ACS Surgery News

Nobody is happy when a patient needs to be transferred. A patient transfer is an unplanned event for all parties involved: the patient, the family, the surgeon requesting a transfer, and the accepting surgeon or physician.

It’s a fact of life that a rural surgeon will, at times, need to transfer patients to a larger center. The reasons should come as no surprise to any surgeon. Sometimes there are simply not enough ICU beds, ICU nurses, ventilators, or respiratory therapists to care for patients. At times, very complicated surgical patients will present through the ED and sometimes a work-up on a hospitalized patient may reveal a complex surgical problem. Despite the best efforts of a rural surgeon, surgical complications will occur and a transfer can be the wisest choice. Trauma patients, especially those with a neurologic injury, will often need to be transferred. And then there is the exhaustion factor: A long stretch of on-call duty, or a series of difficult, time-consuming patients can deplete the mental and physical resources of a rural surgeon and the next patient who comes in the door with a complicated surgical issue will be transferred.

The transferring of patients from a rural hospital to a larger medical center with higher-level technology on hand is becoming more common. An example of this would be a patient with a blunt splenic injury. In years past, this patient could be carefully followed in a rural hospital, and a splenectomy could be done if necessary. With the ability of interventional radiologists to control splenic bleeding by embolization techniques, some of these patients do better if transferred to a larger center. Some rural hospitals used to operate on patients with a ruptured abdominal aortic aneurysm, but now many of these cases are transferred so that the patient can be treated with endovascular techniques. Some patients with GI bleeding are now transferred for possible treatment with embolization techniques.

In many ways, it has gotten easier in recent years to transfer a patient from a rural hospital. Almost all tertiary hospitals now have a transfer team or transfer coordinator that will determine bed availability, and arrange for a conference call between the rural surgeon and the accepting surgeon and other physicians at the larger hospital. Cell phones have allowed for much quicker communication between physicians. Many rural hospitals are now owned or affiliated with a larger medical center, which can allow for a quick transfer. As a result of Emergency Medical Treatment and Active Labor Act laws, a patient’s medical insurance status should not be a determining factor in a transfer.

Although transfers are easier than they once were, it should be noted that a transfer is not the easy or preferred option for most rural surgeons. Many rural surgeons inwardly groan when they realize that a patient needs to be transferred. Most surgeons can’t help having a feeling of defeat when a transfer is needed. Transfers can be very time-consuming, partly because there is usually no transfer team at a rural hospital and the surgeon has to be involved in making the arrangements and speaking with physicians at the larger center.

Because of the time commitment required for a transfer, it’s very important for the patient and his or her family to make a quick and definite decision about where they’d prefer the patient to be transferred to. Occasionally, after investing time to arrange for a transfer to a larger center, the rural surgeon is told that the accepting hospital will accept the patient, but that there are no open beds, which can mean that the patient can be waiting for several days for the transfer to occur, or that the rural surgeon needs to start the transfer process over again with another center. All this means can mean a further investment of time by the rural surgeon.

Ambulance transfer, whether by ground or air, is another complicating factor in transferring a patient. Medicare will pay the base rate and mileage for a medically necessary ambulance transport to the nearest facility that can care for the patient. Private insurance companies follow suit on this issue. If a patient and the family choose to go to a hospital that’s further away than the closest available facility, the patient will be required to pay for the extra mileage involved in the transfer. During a surgical emergency, patients and their families may have a difficult time with this concept, and it can fall to the surgeon to walk them through the decision and its financial implications. More time devoted to the transfer.

Since the rural surgeon best understands the reasons for the transfer, the rural surgeon should be the one making the phone calls to the larger center, and participating in the conference calls with the accepting physicians. This process should not be delegated to the hospitalist or anyone else. The rural surgeon should also take great care to ensure a complete record is sent with the patient and that pertinent x-ray studies are sent on a CD. The rural surgeon should make it clear to the accepting physicians that he/she will do whatever they can to help care for the patient once the patient returns home.

After the transfer has occurred, the rural surgeon should communicate with the accepting physician periodically to follow the patient’s progress. If the rural hospital and the accepting hospital have the same EHR system, the rural surgeon should follow the progress of the patient and communicate with the accepting physician through the EHR email system or some other means. It’s also very helpful to obtain a cell phone number of the patient, or of a key family member, so that the rural surgeon can communicate with the family after the transfer to monitor the patient’s progress.

