General Surgery News (July 2020)

OPINI O N The Top 5 Things I Wish I Knew Before Starting My Intern Year Page 8

GENERAL SURGERY NEWS The Independent Monthly Newspaper for the General Surgeon

GeneralSurgeryNews.com

July 2020 • Volume 47 • Number 7

Life After Burnout: A Case Study

OPINION

Surgeon Shares Story to Normalize Conversation

Fellowship or No, How Do We Ensure Quality?

By MONICA J. SMITH

By BEN GERBER, MD

New Orleans—There is life after burnout, according to one person who would know. In her talk on the topic, Laura S. Johnson, MD, presented a very personal case study: a 28-year-old surgical resident, a Californian relocated to the East Coast; by all accounts a solid, wellliked trainee with no known issues.

“This was me at my least complicated state,” said Dr. Johnson, an associate professor of surgery at Georgetown University School of Medicine, in Washington, D.C., at the 2020 Southeastern Surgical Congress.

From the beginning of her surgical residency in 2005, Dr. Johnson,

T

a club mate, also a surgeon, asked Dr. Johnson if she was all right.

“I didn’t think anything of it— third year is supposed to be the crucible,” she said.

he topic of the recent “Great eat Debates” article, “Should uld Specialty Surgery in Urban Areas as Only be Performed by FellowshippTrained Surgeons?” (www.generneralsurgerynews.com/Section/ The-Great-Debates/644), is especially relevant at this time in our country. Many hospitals and medical centers are in the process of wrestling with the same questions.

Both Dr. Meredith Duke’s and Dr. Robert Stovall’s arguments center on doing what is best for surgical patients, that is, how to decide which surgeons provide high-quality service. The central point of disagreement between the two debaters is

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Surgeon Laura S. Johnson, MD (right), scoring on the attack in the Gold Medal match of the Veteran Women’s Team Saber event at the 2019 US Fencing Association National Championships.

an avid fencer, practiced with a club consistently as a way to stay grounded. Her first two years were challenging but immensely satisfying. “This is where I was meant to be.” But at the beginning of her third year,

In Case You Missed Them: Top Papers in Oncologic, Trauma and General Surgery

Tracheostomy for COVID-19 Patients Experience and Lessons Learned From 125 Cases

Top Picks From Last Year Are Presented At 2020 Southeastern Surgical Congress

I

By MONICA J. SMITH

New Orleans—Many papers published in the surgical literature in 2018-2019 challenged long-held beliefs, suggested future roles for artificial intelligence (AI), and showed that music in the perioperative setting may help with pain control. At the 2020 Southeastern Surgical Congress, three surgeons discussed what they considered the top papers in trauma surgery, surgical oncology and general surgery.

n late February, I was having lunch with two radiation oncolologists and my brother, taking a break from the head and neck eck cancer meeting in Scottsdale [Arizona], to play a round of golf. As the stock market tumbled in response to the rapid d spread of the coronavirus, it became clear that this wasn’t just another version of the usual flu. Once back home in New York, we started thinking about how to prepare for the impending wave of patients.

One of my colleagues talked to me about the possibility of 2 million people dying, and it made me think this might be even more serious. He told me he had come to

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S URGEONS’ LOU N G E

14 Management of Achalasia OP IN ION

16 Moneyball for Health Care R E SIDENT WRITI N G C O N TEST

20 & 22 Let Residents Bill; ‘Stand Up Straight’

A New Generation of Laparoscopic Training See page 9

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Dr. Randall Owen preps for tracheostomy.

By RANDALL P. OWEN, MD

@gensurgnews

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BULLETIN BOARD

JULY 2020 / GENERAL SURGERY NEWS

General Surgery News Welcomes New Editorial Board Members General Surgery News is excited to announce the appointment of two dynamic surgeons to its editorial board. Here is a little bit about them.

Dr. Linda Wong graduated from Stanford University, in California; received her medical degree at the University of California, Irvine; and re completed her general surgery residency at Cedars-Sinai Medical Center, c where two of her attendings were Gary Hoffman, MD, and Leo Gordon, w MD (also editorial board members of General Surgery News). She then did a transplant fellowship at California Pacific Medical Center, in San Francisco. She is currently a professor and the senior associate chairman at the University of Hawaii John A. Burns School of Medicine, in Honolulu. She is a professor and contributing liver cancer researcher at Linda Wong, MD the University of Hawaii Cancer Center, and the director of the liver transplant program at Queens Medical Center.

When she is not doing a million things a day, Dr. Wong has helped Dr. Hoffman write an opinion column for General Surgery News titled “Inflammatory Response.” She is amazed at how much positive feedback and response she has received from these essays, which she initially started writing as a personal diary or to avoid having to enroll in anger management seminars.

Because she was impressed by General Surgery News’ wide readership, she graciously agreed to join the editorial advisory board.

Dr. D Robert Lim is an associate professor of surgery, the vice-chair of education, and the residency program director for the Department of Surgery at Oklahoma dir University School of Medicine at Tulsa. He obtained Un his medical degree from New York Medical College, in Valhalla, N.Y., and completed his residency at William Beaumont Army Medical Center in El Paso, Texas. After his residency, Dr. Lim went on to complete a fellowship program in minimally Robert Lim, MD invasive surgery at Beth Israel Deaconess Medical Center/Harvard Medical School, in Boston. He served 23 years in the U.S. Army, with six deployments to the combat zones of Iraq and Afghanistan. Dr. Lim is board certified in general surgery, is a fellow of the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery, and serves on the board of the Society of American Gastrointestinal and Endoscopic Surgeons.

Now online at generalsurgerynews.com/multimedia ...

PODCAST

VIDEO

Once Upon a Time In the Coelom

Life, Death and Grieving: Surgical Palliative Care

Leo A. Gordon, MD, a general surgeon in Los Angeles, takes an etymologic romp through the abdomen.

Melissa Red Hoffman, MD, shares her personal and professional story of choosing a path in surgical palliative care at the 2020 Southeastern Surgical Congress.

MISSION STATEMENT OF GSN It is the mission of General Surgery News to be an independent and reliable source of news and analysis about the current state of surgery. It strives to provide a venue for discussion and opinions, from all viewpoints, on the issues most important to surgeons.

Senior Medical Adviser Frederick L. Greene, MD Charlotte, NC

Lauren A. Kosinski, MD Chestertown, MD

Editorial Advisory Board

Marina Kurian, MD New York, NY

DISCLAIMER Opinions and statements published in General Surgery News are of the individual author or speaker and do not represent the views of the editorial advisory board, editorial staff or reporters.

Raymond J. Lanzafame, MD, MBA Rochester, NY

CONTACT THE EDITOR Send letters, article ideas or queries to khorty@mcmahonmed.com.

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IN THE NEWS

GENERAL SURGERY NEWS / JULY 2020

Consulting Physicians Can Have Clinical, Financial Drawbacks Research Shows Longer Length of Stay, Greater Mortality, and Higher Cost in Surgical Patients

By MONICA J. SMITH

New Orleans—As the population of surgical patients with complex comorbidities continues to grow, so does the practice of involving consulting physicians in their care. While the use of consultants may be beneficial in some areas, there could be clinical and financial downsides, according to new research.

The study, presented at the 2020 Southeastern Surgical Congress (abstract 13), found the use of consulting physicians was associated with longer length of stay (LOS), higher readmission rates, greater in-hospital mortality and higher cost.

“We had noted that nonsurgeon physicians often are used as consultants in the care of surgical patients,” said Elliott Toy, MD, a surgical resident with AdventHealth in Orlando, Fla. “As care is coordinated among these consultants, patients frequently experience delays in the progression of their care, often waiting for input from a consultant regarding elements of care surgeons could easily manage.”

Evaluations of the effect of consultants on surgical patients tend to be limited and based on low-quality data, Dr. Toy said, noting that many of these studies report conflicting results on the impact of several important outcomes; there are even less data about patient satisfaction.

“Patients often ask, ‘Are you my doctor?,’ which we believe is a surrogate for, ‘Are you the doctor in charge of my care?’ It seems to be a common theme that patients are often not sure who their doctor is.”

Hypothesizing that nonsurgical physicians managing surgical patients might overuse consulting physicians with negative effect, researchers at AdventHealth, led by Sebastian G. de la Fuente, MD, a surgical oncologist and the program director of the advanced upper GI surgery fellowship, looked at LOS, in-hospital mortality, 30-day readmission rates, and costs and contribution margins.

The study included 11,274 patients aged 18 years and older (mean age, 51.4 years) undergoing more than 90 elective and emergent surgical procedures ranging from cholecystectomy to total pancreatectomy. The patients were hospitalized for at least 24 hours; the average LOS was six days; and the readmission rate was 11.6%.

‘In theory, I should be able to care for my patients’ diabetes; I should be able to manage their antihypertensive medication.

But as this study points out, the increasing pressure to do more and more often leads to the involvement of additional consultants to take care of our complex patients.’

—Erin Baker, MD An average of 2.5 consultants were involved in each patient’s care, at a cost of more than $1,300 per consultant; the most common consultants were gastroenterologists, infectious disease specialists and pulmonologists.

For each consulting physician used, the total and variable cost per case increased by $1,347 and $592, respectively.

“We also saw a decrease in the contribution margin per consultant by $350,” Dr. Toy said.

“In addition, we noticed a significant increase in the odds ratio of in-hospital mortality rates and readmissions, at 3% and 5%, respectively, and an increase in LOS by 0.7 days per consult, which demonstrates the delays in care we anecdotally observed for these patients,” he said.

The authors acknowledged that they could not detect the specific charges incurred as professional fees per consultant or the charges generated by the resources used by consultants, but stand by their conviction that consultants be used as judiciously as possible.

“Surgeons should relinquish the care of surgical

patients to nonsurgeons only in exceptional circumstances,” Dr. Toy said.

Erin Baker, MD, a hepatopancreatobiliary surgeon with Atrium Health in Charlotte, N.C., commented that throughout her training and practice, she has observed an increase in her own use of consultants.

“In theory, I should be able to care for my patients’ diabetes; I should be able to manage their antihypertensive medication. But as this study points out, the increasing pressure to do more and more often leads to the involvement of additional consultants to take care of our complex patients,” she said.

Dr. Baker noted the conundrum that surgeons face.

“We’re expected to provide the best possible care for our patient and to manage all of their complex needs, and also to get them out of the hospital as fast and as safely as possible,” she said. “But each consultant extends LOS by nearly a day.”

Dr. Baker noted that the paper did not distinguish patients for whom the surgeon was actually a consultant. “This raises the question: If we take out the number of patients admitted to other medical services and eliminate the surgeon as consultant, would that change the data or analysis?”

Stephen McNatt, MD, a surgeon with Wake Forest Baptist Health in Winston-Salem, N.C., said a caveat to the study can be found in the orthopedic literature.

“They have shown that with medical service dedicated to the care of orthopedic patients, they can drive down cost and LOS. Should there be teams that take care of patients rather than random consultants who do what they do well, but may not be looking at the total patient?”

Dr. de la Fuente said he and his colleagues are aware of the team approach described in the orthopedic literature. “Unfortunately, there is a paucity of data on patients undergoing general surgical procedures, and I think it would be a great area of research for the future, looking at teams rather than consulting individuals.” ■

Obesity Paradox: Outcomes Better in Heavier Emergency Surgery Patients

By MONICA J. SMITH

New Orleans—Despite the comorbidities that often accompany obesity, some disciplines have reported a protective effect in heavier patients, and this paradox may extend to patients undergoing emergency general surgery (EGS), according to new research.

