Facs

 

Recently, I had a trauma call at my scenic little hospital in Maine. “Bleeding leg wound, Dr, Crosslin. We’ve got pressure on it. Come soon.” During my jog across the parking lot to the ER, I drifted into my residency mantra and started reciting the ABCs of trauma care:

Airway, Breathing, CT scan.

Airway, Breathing, C-spine collar.

Airway, Breathing, Consult with ortho.



Okay, so it’s been a while. Four years doesn’t seem like a long time, but that little span serves up a lot of change. You settle into a routine in your isolated, bucolic New England coastal town, where most trauma is related to hauling up lobster crates and having Massachusetts drivers scare the moxie out of locals in the crosswalks, and you forget about the hundreds of Level 1 traumas you managed over 5 years in Boston. The drilled-down, rapid sequence of the primary and secondary surveys gets lost, if just for a moment. Your confident swagger is replaced with a measured, humble shuffle into Trauma Bay 1. Do I scan the leg now? Did I feel for pulses in the foot? Wait, where do the major vessels branch again?

Thankfully, it’s like riding a bike (except the trauma bike is a Kawasaki Ninja burning it at 250 mph down a Maine country back road, without a helmet). Once I knocked away the cobwebs, my confidence came back, and things went smooth as silk. I even did a thoroughly AMPLE interview, enough so to find out the wound was caused by a wood ax that slipped after contact (details changed to protect the innocent!). “It was stupid, Doctor. I got lazy and didn’t sharpen it. The only thing more dangerous than a sharp ax is a dull one.”

After addressing the issue at hand (or in this case, at foot), I kept thinking about the woodsman’s statement. I reflected on how I felt when I entered the trauma bay. Had I been doing enough to keep my own mental tools sharp? Well, actually, no. When did things slip just enough to allow hesitation and a bit of doubt to creep in? Probably sooner than I would care to admit. I certainly don’t think it took all of these 4 years for it to happen.

There has been some discussion of late surrounding the changes to maintenance of certification requirements from the American Board of Surgery. As with anything in surgery, we all need a chance to grumble about how things were better in the good old days. But then we grudgingly have to acknowledge that maybe – just maybe – the new approach makes some sense.

Did anyone really enjoy reporting on a 3-year cycle and taking a high-stakes, nausea-inducing exam every 10 years? I certainly wasn’t looking forward to reporting in this year about my “progress,” especially given how dull I seem to have become in so many subcategories just 4 years after graduation. But reporting every 5 years? That appeals to my inner slacker. Having a more-frequent-but-way-less-stressful examination that can be tailored to my practice? Yes, I’ll give that a shot.

It’s no secret we all are driven to care more about the things we enjoy doing, and educational science has established, quite firmly, the increased likelihood of concrete learning in higher numbers of loosely related fields when the primary subject is of particular interest to the learner. Elementary school teachers implemented that particular tidbit a long time ago. For me, the drive to excel leads me to the oncology, endocrine, and complex hernia reconstruction arenas. I do not pretend to be the world’s authority on trauma surgery, or anorectal surgery, or vascular surgery. I leave that expertise to others I secretly have judged to be far more pathological than myself. But I would be willing to glean more from reviewing those particular subjects if the overall focus is geared toward improving my knowledge and skill in cancer surgery.

In this ultramodern era, when the compendium of medical and surgical knowledge infinitely outpaces our ability to provide “one-stop shopping” services, perhaps it is time we accept the limitations of our interests and our abilities as part of the natural, beneficial evolution of good medical practice. The College’s willingness to work with the ABS to address the hot-button issue of continuing education in an interactive, relevant, timely manner should be a major point of pride. Rather than clinging to the dull ways of the past, I think we all are going to benefit from carrying a collectively sharper ax.

Dr. Crosslin is a general surgeon practicing in Rockport, Maine.

 

Recently, I had a trauma call at my scenic little hospital in Maine. “Bleeding leg wound, Dr, Crosslin. We’ve got pressure on it. Come soon.” During my jog across the parking lot to the ER, I drifted into my residency mantra and started reciting the ABCs of trauma care:

Airway, Breathing, CT scan.

Airway, Breathing, C-spine collar.

Airway, Breathing, Consult with ortho.



Okay, so it’s been a while. Four years doesn’t seem like a long time, but that little span serves up a lot of change. You settle into a routine in your isolated, bucolic New England coastal town, where most trauma is related to hauling up lobster crates and having Massachusetts drivers scare the moxie out of locals in the crosswalks, and you forget about the hundreds of Level 1 traumas you managed over 5 years in Boston. The drilled-down, rapid sequence of the primary and secondary surveys gets lost, if just for a moment. Your confident swagger is replaced with a measured, humble shuffle into Trauma Bay 1. Do I scan the leg now? Did I feel for pulses in the foot? Wait, where do the major vessels branch again?

