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Simulation Training Mimics OR S
imulation training is now a mandatory aspect of every surgeon’s medical education in the United States. The rise of simulation training roughly parallels that of laparoscopic surgery; in the early- and mid-1990s as laparoscopy swept through the country, surgeons at academic centers noted a distinct, severe learning curve for laparoscopic techniques. In particular, training for one of the most basic laparoscopic procedures, the laparoscopic cholecystectomy, varied widely and injuries to the bile duct became increasingly common.1 In some cases, experienced surgeons with excellent operative techniques in
open cases could not perform the most basic laparoscopic techniques. “We wanted to teach people how to tie a knot laparoscopically and guys who were very good at open surgery just couldn’t tie a knot,” said Daniel Jones, MD, professor of surgery at Harvard Medical School and chief of minimally invasive surgery at Beth Israel Deaconess Medical C e n te r, b o t h i n Boston. “And as you can imagine, that’s a problem in surgery.” Simulation pro– vided a way to train surgeons without compromising the future of laparoscopy by cataloging reports of technique-related see TRAINING, page 4
Health Care Reform for Surgeons
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n March 2010, after months of intense wrangling in Congress, a significant health care reform bill became law in the United States. Despite the size of the bill, roughly 2,000 pages detailing everything from government insurance coverage of abortion to “end-of-life services,” experts in health policy say it is still unclear how the Patient Protection and Affordable Care Act will affect surgeons. “When you ask the question, ‘What’s the impact on surgery?’ it’s really a very complex, multiyear, multifaceted process,” said Charles Mabry, MD, a private
practice general surgeon in Pine Bluff, AK, who is chairman of the American College of Surgeons Health Policy Steering Committee. One aspect, Dr. Mabry says, is that the bill rolls out in phases. Parts of the bill take effect this fall; others will take effect years from now. Furthermore, regardless of what may be written on paper, the implementation of the health care reform law will be in the hands of the regulatory agencies that enforce legislation. Finally, at least 20 states have filed see HEALTH CARE REFORM, page 9
INSIDE: IN PRACTICE Follow these tips for financial success in your surgical practice.
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IN TECHNOLOGY A discussion of energy delivery devices in surgery.
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IN THE OR The role of ghrelin and other gut hormones in metabolic surgery.
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IN THE FUTURE Deciding on a surgical career in academia vs private practice.
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IN PRACTICE Financial Prescription for Surgeons:
Reassess Finances and Make a Business Plan F or many practicing surgeons, the past several years have marked a time of significant financial uncertainty. The best step for surgeons at any level to take is to reassess how they are being affected by the current changes in health care and the economy as a whole. For younger physicians, the cost of a private medical education has increased 50% over the past 2 decades, while medical school tuition at public schools has risen 133% over the same period, according to the American Medical Association (AMA).1 Meanwhile, veteran surgeons have struggled for years to stem the decrease in reimbursements for procedures performed. And the Patient Protection and Affordable Care Act signed into law earlier this year will almost certainly negatively affect the fee schedule for surgeons. The financial market crisis in 2007 and 2008 has affected the medical community as well. “The [surgeons] with the greatest burden are probably still in training,” said Anthony Senagore, MD, MBA, chief of colon and rectal surgery, Keck School of Medicine,
“Anytime we look at debt, including student loans, what we do is make sure that the interest rate is appropriate with the alternative investment vehicle.” —Jim Casey, president/CEO of Integrated Wealth Management
Table 1. Mr. Casey’s Financial Words of Wisdom 1. Consider whether or not to pay off debt right away. 2. When paying off student loans, consider investing income if it guarantees a higher return than your loan’s interest rate. 3. Join specialized surgical societies to learn how to respond to changes at the policy and reimbursement levels. 4. Gain ownership of your private practice. 5. Create a personal financial and business plan. 6. Enroll in an effective retirement plan.