“We’ve seen improved outcomes in

overweight and obese cardiac, elective general surgery and oncologic surgical patients,” said Sean R. Maloney, MD, a third-year general surgery resident at Carolinas Medical Center, in Charlotte, N.C. “The aim of our study was to see whether or not obesity has an effect on mortality in emergency general surgery.”

Querying a single-institution EGS database from 2013 to 2015, Dr. Maloney and his colleagues identified 60,604 patients, of whom 64% were at least overweight, and 36% had a body mass index (BMI) of 30 kg/m2 or higher (average BMI, 29 kg/m2). Of note, higher weight was inversely related to age.

Overall, about 11% of the patients underwent surgery. The 30-day mortality rate was 7.6%. In-hospital mortality was highest in underweight patients.

Although mortality was about the same in normal, overweight and obese patients

(including those considered morbidly and super obese), patients in every overweight category were less likely than normalweight patients to die after the initial 30 days out to three years.

To control for confounding variables, the researchers performed a multivariate analysis comparing age, BMI category, whether the patient received resuscitation, if the patient had a laparotomy, the Charleston Comorbidity Index, and other factors.

Results showed that again, underweight patients were most likely to die, with an odds ratio of 1.9 compared with normal-weight patients, and all four obesity categories were associated with a mortality benefit versus normal-BMI patients.

“Obesity appeared to be protective against mortality in our EGS patients,” Dr. Maloney said. “While we may not have the granularity to tell exactly why this

is happening, this is something important for surgeons to understand, as both the obesity rate and the burden of EGS population in our hospitals continue to grow.”

Federico Serrot, MD, a bariatric surgeon and an assistant professor of surgery at Emory University School of Medicine, in Atlanta, asked if the researchers had any thoughts on the pathophysiology underlying the paradox. “It looks like your underweight patients were older; did they tend to be sicker?”

Dr. Maloney said malnutrition is known to be associated with worse results and more complications in surgical patients, which is one explanation for poorer outcomes in underweight patients.

“But there are also normal-weight patients who achieved normal weight after significant weight loss. They could also be significantly malnourished and not prepared to fight the burden of disease.”

■

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IN THE NEWS

GENERAL SURGERY NEWS / JULY 2020

Top Papers in Trauma, Surgical Oncology and General Surgery continued from page 1

Trauma and Emergency General Surgery After consulting with colleagues and looking at Twitter, metrics results and citations, Amy N. Hildreth, MD, an associate professor of surgery at Wake Forest School of Medicine, in Winston-Salem, N.C., came up with her own definition of a top paper: “methodically sound studies that generate conversation and challenge a little dogma.”

resuscitation associated with complications, ICU or hospital lengths of stay, or mortality. In addition, the rate of deep vein thrombosis was lower in the AVP group.

Dr. Hildreth: This challenges the dogma that vasopressors in trauma resuscitation are uniformly bad news.

Coleman JJ, et al. To Sleep, Perchance to Dream: Acute and Chronic Sleep Deprivation in Acute Care Surgeons. J Am Coll Surg. 2019;229(2):166-174. (www.ncbi.nlm.nih.gov/pubmed/30959105)

Lee JM, et al. Hartmann’s Procedure vs Primary Anastomosis with Diverting Loop Ileostomy for Acute Diverticulitis: Nationwide Analysis of 2,729 Emergency Surgery Patients. J Am Coll Surg. 2019;229(1):48-55 (www.ncbi.nlm.nih.gov/pubmed/30902639)

In this analysis of 2,729 emergency surgery patients with acute diverticulitis, 2,521 (94%) underwent a Hartmann’s procedure and 208 (7.6%) underwent primary anastomosis with diverting loop ileostomy (PADLI). Hartmann’s procedure patients tended to be sicker and had a higher mortality rate, but morbidity and hospital length of stay were similar in the two groups.

Dr. Hildreth: A couple of prospective, randomized European trials suggest that PADLI is a safe alternative to Hartmann’s procedure, but they were relatively small and there’s been some concern that the European population differs from our own. After adjusting for severity of illness, this analysis of U.S. patients also found PADLI safe, thus challenging the dogma that surgical intervention for acute diverticulitis requires Hartmann’s procedure.

Sims CA, et al. Effect of Low-Dose Supplementation of Arginine Vasopressin on Need for Blood Product Transfusions in Patients With Trauma and Hemorrhagic Shock. JAMA Surg.

2019;154(11):994-1003 (www.ncbi.nlm.nih.gov/ pubmed/?term=Effect+of+low-dose+supplem entation+of+arginine+vasopressin+on+need+f or+blood)

To investigate the effect of arginine vasopressin (AVP) on trauma patients, researchers randomized 100 trauma patients to an AVP bolus of 4 units plus 0.04 units per minute or less for 48 hours to maintain a mean arterial pressure of at least 65 mm Hg (49 patients) or placebo (51 patients), with a primary outcome of blood product transfusion volume. The AVP group required a lower volume of total blood products than the placebo group (1.7 L vs. 3 L). AVP had no effect on the overall complication rate or rate of

Seventeen acute care surgeons participated in this study, wearing a validated sleep-tracking device over three months.

Excluding in-house call, participants averaged 6.54 hours of sleep per night; 64.8% of sleep patterns were categorized as acute or chronic sleep deprivation.

Sleep deprivation peaked on post-call day 2, and sleep patterns took three days to return to baseline after call.

Dr. Hildreth: On non-call nights, the average sleep latency, which is the time it takes you to fall asleep after your head hits the pillow, was four minutes and 37 seconds. That’s similar to patients with narcolepsy. These findings raise concerns for surgeon health and surgeon performance due to increased stress, increased fatigue and decreased situational awareness. They also raise the question of how we might alter our call schedules so that we’re less sleep deprived moving forward.

Surgical Oncology Eric C. Feliberti, MD, a surgical oncologist and an associate professor of surgery at Eastern Virginia Medical School, in Norfolk, looked for research on common cancers that general surgeons treat and for papers that highlight emerging principles in oncology.

Klaver CEL, et al. Adjuvant Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Patients With Locally Advanced Colon Cancer (COLOPEC): A Multicentre, Open-Label, Randomised Trial. Lancet Gastroenterol Hepatol. 2019;4(10):761-760 (www.ncbi.nlm.nih.gov/pubmed/31371228)

In this assessment of adjuvant HIPEC in patients with locally advanced colon cancer, researchers randomly assigned 100 patients to HIPEC followed by 30 minutes of oxaliplatin, or 102 patients to chemotherapy alone. Peritoneal metastases were diagnosed in 19 (19%) of the experimental group (nine of these diagnoses were made prior to HIPEC

treatment) and 23 (23%) of the control group.

Dr. Feliberti: Evidence suggests that HIPEC improves survival, but this is one of the first prospective RCTs trying to address this question. The conclusion from this paper is that HIPEC didn’t improve the 18-month peritoneal metastasis‒free survival. But there are some criticisms with this paper. First, they used intraperitoneal oxaliplatin for only 30 minutes; most patients in the United States receive mitomycin C for 90 minutes. Second, if you exclude the nine patients diagnosed with metastases before treatment, the 18-month recurrence rate would have been 10%. Finally, this patient population had more left-sided cancers, but right-sided tumors might respond more favorably to HIPEC.

response rate was 55%. Progression-free survival was 76% at nine months and 71% at 12 months.

Dr. Feliberti: Based on this, it does seem that immunotherapy with anti‒ PD-1 agents may become the standard of care for colorectal patients with dMMR or MSI-H. But this represents only 4% of metastatic cancers. The next step is to see if we can move immunotherapy into earlier lines of treatment or in the adjuvant setting in stage 1 to 3 cancers, where the incidence of dMMR and MSI-H is actually 20% to 30%.

Quenet F, et al. A UNICANCER Phase III Trial of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Colorectal Peritoneal Carcinomatosis (PC): PRODIGE 7. J Clin Oncol.

2018;36(18):LBA3503.

Researchers developed an algorithm for an AI system based on a cohort of 25,000 women who underwent mammography in the United Kingdom, and then tested the system on those cases and another 3,000 cases in the United States. With a specificity and sensitivity of 1.1% and 2.7%, respectively, the AI system outperformed single readers in the United Kingdom and performed just as well as two-reader interpretations. In the U.S. set, the AI system was associated with an improvement in specificity and sensitivity of 5.75% and 9.4%. AI also outperformed six radiologists on a random sample of 500 mammograms.

Dr. Feliberti: Most of the advantage was seen in identifying invasive cancers, which are the ones we want to diagnose.

There are some criticisms with this paper, but I think we are going to see more AI in everyday practice. We need to figure out how to incorporate a system that relies on reading algorithms with human experience and judgment.

(https://ascopubs.org/doi/10.1200/ JCO.2018.36.18_suppl.LBA3503)

Researchers randomly assigned 265 patients with metastatic colorectal cancer with carcinomatosis to cytoreduction alone or cytoreduction with HIPEC with oxaliplatin; all patients underwent six months of systemic chemotherapy.

The postoperative mortality rate, 1.5%, did not differ between the two groups.

At 63 months’ follow-up, overall survival was 41.2 months in the non-HIPEC arm and 41.7 months in the HIPEC group (P=0.995).

Dr. Feliberti: In these patients, who already had carcinomatosis, HIPEC didn’t add further benefit to cytoreductive surgery, suggesting that in this patient population all you need to do is cytoreduction alone. But the final paper hasn’t been published yet, so we can’t make any final assumptions about the true role of HIPEC in carcinomatosis for metastatic colorectal cancer yet.

Overman MJ, et al. Durable Clinical Benefit With Nivolumab Plus Ipilimumab in DNA Mismatch Repair-Deficient/Microsatellite Instability-High Metastatic Colorectal Cancer. J Clin Oncol. 2018;36(8):773-779 (www.ncbi.nlm.nih.gov/pubmed/29355075)

Patients with DNA mismatch repair‒ deficient (dMMR)/microsatellite instability‒high (MSI-H) metastatic colorectal cancer (mCRC) underwent combination immunotherapy with ipilimumab and nivolumab. At 13.4 months, the overall

McKinney SM, et al. International Evaluation of an AI System for Breast Cancer Screening. Nature.

2020;577:89-94 (www.ncbi.nlm.nih.gov/pubmed/31894144)

General Surgery To select top papers in general surgery, William W. Hope, MD, an associate professor of surgery at New Hanover Regional Medical Center, in Wilmington, N.C., searched for topics, such as the opioid crisis. He searched “also, educational resources, such as guidelines or reviews, and articles that uplift our field,” he said.

Fu VX, et al. The Effect of Perioperative Music on Medication Requirement and Hospital Length of Stay: A Meta-analysis. Ann Surg. 2019 Jul 26.

[Epub ahead of print] (www.ncbi.nlm.nih.gov/pubmed/31356272)

IN THE NEWS

JULY 2020 / GENERAL SURGERY NEWS

This meta-analysis of 55 studies including 4,968 patients found that perioperative music reduced postoperative opioid needs. During surgery, patients exposed to music also achieved satisfactory sedation with less propofol and midazolam. Perioperative music did not appear to have an effect on length of stay.

Dr. Hope: With all of the problems related to opioid misuse, it seems perioperative music could potentially decrease postoperative opioid needs. This is an intriguing study and maybe something we can take back to our hospitals and talk to our anesthesiologists about.

treatment algorithms have changed so much in the past few years that we’re all trying to keep up. Some of the statements are fairly straightforward, for example, the percutaneous drainage of an abscess, while others are more controversial, like laparoscopic lavage. A lot of people don’t like recommendations, but this is a nice resource.