There are several important principles regarding transferring patients. First and foremost, accepting physicians at larger hospitals should be treated like gold. A wise rural surgeon keeps a list of accepting physicians that he/she has worked with in the past, as well as their cell phone numbers and email addresses. A good reputation as a surgeon requesting a transfer is very helpful, and part of that is never looking to “dump a patient.” A rural surgeon also must work hard at “networking” to get to know personally as many surgeons and physicians at accepting hospitals as possible. This takes effort, but can be accomplished by being active in the state American College of Surgeons Chapter, regional surgical societies, or state medical society. Personally visiting accepting hospitals, and meeting the surgeons and specialists there, is another great way to develop personal contacts. Every experienced rural surgeon knows that personal connections can pay off in many ways, and in particular, making transfers much easier.

The need for patient transfers from rural hospitals will never go away. Rural surgeons certainly appreciate all the help they receive from larger hospitals when it becomes necessary. As a rural surgeon, I would like to thank all surgeons and physicians at larger facilities that help us care for rural patients. Rural surgeons and physicians at larger hospitals need to continue to work together to achieve the best results possible for patients.

Dr. Puls is a general surgeon in Alpena, Mich. He serves as vice chair of the ACS Advisory Council for Rural Surgery.

Nobody is happy when a patient needs to be transferred. A patient transfer is an unplanned event for all parties involved: the patient, the family, the surgeon requesting a transfer, and the accepting surgeon or physician.

It’s a fact of life that a rural surgeon will, at times, need to transfer patients to a larger center. The reasons should come as no surprise to any surgeon. Sometimes there are simply not enough ICU beds, ICU nurses, ventilators, or respiratory therapists to care for patients. At times, very complicated surgical patients will present through the ED and sometimes a work-up on a hospitalized patient may reveal a complex surgical problem. Despite the best efforts of a rural surgeon, surgical complications will occur and a transfer can be the wisest choice. Trauma patients, especially those with a neurologic injury, will often need to be transferred. And then there is the exhaustion factor: A long stretch of on-call duty, or a series of difficult, time-consuming patients can deplete the mental and physical resources of a rural surgeon and the next patient who comes in the door with a complicated surgical issue will be transferred.

The transferring of patients from a rural hospital to a larger medical center with higher-level technology on hand is becoming more common. An example of this would be a patient with a blunt splenic injury. In years past, this patient could be carefully followed in a rural hospital, and a splenectomy could be done if necessary. With the ability of interventional radiologists to control splenic bleeding by embolization techniques, some of these patients do better if transferred to a larger center. Some rural hospitals used to operate on patients with a ruptured abdominal aortic aneurysm, but now many of these cases are transferred so that the patient can be treated with endovascular techniques. Some patients with GI bleeding are now transferred for possible treatment with embolization techniques.

In many ways, it has gotten easier in recent years to transfer a patient from a rural hospital. Almost all tertiary hospitals now have a transfer team or transfer coordinator that will determine bed availability, and arrange for a conference call between the rural surgeon and the accepting surgeon and other physicians at the larger hospital. Cell phones have allowed for much quicker communication between physicians. Many rural hospitals are now owned or affiliated with a larger medical center, which can allow for a quick transfer. As a result of Emergency Medical Treatment and Active Labor Act laws, a patient’s medical insurance status should not be a determining factor in a transfer.

Although transfers are easier than they once were, it should be noted that a transfer is not the easy or preferred option for most rural surgeons. Many rural surgeons inwardly groan when they realize that a patient needs to be transferred. Most surgeons can’t help having a feeling of defeat when a transfer is needed. Transfers can be very time-consuming, partly because there is usually no transfer team at a rural hospital and the surgeon has to be involved in making the arrangements and speaking with physicians at the larger center.

Because of the time commitment required for a transfer, it’s very important for the patient and his or her family to make a quick and definite decision about where they’d prefer the patient to be transferred to. Occasionally, after investing time to arrange for a transfer to a larger center, the rural surgeon is told that the accepting hospital will accept the patient, but that there are no open beds, which can mean that the patient can be waiting for several days for the transfer to occur, or that the rural surgeon needs to start the transfer process over again with another center. All this means can mean a further investment of time by the rural surgeon.

Ambulance transfer, whether by ground or air, is another complicating factor in transferring a patient. Medicare will pay the base rate and mileage for a medically necessary ambulance transport to the nearest facility that can care for the patient. Private insurance companies follow suit on this issue. If a patient and the family choose to go to a hospital that’s further away than the closest available facility, the patient will be required to pay for the extra mileage involved in the transfer. During a surgical emergency, patients and their families may have a difficult time with this concept, and it can fall to the surgeon to walk them through the decision and its financial implications. More time devoted to the transfer.