Thankfully, it’s like riding a bike (except the trauma bike is a Kawasaki Ninja burning it at 250 mph down a Maine country back road, without a helmet). Once I knocked away the cobwebs, my confidence came back, and things went smooth as silk. I even did a thoroughly AMPLE interview, enough so to find out the wound was caused by a wood ax that slipped after contact (details changed to protect the innocent!). “It was stupid, Doctor. I got lazy and didn’t sharpen it. The only thing more dangerous than a sharp ax is a dull one.”

After addressing the issue at hand (or in this case, at foot), I kept thinking about the woodsman’s statement. I reflected on how I felt when I entered the trauma bay. Had I been doing enough to keep my own mental tools sharp? Well, actually, no. When did things slip just enough to allow hesitation and a bit of doubt to creep in? Probably sooner than I would care to admit. I certainly don’t think it took all of these 4 years for it to happen.

There has been some discussion of late surrounding the changes to maintenance of certification requirements from the American Board of Surgery. As with anything in surgery, we all need a chance to grumble about how things were better in the good old days. But then we grudgingly have to acknowledge that maybe – just maybe – the new approach makes some sense.

Did anyone really enjoy reporting on a 3-year cycle and taking a high-stakes, nausea-inducing exam every 10 years? I certainly wasn’t looking forward to reporting in this year about my “progress,” especially given how dull I seem to have become in so many subcategories just 4 years after graduation. But reporting every 5 years? That appeals to my inner slacker. Having a more-frequent-but-way-less-stressful examination that can be tailored to my practice? Yes, I’ll give that a shot.

It’s no secret we all are driven to care more about the things we enjoy doing, and educational science has established, quite firmly, the increased likelihood of concrete learning in higher numbers of loosely related fields when the primary subject is of particular interest to the learner. Elementary school teachers implemented that particular tidbit a long time ago. For me, the drive to excel leads me to the oncology, endocrine, and complex hernia reconstruction arenas. I do not pretend to be the world’s authority on trauma surgery, or anorectal surgery, or vascular surgery. I leave that expertise to others I secretly have judged to be far more pathological than myself. But I would be willing to glean more from reviewing those particular subjects if the overall focus is geared toward improving my knowledge and skill in cancer surgery.

In this ultramodern era, when the compendium of medical and surgical knowledge infinitely outpaces our ability to provide “one-stop shopping” services, perhaps it is time we accept the limitations of our interests and our abilities as part of the natural, beneficial evolution of good medical practice. The College’s willingness to work with the ABS to address the hot-button issue of continuing education in an interactive, relevant, timely manner should be a major point of pride. Rather than clinging to the dull ways of the past, I think we all are going to benefit from carrying a collectively sharper ax.

Dr. Crosslin is a general surgeon practicing in Rockport, Maine.

 

Recently, I had a trauma call at my scenic little hospital in Maine. “Bleeding leg wound, Dr, Crosslin. We’ve got pressure on it. Come soon.” During my jog across the parking lot to the ER, I drifted into my residency mantra and started reciting the ABCs of trauma care:

Airway, Breathing, CT scan.

Airway, Breathing, C-spine collar.

Airway, Breathing, Consult with ortho.



Okay, so it’s been a while. Four years doesn’t seem like a long time, but that little span serves up a lot of change. You settle into a routine in your isolated, bucolic New England coastal town, where most trauma is related to hauling up lobster crates and having Massachusetts drivers scare the moxie out of locals in the crosswalks, and you forget about the hundreds of Level 1 traumas you managed over 5 years in Boston. The drilled-down, rapid sequence of the primary and secondary surveys gets lost, if just for a moment. Your confident swagger is replaced with a measured, humble shuffle into Trauma Bay 1. Do I scan the leg now? Did I feel for pulses in the foot? Wait, where do the major vessels branch again?

Thankfully, it’s like riding a bike (except the trauma bike is a Kawasaki Ninja burning it at 250 mph down a Maine country back road, without a helmet). Once I knocked away the cobwebs, my confidence came back, and things went smooth as silk. I even did a thoroughly AMPLE interview, enough so to find out the wound was caused by a wood ax that slipped after contact (details changed to protect the innocent!). “It was stupid, Doctor. I got lazy and didn’t sharpen it. The only thing more dangerous than a sharp ax is a dull one.”

After addressing the issue at hand (or in this case, at foot), I kept thinking about the woodsman’s statement. I reflected on how I felt when I entered the trauma bay. Had I been doing enough to keep my own mental tools sharp? Well, actually, no. When did things slip just enough to allow hesitation and a bit of doubt to creep in? Probably sooner than I would care to admit. I certainly don’t think it took all of these 4 years for it to happen.

There has been some discussion of late surrounding the changes to maintenance of certification requirements from the American Board of Surgery. As with anything in surgery, we all need a chance to grumble about how things were better in the good old days. But then we grudgingly have to acknowledge that maybe – just maybe – the new approach makes some sense.