Pories S, et al. Leadership in American Surgery: Women Are Rising to the Top. Ann Surg. 2019;269(2):199-205 (www.ncbi.nlm.nih.gov/pubmed/30048312)

This analysis of both the medical literature and surgical societies’ websites

found that increasing numbers of women are rising to leadership positions, both in academic positions and within surgical associations, but the proportion of minority women in leadership positions is still small.

Dr. Hope: This is not so much a scientific paper, but an inspirational one.

There were five women in surgery chairs in the first 150 years of surgery, and now there are almost 20. A lot of this is related to the Association of Women Surgeons.

There’s been a lot of great progress, but minority women are underrepresented.

We need to do better.

■

Do You Have A Story Idea?

If you have an idea for an article or topic you would like to see covered, or are interested in contributing an article yourself, we would like to hear from you.

Contact the editor at khorty@mcmahonmed.com.

Elmously A, et al. Operating Room Attire Policy and Healthcare Cost: Favoring Evidence Over Action for Prevention of Surgical Site Infections.

J Am Coll Surg. 2019;228(1):98-106 To evaluate the impact of the Association of periOperative Registered Nurses’ (AORN’s) 2015 guidelines for OR attire mandated by the Centers for Medicare & Medicaid Services (CMS), researchers looked at 12,585 propensity-matched pairs before and after adoption of these guidelines, comparing surgical site infection rates, microbiology cultures and cost.

They found no difference in surgical site infection rate or in staphylococcal species cultured from wounds. In contrast, cost increased by about $1.00 per each person in the OR, for an additional annual expense of $1,128,078. Extrapolated to all U.S. hospitals, the researchers estimated the extra expense to be $540 million per year.

Dr. Hope: This is for all of you surgeons who get irritated when your hospital or CMS comes to you with a new mandate. As you all know, there has been a big uproar over this mandate. The ACS [American College of Surgeons] has met with AORN and are working on new guidelines. This paper shows how we as surgeons can change policy by using data.

Francis NK, et al. EAES and SAGES 2018 Consensus Conference on Acute Diverticulitis Management: Evidence-Based Recommendations for Clinical Practice. Surg Endosc.

2019;33(9):2726-2741 A joint collaboration by the European Association for Endoscopic Surgery and the Society of American Gastrointestinal and Endoscopic Surgeons, this consensus statement covers six topics relevant to the management of acute diverticulitis (AD): epidemiology, diagnosis and classification, uncomplicated AD, complicated AD, emergency surgery and elective operative management.

Dr. Hope: There is a lot of interest in how to manage AD, partly because the

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8

OPINION

GENERAL SURGERY NEWS / JULY 2020

The Top 5 Things I Wish I Knew Before Starting My Intern Year

By AURIEL T. AUGUST, MD

T

o all the fourth-year medical students out there, congratulations! I know Match Day was not exactly how you pictured in this post–COVID-19 world, but it is still a huge accomplishment, and you should be so proud. While the world is a little different right now than we thought it would be, I know that you all are both excited and anxious to begin your residency. No matter whether you’re a newly minted family medicine doc, OB-GYN or general surgeon, July 1 is going to come with a lot of unknowns. In light of that, I thought I would share some of the things I wish I had known before starting my intern year.

Please, for the love of God, do not take any extra electives in critical care or pulmonology to “give yourself an edge.”

I hate to break it to you, but no matter what you do, no matter how many books you read or rotations you take on, you’re going to feel lost during intern year.

Intern year is not about being the most proficient at ventilator management or a wiz at chest tubes; it is about learning how to work at a hospital. Your days will be spent learning how to replace a patient’s potassium, or how many calls it actually takes to get an interventional radiology procedure done—and nothing can prepare you for that. Very soon, your free time, weekends and holidays will be ripped away from you. Use these last couple of months to enjoy generally deciding what you get to do with your time.

No matter what you do, something will go wrong.

When I was an intern on the transplant surgery service fumbling over how to dose CellCept and making sure every patient’s Prograf level was drawn at the exact same time each morning, inevitably one thing would slip through the cracks. No matter how many times I had called to make sure that creatinine had been drawn, the lab would skip the patient. And as an intern, when

your worth is directly correlated to how many administrative tasks you can successfully execute in a day, I would feel like a failure. But when that lab draw was missed or a medication wasn’t given, my fellow would just say, “Working in a hospital is hard.” And he is right.

When you have humans taking care of other humans, it is an imperfect system, and no matter what you do, things will go wrong. It does not mean you failed.

You will trip and fumble around for months, but you will get up and dust yourself off and come out stronger on the other side.

You will forget what it is like to be a medical student.

This is one I was sure that I would be immune to. I remember being an eager third-year med student and even more ambitious subintern, frustrated with my inability to be any kind of useful. I vowed that when I was an intern, I would always be the kindest person and make sure to fully engage my medical students. Spoiler alert: That did not happen. This one is the equivalent of your parents saying, “You’ll understand when you’re older.” Once you transition from the coddled med student life—I know, you don’t feel coddled—to the sharp world of residency, you will understand that the external pressures on your residents are what sometimes prevent them from being the best teachers. Dear med students, you aren’t being ignored or forcibly kept to past 5 p.m. for our enjoyment; your resident is just trying to finish the interdisciplinary orders before the case manager leaves at 4 p.m.

There are not a lot of “thank-yous.”

This is a sad one to write, but it is the truth. There will come a point where you become “super intern.” You can get numbers for a 15-patient service in 30 minutes; you have the CT reading room extension memorized; you and Liz, the pharmacist, are best buds; and total parenteral nutrition is reordered before 1 p.m.

without missing a beat. You will get to the end of a day where you successfully discharged a patient to a skilled nursing facility on a Friday, and literally no one will acknowledge your hard work. And part of writing this is to remind seniors and attendings to thank your juniors, and to all the interns out there, remember to thank yourselves and be kind to yourselves. Acknowledge your own hard work, and if you’re ever feeling taken for granted, go talk to a patient—they will always say thank you.

It gets better.

Maybe everything I wrote thus far makes internship sound kind of awful, and it kind of is! But it is also kind of amazing. I don’t think any person grows as much as they do during their intern year. No one knows the hospital and the patients as well as the interns on every service, and that is when you really start to feel like a doctor. That is why you went through this whole process to begin with! Like I said, you will trip and fumble around for months, but you will get up and dust yourself off and come out stronger on the other side. The friends you make during your intern year are some of the best, because you’re the ones in the trenches together, fighting the good fight. Misery loves company. Take the time to get to know your co-interns, vent about your bad days, and remember that you are not alone in this crazy world of medical training.

I know there is no substitute for knowing “exactly” what it will be like to be an intern, and as we are all textbook type A personalities, we want to be as prepared as possible. But just trust me on this one: There is no way to prepare, and I absolve you of the responsibility of trying. Use these last few precious weeks of freedom to spend time with your family and friends (at an appropriate social distance), try out a new hobby, check things off your bucket list, and sleep for hours on end uninterrupted. Because come July 1, the hospital owns you, and you will learn how to be an intern.

■ —Dr. August is a surgical resident at Stanford Medicine, in Stanford, Calif.

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9

A New Generation of Laparoscopic Training A Q&A With Martina Vitz, PhD, Head of Training and Education at VirtaMed Why create a new laparoscopic training simulator?

Dr. Vitz: Decades of simulation have provided a wealth of evidence for the efficacy of virtual reality (VR) simulators for laparoscopic skills acquisition.

Papers such as Ahlberg (Am J Surg 2007;193[6]:797-804) and von Websky (J Surg Educ 2012;69[4]:459-467) show transfer validity, significantly reducing the error rate as residents perform their first laparoscopic surgeries.

However, there have been no significant steps toward a more motivating laparoscopic training system and, unfortunately, this has resulted in many simulators being underused. At VirtaMed, we saw an opportunity to synthesize the lessons learned from this evidence with more motivating training concepts, and a new generation of graphics and haptics.

How does a training concept motivate residents to continue learning?

Dr. Vitz: My experience in running a laparoscopic training center demonstrated that trainees need the opportunity to improve specific skills, rather than enduring long procedures. Previous laparoscopic training systems have allowed trainees to either practice specific movements in abstract environments or complete full procedures.

Imagine if sports training only consisted of playing full matches, rather than drilling specific skills, or if an orchestra would need to play the whole score just to improve a certain part.

Repetition gives the opportunity to focus and improve, with a consistent starting point and a measurable result. This is exactly what VirtaMed applied to the LaparoS™, even allowing a trainee to practice handling complications. This is a unique opportunity for a resident to take responsibility, rather than handing over to those with more experience.

Are haptics so relevant for training?

Dr. Vitz: During my 15 years running a training center, I only used VR simulators without haptic feedback because I am convinced it is better to train without haptics than with unrealistic sensations that are distracting.

With VirtaMed’s LaparoS™, trainees coordinate the laparoscope with multiple instruments, including the familiar bumping of shoulders and elbows between trainees, or the collision of instruments within the abdomen.

Together, the training team learns optimal trocar placement, and even experiences the consequences of incorrectly placed trocars.

In the past, it has also been distracting when organs have behaved unnaturally. VirtaMed’s software researchers have developed virtual organs with individual behavior, so for the first time the gallbladder is much more flexible than the denser liver bed. These virtual organs even move with gravity as the patient model is positioned in (reverse) Trendelenburg for the simulated procedure.

What does a successful laparoscopic skills training program look like?

Dr. Vitz: Von Websky and I published, in 2012, that “Access to a simulator is not enough” (Surgery 2012;152[5]:794-801). As discussed above, we need a realistic simulator that triggers the intrinsic motivation of each trainee. Moreover, we need to be flexible enough to integrate the

simulator and its training concept into training programs, as part of the board exam, a mandatory step before the operating room or a recognized entry in log books. I am very happy to work with professors and surgical societies to integrate simulation into the educational pathway.

To learn more about the VirtaMed LaparoS™, visit virtamed.com/laparos.

10

IN THE NEWS

GENERAL SURGERY NEWS / JULY 2020

Tracheostomy and COVID-19 continued from page 1

terms with the possible outcome of his own nonexistence in the upcoming battle. I was glad my perspective included an afterlife rather than nonexistence, but its sudden contemplation weighed heavily. So, besides all the family precautions and shutting down my elective practice of thyroid and parathyroid surgery, it was time to think about preparing for the difficult work.

We had the online classes on how to use a ventilator, town halls, departmental meetings—all of which seemed to indicate that surgeons would be second-tier providers, retooled to become subintensivists in the upcoming war. I was OK with that and ready to be deployed. In fact, I did a few shifts in the Mount Sinai Queens ER and on the regular ward, bringing me back to my days as an intern.

It was amazing to see the dedication and care that the providers there gave. But I also started to realize there were going to be many ventilated patients, which would lead to those patients needing tracheostomies, something I am proficient at and have done for years. Discussions within our own institution were initiated and the intensivists did, in fact, warn that they would be needing tracheostomies on these patients and before 14 or 21 days.

Debate on ‘Real’ Indications As the days rolled by, opinions and position papers on the “real” indications for tracheostomies were vigorously debated. Early in

the pandemic, many institutions in New York City forbade tracheostomies in all COVID-19 patients. Interestingly, the positions that made it into print were the ones that stated tracheostomies were not proven to improve survival, were dangerous to the providers, and thus should be delayed until 14 to 21 days of intubation. I certainly understood and agreed with the need to protect our providers from needless exposure and risk for infection and death, but waiting 21 days didn’t seem to make sense given my long experience interacting with intensivists taking care of ventilated patients. Some of our colleagues were understandably deterred by a report of two Italian ENT physicians who had contracted the virus, one of whom succumbed to COVID-19.

My personal communication with two Italian colleagues revealed that their indications for tracheostomy in COVID-19 patients did not differ from any other requiring prolonged ventilator support.