Since the rural surgeon best understands the reasons for the transfer, the rural surgeon should be the one making the phone calls to the larger center, and participating in the conference calls with the accepting physicians. This process should not be delegated to the hospitalist or anyone else. The rural surgeon should also take great care to ensure a complete record is sent with the patient and that pertinent x-ray studies are sent on a CD. The rural surgeon should make it clear to the accepting physicians that he/she will do whatever they can to help care for the patient once the patient returns home.

After the transfer has occurred, the rural surgeon should communicate with the accepting physician periodically to follow the patient’s progress. If the rural hospital and the accepting hospital have the same EHR system, the rural surgeon should follow the progress of the patient and communicate with the accepting physician through the EHR email system or some other means. It’s also very helpful to obtain a cell phone number of the patient, or of a key family member, so that the rural surgeon can communicate with the family after the transfer to monitor the patient’s progress.

There are several important principles regarding transferring patients. First and foremost, accepting physicians at larger hospitals should be treated like gold. A wise rural surgeon keeps a list of accepting physicians that he/she has worked with in the past, as well as their cell phone numbers and email addresses. A good reputation as a surgeon requesting a transfer is very helpful, and part of that is never looking to “dump a patient.” A rural surgeon also must work hard at “networking” to get to know personally as many surgeons and physicians at accepting hospitals as possible. This takes effort, but can be accomplished by being active in the state American College of Surgeons Chapter, regional surgical societies, or state medical society. Personally visiting accepting hospitals, and meeting the surgeons and specialists there, is another great way to develop personal contacts. Every experienced rural surgeon knows that personal connections can pay off in many ways, and in particular, making transfers much easier.

The need for patient transfers from rural hospitals will never go away. Rural surgeons certainly appreciate all the help they receive from larger hospitals when it becomes necessary. As a rural surgeon, I would like to thank all surgeons and physicians at larger facilities that help us care for rural patients. Rural surgeons and physicians at larger hospitals need to continue to work together to achieve the best results possible for patients.

Dr. Puls is a general surgeon in Alpena, Mich. He serves as vice chair of the ACS Advisory Council for Rural Surgery.

Nobody is happy when a patient needs to be transferred. A patient transfer is an unplanned event for all parties involved: the patient, the family, the surgeon requesting a transfer, and the accepting surgeon or physician.

It’s a fact of life that a rural surgeon will, at times, need to transfer patients to a larger center. The reasons should come as no surprise to any surgeon. Sometimes there are simply not enough ICU beds, ICU nurses, ventilators, or respiratory therapists to care for patients. At times, very complicated surgical patients will present through the ED and sometimes a work-up on a hospitalized patient may reveal a complex surgical problem. Despite the best efforts of a rural surgeon, surgical complications will occur and a transfer can be the wisest choice. Trauma patients, especially those with a neurologic injury, will often need to be transferred. And then there is the exhaustion factor: A long stretch of on-call duty, or a series of difficult, time-consuming patients can deplete the mental and physical resources of a rural surgeon and the next patient who comes in the door with a complicated surgical issue will be transferred.

The transferring of patients from a rural hospital to a larger medical center with higher-level technology on hand is becoming more common. An example of this would be a patient with a blunt splenic injury. In years past, this patient could be carefully followed in a rural hospital, and a splenectomy could be done if necessary. With the ability of interventional radiologists to control splenic bleeding by embolization techniques, some of these patients do better if transferred to a larger center. Some rural hospitals used to operate on patients with a ruptured abdominal aortic aneurysm, but now many of these cases are transferred so that the patient can be treated with endovascular techniques. Some patients with GI bleeding are now transferred for possible treatment with embolization techniques.

In many ways, it has gotten easier in recent years to transfer a patient from a rural hospital. Almost all tertiary hospitals now have a transfer team or transfer coordinator that will determine bed availability, and arrange for a conference call between the rural surgeon and the accepting surgeon and other physicians at the larger hospital. Cell phones have allowed for much quicker communication between physicians. Many rural hospitals are now owned or affiliated with a larger medical center, which can allow for a quick transfer. As a result of Emergency Medical Treatment and Active Labor Act laws, a patient’s medical insurance status should not be a determining factor in a transfer.