University of Southern California in Los Angeles. “Given the economic challenges that began in 2008, the health care reform bill with constraints on fee schedules, and potential educational debt, there will be a disproportionate impact.” For physicians just out of training, student loan debt— which averaged $156,456 for 2009 medical school graduates—can seem overwhelming. However, it is not always the best financial move to solely focus on paying down debt after graduation.1 “Anytime we look at debt, including student loans, what we do is make sure that the interest rate is appropriate with the alternative investment vehicle,” said Jim Casey, president and chief executive officer of Integrated Wealth Management in Los Angeles. Previously, the company was known as Physicians’ Asset Management and worked exclusively with physicians in the AMA, who continue to make up a significant portion of Integrated Wealth Management’s clients, noted Mr. Casey. Student loans typically have a phenomenally low interest rate, so if an alternate investment can guarantee a higher return than the loan’s interest rate, it makes sense to invest extra income instead of simply paying down debt as quickly as possible, advised Mr. Casey. “The real key is to see what money there is, what it is earning, and can it be better utilized,” he said. The majority of surgeons in the United States are in private practices, and on a fundamental level it is essential that trainees eventually gain ownership in any practice that they join. “[Young surgeons] have to make sure, if they are in a group [setting], that they also have ownership in that group,” said Mr. Casey. “That’s going to be one of the best things because there is no better way of investing than investing in yourself.” However, surgeons traditionally have disliked the business aspects of running a medical practice. “Unfortunately, that naïveté somehow has propagated in our field,” said Dr. Senagore. The best resources in this area are the specialized surgical societies, added Dr. Senagore. They provide the most precise information on how practices can adapt their protocols to respond to changes at the policy and reimbursement levels. “To me, the most important thing is to remain flexible and be aware of the market changes,” said Dr. Senagore. As they move into practice, surgeons should formally create a personal financial and business plan, Mr. Casey noted (Table 1). “The earlier a physician can be put on a plan, the better,” he said. “Once they hit mid-life and mid-practice,
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IN PRACTICE can get a good plan in place that’s going to last you from residency all the way through retirement.�
Reference 1. Advocacy policy—medical student debt. American Medical Association. http://www.ama-assn.org/ama/pub/about-ama/ our-people/member-groups-sections/medical-student-section/ advocacy-policy/medical-student-debt.shtml. Accessed August 2, 2010.
Editorial Board they also have to make sure that they revisit their plan so they can change it based on ownership in their practice.� Beyond a traditional practice, surgeons also have the opportunity to generate revenue in other businesses, if they have the time and the desire. For example, surgeons work as consultants, serve as directors or executives for health care companies, and patent medical devices. The key, again, is to remain up to date on niches within the surgical market. “I have multiple interests as a surgeon and with technology, but to put it in perspective, probably 85% of what I do clinically today didn’t exist when I started,� said Dr. Senagore, who is active in several professional surgical societies and involved in the private sector. As private-practice surgeons mature and draw closer to their postsurgical lives, a major mistake that financial planners see is surgeons treating their business finances like an extension of their personal finances. “The biggest problem that we see with [small practices] is their retirement plans,� said Mr. Casey. “A lot of them think they are too small a company to actually have an effective retirement plan.� This often means failing to take advantage of the pretax retirement vehicles available to small businesses. “[Practices] are looking at just a basic plan rather than getting a customized plan that would save them a lot of money in taxes,� said Mr. Casey. These investment vehicles are not limited to specific types of investments such as stocks or mutual funds; instead, they are simply a pre-tax method of investing. Often, these are best used in combination with personal investments to maximize the amount of money saved for retirement, Mr. Casey explained. Ultimately, surgeons must reassess how they are being affected by the economy and health care crisis and respond to those changes accordingly. “The biggest thing I can stress now, after what the markets have been through, is to work with someone who can review where you’ve been and if you’re having any missteps along the way, to just get on the right path again,� Mr. Casey said. “You can’t go back in time, but you
Frederick Greene, MD Chairman, Department of Surgery Carolinas Medical Center Clinical Professor of Surgery University of North Carolina at Chapel Hill School of Medicine Chapel Hill, NC William B. Inabnet, MD Chief, Division of Metabolic, Endocrine and Minimally Invasive Surgery Director of Surgical Sciences, Metabolism Institute Mount Sinai Medical Center New York, NY Adrian Park, MD Campbell and Jeanette Plugge Professor Vice Chair, Department of Surgery Head, Division of General Surgery University of Maryland Medical Center Baltimore, MD J. Scott Roth, MD Associate Professor of Surgery Commonwealth Professor of Minimally Invasive Surgery Chief of Gastrointestinal Surgery and Director of Minimally Invasive Surgery University of Kentucky, College of Medicine Lexington, Kentucky
Copyright Š 2010
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IN SIMULATION
TRAINING continued from page 1
