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Bulletin JULY 2 018 | VO LUME 103 N UMB E R 7 | A MER I C A N CO L L E G E O F S UR G E O NS From Transition to Practice to Mastery in General Surgery
Contents
FEATURES
COVER STORY: From Transition to Practice to Mastery in General Surgery 10
J. David Richardson, MD, FACS; Brooke M. Buckley, MD, FACS; Mohsen M. Shabahang, MD, PhD, FACS;
W. Heath Giles, MD, FACS; Ajit K. Sachdeva, MD, FACS, FRCSC; and R. Phillip Burns, MD, FACS
ACS Clinical Scholars in Residence Program
has lasting impact on surgeons’ careers 17
Tony Peregrin
Gun violence and firearm policy:
An introduction from the ACS COT 24
Ronald M. Stewart, MD, FACS; Deborah A. Kuhls, MD, FACS; and Eileen M. Bulger, MD, FACS
Gun violence and firearm policy in the U.S.:
A brief history and the current status 26 |1
Bethany Strong, MD, MS; Brett Tracy, MD; Naveen Sangji, MD, MPH; and Kaylene Barrera, MD
Can communication proficiency mitigate moral distress among surgeons?
A case study and call to action 34
Sara Scarlet, MD, and Pringl Miller, MD, FACS
2017 ACS Governors Survey:
The increasing role of APPs in providing surgical care 40
David W. Butsch, MD, FACS; Juan C. Paramo, MD, FACS; John Kirby, MD, FACS;
and Peter Andreone, MD, FACS
Clinical Congress 2018 Preliminary Program 45
JUL 2018 BULLETIN American College of Surgeons
Contents continued
COLUMNS A look at The Joint Commission: NCDB-sourced study focuses on
Joint Commission issues alert on post-treatment surveillance for
Looking forward 8 violence prevention in the health colorectal cancer patients 72
David B. Hoyt, MD, FACS care workplace 64 Making quality stick: Optimal
ACS Clinical Research Program: Carlos A. Pellegrini, MD, FACS, Resources for Surgical Quality and
Geriatric assessment and frailty FRCSI(Hon), FRCS(Hon), FRCSEd(Hon) Safety: Beginning your quality
in older cancer patients 56 NTDB data points: Psyched out: improvement journey 74
Clancy J. Clark, MD, FACS; Emily Trauma patients with major Register for ACS Comprehensive
Guerard, MD; and Judy C. psychiatric comorbidities 66 General Surgery Review Course,
Boughey, MD, FACS Richard J. Fantus, MD, FACS, and July 26–29 75
NCDB cancer bytes: Endometrial Kyra Dawson, DO Correction 75
cancer: An increasingly common Coming next month in JACS
gynecologic malignancy 58 NEWS and online now 75
Lisa Gabor, MD NAPRC awards first accreditation
to John Muir Health Rectal Cancer SCHOLARSHIPS
From the Archives: The rescue
of Miss Inez Stone 62 Program 68 ACS 2018 Traveling Fellow to Japan
Information every surgeon reports on experience 77
David L. Nahrwold, MD, FACS
2| should know about the ACSPA- Brian D. Badgwell, MD, FACS
SurgeonsPAC 69
Members in the news 71 MEETINGS CALENDAR
Calendar of events 80
Create a culture of
quality, safety,
and high reliability
It begins here
facs.org/redbook
2018_CM_QualityManual_Bulletin_6.5x4_v01.indd 2 4/3/2018 1:04:24 PM
V103 No 7 BULLETIN American College of Surgeons
The American College of Surgeons is dedicated
to improving the care of the surgical patient
CLINICAL
and to safeguarding standards of care in an
optimal and ethical practice environment.
CONGRESS 2018
The Best Surgical Education. All in One Place.
EDITOR-IN-CHIEF Letters to the Editor October 21–25 Boston, MA
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published monthly by the American College of Surgeons, 633 N. Saint
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Officers and Staff of
the American College of Surgeons
James K. Elsey, MD, FACS Christian Shalgian
Officers Atlanta, GA Advisory Council Director
Barbara L. Bass, MD, FACS
Henri R. Ford, MD, FACS
Los Angeles, CA to the Board AMERICAN COLLEGE OF
SURGEONS FOUNDATION
Houston, TX
PRESIDENT Gerald M. Fried, MD, FACS, FRCSC of Regents Shane Hollett
Montreal, QC (Past-Presidents) Executive Director
Courtney M. Townsend, Jr.,
MD, FACS James W. Gigantelli, MD, FACS ALLIANCE/AMERICAN
Kathryn D. Anderson, MD, FACS COLLEGE OF SURGEONS
Galveston, TX Omaha, NE Eastvale, CA CLINICAL RESEARCH PROGRAM
IMMEDIATE PAST-PRESIDENT B. J. Hancock, MD, FACS, FRCSC W. Gerald Austen, MD, FACS Kelly K. Hunt, MD, FACS
Charles D. Mabry, MD, FACS Winnipeg, MB Boston, MA Chair
Pine Bluff, AR Enrique Hernandez, MD, FACS
FIRST VICE-PRESIDENT L. D. Britt, MD, MPH, CONVENTION AND MEETINGS
Philadelphia, PA FACS, FCCM Robert Hope
Basil A. Pruitt, Jr., MD, Lenworth M. Jacobs, Jr., MD, FACS Norfolk, VA Director
FACS, FCCM, MCCM Hartford, CT
San Antonio, TX John L. Cameron, MD, FACS DIVISION OF EDUCATION
SECOND VICE-PRESIDENT L. Scott Levin, MD, FACS Baltimore, MD Ajit K. Sachdeva, MD,
Philadelphia, PA Edward M. Copeland III, MD, FACS FACS, FRCSC
Edward E. Cornwell III, Director
MD, FACS, FCCM Fabrizio Michelassi, MD, FACS Gainesville, FL
Washington, DC New York, NY A. Brent Eastman, MD, FACS EXECUTIVE SERVICES
SECRETARY Rancho Santa Fe, CA Lynese Kelley