Experience With 125 Patients Over a seven-week period, our team at Mount Sinai performed 125 tracheostomies on ventilated patients with COVID-19. They have all been bedside procedures with a percutaneous technique using disposable bronchoscopes and sometimes ultrasound guidance. There have been no intraoperative deaths or deaths related

From left: Adel Bassily-Marcus, MD (director of surgical ICU), Kyle Willey, MD (assistant director, infection prevention), Randy Owen, MD, and Elizabeth Tse (surgical ICU NP), getting ready for a tracheostomy. Surgeons are wearing powered airpurifying respirators.

IN THE NEWS

JULY 2020 / GENERAL SURGERY NEWS

to the procedure postoperatively. In one case, a tracheostomy tube was found to be dislodged in the subcutaneous tissues of an obese patient three days after placement, at which time she was successfully orotracheally reintubated with subsequent replacement of an extended-length tracheostomy tube with no untoward sequela. Two patients experienced significant bleeding from the wound after anticoagulation was restarted: One patient was managed by again halting the anticoagulation and packing the wound; the other patient was off the ventilator and so the tracheostomy tract was cauterized with silver nitrate at the bedside, averting further problems.

Of the 125 patients undergoing tracheostomy, 25 subsequently died from COVID-19. Twenty patients have been discharged from the hospital; two of them went home directly. Many patients remain in the hospital, with some patients thriving off the ventilator more comfortably, with less need for medications for pain and sedation than endotracheally intubated patients. Using less sedation became an advantage when some medicines threatened to become scarce. Several patients have undergone downsizing and decannulation of their tracheostomy tubes on a daily basis.

communication with the team of intensivists is critical. All agree that patients who are not in this middle group should not undergo tracheostomy, unnecessarily exposing the providers to a plume of respiratory droplets laden with coronavirus for little gain. The intensivists, nurses, respiratory therapists and those working alongside them are putting their lives on the line with constant exposure. If they are telling us that in their best judgment they need a tracheostomy to better care for their patient and to accelerate the progress of that patient, who are we as surgeons to disagree?

On several occasions, we encountered endotracheal tubes nearly occluded by blood and thick mucus. We were told numerous times by intensivists that they had to exchange endotracheal tubes urgently because they were clogged and therefore requested that a tracheostomy be placed for safer management of the airway. After tracheostomy, the inner cannula occasionally was found to be clogged with blood and mucus, which is solved by a simple changing of the inner cannula rather than the need for a much more difficult, emergent orotracheal tube exchange. Proning (turning the patient to

a face-down position) has been utilized for better aeration of the lungs, and the tracheostomy helps to establish a more secure airway compared with an orotracheal tube during these challenging proning events. As with non‒COVID-19 ventilated patients, an increasing number of COVID-19 patients have been weaned from ventilators to tracheostomy collar, freeing up much-needed ventilators and ICU beds for other patients.

Debates on Appropriate PPE Knowing that this wave of patients continued on the following page

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12

IN THE NEWS

GENERAL SURGERY NEWS / JULY 2020

Life After Burnout: A Case Study continued from page 1

But research findings have indicated that surgeons, who are trained to recognize problems in others, tend to be poor assessors of their own well-being. According to one paper, although one-fourth of surgeons scored in the bottom for well-being among physicians, 70% of those surgeons believed their well-being was as good as or superior to that of the average physician (Ann Surg 2014;259[1]:82-88).

The club mate’s concern proved prescient. Several months later at a practice, Dr. Johnson threw her fencing equipment across the room over a simple disagreement on a call. “It was the height of poor sportsmanship, the first time I’d done anything like that in 17 years of fencing. Clearly, something was fundamentally wrong,” she said. Within a week, she was plugged into counseling—“but of course, I told none of my fellow residents what was going on.”

A few months after that initial crisis, Dr. Johnson attended a tournament she had enjoyed in the past. But not this time. Unable to win a bout or land a touch on anyone, she drove home feeling absolutely done with everything.

“It seems so minor in retrospect, but in the moment I felt that if I couldn’t fence, which I had been training in for decades; how did I think I could become a surgeon?” she recounted.

Dr. Johnson was not alone. A decade-old landmark survey of nearly 8,000 surgeons found that 40% screened positive for burnout (Ann Surg 2009;250[3]:463-471).

Tracheostomy continued from the previous page

needing tracheostomy would come, we started working on adequate PPE early on. A debate ensued regarding whether N95 masks would be enough or whether a powered air-purifying respirator (PAPR) would be more appropriate. One factor was how many PAPR devices were available to the institution and whether a perception of needing the PAPR would be created, causing an unnecessary crisis of supply. Some literature showing improved protection with PAPR was cited, but admittedly it was very scant and some were not convinced.

Nevertheless, practical matters again drove the outcome. Given the publication outcry that tracheostomies were high-risk procedures and that some were unwilling to participate, shouldn’t we at least provide the best protection we have to those doing the procedures? Common sense eventually won the discussion (and the fact that the surgeons doing the procedure weren’t willing to do them without PAPR), and a policy ensued that all tracheostomies would be done with PAPR. In fact, many of us (myself included) choose to wear an N95 mask inside the PAPR as well. It’s cumbersome and noisy, but one adapts and the procedure can be performed without being distracted.

Concerns About Aerosolization We also worked out a technique to

She was also not alone in keeping her crisis secret from colleagues.

A 2018 survey of the American College of Surgeons’ board of governors showed that more than 50% of surgeons resisted talking about burnout due to the stigma attached to it.

Dr. Johnson’s willingness to seek treatment, however, may have been unique. A 2019 Medscape survey of 15,000 physicians found only 17% of general surgeons would pursue treatment. The counseling that Dr. Johnson received did make a difference. Despite her posttournament setback, she persisted with both residency and counseling, this time with the recognition and support of her program. Subsequently, things got better.

The experience of working through burnout helped Dr. Johnson learn to monitor her own stressors. She finished residency with the skills to be a successful surgeon and friends she has kept to this day. But this initial success didn’t make her immune to relapse. Last summer, in her seventh year as an attending surgeon, she felt herself starting to slip into old patterns of behavior and went back to therapy.

She now uses her own experience with burnout as an opportunity to normalize the conversation with colleagues and with the residents she works alongside.

“They can see me as a surgeon, not as someone labeled as suffering from burnout; it’s a frame shift that allows us to talk about difficult situations in the context

disconnect the inflow of air from the ventilator leaving the viral filter on the circuit tubing whenever a planned break in the circuit occurs. Thus, when the bronchoscopy swivel adapter is placed, the endotracheal tube cuff is deflated, the bronchoscope is inserted or withdrawn, and finally, when the tracheotomy is made and before the circuit is secured on the new tracheostomy tube, the inflow is disconnected. Thus, the inflow tubing is disconnected about a half-dozen times during the procedure. Despite that, it is obvious that aerosolization during the procedure occurs, and our impression is the bronchoscopy itself is the primary culprit. (Thus, consideration for open procedures has been contemplated, but the warnings against using the Bovey and the logistics of bringing a Bovey generator, headlamp and doing open surgery on a wide ICU bed with very limited help seem prohibitive.) A few times, we attempted the technique publicized by our colleagues at NYU Langone to place the bronchoscope outside of the endotracheal tube within the trachea, but we found this to be technically difficult, prolonging the procedure without much gain.

A Personal Note Our impression at the end of May is we have finally reached a plateau of patients requiring ICU care and ventilators, and the number of tracheostomies

‘As with firefighters who get farther and farther into a burning building without recognizing the danger, resilience in surgeons can sometimes allow us to get too far along a path from which we might need rescuing.’

—Laura S. Johnson, MD of a career, rather than being defined by those moments alone,” Dr. Johnson said.

What protects against burnout, and what doesn’t?

Some speculate that lack of resilience makes physicians vulnerable, but Dr. Johnson thinks this may be backward. “As with firefighters who get farther and farther into a burning building without recognizing the danger, resilience in surgeons can sometimes allow us to get too far along a path from which we might need rescuing.”

But some measures of self-care have been documented to be useful. Surgeons who exercise consistently report lower rates of burnout, as do those who make annual primary care visits. Also, taking steps to mitigate personal stressors may be useful. For example, having identified electronic health record requirements as a trigger for her recurrence, Dr. Johnson is working with her hospital’s information technology department to streamline interactions with the computer system.

As helpful as these personal approaches may be, research on burnout indicates that organization-level interventions, such as reduced workload, more tolerable shift scheduling and enhanced teamwork, would yield greater benefits (JAMA Intern Med 2017;177[2]:195-205). ■

requested has dropped drastically.

Thankfully, every member of our team has remained well without any symptoms of COVID-19. I personally have had two negative antibody tests and one negative nasopharyngeal swab polymerase chain reaction test. We hope and pray this persists. Although I have felt the suffering of these patients, I do believe that what I have experienced is a small fraction of what those working with these patients every day in the ICUs have experienced, and an even smaller fraction of what the families are experiencing. I hope that my joy in being able to provide a service to these patients and our intensivist colleagues has not clouded my judgment about what the right thing to do is, but I think that it has not. I have a sense from what I have witnessed and what my colleagues are reporting to me that this procedure is one important tool in our armamentarium to aid in the recovery of these patients. I trust my colleagues and it is a pleasure to serve alongside them.

May this plague pass over us quickly and never return.

■ —Dr. Owen is chief, Section of Endocrine Surgery, The Mount Sinai Medical Center, New York City.

Co-authors: Drs. Adel BassilyMarcus, Steven Chao, Gustavo

Fernandez-Ranvier, Ardeshir HakamiKermani, Shinobu Itagaki, Andrew Kaufman, Roopa Kohli-Seth, David Lee, Lina Miyakawa, Daniel Nicastri and Hyunsuk Suh, all of Mount Sinai Medical Center, in New York City.

Acknowledgments: Special thanks to Michael L. Marin, MD, the chairman of surgery, and to the courageous teams performing these procedures including Drs. Samuel Acquah and Koichi Nomoto, Dr. Clara Andrews, a visiting anesthesiologist from San Antonio, countless nurses, respiratory therapists, physician’s assistants, nurse practitioners (including James Lieser and Nicole Sampier from Florida), and supporting staff who made the care of these patients possible.

Editorial Commentary The personal sacrifices made by the surgery teams of Drs. Owen and Marin should be commended for engaging head-on the most dangerous general surgery procedure in the epicenter of the COVID-19 pandemic. Their heroic efforts in the New York City hot spots were made possible by their personal faith in the use of protective devices that included PAPRs as essential PPE (see photo) and N95 masks worn during the procedures. Bravo!

—Peter K. Kim, MD, MMM, FACS Editorial advisory board member, General Surgery News

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GENERAL SURGERY NEWS / JULY 2020

Achalasia: Prevalence and Management Dr. Nakhal’s REPLY

elcome to the July issue of The Surgeons’ Lounge. In this issue, Elias Nakhal, MD, a professor of surgery, School of Medicine, Universidad Central de Venezuela, in Caracas, discusses achalasia: prevalence and management. We also feature our next installment of the “The Procedure, the Name”—a history of the Heller myotomy.

We look forward to our readers’ questions, comments and interesting cases to present.

W

Sincerely, Samuel Szomstein, MD, FACS Editor, The Surgeons‘ Lounge Szomsts@ccf.org

QUESTION for Dr. Nakhal From Francisco Ferri, MD, PGY-3, Cleveland Clinic Florida, Weston Achalasia is the best understood of all esophageal motility disorders, and frequently poses a challenge for surgeons. The recent and continuous proliferation of endoscopic procedures, seeking to partially or fully treat the achalasia, have imposed even bigger challenges for surgeons at the time of the operation when dealing with a previously intervened esophagus. I wonder whether you can give us some insights based on your personal experience.