Did anyone really enjoy reporting on a 3-year cycle and taking a high-stakes, nausea-inducing exam every 10 years? I certainly wasn’t looking forward to reporting in this year about my “progress,” especially given how dull I seem to have become in so many subcategories just 4 years after graduation. But reporting every 5 years? That appeals to my inner slacker. Having a more-frequent-but-way-less-stressful examination that can be tailored to my practice? Yes, I’ll give that a shot.

It’s no secret we all are driven to care more about the things we enjoy doing, and educational science has established, quite firmly, the increased likelihood of concrete learning in higher numbers of loosely related fields when the primary subject is of particular interest to the learner. Elementary school teachers implemented that particular tidbit a long time ago. For me, the drive to excel leads me to the oncology, endocrine, and complex hernia reconstruction arenas. I do not pretend to be the world’s authority on trauma surgery, or anorectal surgery, or vascular surgery. I leave that expertise to others I secretly have judged to be far more pathological than myself. But I would be willing to glean more from reviewing those particular subjects if the overall focus is geared toward improving my knowledge and skill in cancer surgery.

In this ultramodern era, when the compendium of medical and surgical knowledge infinitely outpaces our ability to provide “one-stop shopping” services, perhaps it is time we accept the limitations of our interests and our abilities as part of the natural, beneficial evolution of good medical practice. The College’s willingness to work with the ABS to address the hot-button issue of continuing education in an interactive, relevant, timely manner should be a major point of pride. Rather than clinging to the dull ways of the past, I think we all are going to benefit from carrying a collectively sharper ax.

Dr. Crosslin is a general surgeon practicing in Rockport, Maine.

 

Do what’s right for the patient. That statement is the bedrock on which the American College of Surgeons (ACS) stands.

Throughout its nearly 104-year history, the ACS has promoted surgical education and quality improvement. The College’s dedication to education and quality can be traced to the guiding principles of its founder, Franklin H. Martin, MD, FACS. In Dr. Martin’s era, the early 20th century, medical education was in a deplorable state, as documented in the well-known Flexner report of 1910.

To help improve surgical education and training, Dr. Martin first established Surgery, Gynecology & Obstetrics (SG&O, now the Journal of the American College of Surgeons) as a practical journal for practicing surgeons, edited by active surgeons. He published an editorial in the journal inviting surgeons to “learn by watching” and encouraged “every physician in the U.S. and Canada who was interested in surgery to observe the clinics in one of the large medical centers.” Approximately 1,300 physicians responded to Dr. Martin’s charge, resulting in the first Clinical Congress of Surgeons of North America (CCSNA), November 7-9, 1910, in Chicago, IL. After the third CCSNA meeting in 1912, Dr. Martin concluded that further change was necessary, which eventually led to the formation of the ACS in November 1913.

Standards

Dr. Martin was determined that Fellows of the College would meet rigorous criteria that would serve as evidence of their ability to do what’s right for the patient. A problem arose, however. In the first two years of the College’s existence, more than 80 percent of the applicants for Fellowship were rejected because their hospital records were incomplete or nonexistent. Candidates for Fellowship were required to submit the complete records of 50 consecutive major operations and 50 abstracts of major operations in which they were the surgeon or first assistant. To respond to this dearth of supporting material, the ACS, with leadership from John G. Bowman, PhD, the College’s first Director, developed the Minimum Standards for Hospitals. In 1939, the College similarly set forth criteria for graduate surgical training.

The importance of establishing standards for hospitals and surgical training cannot be emphasized enough. These programs fundamentally changed surgical practice and training. If the College had ceased to exist after that achievement, it would have more than fulfilled the expectations of Dr. Martin and other ACS leaders. But this did not happen. Instead, the College continued to inspire quality and to maintain the highest standards for better outcomes through establishment of programs aimed at improving care for cancer and trauma patients.

Committees

The ACS Committee on Cancer published a Standardized Method for Reporting Cancer End Results in 1953. In 1965, other organizations partnered with the College to transform this committee into the Commission on Cancer (CoC), which today uses strict criteria and a rigorous on-site evaluation process to accredit more than 1,530 U.S. cancer centers. This accreditation process is used not only for initial verification of achievement of program standards, but also for periodic review for compliance to maintain accreditation.

Early in its history, the College also established a Committee on the Treatment of Fractures, which evolved into what we now know as the Committee on Trauma (COT). The COT’s guidelines for hospitals to attain or maintain verification as trauma centers—Resources for Optimal Care of the Injured Patient—was first issued in 1976 and now is in its sixth edition.

Another seminal event in trauma took place in 1976—an airplane crash involving James K. Styner, MD, FACS, and his family, in rural Nebraska. His wife died on impact, and his children were severely injured. Angered by the delays his family experienced in receiving appropriate care, Dr. Styner called for the development of adequate facilities and standardized approaches to care for severely injured patients. He combined forces with Paul E. “Skip” Collicott, MD, FACS, and other Nebraska surgeons, to develop the Advanced Trauma Life Support^® program, which introduces physicians and other health care professionals around the world to best practices for initial evaluation and management of trauma patients.