Linda G. Phillips, MD, FACS
William G. Cioffi, Jr., MD, FACS Galveston, TX Director, Leadership Operations
Gerald B. Healy, MD, FACS
Providence, RI Anton N. Sidawy, MD, FACS Wellesley, MA FINANCE AND FACILITIES
TREASURER Gay L. Vincent, CPA
Washington, DC R. Scott Jones, MD, FACS
David B. Hoyt, MD, FACS Director
Chicago, IL Beth H. Sutton, MD, FACS Charlottesville, VA
Wichita Falls, TX HUMAN RESOURCES
4| EXECUTIVE DIRECTOR Edward R. Laws, MD, FACS AND OPERATIONS
Gay L. Vincent, CPA Gary L. Timmerman, MD, FACS Boston, MA Michelle McGovern
Chicago, IL Sioux Falls, SD LaSalle D. Leffall, Jr., MD, FACS Director
CHIEF FINANCIAL OFFICER Steven D. Wexner, MD, FACS Washington, DC INFORMATION TECHNOLOGY
Weston, FL LaMar S. McGinnis, Jr., MD, FACS Brian Harper
Douglas E. Wood, MD, Atlanta, GA Director
Officers-Elect FACS, FRCSEd David G. Murray, MD, FACS DIVISION OF INTEGRATED
(take office October 2018) Seattle, WA Syracuse, NY COMMUNICATIONS
Michael J. Zinner, MD, FACS Patricia J. Numann, MD, FACS Lynn Kahn
Ronald V. Maier, MD, FACS Coral Gables, FL Director
Seattle, WA Syracuse, NY
PRESIDENT-ELECT Carlos A. Pellegrini, MD, FACS JOURNAL OF THE AMERICAN
COLLEGE OF SURGEONS
Mark C. Weissler, MD, FACS
Chapel Hill, NC
Board of Seattle, WA
Timothy J. Eberlein, MD, FACS
J. David Richardson, MD, FACS
FIRST VICE-PRESIDENT-ELECT Governors/ Louisville, KY
Editor-in-Chief
Philip R. Caropreso, MD, FACS Executive Richard R. Sabo, MD, FACS
DIVISION OF MEMBER SERVICES
Patricia L. Turner, MD, FACS
Iowa City, IA
SECOND VICE-PRESIDENT-ELECT Committee Bozeman, MT Director
Seymour I. Schwartz, MD, FACS M. Margaret Knudson, MD, FACS
Diana L. Farmer, MD, FACS, FRCS Rochester, NY
Sacramento, CA Medical Director, Military Health
Board of Regents CHAIR Frank C. Spencer, MD, FACS
New York, NY
Systems Strategic Partnership
Girma Tefera, MD, FACS
Steven C. Stain, MD, FACS
Leigh A. Neumayer, MD, FACS Albany, NY Andrew L. Warshaw, MD, FACS Director, Operation Giving Back
Tucson, AZ VICE-CHAIR Boston, MA
CHAIR PERFORMANCE IMPROVEMENT
Daniel L. Dent, MD, FACS Will Chapleau, RN, EMT-P
Marshall Z. Schwartz, MD, FACS San Antonio, TX Director
Philadelphia, PA
VICE-CHAIR
SECRETARY Executive Staff DIVISION OF RESEARCH AND
Terry L. Buchmiller, MD, FACS EXECUTIVE DIRECTOR OPTIMAL PATIENT CARE
Anthony Atala, MD, FACS Boston, MA Clifford Y. Ko, MD,
Winston-Salem, NC David B. Hoyt, MD, FACS
Therese M. Duane, MD, MS, MSHS, FACS
John L. D. Atkinson, MD, FACS DIVISION OF ADVOCACY
MBA, CPE, FACS, FCCM AND HEALTH POLICY Director
Rochester, MN Fort Worth, TX Frank G. Opelka, MD, FACS David P. Winchester, MD, FACS
James C. Denneny III, MD, FACS Nicole S. Gibran, MD, FACS Medical Director, Quality Medical Director, Cancer
Alexandria, VA Seattle, WA and Health Policy Ronald M. Stewart, MD, FACS
Margaret M. Dunn, MD, FACS David A. Spain, MD, FACS Patrick V. Bailey, MD, MLS, Medical Director, Trauma
Dayton, OH Stanford, CA FACS
Timothy J. Eberlein, MD, FACS David J. Welsh, MD, FACS Medical Director, Advocacy
St. Louis, MO Batesville, IN
V103 No 7 BULLETIN American College of Surgeons
Author bios*
*Titles and locations current at the time articles were submitted for publication.
a b c
d e f
|5
g h i
DR. ANDREONE (a) is a cardiac and thoracic DR. BUCKLEY (e) is associate chair, DR. BUTSCH (h) is clinical associate
surgeon, Sioux Falls, SD, and member, surgery for professional development, and professor, Larner College of Medicine, The
American College of Surgeons (ACS) Board chief, acute care surgery, Anne Arundel University of Vermont, Burlington. He is a
of Governors (B/G) Survey Workgroup. Medical Center, Annapolis, MD, and past- member, ACS B/G Survey Workgroup, and
president, Maryland State Medical Society. Past-President, ACS Vermont Chapter.
DR. BADGWELL (b) is associate professor,
department of surgical oncology, University of DR. BULGER (f) is professor of surgery, DR. CLARK (i) is assistant professor of
Texas MD Anderson Cancer Center, Houston. department of surgery, University of surgery and associate program director for
Washington, and chief of trauma and general surgery, department of surgery,
DR. BARRERA (c) is a postgraduate year trauma medical director, Harborview Wake Forest Baptist Health, Winston-
(PGY)-6 general surgery resident, State Medical Center, Seattle. She is Chair, Salem, NC. He is a member, ACS CRP
University of New York, Downstate, ACS Committee on Trauma (COT). Education Committee and the Alliance
Brooklyn. She is a member, Resident Cancer in the Elderly Committee.
and Associate Society (RAS)-ACS DR. BURNS (g) is professor of surgery
Advocacy and Issues Committee. and chair of surgery, University continued on next page
of Tennessee, Chattanooga.
DR. BOUGHEY (d) is professor of surgery
and vice-chair of research, department of
surgery, Mayo Clinic, Rochester, MN. She
is Chair, ACS Clinical Research Program
(ACS CRP) Education Committee.