Although transfers are easier than they once were, it should be noted that a transfer is not the easy or preferred option for most rural surgeons. Many rural surgeons inwardly groan when they realize that a patient needs to be transferred. Most surgeons can’t help having a feeling of defeat when a transfer is needed. Transfers can be very time-consuming, partly because there is usually no transfer team at a rural hospital and the surgeon has to be involved in making the arrangements and speaking with physicians at the larger center.

Because of the time commitment required for a transfer, it’s very important for the patient and his or her family to make a quick and definite decision about where they’d prefer the patient to be transferred to. Occasionally, after investing time to arrange for a transfer to a larger center, the rural surgeon is told that the accepting hospital will accept the patient, but that there are no open beds, which can mean that the patient can be waiting for several days for the transfer to occur, or that the rural surgeon needs to start the transfer process over again with another center. All this means can mean a further investment of time by the rural surgeon.

Ambulance transfer, whether by ground or air, is another complicating factor in transferring a patient. Medicare will pay the base rate and mileage for a medically necessary ambulance transport to the nearest facility that can care for the patient. Private insurance companies follow suit on this issue. If a patient and the family choose to go to a hospital that’s further away than the closest available facility, the patient will be required to pay for the extra mileage involved in the transfer. During a surgical emergency, patients and their families may have a difficult time with this concept, and it can fall to the surgeon to walk them through the decision and its financial implications. More time devoted to the transfer.

Since the rural surgeon best understands the reasons for the transfer, the rural surgeon should be the one making the phone calls to the larger center, and participating in the conference calls with the accepting physicians. This process should not be delegated to the hospitalist or anyone else. The rural surgeon should also take great care to ensure a complete record is sent with the patient and that pertinent x-ray studies are sent on a CD. The rural surgeon should make it clear to the accepting physicians that he/she will do whatever they can to help care for the patient once the patient returns home.

After the transfer has occurred, the rural surgeon should communicate with the accepting physician periodically to follow the patient’s progress. If the rural hospital and the accepting hospital have the same EHR system, the rural surgeon should follow the progress of the patient and communicate with the accepting physician through the EHR email system or some other means. It’s also very helpful to obtain a cell phone number of the patient, or of a key family member, so that the rural surgeon can communicate with the family after the transfer to monitor the patient’s progress.

There are several important principles regarding transferring patients. First and foremost, accepting physicians at larger hospitals should be treated like gold. A wise rural surgeon keeps a list of accepting physicians that he/she has worked with in the past, as well as their cell phone numbers and email addresses. A good reputation as a surgeon requesting a transfer is very helpful, and part of that is never looking to “dump a patient.” A rural surgeon also must work hard at “networking” to get to know personally as many surgeons and physicians at accepting hospitals as possible. This takes effort, but can be accomplished by being active in the state American College of Surgeons Chapter, regional surgical societies, or state medical society. Personally visiting accepting hospitals, and meeting the surgeons and specialists there, is another great way to develop personal contacts. Every experienced rural surgeon knows that personal connections can pay off in many ways, and in particular, making transfers much easier.

The need for patient transfers from rural hospitals will never go away. Rural surgeons certainly appreciate all the help they receive from larger hospitals when it becomes necessary. As a rural surgeon, I would like to thank all surgeons and physicians at larger facilities that help us care for rural patients. Rural surgeons and physicians at larger hospitals need to continue to work together to achieve the best results possible for patients.

Dr. Puls is a general surgeon in Alpena, Mich. He serves as vice chair of the ACS Advisory Council for Rural Surgery.

Predictive risk factors for cardiac events (CEs) after general and vascular surgery differed significantly, according to a large retrospective study. However, there was no significant difference seen in the overall incidence of CEs between the two types of surgery, reported Derrick Acheampong, MD, and his colleagues at the Icahn School of Medicine at Mount Sinai, New York.

©Thinkstock

They performed a retrospective data analysis of 8,441 adult patients at their large urban teaching hospital; these patients had undergone general or vascular surgery during 2013-2016 and, in the analysis, were grouped by whether they experienced postoperative CEs.

Univariate and multivariate analyses identified predictors of postoperative CE and the association of CEs with adverse postoperative outcomes. CEs were defined as myocardial infarction or cardiac arrest within the 30-day postoperative period.

A total of 157 patients (1.9%) experienced CEs after major general and vascular surgery, with no significant difference in incidence between the two types of surgery (P = .44), according to their report, published online in the Annals of Medicine and Surgery. CE-associated mortality among this group was high, at 55.4%.