• How common is it to see patients with achalasia and previous endoscopic procedures? Do you think that the trend has been increasing over the last few years?

• How would you manage patients with achalasia and a sigmoid esophagus?

• What would be your approach to patients with achalasia and previous thoracotomies?

• Could you talk about your personal experience in Venezuela?

• What challenges do you face as a surgeon in a developing country? What changes have you made, if any, in your daily practice?

How common is it to see patients with achalasia and previous endoscopic procedures? Do you think that the trend has been increasing over the last few years?

According to our experience, the incidence of achalasia and previous endoscopic procedures in the early years of my practice was high. More than 50% of patients diagnosed with achalasia have had some type of prior endoscopic procedure—the most frequent being pneumatic dilatation—and were referred to our office due to recurrence or lack of symptomatic improvement. At that time, patients referred to surgeons after onabotulinumtoxina (Botox, Allergan) injections were either considered too high risk to attempt another endoscopic procedure or had advanced disease with minimal oral intake. Consequently, we frequently found patients with severe esophageal dilation, due to the natural progression of the disease, as well as fibrosis and greater stiffness of the dissection planes. I believe that, in the past five years, gastroenterologists are more prone to refer patients directly to the surgeon without offering endoscopic procedures based on results showing that the laparoscopic technique is safe and provides satisfactory long-term results.

How would you manage patients with achalasia and a sigmoid esophagus?

We have had interesting cases with a severely dilated esophagus to the point of losing the longitudinal axis and completely lying on the diaphragm. One of those patients also had a surgical history of esophageal seromyotomy through a thoracotomy. Although there is an argument for esophagectomy in these cases, several years ago, we had a small series of patients treated with laparoscopic myotomy and good long-term results.

Our thought was that it is always possible to perform esophagectomy after a failed myotomy, so we offered laparoscopic myotomy instead. Our series included six patients with a sigmoid esophagus who were opic myotooffered the option of laparoscopic my, and we had good results in these cases after seven years of follow-up. We do not recommend performing a fundoplication oplication after myotomy in these patientss because nt of conwe think that the small amount er esophatent running through the lower mised with geal sphincter could be compromised ases the presany type of procedure that increases sure in the cardias.

What would be your approach to patients with achaes? lasia and previous thoracotomies?

It is very important to define the intention of the ncludes two cases of thoracotomy. Our experience includes sophageal seromyotpatients who underwent an esophageal d via a thoracotoomy in their youth, approached my. Although both had partiall improvement, reducing the Eckard to a minimum of 6 points, many years later symptoms recurred and the esophagogram showed much more

severely worsened dilatation. Using a laparoscopic approach, we did not find much difficulty in dissecting the distal esophagus. Careful dissection and high-definition images ensured adequate visualization of all the planes in order to avoid injuries.

Could you talk about your personal experience in Venezuela?

Since 2009, we have been working with patients presenting with motor disorders of the esophagus, mainly achalasia. But we have also had the opportunity to treat other conditions, such as hypertensive lower esophageal sphincter, nutcracker esophagus and scleroderma, among others. Since the beginning of our series, we adopted the technique of approaching the abdominal cavity under direct visualization, performing a retroesophageal tunnel, retracting the esophagus with a Penrose drain, and divulsing the longitudinal and circular muscular fibers between two curved dissecting forceps. We always performed an anterior and partial (Dor) fundoplication. We have only performed intraoperative endoscopy in two cases; both were patients with previous myotomies, and we have never left a drain in place. The latter is not because we considered ourselves infallible to complications, but because laparoscopy with high-definition images has given us the possibility of detecting any submucosal injury in the intervened segment of the esophagus at the time of divulsion. My series includes 123 patients with esophageal surgery.

In the first 20 cases, we tried to perform postoperative manometry as part of the follow-up; however, due to favorable postoperative results combined with the high cost of the procedure, we opted not to perform routine postoperative manometry.

What challenges do you face as a surgeon in a developing country? What changes have you made, if any, in your daily practice?

Fortunately, in private practice, we have the possibility to perform all preoperative studies needed without any limitation other than that related to cost to the patient and their ability to pay (cash or through an insurance company). Esophagogastrodu Esophagogastroduodenoscopy, high-resolution manometry and esophag esophagogram are studies that we of all patients with routinely order for the evaluation eval esophageal obstruction. Howtypical symptoms of esop ever, the t situation is completely different in the public health system. There, the lack of minimally invaAchalasia of sive equipment (laparothe esophagus. scopic and/or robotic) and specialized energy sources that were once used by surgeons in our public hospitals have reduced the possibility of performing these types of procedures safely and eeffectively. We hope to see br brighter times in the future of tthe public health system in order to ensure quality training in minimally mini invasive surgery for generation ■ generations to come.

SURGEONS’ LOUNGE

JULY 2020 / GENERAL SURGERY NEWS

The Procedure, the Name

Heller Myotomy

By Vicente J. Cogollo, MD, research fellow, and Lisandro Montorfano, MD, PGY-3 surgical resident, Cleveland Clinic Florida, Weston The Heller myotomy, also known as cardiomyotomy, is the surgical procedure of choice for patients diagnosed with achalasia. It includes division of the longitudinal and circular muscle fibers of the esophagus at the level of the lower esophageal sphincter to relieve tension and improve the transit of food to the stomach.

On April 14, 1913, a German-Prussian surgeon named Ernst Heller made one of the most important contributions to foregut surgery by performing the first cardiomyotomy to treat dysphagia in a patient with achalasia (Figure).

incision, which allowed surgeons to perform the concomitant gastric fundoplication required to ameliorate the gastroesophageal reflux encountered by some patients after the myotomy.

In the 1990s, with the beginning of laparoscopy, these open operations rapidly became outdated and replaced by minimally invasive approaches, showing quicker recovery times and less morbidity.

Not surprisingly, after more than 100 years after its first description, the Heller myotomy has managed to maintain its status as the gold standard surgical approach in patients with achalasia.

Suggested Reading Abir F, Modlin I, Kidd M, et al. Surgical treatment of achalasia: current status and controversies. Dig Surg. 2004;21(3):165-176.

Andreollo NA, Earlam RJ. Heller’s myotomy for achalasia: is an added anti‐ reflux procedure necessary? Br J Surg.

1987;74(9):765-769.

Andreollo NA, Lopes LR, Malafaia O. Heller’s mytomy: a hundred years of success! Arq Bras Cir Dig. 2014;27(1):1-2.

Bhayani NH, Kurian AA, Dunst CM, et al. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia.

Ann Surg. 2014;259(6):1098-1103.

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Figure. Original detailed report with drawings of the first esophageal extramucosal division of muscle fibers performed by Dr. Heller, published in 1914.

Dr. Heller was born in 1877 in Eichenwalde, Germany, completed his medical studies in Germany, and served as a general surgeon during World War I. During his training, he was strongly influenced by famous surgeons from the early 1900s, including Drs. Georg Gottstein and Hans Heyrovsky.

The results of the first Heller myotomy were published in the prestigious journal Mitt Grenzgeb Med Chir (1914;27:141149). A careful description of the technique, outcome and follow-up of the case were reported, with special attention paid to the description of the release of the esophageal muscle fibers. In 1914, the procedure became the preferred surgical approach to treat achalasia among European countries.

Initially, the Heller myotomy was performed through an open thoracotomy.

Later, the decision was made to perform the procedure through a laparotomy

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16

OPINION

GENERAL SURGERY NEWS / JULY 2020

Moneyball for Health Care: Why Hasn’t It Happened?

By BRUCE RAMSHAW, MD B

“M

oneyball,” a book

by Michael Lewis, and later made into a movie starring Brad Pitt, describes the success of applying the principles of data science to develop a winning strategy in baseball. It’s a transferable skill, so why hasn’t Moneyball happened in health care? You would think if data science can be used to win more games in baseball, it could be used to lower costs and improve outcomes. Data science is about measurement and improvement. In baseball, the measurement to be improved is runs scored with the lowest possible budget—producing the most wins per dollar spent.

Similarly, if we want a sustainable health care system, we should measure and improve the value of care we provide, resulting in lower costs and better outcomes over time. If you can measure something, it can be improved. But if something is not being measured, it can’t be improved—and we’re not measuring the value of care in health care, in any organization, in any health care system in the world.

For data science to work, there are basic rules. First, data requires “context,” or a definable process. Attempting to apply data science without context doesn’t work. In sports, context is provided by the specific set of rules for a particular game, like baseball: nine players, three outs, three

Probably the most harmful habit of all, we’ve allowed health care leaders to continue to push the growth and volume model despite the harm done not only to patients, but to doctors and other caregivers as well.

strikes, nine innings, etc. The insight from the application of data science tools applied to baseball will not work the same if applied to a different sport such as American football, with 11 players, four quarters, four downs, etc.

In health care, context means defining each whole patient care process. The specific patient and treatment factors and outcome measures collected will be different for different types of patient care processes. For example, outcome measures used to define the value of care for a breast cancer process will not be the same as those used for a ventral hernia process.

Another principle of data science is it should be applied to measure and improve outcomes that matter most. In baseball, what matters most to improve the value of the team performance is combining salaries (financial measures) with factors that result in the most runs and wins (e.g., on-base percentage).

Applying data science to measure and increase the number of pitches thrown will likely not help win more games.

We’re not typically measuring outcomes that matter in health care. We tend to measure things that are easy to measure, such as if antibiotics are given before surgery, rather than the factors that improve the value of care the most.

We document these easy-to-measure factors, often because of perverse financial incentives or penalties, without measuring to see what effect they have on outcomes. To truly measure value, we should be combining financial measures with outcome measures that matter in the context of each definable whole patient care process. Until we do, we can’t lower costs and improve patient outcomes at the same time.

For over a century, baseball was using data the same as health care is today. At first, baseball statistics were based on the original development of one set of static measurements,

like batting average, runs and runs batted in (RBIs). These statistics were invented in 1845, and presented in the “box score” for each game. The more these old statistics were examined, the less sense they made. They were not the best measures of player and team value, so they didn’t give the best insight into how to score more runs and win more games.

In health care, we also use static measurements that don’t measure value well. Take wound infection, for example. Every hospital in the United States reports wound infection based on the CDC definition: superficial, deep or organ space. But when we asked patients who had wound infections what they thought, they said the CDC definition was not very helpful. Patients thought measuring wound infections by the invasiveness of the treatment and the length of time required to heal their wounds was a much better measurement. When we looked at the data for wound infections after open ventral hernia repairs, the patients were right: Some superficial infections took months or years to heal, requiring invasive surgical procedures, whereas some deep infections were resolved with a single course of oral antibiotics. We can learn to apply better measurements in health care.

It wasn’t until the 1970s, when Bill James, a writer and night watchman at a Stokely Van Camp pork and beans cannery, began to question the status quo of baseball statistics. In 1977, James published a periodical called the “1977 Baseball Abstract: Featuring 18 Categories of Statistical Information That You Just Can’t Find Anywhere Else.”

James developed new ways to measure baseball success and found that runs scored were highly correlated with wins.

He developed weighted correlations that led to a formula that generated what he called “runs created.” As he developed momentum, he met with a small group of friends, including Sports Illustrated writer Dan Okrent, at La Rotisserie Française restaurant, in New York City.

That is where the concept of “Rotisserie” baseball was born. This has developed into a fantasy sports industry, which is worth nearly $10 billion annually.

At that time, the only people interested in these new baseball measurements were the fans. As James continued to develop better measurements, there was one other group that showed interest: player agents. The agents wanted more statistics that validated the value of their clients, the professional baseball players, to justify negotiating larger salaries.