JUL 2018 BULLETIN American College of Surgeons
Author bios continued
j k l
m n o
6|
p q r
DR. DAWSON (j) is a surgical critical care DR. GILES (m) is professor of surgery, DR. KUHLS (p) is professor of surgery;
fellow, University of Illinois/Advocate University of Tennessee, Chattanooga. chief, section of critical care, division
Illinois Masonic Medical Center, Chicago, of acute care surgery; and program
IL, and Resident Member, ACS. DR. GUERARD (n) is assistant professor director, surgical critical care fellowship,
of geriatric oncology, department of University of Nevada Las Vegas School of
DR. FANTUS (k) is vice-chairman, internal medicine, University of Wisconsin Medicine. She is Chair, ACS COT Injury
department of surgery; medical director, School of Medicine and Public Health, and Prevention Control Committee.
trauma services; and chief, section of Madison. She is a member, Alliance
surgical critical care, Advocate Illinois Cancer in the Elderly Committee and DR. MILLER (q) is a general surgeon,
Masonic Medical Center, Chicago. He is principal investigator, Alliance electronic palliative medicine specialist, and
clinical professor of surgery, University geriatric assessment trial (A171603). clinical medical ethicist. She is assistant
of Illinois College of Medicine, Chicago, professor of surgery and medicine, and
and Past-Chair, ad hoc Trauma Registry DR. KIRBY (o) is associate professor of a member, ethics committee, Rush
Advisory Committee, COT. surgery, Washington University School University Medical Center, Chicago.
of Medicine, St. Louis, MO. He is a
DR. GABOR (l) is administrative chief member, B/G Survey Workgroup. DR. NAHRWOLD (r) is emeritus professor
resident, department of obstetrics and of surgery, Northwestern University,
gynecology, NewYork-Presbyterian- Chicago, and Past-Interim Director, ACS.
Columbia University Medical Center, NY.
continued on next page
V103 No 7 BULLETIN American College of Surgeons
Author bios continued
s t u v
w x y
|7
z aa bb cc
DR. PARAMO (s) is a surgical DR. RICHARDSON (v) is professor of DR. SHABAHANG (z) is chief of surgery,
oncologist, Mount Sinai Medical Center surgery and vice-chairman, department of Geisinger Clinic, Danville, PA.
Comprehensive Cancer Center, Miami surgery, University of Louisville School of
Beach; associate clinical professor of Medicine, KY, and Past-President, ACS. DR. STEWART (aa) is chair, department
surgery, Florida International University of surgery, and professor of surgery and
Werbert Wertheim College of Medicine, DR. SACHDEVA (w) is Director, ACS anesthesia, University of Texas Health
Miami; and associate clinical professor of Division of Education, Chicago. Science Center, San Antonio. He is
surgery, Nova Southeastern University Medical Director, Trauma, ACS Division
Dr. Kiran C. Patel College of Osteopathic DR. SANGJI (x) is a surgical critical care of Research and Optimal Patient Care.
fellow, Massachusetts General Hospital,
Medicine, Ft. Lauderdale. He is Chair,
ACS B/G Survey Workgroup. Boston. She is Secretary, RAS-ACS. DR. STRONG (bb) is a general
surgery resident, Brigham and
DR. PELLEGRINI (t) is chief medical DR. SCARLET (y) is a PGY-6 general Women’s Hospital, Boston, MA.
surgery resident and member, hospital
officer, UW Medicine, and vice-president for
medical affairs, University of Washington, ethics committee, University of DR. TRACY (cc) is chief resident, Memorial
North Carolina-Chapel Hill. University Medical Center, Savannah, GA.
Seattle. He is Past-President, ACS.
MR. PEREGRIN (u) is Senior Editor,
Bulletin of the American College of
Surgeons, ACS Division of Integrated
Communications, Chicago.
JUL 2018 BULLETIN American College of Surgeons
EXECUTIVE DIRECTOR’S REPORT
Looking forward
by David B. Hoyt, MD, FACS
H
elping surgeons and their institutions improve An additional track has been added to the agenda
the quality and safety of surgical care always for this year’s Quality and Safety Conference, which
has been and will remain forever at the heart will be dedicated to the red book. Sessions in this track
of all American College of Surgeons (ACS) programs. will explore concepts and resources from the manual,
Over the last few years, we have accelerated these ef- information on QI tools, methodology, nomenclature,
forts and have developed a defined strategy for mov- and organizational design and infrastructure.
ing ACS Quality Programs forward in a cohesive and
coordinated manner.
These programs and details about their growth will Status of ACS Quality Programs
be discussed later this month at the 2018 Quality and Many institutions already recognize the value of
Safety Conference, July 21−24 in Orlando, FL. In this participating in the College’s Quality Programs. At
column, I provide my perspective on the status of ACS present, 2,700 hospitals participate in ACS QI programs,
Quality Programs and where they are headed. including the National Surgical Quality Improvement
Program (ACS NSQIP®), the Metabolic and Bariatric
Surgery Accreditation and Quality Improvement Pro-
The red book gram (MBSAQIP), the Commission on Cancer (CoC),
All ACS Quality Programs are grounded in the fol- the Committee on Trauma (COT), and the National
8| lowing four principles: establish the standards, build Accreditation Program for Breast Centers (NAPBC). A
the infrastructure to support the standards, develop combined total of 4,000 ACS QI programs are in place
databases to measure performance against those stan- throughout the U.S. and Canada.
dards, and provide external peer-review verification. Many institutions that participate in these programs
Last year, the ACS released Optimal Resources for Sur- have significantly reduced surgical site infections and
gical Quality and Safety, also known as the “red book,” other complications. In fact, 82 percent of participating
which seeks to tie these four principles together and to hospitals have experienced decreased complications,
provide a road map for institutions to use on the jour- and 66 percent have seen decreased mortality. On aver-
ney to better outcomes. age, hospitals have prevented 250 to 500 complications
This manual, released at last year’s Quality and annually. If implemented at 4,500 hospitals, the poten-
Safety Conference in New York, NY, outlines all of tial savings are $13 billion to $26 billion per year.
the factors that the College’s 105 years of experience At the core of several of these programs are clinical
have shown to influence patient outcomes, including registries that provide participating institutions with
details on the personnel and committees that should be risk-adjusted outcomes data. These data provide a sci-
in place, the quality improvement (QI) process, disease entifically validated means of determining what factors
management, regulatory issues, data collection and may have influenced a negative outcome, of pinpoint-
analysis, and the educational requirements for members ing outliers, and engaging in root cause analysis.
of the surgical care team. The manual also emphasizes Furthermore, the data extracted from ACS data-
the responsibilities of the individual surgeon. bases have been used in clinical studies that have been
At press time, the College leadership was work- published in leading medical and surgical journals. In
ing to take the red book to the next logical level and the last 20 years, the CoC’s National Cancer Database
developing standards for verifying and accrediting has been cited in 566 peer-reviewed publications, and
institutions as compliant with the red book. In other the COT’s National Trauma Data Bank®/Trauma
words, the red book provides the road map for devel- Quality Improvement Program has been cited in 789
oping QI programs, and the standards manual will peer-reviewed publications. In addition, ACS NSQIP
help set the requirements for institutions to achieve has been cited in 910 such journals in the last 15 years.
