meet clinical demands by 2025 [6]. An aging surgical workforce and increasing surgical sub-specialization driven in part by technological advances have compounded these shortages [1]. As a result, there are fewer general surgeons available to take emergency department call, and to care for patients with time-sensitive general surgical conditions. A survey conducted by the American College of Emergency Physicians in 2005 demonstrated that nearly 75% of emergency department medical directors believed that they had inadequate on-call surgical specialist coverage, up from 66% in 2004 [7].

At the center of these issues, described as “the perfect storm,” is the patient [8]. Just as the needs of the injured patient drove the development of the field of trauma surgery, so did the needs of the emergency general surgery patient drive the development of the acute care surgery paradigm [8]. In response to this crisis the AAST took the lead to develop a response to the patient’s need for access to high quality and timely care for surgical emergencies [9, 10]. In response, and after extensive discussions and deliberations, the AAST developed a training paradigm and a fellowship program in the specialty of acute care surgery [9]. This fellowship-training model follows core general surgery residency requirements, incorporates the Accreditation Council of Graduate Medical Education–approved Surgical Critical Care Fellowship, and is designed to produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and time-sensitive general surgery. Unlike most specialty training, this paradigm strives to create a broad-based surgical specialist, specifically trained in the treatment of acute surgical disease across a wide array of anatomic regions.

Although often used interchangeably, “emergency general surgery” and “acute care surgery” have different meanings, especially relative to the acute care surgery training paradigm. Whereas emergency general surgery refers to acute general surgical disorders, acute care surgery includes surgical critical care and the surgical management of acutely ill patients with a variety of conditions including trauma, burns, surgical critical care, or an acute general surgical condition. The challenges in caring for these patients include around-the-clock readiness for the provision of comprehensive care, the often constrained time for preoperative optimization of the patient, and the greater potential for intraoperative and postoperative complications due to the emergent nature of care. In managing these patients, acute care surgeons are fulfilling a huge patient care demand as the number of patients with acute surgical disorders is on the rise [4, 5]. And, each year, fewer general surgeons are available to participate in emergency room call to care for these patients. The general surgery workforce continues to shrink as each year more general surgeons retire and only about 25% of general surgery resident graduates choose to practice general surgery [11,12]. Hence, there is an increasing gap between the supply of general surgeons and the increasing numbers of patients with acute general surgical disorders. Another factor that contributes to the gap in supply and demand is the growing emphasis on minimally invasive techniques that have encouraged subspecialization. Minimally invasive surgery has also altered the operative experience of residents so that many general surgery graduates no longer feel comfortable taking care of patients with a broad range of general surgical conditions, especially those that are complex and time sensitive [9]. All of these factors support the continuous growing need for the well-trained acute care surgeon.

References

1. A growing crisis in patient access to emergency surgical care.

Bull. Am. Coll. Surg. 2006;91:8-19

2. McCaig LF, Burt CW. National hospital ambulatory medical care survey: 2003 Emergency Department Summary. National Center for Health Statistics, Centers for Disease Control and Prevention. Department of Health and Human Services. Available at

http://www.cdc.gov/nchs/data/ad/ad358.pdf , accessed December 11, 2009.

3. “Hospital Based Emergency Care at the Breaking Point.” Institute of Medicine, Committee on the Future of Emergency Care in the U.S. Health System. Hospital Based Emergency Care at the Breaking Point. Washington, DC: National Academy Press, 2006.

4. Kellermann A. Crisis in the emergency department.

N. Engl. J. Med. 2006; 355:1300-3

5. American Hospital Association. Hospital Statistics 2006. Health Forum LLC, 2006.

6. https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf


7. On-call specialist coverage in U.S. Emergency Departments. American College of Emergency Physicians Survey of Emergency Department Directors. April 2006. Available online at http://www.acep.org/workarea/DownloadAsset.aspx?id=33266

8. Rotondo MF. At the center of the “perfect storm”: the patient.

Surgery 2007; 141:291-2.

9. Jurkovich GJ et al: Acute care surgery: trauma, critical care, and emergency surgery. A report from the Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.

J. Trauma 2005;58:614-6

10. Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD: Acute care surgery: Eraritjaritjaka.

J Am Coll Surg. 2006 Apr; 202(4):698-701 Epub 2006 Feb 21.

11. Fraher EP, Knapton A, Sheldon GF, Meyer A, Ricketts TC. Projecting surgeon supply using a dynamic model.

Ann. Surg. 2013;257:867-72.

12. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery.

J Am. Coll. Surg. 2008;206:782-8

Dr. Davis is professor of surgery, Vice Chairman of Clinical Affairs, chief of the Section of Trauma, Surgical Critical Care and Surgical Emergencies,Yale University School of Medicine; Trauma Medical Director and Surgical Director, Quality and Performance Improvement, Yale–New Haven Hospital, New Haven, Conn. Dr. Jurkovich is chief of surgery, Denver Health Medical Center.

Over 100 years ago, Dr. William S. Halsted wrote: “Every important hospital should have on its resident staff of surgeons at least one who is well and able to deal with any emergency that may arise” (Bull. Johns Hopkins Hosp. 1904;15:267-75). Today, acute care surgeons fulfill that role because, as general surgeons with expertise in trauma, surgical critical care, and emergency general surgery, they provide 24/7 comprehensive care for patients with acute surgical disorders. In less than 10 years, the term “acute care surgery” has become established in the lexicon of surgical practices, training fellowships, and hospital services worldwide. The American Association for the Surgery of Trauma (AAST) Acute Care Surgery fellowship program has grown from infancy to adolescence or perhaps near mature status with 19 approved programs, 59 graduates, and a substantial case log database. These achievements have been brought about in a rapid fashion because of an emphasis on patients and their needs, and a focus on value, i.e., quality care as a cost-efficient means. Emergency Quality Improvement Program (EQIP) is being developed to ensure that patients with time-sensitive general surgical disorders receive the best care in an expeditious manner (J. Trauma Acute Care Surg. 2014;76:884-7). The purpose of this article is to present an overview of the development of acute care surgery. Future articles will cover fellowship training programs and the initiation of quality measures to characterize and validate best practices.

Grace S. Rozycki, M.D., FACS, is the Willis D. Gatch Professor of Surgery; associate chair, department of surgery, Indiana University; and chief of surgery, IUH-Methodist Hospital, Indianapolis.

Gregory J. Jurkovich, M.D., FACS, is chief of surgery, Denver Health Medical Center.

EMERGENCE OF ACUTE CARE SURGERY

Over the last 15 years it has been recognized that there has been an insufficient number of physicians participating in emergency call panels [1]. From 1993 to 2003, there was a 26% increase in the number of patients receiving care in emergency rooms across the country despite a concurrent decrease in the total number of hospitals (703 fewer), hospital beds (198,000 fewer), and emergency departments (425 fewer) [2,3]. In 2005, nearly half of all hospital emergency departments reported that they were routinely at or beyond capacity resulting in ambulance diversion [4]. This is a more severe problem for major teaching institutions, with 79% of their emergency rooms at or over capacity [5]. The Institute of Medicine highlighted this crisis in a report entitled “Hospital Based Emergency Care at the Breaking Point” [3]. Central among the issues discussed in the Institute of Medicine report included the boarding of non-funded and under-funded patients in the nation’s shrinking number of emergency departments, as well as the problem of minimal surge capacity [3]. Further exacerbating issues with access to care are workforce shortages that exist across a range of medical disciplines, but are generally more significant for surgical disciplines. The American Association of Medical Colleges estimates that a 35% increase in the number of surgeons will be necessary to meet clinical demands by 2025 [6]. An aging surgical workforce and increasing surgical sub-specialization driven in part by technological advances have compounded these shortages [1]. As a result, there are fewer general surgeons available to take emergency department call, and to care for patients with time-sensitive general surgical conditions. A survey conducted by the American College of Emergency Physicians in 2005 demonstrated that nearly 75% of emergency department medical directors believed that they had inadequate on-call surgical specialist coverage, up from 66% in 2004 [7].

At the center of these issues, described as “the perfect storm,” is the patient [8]. Just as the needs of the injured patient drove the development of the field of trauma surgery, so did the needs of the emergency general surgery patient drive the development of the acute care surgery paradigm [8]. In response to this crisis the AAST took the lead to develop a response to the patient’s need for access to high quality and timely care for surgical emergencies [9, 10]. In response, and after extensive discussions and deliberations, the AAST developed a training paradigm and a fellowship program in the specialty of acute care surgery [9]. This fellowship-training model follows core general surgery residency requirements, incorporates the Accreditation Council of Graduate Medical Education–approved Surgical Critical Care Fellowship, and is designed to produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and time-sensitive general surgery. Unlike most specialty training, this paradigm strives to create a broad-based surgical specialist, specifically trained in the treatment of acute surgical disease across a wide array of anatomic regions.