The occurrence of a CE following surgery in both groups was significantly associated with increased mortality, as well as pulmonary, renal, and neurological complications, in addition to systemic sepsis, postoperative red blood cell transfusion, unplanned return to the operating room, and prolonged hospitalization, according to the researchers.

However, predictors of CEs risk between vascular and general surgery were significantly different.

For general surgery, American Society of Anesthesiologists (ASA) status greater than 3, dependent functional status, acute renal failure or dialysis, weight loss, creatinine greater than 1.2 mg/dL, international normalized ratio (INR) greater than 1.5, and partial thromboplastin time (PTT) less than 35 seconds were all unique independent predictors of postoperative CEs.

For vascular surgery, the unique significant predictors of postoperative CEs were age greater than 65 years, emergency surgery, diabetes, congestive heart failure, systemic sepsis, and operative time greater than 240 minutes.

The only common predictive risk factors for postoperative CEs for the two forms of surgery were hematocrit less than 34% and ventilator dependence.

“The present study corroborates reported studies that recommend separate predictive CE risk indices and risk stratification among different surgical specialties. Predictors for CE greatly differed between general and vascular surgery patients in our patient population,” the authors stated.

They concluded with the hope that their study “provides useful information to surgeons and allows for the necessary resources to be focused on identified at-risk patients to improve surgical outcomes.”

Dr. Acheampong and his colleagues reported having no disclosures.

[email protected]

SOURCE: Acheampong D et al. Ann Med Surg. 2018. doi: 10.1016/j.amsu.2018.08.001.

Predictive risk factors for cardiac events (CEs) after general and vascular surgery differed significantly, according to a large retrospective study. However, there was no significant difference seen in the overall incidence of CEs between the two types of surgery, reported Derrick Acheampong, MD, and his colleagues at the Icahn School of Medicine at Mount Sinai, New York.

©Thinkstock

They performed a retrospective data analysis of 8,441 adult patients at their large urban teaching hospital; these patients had undergone general or vascular surgery during 2013-2016 and, in the analysis, were grouped by whether they experienced postoperative CEs.

Univariate and multivariate analyses identified predictors of postoperative CE and the association of CEs with adverse postoperative outcomes. CEs were defined as myocardial infarction or cardiac arrest within the 30-day postoperative period.

A total of 157 patients (1.9%) experienced CEs after major general and vascular surgery, with no significant difference in incidence between the two types of surgery (P = .44), according to their report, published online in the Annals of Medicine and Surgery. CE-associated mortality among this group was high, at 55.4%.

The occurrence of a CE following surgery in both groups was significantly associated with increased mortality, as well as pulmonary, renal, and neurological complications, in addition to systemic sepsis, postoperative red blood cell transfusion, unplanned return to the operating room, and prolonged hospitalization, according to the researchers.

However, predictors of CEs risk between vascular and general surgery were significantly different.

For general surgery, American Society of Anesthesiologists (ASA) status greater than 3, dependent functional status, acute renal failure or dialysis, weight loss, creatinine greater than 1.2 mg/dL, international normalized ratio (INR) greater than 1.5, and partial thromboplastin time (PTT) less than 35 seconds were all unique independent predictors of postoperative CEs.

For vascular surgery, the unique significant predictors of postoperative CEs were age greater than 65 years, emergency surgery, diabetes, congestive heart failure, systemic sepsis, and operative time greater than 240 minutes.

The only common predictive risk factors for postoperative CEs for the two forms of surgery were hematocrit less than 34% and ventilator dependence.

“The present study corroborates reported studies that recommend separate predictive CE risk indices and risk stratification among different surgical specialties. Predictors for CE greatly differed between general and vascular surgery patients in our patient population,” the authors stated.

They concluded with the hope that their study “provides useful information to surgeons and allows for the necessary resources to be focused on identified at-risk patients to improve surgical outcomes.”

Dr. Acheampong and his colleagues reported having no disclosures.

[email protected]

SOURCE: Acheampong D et al. Ann Med Surg. 2018. doi: 10.1016/j.amsu.2018.08.001.

Predictive risk factors for cardiac events (CEs) after general and vascular surgery differed significantly, according to a large retrospective study. However, there was no significant difference seen in the overall incidence of CEs between the two types of surgery, reported Derrick Acheampong, MD, and his colleagues at the Icahn School of Medicine at Mount Sinai, New York.