external peer-review verification. That’s a total of 2,265 peer-reviewed publications, for
V103 No 7 BULLETIN American College of Surgeons
EXECUTIVE DIRECTOR’S REPORT
All ACS Quality Programs are grounded in the following
four principles: establish the standards, build the
infrastructure to support the standards, develop databases
to measure performance against those standards,
and provide external peer-review verification.
an average of more than 100 citations annually and Other quality programs that the ACS has helped to
approximately one every three days. develop and implement more recently to improve the
Another important facet of ACS QI programs is care of the surgical patient include Strong for Surgery
accreditation. The CoC, COT, MBSAQIP, and NAPBC and the Agency for Healthcare Research and Quality
all have programs for surveying and verifying institu- (AHRQ) Safety Program for Improving Surgical Care
tions that provide cancer, trauma, bariatric surgery, and Recovery (ISCR) program. Strong for Surgery,
and breast care. originally developed by surgeons in Washington State,
empowers hospitals and clinics to integrate checklists
into the preoperative phase of care to screen patients
What’s next? for potential risk factors that can lead to surgical com-
Right now, some of these programs are undergo- plications and to provide appropriate interventions to
ing some refinements. We plan to retool the CoC’s ensure better surgical outcomes. The AHRQ Safety
accreditation program to incorporate new guidelines Program for ISCR will support hospitals in imple- |9
and standards. MBSAQIP will continue to evolve, menting perioperative evidence-based pathways to
and the COT is rewriting its standards. In addition, meaningfully improve clinical outcomes and reduce
we anticipate that some of the quality programs that hospital length-of-stay for colorectal, orthopaedic,
have launched in recent years will continue to progress. gynecology, emergency general surgery, and bariat-
One example is the Children’s Surgery Verification ric patients.
program. This initiative ensures that hospitals that
provide pediatric care have the appropriate resources
to provide surgical care to patients younger than 18 Learn more
years old. Of course, none of this would be possible without the
In addition, the Coalition for Quality in Geriatric leadership of Clifford Y. Ko, MD, MS, MSHS, FACS,
Surgery’s Geriatric Surgery Verification and Quality and his team in the ACS Division of Research and
Improvement Program is now being piloted in eight Optimal Patient Care. To learn more about these ini-
centers. Funded with a four-year grant from the John tiatives and how you can use ACS Quality Programs
A. Hartford Foundation, the goal of this project is to to improve patient care, be sure to attend the second
develop and implement a Geriatric Surgery Verification annual Quality and Safety Conference. This year’s pro-
and Quality Improvement Program. This program will gram is certain to be a rewarding opportunity to learn
provide a framework for the optimal care of the geri- from experts in the field and to network with other sur-
atric surgical patient, generalizable to more than 4,000 geons who are as dedicated to patient care as you are. ♦
facilities regardless of size, location, or teaching status.
Furthermore, the ACS and other organizations,
including the Society of Thoracic Surgery and the Soci-
ety for Vascular Surgery, are collaborating to develop
specialty-specific quality programs. The ACS also is
working with the American Association for the Sur-
gery of Trauma to develop standards for emergency If you have comments or suggestions about this or other issues, please
surgery with ACS NSQIP support. send them to Dr. Hoyt at lookingforward@facs.org.
JUL 2018 BULLETIN American College of SurgeonsFROM TTP TO MASTERY IN GENERAL SURGERY
From Transition to Practice to Mastery in General Surgery
10 | by J. David Richardson, MD, FACS;
Brooke M. Buckley, MD, FACS;
Mohsen M. Shabahang, MD, PhD, FACS;
W. Heath Giles, MD, FACS;
Ajit K. Sachdeva, MD, FACS, FRCSC;
and R. Phillip Burns, MD, FACS
V103 No 7 BULLETIN American College of SurgeonsFROM TTP TO MASTERY IN GENERAL SURGERY
Development of the TTP Program
HIGHLIGHTS A TTP Steering Committee was formed to develop a
• Describes how the TTP Program offers a model and processes that offered the opportunity for
tailored mentoring experience for young acquiring a year of additional general surgical expe-
surgeons to help them acquire additional rience under the guidance of mentors (see Table 1,
skills and enhance confidence levels page 12). Although this type of program may appear
similar to a fellowship, there were several distinc-
• Summarizes the approval process and
tions. The goal of the TTP Program was a refinement
early results of the TTP Program
of the experience leading to independent practice
• Highlights the experiences of three within the year of mentorship rather than the acquisi-
accredited institutions tion of new knowledge. In academic settings, fellows
• Identifies the evolution of the TTP Program to were often subject to strict duty-hour restrictions,
the new ACS Mastery in General Surgery Program while some nonacademic institutions did not have
a category of practitioners known as fellows. With
the development of the TTP Program, the Steering
I
n 2014, the American College of Surgeons (ACS) Committee decided to emphasize the evolution of
launched an ambitious venture, the Transition the fellow from training to acquisition of experience-
to Practice (TTP) Program in General Surgery, based knowledge. | 11
which was developed for two primary reasons: the The elements of the TTP Program are simple but
annual survey of the ACS Board of Governors con- effective. The participating institution must appoint
sistently listed concerns about “preparedness for an experienced mentor or senior surgeon to direct
practice” as an issue; and although nearly 80 percent the program, as well as additional interested surgeons
of general surgery residents completing training pur- who can provide a breadth and depth of experience.
sued a specialty fellowship, no formal mechanism The senior surgeon must be willing and able to con-
was in place for those individuals pursuing a broad- duct an intake assessment of the Junior Associate’s
based general surgery career to achieve additional abilities and plan a program that meets their specific
experience and mentoring before entering practice. needs. Feedback should be shared quarterly and at
While oversight of graduate surgical training has the completion of the year.
not been within the purview of the ACS for at least a TTP Associates were asked to maintain a log of the
half-century, the College leadership strongly asserts cases performed. A special feature of the TTP Pro-
that the organization needs to provide an opportu- gram is that it allows flexibility to meet the mentees’
nity for graduating residents completing training to needs, as opposed to a residency experience, which
acquire additional experience with guidance from often includes tightly structured rotations and is gen-
senior mentors before entering practice. erally focused on the institution’s needs.
The leaders of the TTP initiative recognized the Several elements, in addition to having a commit-
fact that many graduating surgeons could practice ted program leader, are essential for TTP Programs
independently without additional training. At the to be successful. Because these programs are not
same time, these leaders also sought to develop a pro- accredited by the Accreditation Council for Grad-
gram for graduating general surgery residents with a uate Medical Education, traditional funding from
desire for advanced training in broad-based general federal sources is unavailable; therefore, funding
surgery, and for young surgeons who could benefit must be provided through another source (usually
from an individually tailored mentoring experience the institution). If the institution has a residency pro-
in general surgery to acquire additional skills and gram, the TTP Program must not detract from the
enhance their confidence. residents’ experiences. The institution needs to have
JUL 2018 BULLETIN American College of SurgeonsFROM TTP TO MASTERY IN GENERAL SURGERY
excess surgical capacity sufficient for participation by the Junior
TABLE 1. Associate.