complications. Academic surgeons first borrowed from anesthesiologists, who already were using mannequins for training in airway management, and later, the Society of American Gastrointestinal and Endoscopic Surgeons began developing the Fundamentals of Laparoscopic Surgery (FLS) program. Beginning this year, the American Board of Surgery— which oversees the certification of practicing surgeons— mandated that all surgical residents complete the FLS program before sitting for their boards. As FLS became increasingly widespread following the introduction of portable training boxes, a second track in simulation continued simultaneously—the use of mock operating rooms (ORs) complete with equipment booms, towers, workstations, and multidisciplinary teams of surgeons, anesthesiologists, and nurses. The American College of Surgeons (ACS) began working with the Association of Program Directors in Surgery to establish a standard curriculum for these Accredited Education Institutes. They now offer both basic and comprehensive levels, with nearly 50 accredited simulation centers. “This is now covering all spectrums of learners, from medical students to residents to surgeons in practice,” said Dr. Jones, co-director of the accredited Shapiro Simulation and Skills Center at Beth Israel Deaconess Medical Center. Much like FLS, Dr. Jones expects training at accredited skills labs to become standard practice. “How the program directors choose to implement [the curriculum] right now varies from program to program depending on their resources,” said Dr. Jones. “I think it will evolve to being a standard curriculum and I think in the very least folks will be tested for certification, credentialing, and licensure. You are going to have to go to the simulator lab and clock in ‘X’ number of hours before you are able to have your license recertified.” All simulation, whether it be an FLS box trainer or a complete skills lab, strives for the same goal—the transfer of knowledge from education to the OR. What might be called “surgical ability” is essentially 2-fold: psychomotor skills like suturing or cutting, and cognitive skills like executive decision making, memory, and reasoning. In surgery, you cannot have one without the other. “You have to have them both down, and you can’t really turn one off,” said Dr. Jones. “Thinking about it another way, if you’re so worried about the stitch that you’re not paying attention to blood pressure, you’ve got a problem.” Even 100 years ago surgeons even recognized this. “The actual manipulative part of surgery requires no very great skill. … It is in the mental processes involved in an
“One of the basic tenets of learning is that the best way to learn a concept is to get as many variations of that concept as possible.” —Kanav Kahol, PhD
operation that not a few fail,” wrote famed British surgeon Sir Frederick Treves in 1891.2 Since then, educators have struggled to untangle the relationship between psychomotor skills and cognitive ability. “You start looking at the transfer from the lab environment to the OR [and] there is a lot of very interesting things that happen,” said Kanav Kahol, PhD, assistant professor of biomedical informatics and a researcher at the Simulation Education and Training Center at Arizona State University in Phoenix. “The psychomotor [skill] ends up being a small percentage of the problems that we have to face.” In one study, Dr. Kahol tested surgeon’s psychomotor skills in a pristine simulation environment and then retested them in a “noisy” environment that added cognitive variations including attention and memory. “Those distractions actually contribute to an almost 90% increase in error because they [the surgeons] couldn’t focus,” said Dr. Kahol. However, when Dr. Kahol trained residents in the noisy environment, their proficiency in psychomotor skills promptly came back and error rates fell. “The cognitive variations not only measure and train for attention, they actually make your psychomotor learning a lot more robust,” he said.2 Based on these results, Dr. Kahol argues that simulators like FLS don’t achieve their potential because they separate psychomotor and cognitive skills into 2 different abilities. Learning theory says that skills are best learned in complex environments that include both simultaneously, he noted. “One of the basic tenets of learning is that the best way to learn a concept is to get as many variations of that concept as possible,” said Dr. Kahol. Dr. Kahol is currently validating a model that builds on existing simulators to add a layer of cognitive exercises to the psychomotor tasks. It’s a relatively inexpensive approach, he argues, but in the future it may make simulators like FLS much more effective. In a much more immersive way, skills labs like those at ACS Accredited Education Institutes are adding cognitive tasks like team work and communication to surgical simulations. Taken together, simulation training is getting closer and closer to see TRAINING, page 5
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IN TECHNOLOGY
Introduction to Energy Delivery Devices n this issue of In Training, we present the first installment of Energy Delivery Devices where we seek to educate medical students, residents, fellows, and junior faculty on the history and current use of electrosurgical devices.
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he use of energy in the surgical setting is literally cutting edge; however, as a discipline, electrosurgery is nearly a century old. Developed by physicist William Bovie at Harvard University during the 1920s, electrosurgical generators first were used in the operating room by pioneering neurosurgeon Harvey Cushing, MD, who used energy for everything from basic electrocautery to tracking the pathways of the human sensory cortex.1 A century later, energy has played a pivotal role in the single-most important trend in surgery in the last quarter century: the push toward more minimally invasive procedures. “There’s no question that the [energy delivery devices], as much as anything else, have allowed us to expand our capabilities from traditional approaches to more minimally invasive procedures,” said Scott Steele, MD, chief of colon and rectal surgery at Madigan Army Medical Center in Fort Lewis, WA. Despite their ubiquity and relevance, few surgeons understand the basic principals behind the energy devices they use nearly every time they step into the operating room. “There is a very, very poor understanding of how these electrosurgical devices work,” said Scott Biest, MD, an assistant professor in obstetrics and gynecology at Washington University in St. Louis. “Basically as a resident you are just handed a bovie [an apparatus used for coagulation in surgery aptly named after its inventor] and there is no real teaching as far as what is happening.” There are many kinds of energy used in surgery,
TRAINING
Figure 1b. The EnSeal® TRIO Patented I-BLADE™ jaw design offers uniform compression along the entire seal line.