©Thinkstock

They performed a retrospective data analysis of 8,441 adult patients at their large urban teaching hospital; these patients had undergone general or vascular surgery during 2013-2016 and, in the analysis, were grouped by whether they experienced postoperative CEs.

Univariate and multivariate analyses identified predictors of postoperative CE and the association of CEs with adverse postoperative outcomes. CEs were defined as myocardial infarction or cardiac arrest within the 30-day postoperative period.

A total of 157 patients (1.9%) experienced CEs after major general and vascular surgery, with no significant difference in incidence between the two types of surgery (P = .44), according to their report, published online in the Annals of Medicine and Surgery. CE-associated mortality among this group was high, at 55.4%.

The occurrence of a CE following surgery in both groups was significantly associated with increased mortality, as well as pulmonary, renal, and neurological complications, in addition to systemic sepsis, postoperative red blood cell transfusion, unplanned return to the operating room, and prolonged hospitalization, according to the researchers.

However, predictors of CEs risk between vascular and general surgery were significantly different.

For general surgery, American Society of Anesthesiologists (ASA) status greater than 3, dependent functional status, acute renal failure or dialysis, weight loss, creatinine greater than 1.2 mg/dL, international normalized ratio (INR) greater than 1.5, and partial thromboplastin time (PTT) less than 35 seconds were all unique independent predictors of postoperative CEs.

For vascular surgery, the unique significant predictors of postoperative CEs were age greater than 65 years, emergency surgery, diabetes, congestive heart failure, systemic sepsis, and operative time greater than 240 minutes.

The only common predictive risk factors for postoperative CEs for the two forms of surgery were hematocrit less than 34% and ventilator dependence.

“The present study corroborates reported studies that recommend separate predictive CE risk indices and risk stratification among different surgical specialties. Predictors for CE greatly differed between general and vascular surgery patients in our patient population,” the authors stated.

They concluded with the hope that their study “provides useful information to surgeons and allows for the necessary resources to be focused on identified at-risk patients to improve surgical outcomes.”

Dr. Acheampong and his colleagues reported having no disclosures.

[email protected]

SOURCE: Acheampong D et al. Ann Med Surg. 2018. doi: 10.1016/j.amsu.2018.08.001.

WASHINGTON – A strategy combining stewardship and science is needed to help combat antimicrobial resistance, and updated plans from the U.S. Food and Drug Administration include four key components to address all aspects of product development and use, FDA commissioner Scott Gottlieb, MD, said in a press briefing in Washington on Sept. 14. 

“The FDA plays a unique role in advancing human and animal health” that provides a unique vantage point for coordinating all aspects of product development and application, he said. 

The FDA’s comprehensive approach to the challenge of antimicrobial resistance (AMR) includes:

• Facilitating product development.
• Promoting antimicrobial stewardship.
• Supporting the development of new tools for surveillance.
• Advancing scientific initiatives, including research for the development of alternative treatments.

The FDA’s product development plan to combat AMR includes the creation of incentives for companies to develop new antibiotic products and create a robust pipeline, which is a challenge because of the lack of immediate economic gain, Dr. Gottlieb said.
“It necessary to change the perception that the costs and risks of antibiotic innovation are too high relative to their expected gains,” he emphasized. 

Strategies to incentivize companies include fast track designation, priority review, and breakthrough therapy designation. In addition, the Limited Population Pathway for Antibacterial and Antifungal Drugs (LPAD) is designed to promote development of antimicrobial drugs for limited and underserved populations, Dr. Gottlieb said. The FDA plan also calls for pursuing reimbursement options with the Centers for Medicare & Medicaid Services. 

Promoting antimicrobial stewardship remains an ongoing element of the FDA’s plan to reduce AMR. In conjunction with the release of the FDA’s updated approach to AMR, the FDA’s Center for Veterinary Medicine CVM released a 5-year action plan to promote and support antimicrobial stewardship in not only the agricultural arena, but in companion animals as well. 

The FDA plans to bring all antimicrobials of medical importance that are approved for use in animals under the oversight of CVM, which will pursue the improve labeling on antimicrobial drugs used in the feed and water of food-producing animals, including defining durations of use, Dr. Gottlieb noted.

Supporting the development and improvement of surveillance tools is “essential to understanding the drivers of resistance in human and veterinary settings and formulating appropriate responses” to outbreaks, Dr. Gottlieb said.