ACS TTP STEERING COMMITTEE In addition to the opportunity for mentorship, young surgeons
in this program are embedded in a system where practice man-
J. David Richardson, MD, FACS, Chair agement skills may be acquired. Senior consultation is available
for difficult situations, complex cases, or diagnostic dilemmas.
L.D. Britt, MD, MPH, DSc(Hon), FACS, It is important to note that the program is not designed to
FCCM, FRCSEng(Hon), FRCSEd(Hon), address certain objectives. For example, the program cannot meet
FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), the needs of residents who received inadequate training during
FRCSGlasg(Hon) their residency. Furthermore, the program is aimed at individuals
Brooke M. Buckley, MD, FACS desirous of practicing general surgery and not seeking prepara-
tion for further fellowship training. Finally, this program is not
R. Phillip Burns, MD, FACS designed to be a source of inexpensive labor or to have an indi-
William G. Cioffi, Jr., MD, FACS vidual available to take call.
Thomas H. Cogbill, MD, FACS
E. Christopher Ellison, MD, FACS Approval process and reasons for participation
12 | The TTP Steering Committee and the ACS Division of Education
Julie A. Freischlag, MD, developed a relatively simple application process for this program,
FACS, FRCSEd(Hon) which focuses on the goals and objectives outlined in this arti-
David B. Hoyt, MD, FACS cle. An extensive interview between the program director and
the TTP Steering Committee Chair is conducted to ensure the
John G. Hunter, MD, FACS, FRCSEd(Hon) essential elements of the program are in place. Once approval
Frank R. Lewis, Jr., MD, FACS is granted, the program may begin recruiting Junior Associates.
In this regard, the College serves as a clearinghouse and source
Mark A. Malangoni, MD, FACS of information, and recruitment, hiring, and credentialing occur
Don K. Nakayama, MD, MBA, FACS under the purview of the approved site (as it would be for any
new hire).
Ajit K. Sachdeva, MD, FACS, FRCSC
TTP Program sites have been chosen to participate for sev-
Mohsen M. Shabahang, MD, PhD, FACS eral reasons. Some were former teaching institutions, but their
Beth H. Sutton, MD, FACS residency programs were eliminated with duty-hour restrictions;
many surgeons had enjoyed the interactions with residents, as
well as the opportunity to mentor young surgeons. In other cases,
certain health care systems had an interest in being progressive,
specifically regarding residency training, while other program
participants believed this program provided an opportunity to
vet potential partners or members of their general surgery staff.
Early results of the program
As of June 30, 51 young surgeons have completed the program.
The feedback from participants has been uniformly positive, and
at least 15 young surgeons have been hired by the institutions
where they spent their transition year. At one-year follow-up, all
V103 No 7 BULLETIN American College of SurgeonsFROM TTP TO MASTERY IN GENERAL SURGERY
the young surgeons were practicing general surgery. maintain a surgical practice. It also allowed me to build
The average number of cases performed by program a relationship that provided an opportunity for the
participants during the year was 354, with a range of guidance and advice I needed for my future surgical
198 to 620. In the instance with the large numbers career,” said Michael N. Tran, MD. “Another aspect of
of cases, the transitioning surgeon was interested in the program that I found valuable is the fact that the
and completed many endoscopic cases. The variety year promotes a change from the state of a resident
of cases was broad and typical for a diverse general learner to a mind-set of a surgeon in practice—with
surgery practice. a focus on improving efficiency and productivity.”
The experiences at three accredited institutions Anne Arundel is focused on cost-effective medical
are described in the following paragraphs. practice in its resident training, as well as in its TTP
Program. The faculty and practicing surgeons now
The Anne Arundel Medical Center experience ask value-based questions as well as technical ques-
The TTP Program is a valuable tool in the surgical tions during morbidity and mortality conferences.
training toolbox, according to Brooke M. Buckley, Simply stated, instead of assuming trainees have the
MD, FACS, co-author of this article and TTP Program potential to acquire value-based skills, the faculty is
director, Anne Arundel Medical Center, Annapolis, crafting the curriculum to verify that these elements
MD. Whereas this program faces many challenges are being covered in a robust way with trainees. The
in terms of implementation and practice, the oppor- TTP Associates, during a sensitive time of mentored | 13
tunity to mentor surgical trainees in this setting is independence, are in an ideal frame of mind to receive
invaluable. In the words of the program’s first TTP additional training, and they have found the experi-
Associate, Samar Alami, MD, “I really believe that ence meaningful.
my transition into rural practice has been smooth There is a concern that TTP may be viewed as a
and more self-assured because of this year.” Dr. Alami remediation year, and some program directors may
is now a practicing general surgeon in Batavia, NY. be reluctant to send their brightest trainees to this
This model offers a mentored year of exposure program. Furthermore, some trainees are not sure
to varied practice settings, acquisition of endoscopic what to make of the program and often apply late
skills, and the opportunity to acquire knowledge about as they scramble to understand the opportunities in
the business of medicine and coding. In 2014, Anne the context of an independent career track. In fact,
Arundel was designated as a TTP training site and has the program provides a huge opportunity to offer
provided mentoring for two young TTP Associates. independence in ways that many surgical trainees
Administrators at Anne Arundel saw this program as cannot obtain during their five years of residency.
an opportunity for seasoned surgeons to share their The opportunity to learn a broad business skill set
wisdom and possibly to recruit a future partner. The and organizational awareness, effective negotiation
program has encountered applicants with a significant skills, and risk management and quality improvement
lack of confidence, as well as young surgeons who skills likely flattens the job-change curve, as well as
could be on the verge of a failed career. For this reason, the burnout rate.
growing TTP’s strengths and enhancing the program “The interpersonal, business, and practical con-
to include training in business, communication, and siderations of the surgical world can’t really be fully
leadership embedded in a mentorship-style program, taught in residency. You need to be on your own with
is the model the medical center is now developing. your name on the chart as the surgeon of record to
“During my year, I was able to work one-on-one really be able to get into that mode of thinking,” said
with senior surgeons who had been in practice for Lauren Licata, MD. “I found that position changed
many years. From these relationships, I was able the timbre of the advice I had received as a resident
to have a better understanding of how to build and and as a TTP Associate,” added Dr. Licata, referring
JUL 2018 BULLETIN American College of SurgeonsFROM TTP TO MASTERY IN GENERAL SURGERY
to the fact that she received no practice management and may not have a fully formed idea of what they want
training in residency, although she did receive this in terms of a career.† The TTP Program can aid these
type of instruction in the TTP Program. young surgeons in making well-informed career deci-
Studies have shown that a significant driver of emo- sions because it exposes them to a variety of mentors
tional exhaustion and burnout is loss of autonomy.* and practice settings.
