American College of Surgeons
Board of Governors 2011 Survey Analysis
Timothy C. Flynn, MD, FACS
October 23, 2011
2011 Board of Governors Survey Analyisis Slides (25K PDF)
Two-hundred-sixty-one (97 percent) of the College’s 270 members of the Board of Governors completed an electronic survey related to issues of concern to them and the Fellows they represent.
Physician Reimbursement/Medicare/Medicaid: Overall, on a scale of 1 to 10—with 10 indicating most important—93 percent of the respondents ranked the importance of this issue at 6 or above. Sixty-eight, 85, and 96 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on the sustainable growth rate (SGR), access to care for Medicare and Medicaid patients, hospitals’ political influence, pharmaceutical and medical device companies’ defense of their economic stake in health care, and extinction of private/solo practices.
Health Care Reform and Its Impact on Practice: Overall, 93 percent of the respondents ranked the importance of this issue at 6 or above. Sixty-eight, 62, and 99 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on cost, complication of the legislation and the need to educate the membership, accountable care organizations (ACOs), electronic medical records (EMRs), and the demise of private practices.
Professional Liability/Malpractice/Tort Reform, Risk Management/Patient Safety: Overall, 89 percent of the respondents ranked the importance of this issue at 6 or above. Eighty-six, 46, and 92 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on cost, minimal attention given to tort reform, constant pressure to repeal measures that limit awards, lack of federal legislation, frivolous lawsuits, too many lawyers, and the education and competency of medical expert witnesses.
Medical Education/Graduate Medical Education: Overall, 80 percent of the respondents ranked the importance of this issue at 6 or above. Ninety-three, 92, and 78 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on intrusion into work hours, continuity of care, shift mentality, adequacy of the finished product to practice independently, subspecialization and difficulty in attracting residents to some areas of surgery, fragmentation of general surgery, general surgery coverage, and cost to and high debt of students.
Workforce Issues for Academic Practice/Community Practice: Overall, 78 percent of the respondents ranked the importance of this issue at 6 or above. Seventy-three, 92, and 78 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on hospital practice becoming more common, as are progressively diminished contracts once physicians are employed; difficulty in recruiting to small communities/hospitals; shortage of specialists, especially general surgeons, with the inadequate workforce leading to burnout, more unassigned call, and longer hours; current workforce being trained and inadequate conditions of training; inadequate hospital/ED coverage, particularly in general surgery; and access.
Competency Measurement for the Practicing Surgeon/Newly Trained Surgeon: Overall, 78 percent of the respondents ranked the importance of this issue at 6 or above. Eighty-seven, 69, and 77 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on difficulty in measuring, no guidelines as to what steps to take if surgeons do not pass testing, poor measures making privileging and peer review difficult to do well, medical/legal issues, work hours are compromising newly trained surgeons as the general age of practicing surgeons increases, those entering practice still need training as too many appear to be less thoroughly trained and in need of more hands-on experience.
Continuing Medical Education: Overall, 67 percent of the respondents ranked the importance of this issue at 6 or above. Eighty-seven, 100, and 62 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on the need to increase online offerings as the “meeting” format is expensive and inefficient, CME mandates are becoming increasingly burdensome for physicians trying to keep practices afloat, arbitrary requirements are making it more difficult for CME to be offered even by academic institutions, loss of industry support is impacting quality, the need for content that is relevant and retained is being ignored, need to include simulation components/hands-on experience routinely, and need to allow SESAP™ CME credit to be obtained after each module is completed rather than all modules are completed, as doing so would allow surgeons to use part of SESAP to meet MOC requirements during one 3-year period and another part during a second 3-year period.
Credentialing for New Technology: Overall, 66 percent of the respondents ranked the importance of this issue at 6 or above. Seventy-two, 85, and 64 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on the lack of standards, the need for cost/benefit analysis, an effective “medical arms race” with market share and not patient welfare as the goal, and guidance on use, as 8-hour hysterectomies with the robot do happen.
Trauma Care: Overall, 64 percent of the respondents ranked the importance of this issue at 6 or above. Seventy-three, 77, and 62 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on disparity of quality between urban and rural trauma care, coverage/quality coverage due to inadequate or lack of compensation coupled with litigation, the need for increased funding on the federal level, and the desire for more ATLS/DSTC courses in international countries.
Funding for Education Activities/Research: Overall, 63 percent of the respondents ranked the importance of this issue at 6 or above. Ninety, 77, and 59 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on recent cuts that threaten the ability of American medicine to maintain a premier research engine; funding that comes from university budgets is usually low, and outside funding is usually supplemented; and as far as education activities and research go, funding is the greatest challenge and a constant struggle.
Relationships and Contracting with Managed Care Organizations/Hospitals: Overall, 63 percent of the respondents ranked the importance of this issue at 6 or above. Fifty-four, 31, and 66 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on contracts and the need for information/courses and hospitals and HMOs still dictate, appear to have all of the leverage, and make arbitrary decisions that put the surgeon between the patient and the payor.