Although often used interchangeably, “emergency general surgery” and “acute care surgery” have different meanings, especially relative to the acute care surgery training paradigm. Whereas emergency general surgery refers to acute general surgical disorders, acute care surgery includes surgical critical care and the surgical management of acutely ill patients with a variety of conditions including trauma, burns, surgical critical care, or an acute general surgical condition. The challenges in caring for these patients include around-the-clock readiness for the provision of comprehensive care, the often constrained time for preoperative optimization of the patient, and the greater potential for intraoperative and postoperative complications due to the emergent nature of care. In managing these patients, acute care surgeons are fulfilling a huge patient care demand as the number of patients with acute surgical disorders is on the rise [4, 5]. And, each year, fewer general surgeons are available to participate in emergency room call to care for these patients. The general surgery workforce continues to shrink as each year more general surgeons retire and only about 25% of general surgery resident graduates choose to practice general surgery [11,12]. Hence, there is an increasing gap between the supply of general surgeons and the increasing numbers of patients with acute general surgical disorders. Another factor that contributes to the gap in supply and demand is the growing emphasis on minimally invasive techniques that have encouraged subspecialization. Minimally invasive surgery has also altered the operative experience of residents so that many general surgery graduates no longer feel comfortable taking care of patients with a broad range of general surgical conditions, especially those that are complex and time sensitive [9]. All of these factors support the continuous growing need for the well-trained acute care surgeon.

References

1. A growing crisis in patient access to emergency surgical care.

Bull. Am. Coll. Surg. 2006;91:8-19

2. McCaig LF, Burt CW. National hospital ambulatory medical care survey: 2003 Emergency Department Summary. National Center for Health Statistics, Centers for Disease Control and Prevention. Department of Health and Human Services. Available at

http://www.cdc.gov/nchs/data/ad/ad358.pdf , accessed December 11, 2009.

3. “Hospital Based Emergency Care at the Breaking Point.” Institute of Medicine, Committee on the Future of Emergency Care in the U.S. Health System. Hospital Based Emergency Care at the Breaking Point. Washington, DC: National Academy Press, 2006.

4. Kellermann A. Crisis in the emergency department.

N. Engl. J. Med. 2006; 355:1300-3

5. American Hospital Association. Hospital Statistics 2006. Health Forum LLC, 2006.

6. https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf


7. On-call specialist coverage in U.S. Emergency Departments. American College of Emergency Physicians Survey of Emergency Department Directors. April 2006. Available online at http://www.acep.org/workarea/DownloadAsset.aspx?id=33266

8. Rotondo MF. At the center of the “perfect storm”: the patient.

Surgery 2007; 141:291-2.

9. Jurkovich GJ et al: Acute care surgery: trauma, critical care, and emergency surgery. A report from the Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery.

J. Trauma 2005;58:614-6

10. Moore EE, Maier RV, Hoyt DB, Jurkovich GJ, Trunkey DD: Acute care surgery: Eraritjaritjaka.

J Am Coll Surg. 2006 Apr; 202(4):698-701 Epub 2006 Feb 21.

11. Fraher EP, Knapton A, Sheldon GF, Meyer A, Ricketts TC. Projecting surgeon supply using a dynamic model.

Ann. Surg. 2013;257:867-72.

12. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: longterm data from the American Board of Surgery.

J Am. Coll. Surg. 2008;206:782-8

Dr. Davis is professor of surgery, Vice Chairman of Clinical Affairs, chief of the Section of Trauma, Surgical Critical Care and Surgical Emergencies,Yale University School of Medicine; Trauma Medical Director and Surgical Director, Quality and Performance Improvement, Yale–New Haven Hospital, New Haven, Conn. Dr. Jurkovich is chief of surgery, Denver Health Medical Center.

NEW ORLEANS – Renal mass biopsy has traditionally played a restricted diagnostic role, but with its improved diagnostic accuracy, it is becoming a viable clinical tool in the modern era, according to Dr. Matthew Maurice.

“We were seeking to understand the current role of biopsy in the management of renal masses, said Dr. Maurice, a urology resident at University Hospitals Case Medical Center in Cleveland. “We used the National Cancer Database and looked at data from 2003 to 2011; what we saw was a rise in renal mass biopsy in the final 3 years of the study. It’s a very small increase, but a statistically significant increase, with people in 2011 having 1.3 times higher odds of being biopsied than they would have had in 2003.”