Figure 1a. The bipolar EnSeal® device and the ultrasonic Harmonic® device deliver maximum energy performance and minimal thermal tissue damage.
including ultrasonic, radiofrequency (RF), light, thermal, hydromechanical, cryogenic, and microwave technologies. However, the most popular are RF and ultrasonic energy devices—technologies that are used for cutting and coagulating in everyday surgical practice (Figure 1a). In the modern era, there are RF devices that use monopolar and bipolar electrodes, as well as ultrasonic devices that use mechanical energy. With monopolar and bipolar technology, the key is the conversion of electric energy into heat energy. At a see ENERGY DELIVERY DEVICES, page 6
need to do is just put everything in the mix and let the user get the maximum variations.”
continued from page 4
mimicking a true OR environment. “Traditionally, people have looked at a nice little rampup model of education—let’s first learn in a nice pristine environment and then learn in a noisy environment,” said Dr. Kahol. “And that’s one way of learning, but what we are really starting to see from learning theory is that learning is not very organized. It’s really disorganized and what you
References 1. Deziel DJ, Millikan KW, Economou SG, et al. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg. 1993;165(1):9-14. 2. Kahol K, Vankipuram M, Smith ML. Cognitive simulators for medical education and training. J Biomed Inform. 2009;42(4):593-604.
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ENERGY DELIVERY DEVICES continued from page 5
very basic level, when an electric current runs into some form of resistance, the resistance causes electricity to turn into heat. In surgery, the resisting force is human tissue. Monopolar energy uses the patient’s tissue to complete a circuit between the energy source—a bovie wand—and an unstimulated return pad, or patient plate. Bipolar devices have 2 charged electrodes at the end of a pair of forceps, and a current passes through tissue pinched between the forceps arms. Voltage differs between monopolar and bipolar devices. On a monopolar device, where electricity is being forced through a larger volume of tissue, generators may be pushing 6,000 volts; in a traditional bipolar device, which pushes a current through the relatively tiny bit of tissue pinched between the forceps, it only may push 1,000 volts, noted Dr. Biest. Current passed through the electrodes of all RF devices can be sent as a continuous, uninterrupted waveform (CUT waveform). It can also be interrupted via manipulation in which bursts of current are generated (COAG waveform). Sometimes the current is “blended” with both forms. Tissue responds in one of several ways, depending on which of the 3 waveforms is used. The CUT waveform does just what its name implies—it cuts. Cells are very rapidly heated and burst under pressure. The COAG waveform heats tissue more slowly, driving water out and causing cell plasma to coagulate and blood vessels to shrink. Blended waveforms can be used to cut and coagulate tissue in a single motion. “[RF] devices create hemostasis by constricting the
blood vessel. It shrinks and you get a proximal thrombus formation,” said Dr. Biest. Basic physics provides the understanding to best manipulate tissue and prevent complications: electric power equals voltage squared over resistance (P=V2/R).2 “The reason this is so important is that voltage is the force that pushes electrons through the tissue and the greater the force there is, the greater the risk for potential injury,” said Dr. Biest. So, if voltage goes up in response to increased resistance, there is more heat—formally known as thermal spread—which increases the likelihood of an unintentional burn. “If you can minimize the amount of heat that is generated, you have less collateral damage [and] less damage to surrounding structures,” added Dr. Steele. Thus, the drawbacks of monopolar devices are heat sink, reduced visibility due to smoke, and unpredictable current pathways which increase the risk for collateral tissue injury. The latest third-generation bipolar devices are known as vessel sealers because they use heat and high compression to obliterate the blood vessel lumen and create a high-strength seal. They use advanced insulating technology and low wattage to reduce thermal spread. These devices can seal blood vessels up to 7 mm at 3 to 7 times the systolic pressure (Figure 1b, page 5; Figure 2a). Finally, there are the ultrasonic or mechanical devices. An ultrasonic device cycles an extremely small “active blade” at 55,500 cycles per second; this ultra-rapid cycling transfers mechanical energy to adjacent tissue. Used as a cutting device, the vibrating tip causes cellular water to vaporize and rupture cells; as a coagulating device, the mechanical energy denatures proteins into a coagulum. see ENERGY DELIVERY DEVICES, page 10
Figure 2a. The EnSeal® TRIO allows surgeons to simultaneously seal and transect vessels ≤7mm (along with large tissue pedicles and vascular bundles) with minimal thermal spread.
Figure 2b. The Harmonic® Focus Long Curved Shears offer precision and multifunctionality for open procedures.