To help meet this goal, the FDA will expand sampling via the National Antimicrobial Resistance Monitoring System (NARMS) database, he said. Other surveillance goals include supporting genomics research and expanding AMR monitoring to include pathogens associated with animal feed and companion animals, he added. 

As part of the final component of the FDA’s AMR strategy to advance scientific initiatives, the FDA has released a new Request for Information “to obtain additional, external input on how best to develop an annual list of regulatory science initiatives specific for antimicrobial products,” Dr. Gottlieb announced. The FDA intends to use the information gained from clinicians and others in its creation of guidance documents and recommendations to streamline the antibiotic development process. He also cited the FDA’s ongoing support of partnerships with public and private organizations such as the Clinical Trials Transformation Initiative, which focuses on drug development for severe bacterial infections with current unmet medical need.

“We need to harness science and policy to help our public health systems and researchers become nimbler in the battle against drug-resistant pathogens,” Dr. Gottlieb concluded. 

In a panel discussion following the briefing, several experts offered perspective on the FDA’s goals and on the challenges of AMR. 

William Flynn, DVM, deputy director of science policy for the Center of Veterinary Medicine, noted some goals for reducing the use of antibiotics in the veterinary arena. 

“We are trying to focus on the driver: What are the disease conditions that drive use of the product,” he said. Ideally, better management of disease conditions can reduce reliance on antibiotics, he added. 

Also in the panel discussion, Steven Gitterman, MD, deputy director of the division of microbiology devices at the Center for Devices and Radiological Health, emphasized the value of sustainable trial databases so AMR research can continue on an ongoing basis. Finally, Carolyn Wilson, PhD, associate director of research at the Center for Biologics Evaluation and Research, noted that the FDA’s research and development efforts include antibiotic alternatives, including live biotherapeutic products, fecal microbiota transplantation, and bacteriophage therapy.

Visit www.fda.gov for a transcript of Dr. Gottlieb’s talk, and for the updated FDA website page with more details on the agency’s plans to combat antimicrobial resistance. 

Dr. Gottlieb and the panelists had no financial conflicts to disclose.

WASHINGTON – A strategy combining stewardship and science is needed to help combat antimicrobial resistance, and updated plans from the U.S. Food and Drug Administration include four key components to address all aspects of product development and use, FDA commissioner Scott Gottlieb, MD, said in a press briefing in Washington on Sept. 14. 

“The FDA plays a unique role in advancing human and animal health” that provides a unique vantage point for coordinating all aspects of product development and application, he said. 

The FDA’s comprehensive approach to the challenge of antimicrobial resistance (AMR) includes:

• Facilitating product development.
• Promoting antimicrobial stewardship.
• Supporting the development of new tools for surveillance.
• Advancing scientific initiatives, including research for the development of alternative treatments.

The FDA’s product development plan to combat AMR includes the creation of incentives for companies to develop new antibiotic products and create a robust pipeline, which is a challenge because of the lack of immediate economic gain, Dr. Gottlieb said.
“It necessary to change the perception that the costs and risks of antibiotic innovation are too high relative to their expected gains,” he emphasized. 

Strategies to incentivize companies include fast track designation, priority review, and breakthrough therapy designation. In addition, the Limited Population Pathway for Antibacterial and Antifungal Drugs (LPAD) is designed to promote development of antimicrobial drugs for limited and underserved populations, Dr. Gottlieb said. The FDA plan also calls for pursuing reimbursement options with the Centers for Medicare & Medicaid Services. 

Promoting antimicrobial stewardship remains an ongoing element of the FDA’s plan to reduce AMR. In conjunction with the release of the FDA’s updated approach to AMR, the FDA’s Center for Veterinary Medicine CVM released a 5-year action plan to promote and support antimicrobial stewardship in not only the agricultural arena, but in companion animals as well. 

The FDA plans to bring all antimicrobials of medical importance that are approved for use in animals under the oversight of CVM, which will pursue the improve labeling on antimicrobial drugs used in the feed and water of food-producing animals, including defining durations of use, Dr. Gottlieb noted.

Supporting the development and improvement of surveillance tools is “essential to understanding the drivers of resistance in human and veterinary settings and formulating appropriate responses” to outbreaks, Dr. Gottlieb said.

To help meet this goal, the FDA will expand sampling via the National Antimicrobial Resistance Monitoring System (NARMS) database, he said. Other surveillance goals include supporting genomics research and expanding AMR monitoring to include pathogens associated with animal feed and companion animals, he added. 