Interestingly, the group of people who showed no interest in these better measurements and the application of data

science to baseball were the owners and managers of the teams. The people most invested in the outcomes of the games had no interest in changing how they used their data and managed their teams.

James, working with a company called STATS Inc., tried to persuade teams that they should use the new measures he had developed. Teams just weren’t interested.

Part of the problem was that baseball already had its data company, Elias Sports Bureau. The company had the contract for managing all of baseball’s statistics. Like with the current generation of electronic health records in health care, baseball at that time did not think there was any need to change. The company certainly did not want to admit or believe that the statistics they were paid to collect and publish were poor indicators of player and team value. There was no appetite or incentive for innovation or improvement.

The status quo was not challenged again until two entrepreneurs from the financial industry took what they learned about how to use data science applied to financial derivatives, and realized they could do the same thing in baseball. They started a company called AVM (Advanced Value Matrix) Systems in 1994, and approached teams to see if they could consult and apply their data science methods to baseball.

Change did not come easily. It wasn’t until the Oakland A’s were sold to a more frugal ownership group that there was enough financial pressure to make changes to the status quo. The inequities in baseball budgets rose to the level where some teams could afford the best individual players and others could not.

Change usually only occurs when the pain of the status quo rises to a level greater than the discomfort of making a change.

When the new owners refused to match the salary offers for star players who were plucked away by the wealthy teams, like the Yankees, then the A’s management, with Billy Beane in charge as the A’s general manager, felt the pressure to make changes in how they operated. Billy had read every one of Bill James’ “Baseball Abstract” publications, and he discovered that baseball was not using data appropriately.

Paul DePodesta was an intern for the Cleveland Indians when Billy met him.

Paul graduated from Harvard University with a degree in economics, but his real passion was the intersection between economics and psychology, a discipline now called behavioral economics. Paul had recently met the Wall Street traders-turned-baseball data gurus during one of their initial sales calls and he was

OPINION

JULY 2020 / GENERAL SURGERY NEWS

Change usually only occurs when the pain of the status quo rises to a level greater than the discomfort of making a change. intrigued. Soon after that, Billy Beane hired Paul, and Paul convinced Billy to hire AVM Systems. With the help of Paul and AVM systems, Billy began to apply data science to the Oakland A’s.

Moneyball was the result.

Today our health care system’s use of data is similar to where baseball was in the 1990s. We’ve learned many wrong lessons. From reductionist tools, like prospective randomized controlled trials, we’ve learned to apply treatments that seem best for the average patient to all patients, regardless of differences in each local environment and the biologic variability of patient subpopulations. We’ve learned that training to be a doctor should allow us to use our training and experience, without appropriate data, to make treatment recommendations. Probably the most harmful habit of all, we’ve allowed health care leaders to continue to push the growth and volume model despite the harm done not only to patients, but to doctors and other caregivers as well.

The financial constraints and inequities in health care are worsening and are contributing to more and more harm for patients, employers and in some cases, even for doctors themselves. Tragically, there are reports in the United States of young people dying because they can’t afford insulin. Doctors are dying by suicide at a rate greater than in the general population.

A main challenge to make necessary changes in health care is to let go of the pride and the belief that we (doctors, hospitals, insurers, even patients sometimes) know what is best for any given situation. Billy Beane describes the mindset required to make this change in the book: “The hardest thing … is there is a certain pride, or lack of pride to do this right.” Letting go of beliefs and the way we’ve always done things is hard and uncomfortable. But discomfort is a normal and necessary part of learning, and transformation can’t occur without changing our mindsets and the structure for how we care for patients and manage data.

There is a major difference between applying data science to baseball and to health care. Ultimately, baseball is a competitive sport—it’s about winning, beating another team. When other major league teams learned to apply data science to their organizations, the advantage for the Oakland A’s was diminished.

In fact, just two years after the A’s had tied the Yankees for the most wins during the 2002 season with one of the lowest budgets in baseball, the Boston Red Sox won their first World Series in almost 100 years using the same principles of data science.

This data-driven effort was led by Theo Epstein, the new general manager, and Bill James, who was hired by Boston’s owner, John Henry, in 2003.

In health care, we should not be competing. We should be focused on a goal that aligns all of us: improving the value of care for all patients with any disease or

health problem. When we align around the goal of value and work collaboratively to improve value for patients, we can apply one of the most important tools of data science: the ensemble model for learning. If every clinical team in each local environment were to implement a value-based continuous learning model and then network the learnings from each clinical team, we could improve value forever.

Data science is real, but very different from the reductionist science paradigm we’ve been taught and are functioning under in health care today. Until we feel

that the pain of continuing to suffer in this reductionist status quo is worse than the discomfort of learning and applying a new data science paradigm, like Moneyball did for baseball, we will continue to suffer the consequences. I believe the inequities and harm resulting from our current system structure are enough to commit to making this change now. ■ —Dr. Ramshaw is a general surgeon and data scientist in Knoxville, Tenn., and a managing partner at CQInsights. You can read more from him on his blog: www.bruceramshaw.com/blog.

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17

OPINION

GENERAL SURGERY NEWS / JULY 2020

Fellowship or No, How Do Surgeons Ensure Quality? continued from page 1

as he approached retirement. His career was extended by the ability to shift focus over time as his life changed. Over the decades of his career, he found a gradually changing clinical focus that fit well with the needs of the community and the physical changes that come with being an aging surgeon, to continue serving patients for many additional years.

Consider the community of surgeons in our nation. If everyone is a subspecialist who achieves this status through fellowship, what do we do with those for whom the choice doesn’t work well for 35 years?

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A typical five-year general surgery training program educates residents in a wide breadth of various procedures and diseases. Consider also the scope and number of subspecialty fellowships that are currently available in the surgical educational environment in America. Now let’s assume that only fellowship specialists are qualified to offer surgery for all procedures within their scope. If that is the case, what’s left for the general surgeon? What disease or procedure is not claimed to be performed with higher quality by a fellowship graduate?

Recently, abdominal wall reconstruction fellowships have

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summed up by Dr. Duke’s comment near the end of her rebuttal, where she states, “One can, however, utilize fellowship training as a proxy for specialty competence.” This one statement is at the heart of the different positions held by “general surgeons” and “specialty surgeons.”

Dr. Duke’s position is that if a surgeon completes a fellowship, then it is reasonable to assume that they provide quality service, and that by extension, the service provided by “nonspecialists” is possibly not high quality. On the other side, Dr. Stovall asserts, in his rebuttal, that clinical experience and the efforts of a surgeon in practice can be a pathway to achieve excellent quality without fellowship training.

Both debaters essentially miss the point, as they are arguing about various opinions on whether fellowship is the only pathway to surgical quality. Radically more important is the question of how to ensure quality for all patients. Additionally, there are two other major factors in this debate that are neglected by the debaters. First, we should talk about the effect of the topic question upon the profession of surgery, and secondly how that question affects the health care system in our country.

My experience as a member of multiple local quality assurance committees has shown me that fellowship training does not automatically ensure quality care in all instances. Undoubtedly, I’m not the only person who has made this observation. I’m sure that all of us can think of some colleagues who are fellowship-trained and also have quality concerns. Additionally, most of us can think of colleagues who are general surgeons and also offer high-quality surgery typically considered to be part of a specialty.

There is also such a thing as a high-volume surgeon who doesn’t follow most recent guidelines for specialty surgery.

Therefore, I feel Dr. Duke’s claim that fellowship training equals competence is not universally true. Neither does experience automatically lead to excellence.

Quality is a separate thing from training or experience. It is often achieved with experience and with training, but quality is not always the result of training and/ or experience. If the true aim is to ensure universal quality standards, then quality should be the focus rather than training or experience as surrogates to presume quality.

On a different note, consider the profession of surgery itself for a few minutes.

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What ‘competency’ means should be specific for each disease and procedure, but a competency-based model for surgical certification is the unassailable ideal method to ensure quality in all practice environments, by any provider, regardless of training or experience. begun, and with that even hernia work is no longer within the scope of a general surgeon. Acute care surgeons are specialists at emergency surgery—so the general surgeon is no longer most qualified at handling emergencies on call. The profession is nearly entirely picked over with very little left for the general surgeon to be qualified to offer to patients.

Furthermore, I recall an example of a surgeon who attended a morbidity and mortality conference when I was in residency. He was over 70 and retired at the time. His practice had been conducted for more than 40 years, having started with a focus on hernia work, then later taking an interest in colorectal, and switching to a primarily outpatient breast practice in the last 10 years

Will all those 55-year-old surgeons have to go back to fellowship training in a different specialty? What a problem this will create for the hospitals and health care system as surgical careers end sooner and career flexibility is diminished. Suppose a hospital has five colorectal surgeons who all wish they had more work to do, and no abdominal wall reconstruction specialists. I suppose all their hernia patients are referred to another community? The proliferation of highly focused practice models that are also highly inflexible creates increasingly likely problems with delivery of service in a community unless there is a surplus of surgeons for all specialities available.

Consequently, a specialty-only model will worsen the disparity of quality for

lower population density areas compared with highly populated areas.

In summary, there are several “side effects” of restricting procedures to specialists only. Moreover, the burden of those side effects is levied on the outsiders, surgeons who are not fellowship-trained lose parts of their practice, medical communities of lower density cannot provide quality to their patients, and surgeons who need/wish to change the direction of their career are forced into early retirement. All this in the name of improved quality for patients, following from the possibly incorrect presumption that fellowship training provides improved quality.

The solution to any perceived quality problem is not restricting procedures to those who have completed fellowship. Rather, I feel that Dr. Ioana Baiu’s essay published as part of GSN’s Resident Writing Contest is a particularly relevant idea (“Serving Time: Let’s Move to a Competency-Based Training Model”; www.generalsurgerynews.com/ In-the-News/Article/05-20/ Serving-Time-Let’s-Move-toa-Competency-Based-TrainingModel/58332). Her proposal is to transition residency training to a competency-based model.

Why not apply the same process to the questions of surgical competency while in practice? What “competency” means should be specific for each disease and procedure, but a competency-based model for surgical certification is the unassailable ideal method to ensure quality in all practice environments, by any provider, regardless of training or experience. Establishing a certification system to provide meaningful feedback to surgeons and monitor competency in all surgical procedures would be a tremendous effort, akin to a moon launch. However, it would also bring certification in the profession of surgery squarely into the 21st century, where all concerns about quality are clearly known. Moreover, a quality-based certification system also settles the question of the relationship between quality and fellowship-specialty training or experience in practice on an individual basis. With a system like this, the onus to be accountable for high quality rests where it belongs: on the surgeon as they are at that point in their career, rather than on a possibly remote history of hav■ ing completed a fellowship.

—Dr. Gerber is a general surgeon in Peoria, Ill.

OPINION

JULY 2020 / GENERAL SURGERY NEWS

Generally Speaking …

By KENNETH MURPHY, MD

read the Great Debates article on “Specialty-Specific Surgery” [April 2020, insert at page 16] with great interest—and rising temperature. Spoiler alert: I am a nearly 70-year-old card-carrying solo general surgeon— yes, a dinosaur—and a veteran of 30 years’ practice before disability forced me to retire. I was the first trainee in my program to be “allowed” to experience the five-year residency (rather than four). I need not conjure up visions of “iron interns” and 100-hour workweeks to find satisfactory reasons why urban-area—or any other area—surgery should only be done by fellowship-trained surgeons.

First, to the opining: • Back in the “glory days,” we barely had anything more than OB-GYN instruments anyway. (Weren’t they bent and rusted as well?)

• I suggest that Whipples and abdominal aortic aneurysm repairs are altogether “other dogs” and qualify in most anyone’s book for subspecialty status.