What better way to regain control than through action-
able skills and time-management techniques as you The Geisinger experience
begin your independent practice? The TTP Program Geisinger Health System became interested in start-
provides a practical surgical practice curriculum that ing a TTP Program after learning about the concept,
is supported by a mentored first year in practice. according to John E. Widger, MD, FACS, TTP Pro-
Another factor that highlights the value of this pro- gram Director, Geisinger, Danville, PA. This health
gram is related to the fear of failure experienced by care system, which has multiple types of practices,
some residents when it comes to launching an indepen- including small office to tertiary care settings, pro-
dent practice. A notable portion of graduating surgical vides an ideal environment to mentor a young surgeon
residents typically experience insecurity about their who has chosen to practice general surgery. Geisinger
ability to practice successfully. This program helps administrators saw this program as an opportunity
young surgeons feel more confident about their abil- for mentees to sharpen their skills in a supervised
14 | ity to practice general surgery. environment and to learn real-world solutions for
It is time to change the title of this program to increasing efficiency in a general surgery practice—
emphasize mastery in the field of general surgery. This including billing and the economics related to running
revised program title should signal the improved con- a practice. The TTP Program also could provide guid-
fidence and real-world skills that are the foundation ance to help a young surgeon determine what type of
of this model. The program can potentially support practice to pursue in the future.
career goals related to private practice or work in rural One of the issues that arose early on in the imple-
environments. As the program grows, it should support mentation of the program at Geisinger centered on
the development of an adequate workforce to meet the the interaction of the TTP Associate with the senior
needs of the future. residents. At the beginning, the TTP Associate was
Participating programs will need buy-in and part- assigned to multiple faculty members, both senior
nership with our residency program directors to allow, and junior, to get exposure to multiple methods and
and even encourage, their brightest trainees to follow a styles. With time, Geisinger realized that limiting the
path involving the TTP Program. This program offers TTP Associate’s interactions to more senior faculty
participants a unique opportunity to gain practical was of greater benefit from a consistency standpoint,
skills without pursuing an additional degree. What if and at that point, the interactions with the residents
we could keep our early practice surgeons where they became even more constructive. The senior faculty is
first land because they made well-informed decisions? composed of general surgeons who are comfortable
Industry experts point out that tens of thousands of with the TTP Associate teaching residents and walk-
final-year residents and fellows are looking for a job ing residents through the cases.
each year, which can be a difficult process as residents The program has been structured such that the
typically work in a somewhat protected environment TTP Associate spends long stretches of time at two
general surgery sites away from the tertiary care cen-
*Campbell DA Jr, Sonnad SS, Eckhauser FE, Campbell KK, Greenfield ters, if possible. These rotations range from four to six
LJ. Burnout among American surgeons. Surgery. 2001;130(4):696-702. months each and allow the TTP Associates to develop
†
Page L. Seven job search mistakes of new physicians. Medscape. April 7,
2015. Available at: www.medscape.com/viewarticle/842301. Accessed a practice of their own under the supervision of senior
April 19, 2018. physicians. Geisinger administrators chose to have
V103 No 7 BULLETIN American College of SurgeonsFROM TTP TO MASTERY IN GENERAL SURGERY
two sites instead of one in order to expose the learner Associates have stayed on at Geisinger as attending
to different practice sites and styles. The types of cases surgeons.
that learners are exposed to include endoscopy, hernia In Geisinger’s TTP Program, the main simulation
repair, gallbladder surgery, breast surgery, and colon activity focuses on robotic skills. Each TTP Associate
surgery, among other general surgery procedures. must become certified in robotic surgery, which is pred-
During these rotations, the learner also is assigned icated on the completion of case observations, online
to approximately six weeks and six weekends on the modules, simulation, and participation in operations on
emergency general surgery service at the tertiary both the secondary console and primary console. The
care center. Finally, between the two long rotations, evaluation of the TTP Program and the TTP Associ-
the TTP Associate is assigned to services based on ate occurs through a series of quarterly meetings that
his or her interests. These are usually at the tertiary include the program director, associate program direc-
care center and include surgical oncology, colorectal tor, and two site directors, along with the coordinator
surgery, and general surgery with a focus on major of the program. At these two-hour meetings, the TTP
abdominal wall defects. Associate’s performance is discussed and feedback is
With the initial success of the program and gradua- shared. The TTP Associate also offers an evaluation
tion of three TTP Associates, Geisinger administrators of the program. These stakeholders discuss methods
made the decision to expand its complement of learners for improving the program, and changes are made
to two per year. This decision was made with the idea subsequently. | 15
that each TTP Associate would spend approximately Mohsen M. Shabahang, MD, PhD, FACS, co-author
four to five months at the primary practice where the of this article, is the department chair at Geisinger,
program director is based. Each TTP Associate has a and he supports the concepts on which this program
few months between the long rotations to work on the is based. The residents Geisinger trains may be clini-
more advanced services at the tertiary care centers. cally and technically ready to practice; however, they
Whereas the program has two different general sur- do not learn how to successfully develop a practice.
gery residencies, the two TTP Associates interacted For years, Geisinger has relied on the senior partners
with completely different groups of residents. to help guide the junior surgeons. This program allows
As Geisinger administrators began launching the for maturation of general surgeons through mentoring
program, some health care system leaders expressed in a controlled and learner-centered environment. The
concern about the financial impact of the program. TTP Program is not a form of remediation, but rather
The TTP Associates are paid at the postgraduate year- it is a way to underscore the key role of general surgery
six level. However, the expense associated with their in the delivery of surgical care in the U.S. This program
compensation and benefits is actually $150,000 annu- trains surgeons who serve all the different communi-
ally per participant, while over the first three years ties that exist in health care. Our patients deserve that.