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Role of Gut Hormones in Metabolic Surgery B “Ghrelin is really a mystery. It is not clear
ariatric surgeries such as gastric banding, Roux-en-Y gastric bypass, and sleeve gastrectomy all have been shown to reliably produce weight loss in obese patients. if this is a major mechanism of bariatric However, there is much to learn about the biologic pathways behind bariatric surgery’s impressive outcomes. surgery, because pharmacologic Take, for example, ghrelin, which was first identified approaches that block the ghrelin pathway in 1999 and arguably is the most well studied of the gut don’t seem to work, and some of them hormones. “There is a lot of contradictory evidence about ghrelin,” have paradoxical results.” said Daniel Herron, MD, chief of laparoscopic and bariatric —Daniel Herron, MD surgery at Mount Sinai Hospital in New York City. “It’s the only gut hormone we know that increases food intake. As to whether it’s the main mechanism through which bariatric surgery causes weight loss, or if it’s a secondary mechadifferent subtypes of ghrelin—not just one hormone—and nism, or a reactive response, the data so far are unclear.” that still has not yet been clarified.” One issue with understanding the hormonal changes Regarding the relationship between hunger and these associated with weight loss is that the relationship hormones, “it is so complex that [ghrelin] fades into the between the stomach and the brain—hunger and satiety, background,” said Dr. Meguid. in effect—is ancient, whereas our diet is quite modern. Because ghrelin is produced mainly by cells lining the Ghrelin tells the brain to eat, but in a society with an overfundus, more “powerful” weight loss operations, like abundance of calories, there isn’t a great need to remind gastric bypass as opposed to gastric banding or sleeve the brain to consume. gastrectomy, have a greater effect on ghrelin production. “In the overall balance of hormones that regulate food “There is some evidence to suggest that the greater the intake, [ghrelin] is probably archaic,” said Michael M. disruption of food exposure to the gastrointestinal tract, Meguid, MD, PhD, professor emeritus of surgery, neurothe greater the reduction in ghrelin,” said Dr. Herron. science, and physiology at Upstate Medical University However, as surgeons and endocrinologists looked in Syracuse, NY. “Our industrial-food, over-consumption more closely at gut hormone levels following bariatric society has probably overwhelmed this hormone.” procedures, some very mysterious paradoxes emerged. However, as bariatric surgery became increasingly For example, when patients decrease their caloric popular in late 1990s and 2000s, much intake as part of a diet, ghrelin levels attention was paid to ghrelin with the idea increase—the body is demanding more that reductions in ghrelin were the cause food to compensate for the lost weight. of weight loss following bariatric surgery. However, when patients undergo weight One of the landmark studies at this time, loss operations, which also result in fewer conducted by David Cummings, MD, at the calories, ghrelin levels do not increase; in University of Washington in Seattle, and fact, they often go down.1 published in The New England Journal of “You would [expect] that someone who Medicine, concluded that “gastric bypass has had their stomach substantially reduced is associated with markedly suppressed in size would have increased ghrelin levels, ghrelin levels, possibly contributing to the but that has not been shown to be the case,” weight-reducing effect of the procedure.”1 said Dr. Herron. “In fact, we see the opposite. After a bariatric operation, depending on Findings like this prompted a great deal the operation, you’ll see varying levels of of excitement about ghrelin, and more decrease in ghrelin levels, in general.” research into the role of gut hormones One of the possible causes of different and bariatric surgery followed (Figure). It Figure. Ghrelin is a naturally occurring gastrointestinal became clear, however, that these biologic hormone that stimulates hunger. outcomes in bariatric surgical procedures, and the impact of ghrelin postoperatively, is pathways are very complex. The image depicted shows a surgical technique, Dr. Meguid said. “There are many different gut hormones molecular representation of the When surgeons transitioned from open to that are involved in appetite regulation, first 10-terminal amino acids. and ghrelin is just one of them,” said Figure courtesy of Kim D. Janda, PhD, and laparoscopic approaches in bariatric surgery, Dr. Herron. “There also may be multiple The Scripps Research Institute see METABOLIC SURGERY, page 8
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METABOLIC SURGERY continued from page 7
it became much more difficult to preserve the vagus nerve, which is responsible for transmitting information about hunger and satiety from the stomach to the brain. When weight loss surgeries involve stapling around the upper stomach or the lesser curvature, there is a possibility that the vagus nerve could be divided. “It is really quite crucial because ghrelin has receptors that stimulate this nerve which goes directly to the brain,” said Dr. Meguid. “So [if] you crush it or divide it, you interfere with its capacity to send signals to and from the brain. So that’s the primary reason why you have different results.” As surgeons attempted to clarify how weight loss surgery affected ghrelin, medical approaches to suppressing ghrelin proceeded as well. Among the most noteworthy was an “anti-obesity vaccine.” Receptor antagonists as well as RNAlike “spiegelmers” also were sought to block, suppress, and generally interfere with ghrelin binding. Medical approaches looked promising in animal studies, particularly in rats, but the animal data did not translate to humans. “Unfortunately, when you take these approaches and use them in humans, they don’t make any difference and may even cause an increase in hunger,” said Dr. Herron. One possibility, Dr. Meguid believes, may be to combine surgical and pharmacologic approaches in much the same way that cancer therapy evolved. Surgery would remove the weight, in effect, and medicines would keep it from returning. “I can see that one of the approaches would be to give [drugs] like we do in cancer,” said Dr. Meguid. “You do the operation and then you start the patient on adjuvant therapy, such as vaccination with an antibody, in order to try to ameliorate an increase in weight.”