Dr. Maurice and his colleagues at Case Medical conducted a study examining renal mass biopsy use in the modern era, and presented their findings in a poster at the annual meeting of the American Urological Association.

Using the National Cancer Database (NCDB), Dr. Maurice and his colleagues identified all patients diagnosed with renal cell carcinoma (RCC) between 2003 and 2011. Patients within the RCC cohort were then classified as having undergone renal biopsy or not. Renal biopsy utilization rates were plotted over time, and patient, disease, provider, and treatment variables were evaluated via univariate and multivariate logistic regression models to determine the predictors of renal biopsy.

Out of 304,583 patients with kidney cancer, 35,942 patients (11.8%) underwent renal mass biopsy. From 2009 to 2011, Dr. Maurice and his coinvestigators observed a significant increase in biopsy use; patients diagnosed with a renal mass in 2011 had 1.3 times higher odds of being biopsied compared with those diagnosed in 2003 (odds radio, 1.3, confidence interval, 1.3-1.4, P < .01).

Eventual treatment was the strongest predictor of biopsy utilization. “Patients receiving observation or thermal ablative therapy (either cryoablation or radiofrequency ablation) were much more likely to receive biopsy than were those who received surgical therapy such as radical or partial nephrectomy,” Dr. Maurice explained. “So it seems like those treatments are driving the use of renal biopsy utilization in contemporary patients.”

Compared to patients treated with partial nephrectomy, patients managed with observation, cryoablation, or radiofrequency ablation had 4.2, 8.0, and 19.1 times the odds of being biopsied, respectively (OR, 4.2, CI, 4.0-4.5, P < .01; OR, 8.0, CI, 8.0-8.1, P < .01; OR, 19.1, CI, 18.4-19.7, P < .01). Patients with other known cancers, bulky lymph node involvement, or small masses ranging from 2 to 4 cm in size were also more likely to be biopsied (P < .01).

“Nonacademic hospitals were more likely to biopsy,” he added. “It could be that these hospitals are using observation and thermal ablative therapies more frequently.” Conversely, wealthier patients, patients treated at academic hospitals, and patients treated in the Northeast were significantly less likely to be biopsied. (P < .01).

On the basis of the data analyzed in this study, Dr. Maurice and his colleagues concluded that there is a trend in use of renal mass biopsy in nonacademic centers in recent years, particularly among patients with small renal masses and in those who eventually undergo observation or focal ablative therapies. Lesser indications predicting the usage of renal mass biopsy include the existence of other primary cancers and bulky lymph nodes.

Dr. Maurice reported no relevant financial relationships.

NEW ORLEANS – Renal mass biopsy has traditionally played a restricted diagnostic role, but with its improved diagnostic accuracy, it is becoming a viable clinical tool in the modern era, according to Dr. Matthew Maurice.

“We were seeking to understand the current role of biopsy in the management of renal masses, said Dr. Maurice, a urology resident at University Hospitals Case Medical Center in Cleveland. “We used the National Cancer Database and looked at data from 2003 to 2011; what we saw was a rise in renal mass biopsy in the final 3 years of the study. It’s a very small increase, but a statistically significant increase, with people in 2011 having 1.3 times higher odds of being biopsied than they would have had in 2003.”

Dr. Maurice and his colleagues at Case Medical conducted a study examining renal mass biopsy use in the modern era, and presented their findings in a poster at the annual meeting of the American Urological Association.

Using the National Cancer Database (NCDB), Dr. Maurice and his colleagues identified all patients diagnosed with renal cell carcinoma (RCC) between 2003 and 2011. Patients within the RCC cohort were then classified as having undergone renal biopsy or not. Renal biopsy utilization rates were plotted over time, and patient, disease, provider, and treatment variables were evaluated via univariate and multivariate logistic regression models to determine the predictors of renal biopsy.

Out of 304,583 patients with kidney cancer, 35,942 patients (11.8%) underwent renal mass biopsy. From 2009 to 2011, Dr. Maurice and his coinvestigators observed a significant increase in biopsy use; patients diagnosed with a renal mass in 2011 had 1.3 times higher odds of being biopsied compared with those diagnosed in 2003 (odds radio, 1.3, confidence interval, 1.3-1.4, P < .01).

Eventual treatment was the strongest predictor of biopsy utilization. “Patients receiving observation or thermal ablative therapy (either cryoablation or radiofrequency ablation) were much more likely to receive biopsy than were those who received surgical therapy such as radical or partial nephrectomy,” Dr. Maurice explained. “So it seems like those treatments are driving the use of renal biopsy utilization in contemporary patients.”