of the program, the combination of professional and
hospital revenues and expenses has generated a posi- The Chattanooga rural experience
tive margin above $400,000. One of the great advantages of the TTP Program’s
It is worth noting that these TTP Associates are design is the enormous flexibility it provides for vary-
credentialed in the system like any other attending ing training experiences beyond residency, according
physician and receive the same benefits. Since the to W. Heath Giles, MD, FACS, TTP Program Director,
inception of this program in 2014, Geisinger has had University of Tennessee, Chattanooga, and co-author
five TTP Associates come through the program— of this article. A Junior Associate in the Chattanooga
three graduates of Geisinger’s residency program and program wanted to practice in a rural environment
two from outside organizations. All have been resi- with the goal of performing a number of procedures
dents in very good standing. Of the five, two TTP that general surgeons rarely perform. He did not want
JUL 2018 BULLETIN American College of SurgeonsFROM TTP TO MASTERY IN GENERAL SURGERY
to learn on the job once he arrived, but instead sought As a result, the ACS TTP Steering Committee has
to attain proficiency in order to better serve patients expanded the concept and rebranded the program to
in the community. One of his future senior partners, underscore its aim to provide a mastery of the ele-
who ran the general surgery rural rotation, performed ments of general surgery practice. The program is now
many cases outside the usual domain of general surgery called the ACS Mastery in General Surgery Program.
practice. Therefore, a rural experience was arranged Clearly, mastery is a lifelong pursuit, but this program
in the practice group he planned to join. is designed to establish the foundation for excellence
During that year, he performed more than 550 cases, through specific skill acquisition and mentorship. Fur-
which allowed him to become facile in many nontra- ther skill development and refinement is expected to
ditional general surgery procedures. For example, he occur across the lifetime of the surgeon’s practice.
performed 90 otolaryngology cases, including tonsil- In addition, the Mastery Program encompasses ele-
lectomy and myringotomy/tubes. He also performed ments of business acumen, practice management, and
general flap reconstruction for soft-tissue excisions, the nontechnical skills necessary in surgical practice.
and completed 105 dialysis procedures with university- The College is developing several modules on leader-
based vascular surgeons. ship, practice management, and other relevant skills
Although difficult to measure, an invaluable aspect to enhance the existing model for the program.
of the program was the opportunity to develop rela- The TTP Steering Committee and the individual
16 | tionships with community physicians, future partners, directors of the program are proud of the accomplish-
and hospital administrators. The extensive experience ments achieved thus far. At the end of this academic
provided by the TTP Program fully prepared this Junior year, more than 50 young surgeons will have com-
Associate to seamlessly join that rural practice. pleted the program, and if each graduate practices for
at least 30 years, that equates to a total of 1,500 prac-
tice years. This program continues to be focused on
Launch of the ACS Mastery in training competent and confident general surgeons,
General Surgery Program and will continue to bring greater attention to this
The ACS has encountered several obstacles in the important stage in a young surgeon’s training and pro-
development of the TTP Program. The most difficult fessional development. The ACS is committed to this
challenge may be explaining the basic concept: Is it a effort and other approaches to reinvigorating general
fellowship or something else? The TTP Program has surgery as a career.
certainly been an innovative concept, particularly for To obtain a list of approved ACS Mastery in Gen-
general surgery—although funding is an issue at some eral Surgery Program sites, contact Rachel Williams
institutions, despite the fact that the Junior Associate Newman at 312-202-5653, e-mail MasteryGS@facs.
may bill for services. Details regarding the mission and org, or visit facs.org/masterygs. ♦
purpose of the TTP Program have been disseminated
to the surgical educators’ community, even though
many surgeons who might benefit from the experi- Acknowledgment
ence are unaware of its existence. Furthermore, many The TTP Steering Committee would like to recognize
surgical educators, including program directors of gen- the efforts of Linda K. Lupi, MBA, Assistant Director,
eral surgery residencies, erroneously view this as a Education Administration and Education Scholarship,
remedial one. Although many young surgeons may and Rachel Williams Newman, MS, Manager, Education
lack the confidence to allow a comfortable entry into and Training to Support Transitions in Surgery, from the
practice, the TTP Program is not designed to instruct ACS Division of Education, whose skills, commitment,
those who were poorly trained during the primary and tireless efforts have been key to the success of this
surgical residency. unique program.
V103 No 7 BULLETIN American College of SurgeonsACS CLINICAL SCHOLARS IN RESIDENCE
From left: Drs. Bilimoria,
Ingraham, Paruch, and Raval
| 17
ACS Clinical Scholars in Residence Program
has lasting impact on surgeons’ careers
by Tony Peregrin
T
he American College of Surgeons (ACS) Clinical two years at the ACS headquarters in Chicago. The
Scholars in Residence Program prepares early goal of the master’s program is to educate clinicians in
career clinicians to use data-driven research to health care services and outcomes specifically within
address issues in health care quality, health policy, institutional and health care delivery systems, as well
and patient safety. The two-year fellowship program, as in the external environment that shapes health
initiated in 2005, provides ACS Clinical Scholars policy.
with exposure to the ACS National Surgical Quality In addition, ACS Clinical Scholars are assigned
Improvement Program (ACS NSQIP®), the National mentors representing a diverse background to guide
Cancer Database (NCDB), the National Trauma Data participants in their research.
Bank® (NTDB®), the Trauma Quality Improvement The program is open to Resident Members of the
Program, and other data registries with the dual College who have completed two to three years of
goal of conducting research to enhance the College’s surgical training. In total, 16 scholars have completed
quality improvement (QI) initiatives and preparing the program; at present, five residents are ACS Clini-
residents for a career in academic surgery.1 cal Scholars.2
ACS Clinical Scholars also earn a master’s degree In this article, four previous ACS Clinical Scholars
in health services and outcomes research or health describe how the fellowship affected their career path
care quality and patient safety at Northwestern Uni- and why this program continues to result in improved
versity’s Medical School, Chicago, IL, during their patient outcomes and safer patient care.
JUL 2018 BULLETIN American College of SurgeonsACS CLINICAL SCHOLARS IN RESIDENCE
Dr. Bilimoria (fourth from left);
David P. Winchester, MD, FACS,
Medical Director, Cancer, ACS
DROP-C (second from right);
and Dr. Cohen (far right), with
research fellows
Dr. Bilimoria: Defining the role was very appealing, as was the opportunity to have a
of the ACS Clinical Scholar hand in crafting and developing the College’s Quality
As the inaugural ACS Clinical Scholar in Residence, Programs.”