ACS Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS, has led more recent COT initiatives, including development of the Advanced Trauma Operative Management^® course and the Hartford Consensus^TM. This panel—composed of trauma care professionals and government officials—developed the Stop the Bleed program—an initiative aimed at enhancing survival from mass casualty and active shooter events.

Another important committee that the College established to ensure surgeons are prepared to do what’s right for the patient is the Committee on Emerging Surgical Technology and Education (CESTE). Launched in 1992 with the late C. James Carrico, MD, FACS, as the inaugural Chair, CESTE was charged with developing processes to evaluate emerging surgical technology for safety and effectiveness, creating standardized education programs, and measuring outcomes. Two of the College’s most important education and quality programs sprang from CESTE—the Accredited Education Institutes, under the leadership of Ajit K. Sachdeva, MD, FACS, Director, ACS Division of Education, and the Division of Research and Optimal Patient Care, first led by R. Scott Jones, MD, FACS, and now under the purview of Clifford Y. Ko, MD, MS, FACS.

 

The future is in your hands

Unquestionably, the ACS and its leaders have a rich history of doing what’s right for the patient. The future, however, belongs to you. I want to encourage you to participate in all the activities of your College at the local, state, and national levels. Establish personal relationships with leaders. Be an advocate for our education and quality programs. I am confident that there are those among you who will become the leaders who will continue the evolution of the College and inspire quality, maintain the highest standards, and ensure better outcomes.
 

Dr. Townsend is the Robertson-Poth Distinguished Chair in General Surgery, department of surgery, University of Texas Medical Branch (UTMB), Galveston; professor of surgery, department of surgery, professor of physician assistant studies, School of Allied Health Sciences; and graduate faculty in the cell biology program, UTMB. He is the 97th President of the ACS.

 

Do what’s right for the patient. That statement is the bedrock on which the American College of Surgeons (ACS) stands.

Throughout its nearly 104-year history, the ACS has promoted surgical education and quality improvement. The College’s dedication to education and quality can be traced to the guiding principles of its founder, Franklin H. Martin, MD, FACS. In Dr. Martin’s era, the early 20th century, medical education was in a deplorable state, as documented in the well-known Flexner report of 1910.

To help improve surgical education and training, Dr. Martin first established Surgery, Gynecology & Obstetrics (SG&O, now the Journal of the American College of Surgeons) as a practical journal for practicing surgeons, edited by active surgeons. He published an editorial in the journal inviting surgeons to “learn by watching” and encouraged “every physician in the U.S. and Canada who was interested in surgery to observe the clinics in one of the large medical centers.” Approximately 1,300 physicians responded to Dr. Martin’s charge, resulting in the first Clinical Congress of Surgeons of North America (CCSNA), November 7-9, 1910, in Chicago, IL. After the third CCSNA meeting in 1912, Dr. Martin concluded that further change was necessary, which eventually led to the formation of the ACS in November 1913.

Standards

Dr. Martin was determined that Fellows of the College would meet rigorous criteria that would serve as evidence of their ability to do what’s right for the patient. A problem arose, however. In the first two years of the College’s existence, more than 80 percent of the applicants for Fellowship were rejected because their hospital records were incomplete or nonexistent. Candidates for Fellowship were required to submit the complete records of 50 consecutive major operations and 50 abstracts of major operations in which they were the surgeon or first assistant. To respond to this dearth of supporting material, the ACS, with leadership from John G. Bowman, PhD, the College’s first Director, developed the Minimum Standards for Hospitals. In 1939, the College similarly set forth criteria for graduate surgical training.

The importance of establishing standards for hospitals and surgical training cannot be emphasized enough. These programs fundamentally changed surgical practice and training. If the College had ceased to exist after that achievement, it would have more than fulfilled the expectations of Dr. Martin and other ACS leaders. But this did not happen. Instead, the College continued to inspire quality and to maintain the highest standards for better outcomes through establishment of programs aimed at improving care for cancer and trauma patients.

Committees

The ACS Committee on Cancer published a Standardized Method for Reporting Cancer End Results in 1953. In 1965, other organizations partnered with the College to transform this committee into the Commission on Cancer (CoC), which today uses strict criteria and a rigorous on-site evaluation process to accredit more than 1,530 U.S. cancer centers. This accreditation process is used not only for initial verification of achievement of program standards, but also for periodic review for compliance to maintain accreditation.

Early in its history, the College also established a Committee on the Treatment of Fractures, which evolved into what we now know as the Committee on Trauma (COT). The COT’s guidelines for hospitals to attain or maintain verification as trauma centers—Resources for Optimal Care of the Injured Patient—was first issued in 1976 and now is in its sixth edition.

Another seminal event in trauma took place in 1976—an airplane crash involving James K. Styner, MD, FACS, and his family, in rural Nebraska. His wife died on impact, and his children were severely injured. Angered by the delays his family experienced in receiving appropriate care, Dr. Styner called for the development of adequate facilities and standardized approaches to care for severely injured patients. He combined forces with Paul E. “Skip” Collicott, MD, FACS, and other Nebraska surgeons, to develop the Advanced Trauma Life Support^® program, which introduces physicians and other health care professionals around the world to best practices for initial evaluation and management of trauma patients.