• Laparoscopic cholecystectomy was, in the first place, a natural extension of procedures already being performed by lowly “general surgeons.” Try to find a surgeon today who can open the patient and expertly fix the complications created laparoscopically, or who has done a common bile duct exploration or a sphincteroplasty; and, in the second place, lap chole was a procedure whose advancement was driven essentially by public demand rather than by sound, traditional medical research.

There are definitely things better left to the fellowship-trained surgeon: vascular surgery, pancreatic surgery, and thoracic and cardiovascular surgery. Advanced training, and some boards, already exist for these areas.

But just because a lowly general surgeon does only a dozen procedures (or 25 or 50, who’s to say?) a year does not mean that he or she can or cannot do it expertly and should or should not be allowed to do it.

Now to the reasons why I believe this heresy would not be a good thing.

I

as in need of expertise as the bigcity folk—perhaps more so, since rural patients are often poorer, less healthy, and have less access to health care. Further, the need for a specialty-specific, fellowshiptrained surgeon would not always be predictable before having one’s hands or a scope in the abdomen or chest. Sending patients to urban areas for the “special”—my bad—specialty-specific surgeon for care would be inappropriate and occasionally downright dangerous.

I do not accept that our capacity for knowledge and performance is so limited that we can only master a small area of medicine or that we should be reduced to being “carpenters.”

• The added fellowship time will increase the cost of education and training, assuming sufficient spots were available.

• Where one chooses to live and raise a family will be limited, depending on whether one is a lowly “general surgeon” or a fellowship-trained specialty-specific one.

• Will this philosophy create liability issues? If one’s operation goes badly and was not done by a “golden guy or gal,” is a lawsuit justifiable? In today’s climate, would it be class action? Would we see TV commercials and informercials on behalf of attorneys?

• Who will define the “urban area”? The American College of Surgeons? The American Board of Surgery? CMS [the Centers for Medicare & Medicaid Services], God forbid? Will the cutoff for an urban area be a million people? 25,000? Case by case?

• Finally, general surgeons have already ceded sizable portions of our field to others, for reasons outside the scope of this narrative. Consider the following: – Gastroenterologists today perform most of the GI endoscopy.

– Wound care, formerly in the surgical ballpark, is today performed mainly by a variety of nonsurgeon providers.

– Teams of dietitians, pharmacists, nurses and others are now responsible for patients’ nutritional needs, and in particular TPN [total parenteral nutrition]; the general surgeon was once called on to impart this knowledge and care, but today is sometimes not even on the “nutritional team.”

– Procedures such as central venous catheter and chest tube insertions, once in the domain of the surgeon, are now done mostly by radiologists.

– In many places, intensivists now run the surgical ICU, and it is off-limits to “lowly” general surgeons.

– Hospitalists perform pre- and postsurgical care on the wards.

– Paraprofessionals, such as nurse practitioners and physician assistants, perform ER and ward consultations, make hospital rounds, and conduct office visits. (I have even seen medical records reflecting operative “opening” and “closing” done by paraprofessionals, and will not dare broach this topic here.)

• What will be the “broad variety of routine general surgical issues, usually in rural locations” that the “shrinking pool of graduates” will be competent to manage? Appendicitis? Inguinal hernia repairs?

Colon resection for perforated diverticulitis? Having worked in a rural practice, I can testify that there are patients just as ill, just as complicated, and just

While the explosion of medical and other knowledge is a given, it does not relieve any of us of the need for continuous study, learning and educational advancement. I do not accept that our capacity for knowledge and performance is so limited that we can only master a small area of medicine or that we should be reduced to being “carpenters.” Otherwise, the day will come when

• Patient access to needed surgery would be decreased and/or delayed. The number of general surgeons is decreasing, and more trainees choose to subspecialize; there will never be enough of either to go around. Solos and small partnerships are dwindling. Waiting times for appointments are already bad—they would become incomprehensible. While in practice, my experience was that subspecialists somehow usually found ways not to be on call, limiting the availability of needed expertise.

the hernia specialist—who, after all, should know how to prevent them—will make and close whatever incisions/trocar sites are necessary; the “lowly” general surgeon will lyse the adhesions to allow surgical access and vision; the urologic surgeon will locate the ureters and perhaps memorialize them with stents; the colorectal surgeon will remove the neoplasm; and the gynecologic surgeon will perform the total abdominal hysterectomy with bilateral salpingo-oophorectomy because the tumor is attached thereto. Really?

I submit that we consider whether now is the time for the “lowly” general surgeon to return toward his and her roots and to a place where we are more, rather than less, general—where we will be consulted and relied upon to manage antibiotic therapy, anticoagulant use, nutrition, wound problems, and all of the other issues that traditionally were part and parcel of the field of general surgery. Oh, and by the way, we should perform the pre- and postoperative care as well. Our own college has a pretty concise statement on the responsibilities of the surgeon (Statement on Principles Underlying Perioperative Responsibility). Such a nowadays radical concept can, in my opinion, only result in better surgical care, since there will then be a captain of the ship ■ instead of a task force with no one in charge.

—Dr. Murphy is a general surgeon in Conway, Ark.

Relevant Statements of the American College of Surgeons Statement on Credentialing and Privileging and Volume Performance Issues www.facs.org/about-acs/statements/111-credentialing Statement on Emerging Surgical Technologies and the Evaluation of Credentials www.facs.org/about-acs/statements/18-emerging-tech Statement on Issues to Be Considered Before New Surgical Technology Is Applied to the Care of Patients www.facs.org/about-acs/statements/23-issues-new-tech Statement on Principles Underlying Perioperative Responsibility www.facs.org/about-acs/statements/25-perioperative Statement on Scope of Practice www.facs.org/about-acs/statements/40-scope-of-practice Statement on the Surgical Workforce www.facs.org/about-acs/statements/57-surgical-workforce Verification by the American College of Surgeons for the Use of Emerging Technologies www.facs.org/about-acs/statements/30-verification-emerging-tech

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20

RESIDENT WRITING CONTEST

GENERAL SURGERY NEWS / JULY 2020

Want to Increase Surgical Resident Autonomy?

Let Them Bill for Procedures

By REBECCA WILLIAMS-KARNESKY, MD, PhD

“I

’m going to time you out; then I’m going ing next door to start the next case. I’ll be back to check on you; let me know if you need ed anything.”

Those were the words my attending said d to me before he left me to operate alone— totally alone—for the first time. I was doing an elective inguinal hernia repair, an operation I’d done a fair number of times before. But this time it felt different.

There was no security blanket: no attending to watch over my shoulder, no chief to guide me through, no junior to act as a second pair of eyes, as inexperienced as they might be. It was just me and the scrub technician as my first assist. “Do you want a scalpel?” she asked.

“Right,” I replied, taking the blade. “Incision.” I called out, loud enough so the anesthesiologist could hear. I was the surgeon.

to qualify for reimbursement.5 Although the intent of these t legislative policies was to increase faculty supervision of residents in order to decrease rates su oof medical errors, the impact has been a decrease iin autonomy for surgical residents.

This phenomenon is unintentionally documented in one study looking at the impact of duty hour restrictions on surgery resident case volumes.6 Although the total number of major cases performed by general surgery residents decreased by only 2.3% post–duty hour restrictions, teaching assistant cases—defined as cases in which a senior-level resident takes a junior resident through an operation—declined by 66%.6 Data from this study show that the decrease in the number of teaching assistant cases began in the late 1990s, before duty hours were enacted and around the time the CMS billing requirements for resident services were changed.

Honorable Mention

The Autonomy Crisis in Surgical Residency Perhaps the single most important issue facing young surgeons today is readiness for independent practice at the completion of residency. Many young surgeons lack confidence in their skills, even if they are highly qualified. One survey of 676 graduating chief residents from 55 general surgery training programs found that 23% of respondents did not feel adequately prepared to practice as a general surgeon.1 Residents aren’t the only ones who feel they aren’t ready for independence. A 2013 survey of surgical fellowship directors revealed that this group believed their incoming fellows were woefully unprepared for independent practice. Strikingly, 30% of responding fellowship directors believed incoming fellows could not perform a laparoscopic cholecystectomy independently, and 66% thought that incoming fellows were unable to operate unsupervised for 30 minutes during a major surgical procedure.2

Duty Hours Aren’t to Blame In 2003, in response to widely publicized concerns about resident supervision and medical errors,3 the Accreditation Council for Graduate Medical Education (ACGME) implemented the common standards for duty hours for residents, limiting surgery residents to 80 hours per week of work. Since that time, the argument has been made that because duty hours limit the amount of time residents spend in the hospital, they have led to a decrease in operative case volumes resulting in decreased resident autonomy.

However, around the time duty hours limits were being enforced by the ACGME, Medicare and Medicaid policies restricting billing for procedures performed by resident physicians also were enacted.4 A 2002 mandate by the Center for Medicare & Medicaid Services (CMS) required attendings to be present for “critical” portions of a case in order to be able to bill for them.4 This new requirement added to 1997 legislation mandating that physicians billing in a teaching setting involving resident care meet specific criteria, including “personally performing” the service in order

Resident-led billing would incentivize institutions to educate residents about the complex coding structures used for reimbursement, a skill that is frequently lacking in residency training.

Potential Models for Billing For Resident-Led Procedures Despite high-profile stories in the popular press depicting resident autonomy as a detriment to patient safety,7,8 there is increasing evidence that operations in which residents are allowed to function autonomously are safe and do not result in higher rates of complications than those in which an attending is present for the entire procedure.9-11 A 2017 study comparing outcomes of 1,649 appendectomies performed by unsupervised general surgery residents (n=548) versus those supervised by an attending surgeon (n=1,101) found no significant difference in overall postoperative complications or hospital length of stay.10 In order to successfully enact billing for resident-led services, it is important to begin by selecting appropriate procedures. In the era of milestones,12 entrustable professional activities13 and robust instruments for evaluating the technical skills of residents,14,15 this is increasingly possible. One example might be allowing residents in their third year and above to bill for minor procedures in a resident-run clinic, a paradigm

that has already been shown to be feasible and safe for patient care.16 Another example might be allowing fifth-year residents who have met their ACGME level 4 milestones12 and have been documented to have obtained “supervision only” status on intraoperative performance evaluations15 to bill for specific core operations, such as cholecystectomies, inguinal hernia repairs, appendectomies and ventral hernia repairs.

Models like the “chief resident service” at Gundersen Health System, in La Crosse, Wis., have successfully approximated this paradigm.17

Resident Billing Will Increase Educational Opportunities Allowing residents to bill for specific procedures would have additional educational benefits. If residents were allowed to bill for procedures, they would also be required to dictate the operative report, a critical skill for functioning as an independent surgeon. At some institutions, residents are not allowed to dictate operative reports due to billing concerns. I recently saw an informal poll on Twitter, started by a general surgery resident who asked: “How often do/did you dictate in surgical residency?” Of 133 respondents, only 25.6% said always, 36.8% said often, 21.1% said rarely, and a shocking 16.5% said “never.”18 Resident-led billing would also incentivize institutions to educate residents about the complex coding structures used for reimbursement, a skill that is frequently lacking in residency training.19-21 The need for this type of education is evidenced by the creation of “transitional years,” like the American College of Surgeons Mastery in General Surgery Program.22 In addition to being designed to “build autonomy, decision-making, and clinical skills,” this program emphasizes that trainees will receive education about billing and medical liability.22 Litigation is also a major driver of reduced resident autonomy, especially when attending physicians are held vicariously liable for negligence on the part of trainees.23 Allowing residents to bill for procedures would need to be coupled with changes in medicolegal liability that supports resident autonomy.24 These efforts would necessitate engagement with agencies such as CMS and require encouraging third-party payors to reimburse for resident-led services.

