The American College of Surgeons (ACS) is in its centennial year. As part of our commemoration of this historic occasion, we are looking back not only at some of the remarkable achievements of the College’s founders, but also ahead to see what the next hundred years may hold for surgery. Four issues of pressing urgency are access to care, rural surgery (workforce shortage/maldistribution), surgical education, and internationalism – all of which are closely connected.
The College is committed to ensuring that surgical patients have access to high-quality, safe, appropriate, and affordable surgical care. Barriers to receiving this level of care–in addition to gender, race, age and income–include lack of insurance, long wait times, geography, and maldistribution or shortages of surgeons.
As the United States proceeds in implementing the Affordable Care Act, the ACS must speak wisely and forcefully about what does and does not work for surgical patients with respect to public policy. In matters political we must always advocate for what is best for our patients. When we do that we will never be wrong.
In our discussions with legislators and policymakers, we should focus on the “Value Proposition,” which is Value = Quality/Cost. The surprise in this proposition is that increasing quality decreases cost as best practices come into play. Inappropriate variation–that is, waste–is eliminated. One good example of the College’s contributions to fulfillment of this proposition is the development and proliferation of the ACS National Surgical Quality Improvement Program.
Rural health care
Rural communities often bear the brunt of surgeon shortages and maldistribution. For surgical trainees who are suited to rural life, we must provide support and broad training.
The College has a model that may be useful in addressing surgeon shortages and maldistribution. A hallmark of the ACS Committee on Trauma’s (COT) Inclusive Trauma System Model is regionalization, which ensures that the right patient gets to the right place in the right time. We should ensure that similar systems are in place to support rural surgeons in caring for patients when they can, but also to move patients out through established channels to a higher level of care when appropriate. The newly formed ACS Advisory Council for Rural Surgery is exploring these and other opportunities and will help develop policies and programs that are supportive of rural surgeons and their patients.
As wonderfully as the Halsted model worked for training 20th century surgeons, it does not fit the 21st century reality. It was outdated even before the introduction of the 80-hour workweek. And then there is debt. The average U.S. medical graduate has debt exceeding $100,000, and nearly a quarter owe $200,000 or more.
Meanwhile, young surgeons are appropriately seeking a balanced lifestyle while being expected to lead multidisciplinary teams caring for ever-more complex surgical disease. I believe the ACS, the specialty societies, the American Board of Surgery, the American Surgical Association, the Royal College of Physicians and Surgeons of Canada, and all international surgical leaders should collaborate in recreating surgical education for this century.
The world is flat, and all these concerns about access, rural surgery, and surgical education are profoundly international as well. The Advanced Trauma Life Support® course (ATLS®) is the College’s most widespread international program, with 1.3 million physicians trained in 63 countries since the program began in 1980. Haile T. Debas, MD, FACS, has said that trauma is a global endemic. The ACS, through the Committee on Trauma, must address this global endemic in peace, war, and disaster. As Dr. Debas has said, “We should have a diplomacy of health,” and there is no better example of fulfillment of this policy in the ACS than the COT’s ATLS program. ATLS is truly an ACS international phalanx.
International collaboration is essential to the future of our profession. For that reason, I have made a high priority during my presidential year of supporting the excellent work of the ACS International Relations Committee and of collaborating with the leaders of international surgical colleges and societies. To this end, the ACS will host a meeting of Presidents of international surgical societies at our Washington Office in July 2013 where we will seek solutions to common problems. We have much to do together.
Because there are serious challenges ahead in this new century, the ACS needs diverse leadership at every level. It can be a wonderful two-way street, with younger Fellows contributing their energy and fresh vision, and the more senior among us offering support and crucial leads as to how things get done. My greatest wish for all Fellows of the American College of Surgeons is the joy of a life in surgery that has been mine.
Dr. Eastman is President of the American College of Surgeons.