ACS Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS, has led more recent COT initiatives, including development of the Advanced Trauma Operative Management^® course and the Hartford Consensus^TM. This panel—composed of trauma care professionals and government officials—developed the Stop the Bleed program—an initiative aimed at enhancing survival from mass casualty and active shooter events.

Another important committee that the College established to ensure surgeons are prepared to do what’s right for the patient is the Committee on Emerging Surgical Technology and Education (CESTE). Launched in 1992 with the late C. James Carrico, MD, FACS, as the inaugural Chair, CESTE was charged with developing processes to evaluate emerging surgical technology for safety and effectiveness, creating standardized education programs, and measuring outcomes. Two of the College’s most important education and quality programs sprang from CESTE—the Accredited Education Institutes, under the leadership of Ajit K. Sachdeva, MD, FACS, Director, ACS Division of Education, and the Division of Research and Optimal Patient Care, first led by R. Scott Jones, MD, FACS, and now under the purview of Clifford Y. Ko, MD, MS, FACS.

 

The future is in your hands

Unquestionably, the ACS and its leaders have a rich history of doing what’s right for the patient. The future, however, belongs to you. I want to encourage you to participate in all the activities of your College at the local, state, and national levels. Establish personal relationships with leaders. Be an advocate for our education and quality programs. I am confident that there are those among you who will become the leaders who will continue the evolution of the College and inspire quality, maintain the highest standards, and ensure better outcomes.
 

Dr. Townsend is the Robertson-Poth Distinguished Chair in General Surgery, department of surgery, University of Texas Medical Branch (UTMB), Galveston; professor of surgery, department of surgery, professor of physician assistant studies, School of Allied Health Sciences; and graduate faculty in the cell biology program, UTMB. He is the 97th President of the ACS.

 

Do what’s right for the patient. That statement is the bedrock on which the American College of Surgeons (ACS) stands.

Throughout its nearly 104-year history, the ACS has promoted surgical education and quality improvement. The College’s dedication to education and quality can be traced to the guiding principles of its founder, Franklin H. Martin, MD, FACS. In Dr. Martin’s era, the early 20th century, medical education was in a deplorable state, as documented in the well-known Flexner report of 1910.

To help improve surgical education and training, Dr. Martin first established Surgery, Gynecology & Obstetrics (SG&O, now the Journal of the American College of Surgeons) as a practical journal for practicing surgeons, edited by active surgeons. He published an editorial in the journal inviting surgeons to “learn by watching” and encouraged “every physician in the U.S. and Canada who was interested in surgery to observe the clinics in one of the large medical centers.” Approximately 1,300 physicians responded to Dr. Martin’s charge, resulting in the first Clinical Congress of Surgeons of North America (CCSNA), November 7-9, 1910, in Chicago, IL. After the third CCSNA meeting in 1912, Dr. Martin concluded that further change was necessary, which eventually led to the formation of the ACS in November 1913.

Standards

Dr. Martin was determined that Fellows of the College would meet rigorous criteria that would serve as evidence of their ability to do what’s right for the patient. A problem arose, however. In the first two years of the College’s existence, more than 80 percent of the applicants for Fellowship were rejected because their hospital records were incomplete or nonexistent. Candidates for Fellowship were required to submit the complete records of 50 consecutive major operations and 50 abstracts of major operations in which they were the surgeon or first assistant. To respond to this dearth of supporting material, the ACS, with leadership from John G. Bowman, PhD, the College’s first Director, developed the Minimum Standards for Hospitals. In 1939, the College similarly set forth criteria for graduate surgical training.

The importance of establishing standards for hospitals and surgical training cannot be emphasized enough. These programs fundamentally changed surgical practice and training. If the College had ceased to exist after that achievement, it would have more than fulfilled the expectations of Dr. Martin and other ACS leaders. But this did not happen. Instead, the College continued to inspire quality and to maintain the highest standards for better outcomes through establishment of programs aimed at improving care for cancer and trauma patients.

Committees

The ACS Committee on Cancer published a Standardized Method for Reporting Cancer End Results in 1953. In 1965, other organizations partnered with the College to transform this committee into the Commission on Cancer (CoC), which today uses strict criteria and a rigorous on-site evaluation process to accredit more than 1,530 U.S. cancer centers. This accreditation process is used not only for initial verification of achievement of program standards, but also for periodic review for compliance to maintain accreditation.

Early in its history, the College also established a Committee on the Treatment of Fractures, which evolved into what we now know as the Committee on Trauma (COT). The COT’s guidelines for hospitals to attain or maintain verification as trauma centers—Resources for Optimal Care of the Injured Patient—was first issued in 1976 and now is in its sixth edition.