Karl Bilimoria, MD, MS, FACS, performed numerous A key component of the Clinical Scholars program
studies focused on improving care for surgical and is the opportunity for young clinicians to earn a Master
oncology patients using data from the NCDB. He also of Science in Health Services and Outcome Research.
worked extensively on ACS NSQIP to assess hospital “We wanted to make sure that if the Fellows were
surgical quality data, developing multiple initiatives doing this kind of work that they received formal train-
for that program. ing as well, and Northwestern has been a huge partner
Before entering the ACS Clinical Scholars program, in reaching this goal,” Dr. Bilimoria said. “You need
Dr. Bilimoria attended medical school at Indiana Uni- this formal training and the underpinnings of research
versity, Indianapolis, and completed his general surgery methodology to be able to really have a diverse set of
residency at Northwestern University. In 2011, he tools for research, specifically skills related to study
18 | entered a surgical oncology fellowship at MD Ander- design, biostatistics, and epidemiology.”
son Cancer Center, Houston, TX. Today, Dr. Bilimoria is a surgical oncologist focusing
“The goal was to use the NCDB for a wide variety on melanoma and sarcoma at Northwestern Memorial
of research in order to identify what are good research Hospital, and he is the founding director of the Surgical
uses of the database and then to try to improve the qual- Outcomes and Quality Improvement Center (SOQIC),
ity of the data and the NCDB through what we learned within the Feinberg School of Medicine. The SOQIC
through the research process,” Dr. Bilimoria said. “We has earned more than $30,000,000 in research funding
also needed more quality measures, so a lot of the work and has published more than 300 articles. Dr. Bilimoria
centered on quality measure development and test- attributes this success to his time as an ACS Clinical
ing. I also did some of the initial work in building out Scholar.
some aspects of the very early NSQIP program, such as “The Clinical Scholars program has served as the
developing the ACS NSQIP Surgical Risk Calculator.” foundation for everything I do now in my research,
At the time, residents had few opportunities to quality improvement, and health policy endeavors,”
engage in this kind of work, and it was the College’s Dr. Bilimoria said. “One of the biggest things I do right
first foray into this type of research, Dr. Bilimoria said. now is oversee the Illinois Surgical Quality Improve-
He first proposed the idea for the program to David P. ment Collaborative, which is composed of 57 hospitals
Winchester, MD, FACS, Medical Director, ACS Cancer throughout Illinois and is one of the biggest and most
Programs, and then ACS Executive Director Thomas robust collaboratives in the country.”3
R. Russell, MD, FACS, who offered their enthusiastic An extensive knowledge of the ACS NSQIP pro-
endorsement. gram and data also contributed to Dr. Bilimoria’s role
Dr. Bilimoria said the program’s rollout went rela- as principal investigator for the Flexibility in Duty Hour
tively smoothly. “It was not a matter of overcoming Requirements for Surgical Trainees (FIRST) Trial pub-
specific challenges, but of really trying to define what lished in 2016.4 The FIRST Trial randomized 117 U.S.
the role of the scholar could be,” he said. “It really general surgery residency programs and 151 affiliate
was like being a kid in a candy store—you could set hospitals to different duty-hour policies and showed
it up in any number of ways. The idea of being able that flexibility in resident work hours does not affect
to have access to some of the best data for research patient safety or overall resident well-being.
V103 No 7 BULLETIN American College of SurgeonsACS CLINICAL SCHOLARS IN RESIDENCE
Dr. Ingraham (second from
right) operating with Tanya
Rinderknecht, MD (second
from left), a resident at
Stanford. The two physicians
were volunteering in Haiti
with a group from the
University of Cincinnati.
“Having a deep understanding of how ACS NSQIP Dr. Bilimoria said that participating in the ACS
works really helped lead the way to developing the Clinical Scholars program is a singular experience, par-
FIRST Trial,” Dr. Bilimoria said. “The FIRST Trial is ticularly for residents interested in pursuing a career
the first of its kind, and labeled as “first” for a variety in surgical health services, health policy, or quality
of reasons, including the fact that it was one of the improvement research.
first registry trials that was done with NSQIP—which
makes it pretty unique, and I hope that it serves as a
model for many other investigators to do registry trials Dr. Ingraham: Developing writing skills
going forward.” Angela Ingraham, MD, MS, an ACS Scholar in Resi-
In addition to working with ACS databases and dence from July 2008 to June 2010, has focused her
receiving formal instruction in research methodol- research on emergency general surgery. As a Clinical
ogy, the ACS Clinical Scholars program offers junior Scholar, Dr. Ingraham’s research examined patient-
clinicians access to experienced mentors. and hospital-level outcomes following emergency
“The mentorship part is a critical component general surgery using data from ACS NSQIP. | 19
of what I consider my responsibilities right now,” Dr. Ingraham received her medical degree from
explained Dr. Bilimoria. “Working with bright, curi- Loyola University Chicago Stritch School of Medi-
ous residents is constantly refreshing. And giving them cine, IL. She was a general surgery resident at the
some basic tools for research, policy, politics, and pro- University of Cincinnati, OH, and an acute care sur-
fessional development is enjoyable, but I also learn a gery fellow at the University of Pittsburgh School of
ton from them. The Clinical Scholars are constantly Medicine, PA. At present, Dr. Ingraham is an assistant
questioning clinical issues and coming up with cre- professor of surgery, University of Wisconsin (UW)
ative research ideas, and that back and forth is really Madison, and she is an investigator in the Wisconsin
important. I think I was like this as a scholar, too.” Surgical Outcome Research Program, UW.
For example, a research fellow suggested a research Until recently, emergency general surgery patients
idea that Dr. Bilimoria thought was uninteresting. “But really didn’t have a “home” in terms of quality,
the research fellow was persistent in making a case Dr. Ingraham said. “Through my research, as well
and ran some preliminary data, and then brought it as many of the collaborations and connections that
back. And when I looked at it again, I realized it would I made through the Clinical Scholars program, I’ve
probably be a landmark study, and that the fellow’s been able to highlight this very vulnerable group of
persistence and view of the situation was correct. And patients and the fact that we need to focus QI efforts
I loved that the fellow didn’t give up on it despite get- in this area.”
ting an unfavorable initial review from me.” Improving the quality of care begins with solid
Mark Cohen, PhD, Statistical Manager, Continuous data analysis. Dr. Ingraham said one of the most
Quality Improvement (CQI), ACS Division of Research valuable aspects of the program was learning how
and Optimal Patient Care (DROP-C), also said he has to communicate with statisticians. “As a scholar, I
learned a lot as a mentor to Clinical Scholars. “Even in did my own data analysis, and I got to learn about,
the statistics realm, scholars sometimes use approaches for example, SAS (previously known as the Statistical
for their research that we’re not very familiar with,” Analysis System), which is one of the most commonly
Dr. Cohen said. “It’s a refreshing role reversal when we used statistical programs and was developed by the SAS
learn about new methods from them.” Institute. Today, as a faculty member, I don’t always
JUL 2018 BULLETIN American College of SurgeonsYou can also read