Compared to patients treated with partial nephrectomy, patients managed with observation, cryoablation, or radiofrequency ablation had 4.2, 8.0, and 19.1 times the odds of being biopsied, respectively (OR, 4.2, CI, 4.0-4.5, P < .01; OR, 8.0, CI, 8.0-8.1, P < .01; OR, 19.1, CI, 18.4-19.7, P < .01). Patients with other known cancers, bulky lymph node involvement, or small masses ranging from 2 to 4 cm in size were also more likely to be biopsied (P < .01).

“Nonacademic hospitals were more likely to biopsy,” he added. “It could be that these hospitals are using observation and thermal ablative therapies more frequently.” Conversely, wealthier patients, patients treated at academic hospitals, and patients treated in the Northeast were significantly less likely to be biopsied. (P < .01).

On the basis of the data analyzed in this study, Dr. Maurice and his colleagues concluded that there is a trend in use of renal mass biopsy in nonacademic centers in recent years, particularly among patients with small renal masses and in those who eventually undergo observation or focal ablative therapies. Lesser indications predicting the usage of renal mass biopsy include the existence of other primary cancers and bulky lymph nodes.

Dr. Maurice reported no relevant financial relationships.

NEW ORLEANS – Renal mass biopsy has traditionally played a restricted diagnostic role, but with its improved diagnostic accuracy, it is becoming a viable clinical tool in the modern era, according to Dr. Matthew Maurice.

“We were seeking to understand the current role of biopsy in the management of renal masses, said Dr. Maurice, a urology resident at University Hospitals Case Medical Center in Cleveland. “We used the National Cancer Database and looked at data from 2003 to 2011; what we saw was a rise in renal mass biopsy in the final 3 years of the study. It’s a very small increase, but a statistically significant increase, with people in 2011 having 1.3 times higher odds of being biopsied than they would have had in 2003.”

Dr. Maurice and his colleagues at Case Medical conducted a study examining renal mass biopsy use in the modern era, and presented their findings in a poster at the annual meeting of the American Urological Association.

Using the National Cancer Database (NCDB), Dr. Maurice and his colleagues identified all patients diagnosed with renal cell carcinoma (RCC) between 2003 and 2011. Patients within the RCC cohort were then classified as having undergone renal biopsy or not. Renal biopsy utilization rates were plotted over time, and patient, disease, provider, and treatment variables were evaluated via univariate and multivariate logistic regression models to determine the predictors of renal biopsy.

Out of 304,583 patients with kidney cancer, 35,942 patients (11.8%) underwent renal mass biopsy. From 2009 to 2011, Dr. Maurice and his coinvestigators observed a significant increase in biopsy use; patients diagnosed with a renal mass in 2011 had 1.3 times higher odds of being biopsied compared with those diagnosed in 2003 (odds radio, 1.3, confidence interval, 1.3-1.4, P < .01).

Eventual treatment was the strongest predictor of biopsy utilization. “Patients receiving observation or thermal ablative therapy (either cryoablation or radiofrequency ablation) were much more likely to receive biopsy than were those who received surgical therapy such as radical or partial nephrectomy,” Dr. Maurice explained. “So it seems like those treatments are driving the use of renal biopsy utilization in contemporary patients.”

Compared to patients treated with partial nephrectomy, patients managed with observation, cryoablation, or radiofrequency ablation had 4.2, 8.0, and 19.1 times the odds of being biopsied, respectively (OR, 4.2, CI, 4.0-4.5, P < .01; OR, 8.0, CI, 8.0-8.1, P < .01; OR, 19.1, CI, 18.4-19.7, P < .01). Patients with other known cancers, bulky lymph node involvement, or small masses ranging from 2 to 4 cm in size were also more likely to be biopsied (P < .01).

“Nonacademic hospitals were more likely to biopsy,” he added. “It could be that these hospitals are using observation and thermal ablative therapies more frequently.” Conversely, wealthier patients, patients treated at academic hospitals, and patients treated in the Northeast were significantly less likely to be biopsied. (P < .01).

On the basis of the data analyzed in this study, Dr. Maurice and his colleagues concluded that there is a trend in use of renal mass biopsy in nonacademic centers in recent years, particularly among patients with small renal masses and in those who eventually undergo observation or focal ablative therapies. Lesser indications predicting the usage of renal mass biopsy include the existence of other primary cancers and bulky lymph nodes.

Dr. Maurice reported no relevant financial relationships.