Meanwhile, researchers are still untangling the metabolic pathways underlying weight loss. The latest research is upending the old idea that ghrelin is the “hunger hormone”; in fact, ghrelin must be activated by a fatty acid in order to function and thus may be more of an indicator to the brain that dietary fats and nutrients are available.2 This is further supported by studies linking activated ghrelin with secretion of growth hormones.3 Although clinical studies have not delineated between activated and inactive forms of ghrelin in their analyses, the most recent data suggests that there is an increase in fasting ghrelin after gastric banding that occurs over time, suggesting that weight loss may account for the change after gastric banding. Following gastric bypass, ghrelin levels seem to vary, but several studies report that fasting ghrelin levels decrease much more rapidly—as early as 2 to 6 weeks after surgery—suggesting that the decrease may be due to altered anatomy following this operation.4 “Ghrelin is really a mystery,” said Dr. Herron. “It is not clear if this is a major mechanism of bariatric surgery, because pharmacologic approaches that block the ghrelin pathway don’t seem to work, and some of them have paradoxical results.”
References 1. Cummings DE, et al. Plasma ghrelin levels after dietinduced weight loss or gastric bypass surgery. N Engl J Med. 2002;346(21):1623-1630. 2. Kirchner, et al. GOAT links dietary lipids with the endocrine control of energy balance. Nat Med. 2009;15(7):741-745. 3. Nass R, et al. Evidence for acyl-ghrelin modulation of growth hormone relase in the fed state. J Clin Endocrinol Metab. 2008;93(5):1988-1994. 4. Korner J, et al. Prospective study of gut hormone and metabolic changes after adjustable gastric banding and roux-en-y gastric bypass. Int J Obes (Lond). 2009;33(7):786–795.
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HEALTH CARE REFORM continued from page 1
suits challenging Congress’ authority to regulate health care, with the hope that the Supreme Court might strike down the law. “We are sitting here scratching our heads,” said Dr. Mabry. “We understand what the bill says they are going to do, but the legislation that was written hasn’t been interpreted by … the regulatory bodies.” Any discussion of the law’s effect must begin with a brief background on the current state of surgery. The first major issue is that reimbursement for surgical procedures has stayed essentially flat for 2 decades. “Over the last 20 years, surgeons’ income-earning ability has been reduced because the conversion factor has been relatively flat, while our costs have continued to rise,” Dr. Mabry said. “More and more surgeons are finding that they can no longer practice medicine under the fee-for-service system.” The other factor, with which most surgeons are intimately familiar, is that the country as a whole is facing a shortage of general surgeons. “We are not only running out of surgeons, we have run out of surgeons,” said Dr. Mabry, who has testified before Congress on the effect these 2 factors are having on community surgical practices. In this context, President Obama and Democrats in Congress have sought to “bend the curve”—that is, reduce the rate at which health care costs are rising each year.1 On a macro level, this boils down to value, Dr. Mabry said. Surgeons in the United States have long been paid according to the number of tasks they perform, regardless of patients’ ultimate outcomes; health care reform seeks to pay surgeons based on how well they do. “Under the current system, physicians and surgeons are paid for the volume of work that they do,” Dr. Mabry said. “In the new system—value-based payment—the value equation [value = quality/cost] will be important and payment will be more based on the value that they deliver, rather than the volume of procedures or visits that they produce.” Much of this involves comparative effectiveness research, which in terms of surgery means attempting to compare differing surgical steps, or processes of care. Surgeons’ reimbursement then may be based on following the complete list of processes. The problem is that it can be very difficult to precisely gauge patients’ risks for complications. Furthermore, it is very difficult to show that a particular surgeon’s approach avoided complications. “How do we prove that [a complication] didn’t happen specifically because of the individual surgeon’s expertise or approach?” said Anthony Senagore, MD, MBA, chief of colon and rectal
“Under the current system, physicians and surgeons are paid for the volume of work that they do. In the new system—valuebased payment—the value equation will be important and payment will be more based upon the value that they deliver, rather than the volume of procedures or visits that they produce.” —Charles Mabry, MD
surgery at the Keck School of Medicine at the University of Southern California in Los Angeles. “That’s why a lot of these checklist approaches are laudable, but a bit naïve operationally.” Surgery is far more complicated, Dr. Senagore argues, and in the case of some surgical process measures like tight glucose control, outcomes actually have been adversely affected by implementing a process measure prior to confirming the risk–benefit ratio.2 Only after confirmation of these measures should a process-oriented, checklist approach be fully implemented. “Process measures that support the concept of quality improvement have been difficult to validate,” Dr. Senagore added. “Some of the process measures that have been proposed have been outright negative, not positive, in terms of outcomes and cost. Hopefully, Medicare and our health care system will move toward risk-adjusted outcomes as the optimal benchmarking for clinical care.” One way in which health care reform very likely will affect reimbursement for surgery is through a “bundled payment” for treating a disease as a whole instead of reimbursement for all of the individual steps involved. For example, Dr. Mabry said, “the hospital will get a flat payment for a knee replacement and they’d have to see HEALTH CARE REFORM, page 10