Moving Toward Resident Autonomy I feel fortunate to be training in a residency program in which I have experienced real autonomy. Experiences like my first solo inguinal hernia repair have allowed me to understand what it is like to operate independently.

But talking to residents from other programs and reading the literature, I know this is the exception and not the rule. Allowing residents to bill for procedures has the potential to drastically increase resident autonomy and help ensure that young surgeons are better prepared for independent practice.

■ References [The list of references can be found in the online version of this article at https://bit.ly/31fmrbQ] —Dr. Williams-Karnesky is a surgical education research fellow, Department of General Surgery, University of New Mexico Hospital, Albuquerque.

OPINION

JULY 2020 / GENERAL SURGERY NEWS

Living in a Virtual World

By FREDERICK L. GREENE, MD

n this issue of General Surgery News, we once again feature reports from the Southeastern Surgical Congress annual meeting, one of a multitude of national and regional surgical gatherings attended and highlighted by our superb reporting staff each year. It is also apparent that the meeting, which took place in New Orleans Feb. 8-11, 2020, represented one of the last such enclaves that occurred prior to the constraints imposed by the COVID-19 pandemic. Over the past several months, a multitude of medical organizations have either canceled or postponed their 2020 iterations. For some of these professional societies, planning for 2021 is ongoing, whereas for others, attempts to have virtual opportunities for professional education have occurred.

It is apparent that modern teleconferencing technology may indeed allow for transmission of lectures, slide presentations, question-and-answer sessions, and so forth. I have tried my best to partake of these offerings over the last few months when made available by organizations to which I belong. I must admit that sitting in front of my computer, unshaven and not having to don a coat and tie, has really resonated! I will also admit that the subject matter presented has held less appeal for me

I

than the opportunity to experience fully how technology might replace actually being there. From this limited experience, as a longstanding attendee at medical meetings, I have come away disappointed in every case.

For me, there is nothing that replaces the in-person ambiance in witnessing the presentation from a seasoned presenter or in experiencing the anguish along with a young resident presenting his or her first plenary session paper. No virtual format can replace witnessing, in real time, the give-and-take between a questioner and presenter following a provocative presentation.

A virtual rendering can never replace the opportunity to take a young surgical mentee up to the dais to congratulate a well-known surgeon after he or she has

For me, there is nothing that replaces the in-person ambiance in witnessing the presentation from a seasoned presenter or in experiencing the anguish along with a young resident presenting his or her first plenary session paper.

given a stirring named lecture. No matter what iteration of a webinar or video format is used, there is no replacement for the excitement and incalculable benefits of participating in a living, nonvirtual educational program. That excitement has stayed with me since my first American College of Surgeons Clinical Congress attended as a PGY3 in 1972!

Over many years, the fate of large professional society assemblies has been debated even before the ravages of COVID-19. Many have opined that the increasing cost and difficulty of travel, the enhanced opportunities for virtual learning, the pressures of greater RVU [relative value unit] generation, the additional barriers between technical exhibitors and clinicians, and changing generational attitudes toward traditional organizational meetings would collectively lead to the disappearance of established in-person annual societal meetings.

All organizations are indeed facing these varying pressures. continued on page 22

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RESIDENT WRITING CONTEST

GENERAL SURGERY NEWS / JULY 2020

Stand Up Straight

By VANESSA A. HORTIAN, DO, MS, LAC

I

t was as though the world stopped in preparation for this instant. All I heard was, “Stand Up Straight.”

Scene Although somewhat cliché for a general surgery contest, please bear with me as the scene is set in an operating room during a laparoscopic cholecystectomy. As an intern, I held the camera and received ongoing constructive criticism about how close to zoom and how much to move. Nonetheless, I accepted my fate. The scrub tech graciously offered me the camera and bestowed it upon me at the case start, and I became the receiver of incessant feedback about my driving skills.

Fast forward to near the end of the case. This is the anticipated moment when the intern breathes a sigh of relief as the camera duties are finished, hopes the attending suffers mild amnesia regarding the camera skills, or lack thereof, that were demonstrated during that case, and awaits eagerly for the question. Then, it happened.

My attending asked, “Vanessa, do you want to close skin?” I answered with a resounding and confident, “Yes, absolutely,” and assumed my position. This was my moment to regain any semblance of credibility. I ran through all the details in my head that I would need to effectively close skin at a trocar site, including suture material and name, needle driver size, etc. Surgical success stands on preparation, so in my head, I was prepared. I received the loaded needle driver and Adson forceps from the scrub tech, felt the pressure of everyone staring at my hands, reached in to grasp the skin edge with the Adson in my left hand, and ensured the needle tip would enter the tissue at 90 degrees via my right hand.

Cut! Correction, via my right wrist, because all top surgeons know that suturing is all in the wrist.

Take Two Regardless, I was set up to throw my best first throw. It was as though the world stopped in preparation for this

instant. All I heard was, “Stand Up Straight.” Confusion ensued on my part, and I wasn’t sure if it was my Armenian Grandmother speaking to me from her grave, or if it was my Attending. I realized it was my Attending, and before I could compute why he was looking at my posture and not looking at the seemingly near perfect first throw I was about to make, I quickly stood up straight, re-connected my head to my body, a disconnection that all too many of us do, and realized how un-straight I was standing.

Enter, the Oprah Aha moment. I thanked my attending for his observation and the case, and finished suturing.

End Scene

first holistic inpatient psychiatric unit, in Queens, New York. I then pursued certification as a yoga instructor and personal trainer, which exponentially increased my appreciation for the roles of body and mind in healing.

While involved in NIH-funded clinical research at Columbia University’s Rosenthal Center for Complementary and Alternative Medicine, in New York City, I developed a deep interest in integrative medicine and pursued a Master of Science in Acupuncture. I became a National Diplomate of Acupuncture, established a Manhattan practice, and am currently a licensed acupuncturist in New Jersey, New York, Pennsylvania, and South Carolina.

Based on my commitment to academics and integrative medicine, Memorial Sloan Kettering Cancer Center’s Integrative Medicine Service sought My path to me out as its first-ever To some, this aha Education Coordinator. surgery has moment may seem inconI then decided that augbeen anything sequential. To me, it menting my biomedical was a poignant moment but traditional, knowledge would allow that served as the springme to provide more comyet it is board for this piece. Thereprehensive care. I comfore, when asked one thing pleted an accelerated precisely I would change about surpost-baccalaureate prothis path gical education, I would gram, graduated with that institute a physical training Sigma Sigma Phi Honors program that includes both from Edward Via Colprovides intraoperative ergonomics lege of Osteopathic Medthe and lifestyle-based funcicine, in Spartanburg, SC, tional mobility modules to and am now honored to foundation develop resident physiserve as a PGY-2 general from which cal strength and awaresurgery resident.

I can serve ness both inside and I outline my academoutside the operating ic and professional jouras a surgery room. As to the “why” ney not to list accolades, resident who but rather to highlight for this idea, allow me to elucidate. precisely why my aha understands My path to surgery moment was so transforawareness has been anything but mational. Reflecting on traditional, yet it is prethat day in the OR, sevand its cisely this path that proimplications eral lessons were revealed. vides the foundation from My attending did care in facilitating about more than just my which I can serve as a surgery resident who undera successful hands, and he realized stands awareness and its the importance of surcareer. implications in facilitating a gical body mechanics. It successful career. After servwas humbling because, if ing as peer counselor and health educator I, with years of training in these modalduring my undergraduate studies at Rut- ities, still needed a reminder to “Stand gers University, in New Jersey, I worked Up Straight,” then most of my fellow post-graduation to create a unique ther- residents would benefit from teachings apeutic milieu at Elmhurst Hospital’s about awareness, functional mobility and

Honorable Mention

Virtual World continued from page 21

I guess the ultimate reason for keeping our in-person opportunities for learning intact is that humans need human interaction. No matter the technological advances that are realized from teleconferencing and innovations

that augment our virtual world, we all benefit from in-person networking with our colleagues. The opportunities to engage in a chance conversation during a shuttle bus ride from the hotel to the meeting venue; the benefit of participating in a dialogue with a technical representative to discuss a new innovation; or the excitement of just sitting in a hall with several hundred other surgical colleagues

ergonomics. From that moment, I have become committed to serving as a catalyst regarding body awareness in the surgical world. My observations have yielded a lack of knowledge and awareness from colleagues about proper body mechanics, both inside and outside the OR, and the resultant potential for/reality of repetitive stress injuries, increased burnout rates, decreased overall and technical efficacy, and decreased quality of life. On an optimistic note, I have observed sincere interest regarding learning and implementing movement, particularly related to improving surgical performance.

Additional support for increasing physical awareness in surgical education comes from two of the four osteopathic medicine tenets. The first states the person is a unit of body, mind and spirit, and the second states structure and function are reciprocally interrelated. Interestingly, Dr. Edward D. Verrier, MD, FACS, provided a lecture at the American College of Surgeons Clinical Congress in Washington, DC, in October 2016 that supported the need for surgical education evolution. Dr. Verrier outlined a myriad of surgical practice changes, but without commensurate surgical education changes. He made recommendations via a thought-provoking comparison of training elite athletes and master surgeons. This perspective supports instituting not only physical training to surgical residency, but an overall paradigm shift at incorporating training aimed at the interrelatedness between mind and body in training elite individuals.

In closing, I express extreme gratitude for providing a platform from which I may demonstrate my passion for this work. In that vein, to the minds, hands, vertebra, muscles, and joints of my fellow residents, esteemed attendings, and all other colleagues who wish for a long and prosperous surgical career—whether it’s Bob Marley who motivates you to “Get Up, Stand Up;” your grandma who pinches your ear until you are Eiffel Tower-tall; your yoga teacher that suggests mountain pose for chakra alignment; or your attending invested in your growth as a surgeon, please—“Stand Up Straight.” It turns out ■ that grandma was right all along.

—Dr. Hortian is a PGY-3 surgical resident, UPMC Pinnacle, Harrisburg, Pa. She was a PGY-2 when she submitted this essay.

who are enjoying the moment with you—these are the experiences that keep bringing us back. Until my next inperson get-together, however, I will enjoy the reports in this edition of General Surgery News and will pine for the opportunity to see all of you once again in person.

■ —Dr. Greene is a surgeon in Charlotte, N.C.

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References: 1. Garvey PB, Giordano SA, Baumann DP, Liu J, Butler CE. Long-term outcomes after abdominal wall reconstruction with acellular dermal matrix. J Am Coll Surg. 2017;224(3):341-350. 2. Golla D, Russo CC. Outcomes following placement of non-cross-linked porcine-derived acellular dermal matrix in complex ventral hernia repair. Int Surg. 2014;99(3):235-240. 3. Liang MK, Berger RL, Nguyen MT, Hicks SC, Li LT, Leong M. Outcomes with porcine acellular dermal matrix versus synthetic mesh and suture in complicated open ventral hernia repair. Surg Infect (Larchmt). 2014;15(5):506-512. 4. Booth JH, Garvey PB, Baumann DP, et al. Primary fascial closure with mesh reinforcement is superior to bridged mesh repair for abdominal wall reconstruction. J Am Coll Surg. 2013;217(6):999-1009. 5. Richmond B, Ubert A, Judhan R, et al. Component separation with porcine acellular dermal reinforcement is superior to traditional bridged mesh repairs in the open repair of significant midline ventral hernia defects. Am Surg. 2014;80(8):725-731.

Allergan® and its design are trademarks of Allergan, Inc. STRATTICE™ and its design are trademarks of LifeCell Corporation, an Allergan affiliate. © 2019 Allergan. All rights reserved. STM122822 04/19