Pay-for-Performance: Overall, 62 percent of the respondents ranked the importance of this issue at 6 or above. Sixty-six, 83, and 60 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on potential for care being denied to high-risk patients; the need for validated benchmarks, transparent results, and a noncumbersome process; pay-for-performance is viewed as punitive and a way to cut reimbursements; costly; and the hassle factor seems to exceed potential rewards.
Peer Review Issues: Overall, 55 percent of the respondents ranked the importance of this issue at 6 or above. Sixty-eight, 69, and 53 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on the need for more emphasis on nonpunitive peer review that is educational and allows for appropriate system changes where applicable, predatory credentialing and malignant peer reviews that are still a real occurrence, many times peer review becomes litigious, and discoverability is a major problem.
Medical School Issues: Overall, 51 percent of the respondents ranked the importance of this issue at 6 or above. Eight-six, 77, and 45 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on medical student debt not being compatible with falling reimbursements, education of future surgeons needs to involve more exposure to surgery at an earlier stage and more hands-on experience as opposed to virtual training, the watering down of all aspects of medical training, and not producing enough doctors.
Hospital Privileging Issues: Overall, 50 percent of the respondents ranked the importance of this issue at 6 or above. Sixty-two, 62, and 47 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on scope of practice and turf battles; hospital control of employees, including privileging; and conversations by hospital CEOs about changing hospital bylaws to privilege only hospital-employed physicians and surgeons.
International Fellows’ Ability to Attend Clinical Congress: Overall, 36 percent of the respondents ranked the importance of this issue at 6 or above. Eighty, 62, and 28 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on financial difficulties for different reasons such as severity of economic crisis, increasing costs, exchange control, and strong undervaluation of currency; the registration fee has had a serious and detrimental effect; and need to invest in technology to obviate the need to travel.
Credentialing of International Applicants: Overall, 33 percent of the respondents ranked the importance of this issue at 6 or above. Seventy-seven, 69, and 24, percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on training and credentialing as being equivalent, and the possibility of easing workforce shortages.
ACS Support of Young International Surgeons Training in U.S. after Residency: Overall, 32 percent of the respondents ranked the importance of this issue at 6 or above. Eighty-seven, 54, and 23 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on the possibility of easing the workforce shortage, important contribution to the quality of surgical care worldwide, and a good initiative to be continued.
Assistants at Surgery: Overall, 32 percent of the respondents ranked the importance of this issue at 6 or above. Seventy, 31, and 26 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on burgeoning workforce shortages and the need to train adequate numbers as reliance on PAs and nonphysicians is becoming the rule, adequate reimbursement is important as there is currently little to none, and it is a safety issue.
International Fellows’ Access to ACS Services/Benefits: Overall, 28 percent of the respondents ranked the importance of this issue at 6 or above. Eighty-one, 46, and 20 percent of the International, Canadian, and U.S. respondents, respectively, scored this issue at 6 or above. Concerns related to this issue that were reiterated throughout the comments focused on the fact that all international members should have complete access to all ACS services and benefits.
Other Issues of Concern: Overall, 48 percent of the respondents ranked the importance of other issues at 6 or above. Forty-six, 50, and 49 percent of the International, Canadian, and U.S. respondents, respectively, scored other issues at 6 or above. Concerns that were reiterated throughout the comments focused on the rising cost of attending meetings; the high costs of new technologies and surgical instruments, especially for those in poor countries; ACS representation on an international stage such as the World Health Assembly; expanded ACS role in disaster education and response; holding the ACS annual meeting in different regions of the world; sensitivity to academic and private practice surgeons as their interests are often quite different; the need to maintain the private practice surgeons in the leadership of the College; co-management of postoperative patient by non-MD practitioners often results in fee-splitting and divides MDs in regard to scope of practice issues; Governors’ input/influence is still weak; increase the representation of private practice surgeons on the leadership committees of the College since it is heavily focused toward the academic surgeon in many ways; big divide between the College and it chapters; active participation of International Fellows in Clinical Congress; support of military surgeons while they are in service and after; representation of surgical specialties in the ACS is an important issue to those from specialty disciplines; and the subspecialties must all band together.
The following concerns/suggestions/comments/commendations were extracted from the “narrative” section of the B/G surveys and are not necessarily related to any of the previous issues.
- Concern regarding access to ACS program/learning/training in “flyover” states where there are no academic medical centers.
- Would favor the ACS sponsoring television shows, documentaries, newspaper articles, and Internet blogs.
- Wish to see the ACS take a more active role in surgical education and training and improvement of surgical care in developing countries.
- The ACS is the only nationally credible umbrella organization for practicing surgeons that has the opportunity to play a meaningful role in influencing the outcome of otherwise politically guided health care reform. It is critical that surgical specialties unite on most issues and present rational justification for value of services.
- Quality of care has been greatly diminished by attempts to control doctors. The ACS should support private practice.
- Do not think that the ACS is as engaged at the local and state levels as it is at the national level.
- The ACS also needs to protect general surgery from erosion by the increasing number of surgical subspecialties.
Revised November 29, 2011