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[divide] up the money among all the different providers.” Approaches like this one are designed to reduce inefficiencies and unnecessary procedures at the hospital and provider levels. “There are a lot of needless tests,” said Dr. Mabry. Much of this is imaging or invasive testing that is effective but overused, or procedures ordered by physicians simply as “defensive medicine” to protect themselves in potential lawsuits. However, surgeons play little to no role in this area. “For surgeons who do major surgery, it’s very hard to abuse the system, number 1; and number 2, there’s no incentive for us to abuse the system,” Dr. Mabry said. “So from a surgeon’s standpoint, we are not causing the trouble, but [we] are still being put in the same cell block as the other prisoners who are causing the trouble.” One effect of this type of bundled reimbursement is that surgeons will likely ally themselves more and more with large organizations, either bigger physician groups or hospitals, a trend that is already occurring. “If health care reform goes toward reimbursement of institution-based practices, clearly to be employed with an institution or to be affiliated with an organization is going to be important,” said Dr. Senagore. Finally, it must be noted that health care reform did not
“Over the last 20 years, surgeons’ incomeearning ability has been reduced because the conversion factor has been relatively flat, while our costs have continued to rise.” —Charles Mabry, MD
include 2 significant issues for surgeons: the lack of medical malpractice reform, and a failure to address the “sustainable growth rate” (SGR), which determines Medicare reimbursements to physicians. Continuing to use the existing SGR formula could mean a further 20% decrease in reimbursements for caring for Medicare patients beginning in December—a further disincentive to go into medicine, Dr. Mabry said. “It’s something that Congress really should have addressed in the bill. That’s a real failure,” he said.
References 1. Obama B. Remarks by the President after meeting with Senate Democrats. Office of the Press Secretary. December 15, 2009. http://www.whitehouse.gov/the-press-office/remarks-presidentafter-meeting-with-senate-democrats. Accessed August 10, 2010. 2. NICE-SUGAR study investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-1297.
IN TECHNOLOGY
ENERGY DELIVERY DEVICES continued from page 6
Depending on the nature of the procedure, a surgeon may choose to use an RF device that uses monopolar or bipolar energy or an ultrasonic device that uses mechanical energy. There are pros and cons to both and surgeons may choose to apply an ultrasonic device to certain procedures and an RF device to other procedures depending on what the situation warrants. In ultrasonic devices, no electricity is passed to the patient and the devices have extremely low thermal spread. This results in less smoke and charring—which allows better visibility during surgery—and produces safer seals with minimal collateral thermal damage. Ultrasonic instruments also can alleviate the burden of instrument exchanges during procedures, and allow for more precise cutting (Figure 2b, page 6). These latest vessel-sealing devices are allowing more operations to be performed as minimally invasive procedures. “They’ve allowed [us] to be able to seal major
vessels through a minimally invasive approach and to do dissection and flaps with less tissue damage,” said Dr. Steele. New devices are easier to use than their predecessors, however, surgeons still need to understand the science behind energy regardless of the device they ultimately choose to use. “Everyone has to make up their own mind as a surgeon as to what they feel most comfortable with, [but] you need to understand how to manipulate the generator so as to decrease your risk,” said Dr. Biest. “Because let’s face it, that’s what we are all talking about in surgery—decreasing risk, regardless of what instrumentation you elect to use.”
References 1. Voorhees JR, Cohen-Gadol AA, Laws ER, Spencer DD. Battling blood loss in neurosurgery: Harvey Cushing’s embrace of electrosurgery. J Neurosurg. 2005;102(4):745-752. 2. UK Automotive Training Academy. http://ataukltd.co.uk/website/Ohm%27s/ohms.html. Accessed August 6, 2010.
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2010 • VOL. 1, ISSUE 1
IN
THE
FUTURE
Academia or Private Practice?
Surgeons Weigh In
A
lthough many surgeons ultimately will work in private practice instead of academia, some surgeons— especially those who pursue advanced laparoscopic training—will have a choice between these career paths. The decision is a complex one, particularly in view of changes that the health care reform law will likely bring to surgical practice in the United States. Understanding the benefits of each practice type may better prepare trainees for their eventual landing point. Generally, a career in academia is centered on research and publishing, as well as education and training. Surgeons in academia often say they feel they are part of a larger surgical culture, contributing not just to individual patients but to the field as a whole. “For me, it was the fun of having questions and getting answers, making a difference that seemed a little bit bigger than my own wallet,” said Daniel Jones, MD, professor of surgery at Harvard Medical School and chief of minimally invasive surgery at Beth Israel Deaconess Medical Center, both in Boston. Dr. Jones was fortunate to train in minimally invasive surgery (MIS) at a time when these programs were popping up around the country. One private practice group offered him “a ski lift ticket, a golf course pass, and time to do both,” but Dr. Jones felt the advanced laparoscopic skills he acquired in fellowship should be used to make contributions to the field of surgery at large.