Another seminal event in trauma took place in 1976—an airplane crash involving James K. Styner, MD, FACS, and his family, in rural Nebraska. His wife died on impact, and his children were severely injured. Angered by the delays his family experienced in receiving appropriate care, Dr. Styner called for the development of adequate facilities and standardized approaches to care for severely injured patients. He combined forces with Paul E. “Skip” Collicott, MD, FACS, and other Nebraska surgeons, to develop the Advanced Trauma Life Support^® program, which introduces physicians and other health care professionals around the world to best practices for initial evaluation and management of trauma patients.

ACS Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS, has led more recent COT initiatives, including development of the Advanced Trauma Operative Management^® course and the Hartford Consensus^TM. This panel—composed of trauma care professionals and government officials—developed the Stop the Bleed program—an initiative aimed at enhancing survival from mass casualty and active shooter events.

Another important committee that the College established to ensure surgeons are prepared to do what’s right for the patient is the Committee on Emerging Surgical Technology and Education (CESTE). Launched in 1992 with the late C. James Carrico, MD, FACS, as the inaugural Chair, CESTE was charged with developing processes to evaluate emerging surgical technology for safety and effectiveness, creating standardized education programs, and measuring outcomes. Two of the College’s most important education and quality programs sprang from CESTE—the Accredited Education Institutes, under the leadership of Ajit K. Sachdeva, MD, FACS, Director, ACS Division of Education, and the Division of Research and Optimal Patient Care, first led by R. Scott Jones, MD, FACS, and now under the purview of Clifford Y. Ko, MD, MS, FACS.

 

The future is in your hands

Unquestionably, the ACS and its leaders have a rich history of doing what’s right for the patient. The future, however, belongs to you. I want to encourage you to participate in all the activities of your College at the local, state, and national levels. Establish personal relationships with leaders. Be an advocate for our education and quality programs. I am confident that there are those among you who will become the leaders who will continue the evolution of the College and inspire quality, maintain the highest standards, and ensure better outcomes.
 

Dr. Townsend is the Robertson-Poth Distinguished Chair in General Surgery, department of surgery, University of Texas Medical Branch (UTMB), Galveston; professor of surgery, department of surgery, professor of physician assistant studies, School of Allied Health Sciences; and graduate faculty in the cell biology program, UTMB. He is the 97th President of the ACS.

We were called to the emergency department to see a young woman, DR, with metastatic endometrial cancer. She had presented with abdominal pain and was found to have evidence of perforation on CT imaging. The CT also demonstrated the unresectable uterus and multiple peritoneal implants. The tumor had not been responsive to the last bout of chemotherapy. DR had been less active, and had lost significant weight over the last several months. A former real estate agent, she hadn’t worked since her diagnosis. She lived with a friend and had a daughter who was very worried about her condition.

I was also worried. After looking at the CT I had told the resident over the phone that operation might not be a great choice. Yes but the family "wants everything done," she replied... CRINGE. "I’ll be over," I said.

Why do we cringe at this statement? Perhaps we feel trapped by a family (or a medical team) who suggests we do everything. There is no out. The die has been cast. This is certainly the case when a non-surgical team has suggested to a family the option of a last-ditch operative intervention. What scares us about the family who wants "everything done"? Often, we don’t think we should be intervening with a surgical operation when the outcome appears dismal. We are concerned with litigation if we don’t try "everything." We fear the communication challenge of speaking with a family with "unrealistic expectations."

But if we take a step back, we might gain some appreciation for the family perspective. Who wouldn’t want everything done to save a loved one, or to prolong our time with a loved one? Who wouldn’t want everything done that might maximize the opportunity for recovery? And who would ever want to do nothing for a loved one in a medical crisis?

I have witnessed (and participated in) two responses to these challenging moments. The first is to acquiesce and perform an operation as a "last-ditch effort." The second is to simply refuse to intervene or even refuse the consult. Neither of these approaches is serves the patient, his or her family, or the health care team (including ourselves). To simply acquiesce puts the patient at increased risk of suffering, gives the family a false notion of hope, and creates moral distress in our team. To simply refuse and walk away leads to patient and family abandonment (with a lack of understanding why operative intervention is not indicated) and leads to conflict within our health care team.

I suggest we enter these situations with the premise that we always do everything and we never do nothing. We do our best to provide treatments to meet the goals and needs of our patients and their loved ones. At times, this may mean a surgical intervention to restore a patient to full premorbid health. At others, this may mean an operation to alleviate suffering, for example, from a malignant bowel obstruction. And sometimes this means not operating as it will only increase or prolong suffering. Yet in the latter situation, there are plenty of appropriate interventions: relieving pain or dyspnea, providing spiritual support, promoting bereavement, and assisting all participants in avoiding complicated grief. These therapies can and should be provided with the same aggressive approach with which we provide operative therapy.

With this approach we are able to reassure our patients and their loved ones that our interests lie in providing the best possible treatments in meeting their goals and needs. And that no matter what, we will find a means to help in some way.