“It wasn’t golf and skiing, but it was fun in a different way, and I was making contributions,” he said. Now years later, Dr. Jones has published books and hundreds of papers, launched surgical skills centers in France and Dubai, and currently sits on executive boards and committees for several prominent national surgical societies. One of the best aspects of an academic career is coverage by colleagues, added Dr. Jones. “In an academic group practice, you can get coverage for those activities that are valued as collectively important.” “It also allows a surgeon to go out of town without the fear of losing our practice the next day,” he said. The collective group is the source of both the advantages and disadvantages of academic life (Table 2). Academic surgeons tend to see rare and challenging cases; they also manage the sickest patients, which community surgeons can refer to them when needed. Academic surgeons also have a broad network of colleagues to call on. “When a difficult problem comes in, I have a very wide group of colleagues that I can work with or ask to give me feedback, and I think that’s a little bit different than the general practice surgeon,” Dr. Jones said. In private practice, the benefits and restrictions of the academic group are forgone for the freedom and risk of ownership. see ACADEMIA VS PRIVATE, page 12
Table 2. Pros and Cons of Academia Versus Private Practice
Academia
Private practice
Pros
Cons
Feel like integral part of the surgical community
Earning potential is limited
Ability to have colleagues cover shifts for collectively valued activities
Quotas on case output to ensure profits to the institution
Large group of colleagues to lean on for difficult cases
Publishing/teaching mandatory but not compensated financially/prioritized
Typically make more money, can augment salary with higher caseload
Lowered sense of participation in the progression of the field
Have control over your practice/hours
Must learn the business end of managing a practice, juggling employees, benefits, overhead, etc.
Freedom to pursue whatever research/published articles they wish to work on
Longer hours to maintain surgical and administrative aspects of practice
Freedom to travel, vacation, participate in hobbies
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12
VOL. 1, ISSUE 1 • 2010
IN THE FUTURE
ACADEMIA VS PRIVATE continued from page 11
Private practice surgeon Daniel Cottam, MD, finished training in much the same way as Dr. Jones—with advanced skills that were in high demand. He had several job options at prestigious academic medical centers, but chose private practice because the rewards aligned with the demands. At every academic institution he visited, surgeons had to perform a set number of surgeries. “Everyone had to produce in terms of the number of surgeries to make money for the hospitals or the medical school. That was most important to the administration,” Dr. Cottam said. “Publishing and teaching was something that you had to do but they didn’t pay you or care about it that much.” Academic surgeons were asked to produce at high volume but weren’t rewarded proportionately, added Dr. Cottam. “And that is nothing against academic physicians; that’s just what happens when you work for a big organization—[they] take the profit from you individually to put it back into the institution.” When he was interviewing for surgical positions, Dr. Cottam found that private practice surgeons typically made at least double the salary of academic surgeons. However, the biggest breakthrough for Dr. Cottam, who enjoys research, was discovering that a significant amount of published research is produced in private surgical practices. “When I started looking around at the number of people who were academically active yet were still in private practice, I was astounded,” Dr. Cottam said. “I had just never conceptualized people publishing academic
papers outside of a big, fancy medical center.” That sealed it for him, and now years later, Dr. Cottam runs a very successful 2-physician bariatric practice in Utah and routinely contributes papers to major bariatric surgery journals. Generally, the main benefit of private practice is control. Surgeons with some degree of ownership in a private practice can usually dictate their income. That may mean doing fewer procedures, abandoning certain operations altogether, or taking longer vacations. “The flipside is that whenever you’re not working, you’re not making money, but your overhead is still there,” Dr. Cottam said. “But for people who really like to have control, private practice is the only way to go.” However, control also means hiring and firing, handling human resources issues, and negotiating with insurance payers and hospitals. “The reality is that when you go into private practice, you have to ask yourself, ‘Is it worth it to spend the additional hours looking over the staff and watching over the bottom line to be successful [and] take that 50% to 200% pay raise?’” Dr. Cottam said. Although private practice and academic surgeons often say they value different things, Dr. Cottam is convinced that being successful in either arena requires the same skills, whether that means being available to sit on yet another committee or to manage a surgical patient at a community hospital into the wee hours of the night. “When you see a very successful academic and a very successful private [practice] physician, I doubt the skills are that much different,” Dr. Cottam said. “It’s all about making relationships and being available.”