As we sat in the emergency department, we reassured DR that we were there to help and find the best course of action. We admitted our uncertainty with the immediate prognosis with or without operative intervention, but that ultimately she was dying from the cancer. She expressed that she was not ready to die. "I hope we can avoid death as long as possible," I said. "While I am unsure which course of action will prolong your life the most, I am concerned that with operation your death has a higher likelihood of occurring in the midst of a prolonged ICU stay. If we try antibiotic therapy and pain control you might have more of an opportunity to spend time with your daughter and friends." We recommended avoiding operation, focusing on symptom management, and maximizing time with her loved ones.

DR wanted time. She was admitted for antibiotic therapy and aggressive symptom control with a consult to palliative medicine. She stabilized and was able to be transitioned to home hospice with her daughter and friend as caretakers.

 

This approach is effectively one of risk and benefit, recognition of uncertainty, and adherence to patient values. We recognize the inevitability of death from the beginning of a serious illness and openly discuss with our patients their fears and goals. We join with them in the uncertain future and the hard decisions to come. We work with patients to embrace life-enhancing therapies and to forgo death-avoiding therapies in order to maximize those that work toward patient-centered outcomes. This is a world in which we aggressively do everything to promote health, broadly defined, and ameliorate suffering. We always do everything.

Dr. Weinstein is an ACS Fellow and associate professor of surgery at Thomas Jefferson University in Philadelphia. He is director of the surgical intensive care unit and Executive Medical Co-Director of the Thomas Jefferson University Hospital Center for Critical Care. He is a member of the Palliative Care Task Force of the American College of Surgeons.

We were called to the emergency department to see a young woman, DR, with metastatic endometrial cancer. She had presented with abdominal pain and was found to have evidence of perforation on CT imaging. The CT also demonstrated the unresectable uterus and multiple peritoneal implants. The tumor had not been responsive to the last bout of chemotherapy. DR had been less active, and had lost significant weight over the last several months. A former real estate agent, she hadn’t worked since her diagnosis. She lived with a friend and had a daughter who was very worried about her condition.

I was also worried. After looking at the CT I had told the resident over the phone that operation might not be a great choice. Yes but the family "wants everything done," she replied... CRINGE. "I’ll be over," I said.

Why do we cringe at this statement? Perhaps we feel trapped by a family (or a medical team) who suggests we do everything. There is no out. The die has been cast. This is certainly the case when a non-surgical team has suggested to a family the option of a last-ditch operative intervention. What scares us about the family who wants "everything done"? Often, we don’t think we should be intervening with a surgical operation when the outcome appears dismal. We are concerned with litigation if we don’t try "everything." We fear the communication challenge of speaking with a family with "unrealistic expectations."

But if we take a step back, we might gain some appreciation for the family perspective. Who wouldn’t want everything done to save a loved one, or to prolong our time with a loved one? Who wouldn’t want everything done that might maximize the opportunity for recovery? And who would ever want to do nothing for a loved one in a medical crisis?

I have witnessed (and participated in) two responses to these challenging moments. The first is to acquiesce and perform an operation as a "last-ditch effort." The second is to simply refuse to intervene or even refuse the consult. Neither of these approaches is serves the patient, his or her family, or the health care team (including ourselves). To simply acquiesce puts the patient at increased risk of suffering, gives the family a false notion of hope, and creates moral distress in our team. To simply refuse and walk away leads to patient and family abandonment (with a lack of understanding why operative intervention is not indicated) and leads to conflict within our health care team.

I suggest we enter these situations with the premise that we always do everything and we never do nothing. We do our best to provide treatments to meet the goals and needs of our patients and their loved ones. At times, this may mean a surgical intervention to restore a patient to full premorbid health. At others, this may mean an operation to alleviate suffering, for example, from a malignant bowel obstruction. And sometimes this means not operating as it will only increase or prolong suffering. Yet in the latter situation, there are plenty of appropriate interventions: relieving pain or dyspnea, providing spiritual support, promoting bereavement, and assisting all participants in avoiding complicated grief. These therapies can and should be provided with the same aggressive approach with which we provide operative therapy.

With this approach we are able to reassure our patients and their loved ones that our interests lie in providing the best possible treatments in meeting their goals and needs. And that no matter what, we will find a means to help in some way.

As we sat in the emergency department, we reassured DR that we were there to help and find the best course of action. We admitted our uncertainty with the immediate prognosis with or without operative intervention, but that ultimately she was dying from the cancer. She expressed that she was not ready to die. "I hope we can avoid death as long as possible," I said. "While I am unsure which course of action will prolong your life the most, I am concerned that with operation your death has a higher likelihood of occurring in the midst of a prolonged ICU stay. If we try antibiotic therapy and pain control you might have more of an opportunity to spend time with your daughter and friends." We recommended avoiding operation, focusing on symptom management, and maximizing time with her loved ones.

DR wanted time. She was admitted for antibiotic therapy and aggressive symptom control with a consult to palliative medicine. She stabilized and was able to be transitioned to home hospice with her daughter and friend as caretakers.

 

This approach is effectively one of risk and benefit, recognition of uncertainty, and adherence to patient values. We recognize the inevitability of death from the beginning of a serious illness and openly discuss with our patients their fears and goals. We join with them in the uncertain future and the hard decisions to come. We work with patients to embrace life-enhancing therapies and to forgo death-avoiding therapies in order to maximize those that work toward patient-centered outcomes. This is a world in which we aggressively do everything to promote health, broadly defined, and ameliorate suffering. We always do everything.

Dr. Weinstein is an ACS Fellow and associate professor of surgery at Thomas Jefferson University in Philadelphia. He is director of the surgical intensive care unit and Executive Medical Co-Director of the Thomas Jefferson University Hospital Center for Critical Care. He is a member of the Palliative Care Task Force of the American College of Surgeons.

We were called to the emergency department to see a young woman, DR, with metastatic endometrial cancer. She had presented with abdominal pain and was found to have evidence of perforation on CT imaging. The CT also demonstrated the unresectable uterus and multiple peritoneal implants. The tumor had not been responsive to the last bout of chemotherapy. DR had been less active, and had lost significant weight over the last several months. A former real estate agent, she hadn’t worked since her diagnosis. She lived with a friend and had a daughter who was very worried about her condition.

I was also worried. After looking at the CT I had told the resident over the phone that operation might not be a great choice. Yes but the family "wants everything done," she replied... CRINGE. "I’ll be over," I said.

Why do we cringe at this statement? Perhaps we feel trapped by a family (or a medical team) who suggests we do everything. There is no out. The die has been cast. This is certainly the case when a non-surgical team has suggested to a family the option of a last-ditch operative intervention. What scares us about the family who wants "everything done"? Often, we don’t think we should be intervening with a surgical operation when the outcome appears dismal. We are concerned with litigation if we don’t try "everything." We fear the communication challenge of speaking with a family with "unrealistic expectations."

But if we take a step back, we might gain some appreciation for the family perspective. Who wouldn’t want everything done to save a loved one, or to prolong our time with a loved one? Who wouldn’t want everything done that might maximize the opportunity for recovery? And who would ever want to do nothing for a loved one in a medical crisis?

I have witnessed (and participated in) two responses to these challenging moments. The first is to acquiesce and perform an operation as a "last-ditch effort." The second is to simply refuse to intervene or even refuse the consult. Neither of these approaches is serves the patient, his or her family, or the health care team (including ourselves). To simply acquiesce puts the patient at increased risk of suffering, gives the family a false notion of hope, and creates moral distress in our team. To simply refuse and walk away leads to patient and family abandonment (with a lack of understanding why operative intervention is not indicated) and leads to conflict within our health care team.

I suggest we enter these situations with the premise that we always do everything and we never do nothing. We do our best to provide treatments to meet the goals and needs of our patients and their loved ones. At times, this may mean a surgical intervention to restore a patient to full premorbid health. At others, this may mean an operation to alleviate suffering, for example, from a malignant bowel obstruction. And sometimes this means not operating as it will only increase or prolong suffering. Yet in the latter situation, there are plenty of appropriate interventions: relieving pain or dyspnea, providing spiritual support, promoting bereavement, and assisting all participants in avoiding complicated grief. These therapies can and should be provided with the same aggressive approach with which we provide operative therapy.

With this approach we are able to reassure our patients and their loved ones that our interests lie in providing the best possible treatments in meeting their goals and needs. And that no matter what, we will find a means to help in some way.

As we sat in the emergency department, we reassured DR that we were there to help and find the best course of action. We admitted our uncertainty with the immediate prognosis with or without operative intervention, but that ultimately she was dying from the cancer. She expressed that she was not ready to die. "I hope we can avoid death as long as possible," I said. "While I am unsure which course of action will prolong your life the most, I am concerned that with operation your death has a higher likelihood of occurring in the midst of a prolonged ICU stay. If we try antibiotic therapy and pain control you might have more of an opportunity to spend time with your daughter and friends." We recommended avoiding operation, focusing on symptom management, and maximizing time with her loved ones.

DR wanted time. She was admitted for antibiotic therapy and aggressive symptom control with a consult to palliative medicine. She stabilized and was able to be transitioned to home hospice with her daughter and friend as caretakers.

 

This approach is effectively one of risk and benefit, recognition of uncertainty, and adherence to patient values. We recognize the inevitability of death from the beginning of a serious illness and openly discuss with our patients their fears and goals. We join with them in the uncertain future and the hard decisions to come. We work with patients to embrace life-enhancing therapies and to forgo death-avoiding therapies in order to maximize those that work toward patient-centered outcomes. This is a world in which we aggressively do everything to promote health, broadly defined, and ameliorate suffering. We always do everything.

Dr. Weinstein is an ACS Fellow and associate professor of surgery at Thomas Jefferson University in Philadelphia. He is director of the surgical intensive care unit and Executive Medical Co-Director of the Thomas Jefferson University Hospital Center for Critical Care. He is a member of the Palliative Care Task Force of the American College of Surgeons.