As part of the final component of the FDA’s AMR strategy to advance scientific initiatives, the FDA has released a new Request for Information “to obtain additional, external input on how best to develop an annual list of regulatory science initiatives specific for antimicrobial products,” Dr. Gottlieb announced. The FDA intends to use the information gained from clinicians and others in its creation of guidance documents and recommendations to streamline the antibiotic development process. He also cited the FDA’s ongoing support of partnerships with public and private organizations such as the Clinical Trials Transformation Initiative, which focuses on drug development for severe bacterial infections with current unmet medical need.

“We need to harness science and policy to help our public health systems and researchers become nimbler in the battle against drug-resistant pathogens,” Dr. Gottlieb concluded. 

In a panel discussion following the briefing, several experts offered perspective on the FDA’s goals and on the challenges of AMR. 

William Flynn, DVM, deputy director of science policy for the Center of Veterinary Medicine, noted some goals for reducing the use of antibiotics in the veterinary arena. 

“We are trying to focus on the driver: What are the disease conditions that drive use of the product,” he said. Ideally, better management of disease conditions can reduce reliance on antibiotics, he added. 

Also in the panel discussion, Steven Gitterman, MD, deputy director of the division of microbiology devices at the Center for Devices and Radiological Health, emphasized the value of sustainable trial databases so AMR research can continue on an ongoing basis. Finally, Carolyn Wilson, PhD, associate director of research at the Center for Biologics Evaluation and Research, noted that the FDA’s research and development efforts include antibiotic alternatives, including live biotherapeutic products, fecal microbiota transplantation, and bacteriophage therapy.

Visit www.fda.gov for a transcript of Dr. Gottlieb’s talk, and for the updated FDA website page with more details on the agency’s plans to combat antimicrobial resistance. 

Dr. Gottlieb and the panelists had no financial conflicts to disclose.

WASHINGTON – A strategy combining stewardship and science is needed to help combat antimicrobial resistance, and updated plans from the U.S. Food and Drug Administration include four key components to address all aspects of product development and use, FDA commissioner Scott Gottlieb, MD, said in a press briefing in Washington on Sept. 14. 

“The FDA plays a unique role in advancing human and animal health” that provides a unique vantage point for coordinating all aspects of product development and application, he said. 

The FDA’s comprehensive approach to the challenge of antimicrobial resistance (AMR) includes:

• Facilitating product development.
• Promoting antimicrobial stewardship.
• Supporting the development of new tools for surveillance.
• Advancing scientific initiatives, including research for the development of alternative treatments.

The FDA’s product development plan to combat AMR includes the creation of incentives for companies to develop new antibiotic products and create a robust pipeline, which is a challenge because of the lack of immediate economic gain, Dr. Gottlieb said.
“It necessary to change the perception that the costs and risks of antibiotic innovation are too high relative to their expected gains,” he emphasized. 

Strategies to incentivize companies include fast track designation, priority review, and breakthrough therapy designation. In addition, the Limited Population Pathway for Antibacterial and Antifungal Drugs (LPAD) is designed to promote development of antimicrobial drugs for limited and underserved populations, Dr. Gottlieb said. The FDA plan also calls for pursuing reimbursement options with the Centers for Medicare & Medicaid Services. 

Promoting antimicrobial stewardship remains an ongoing element of the FDA’s plan to reduce AMR. In conjunction with the release of the FDA’s updated approach to AMR, the FDA’s Center for Veterinary Medicine CVM released a 5-year action plan to promote and support antimicrobial stewardship in not only the agricultural arena, but in companion animals as well. 

The FDA plans to bring all antimicrobials of medical importance that are approved for use in animals under the oversight of CVM, which will pursue the improve labeling on antimicrobial drugs used in the feed and water of food-producing animals, including defining durations of use, Dr. Gottlieb noted.

Supporting the development and improvement of surveillance tools is “essential to understanding the drivers of resistance in human and veterinary settings and formulating appropriate responses” to outbreaks, Dr. Gottlieb said.

To help meet this goal, the FDA will expand sampling via the National Antimicrobial Resistance Monitoring System (NARMS) database, he said. Other surveillance goals include supporting genomics research and expanding AMR monitoring to include pathogens associated with animal feed and companion animals, he added. 

As part of the final component of the FDA’s AMR strategy to advance scientific initiatives, the FDA has released a new Request for Information “to obtain additional, external input on how best to develop an annual list of regulatory science initiatives specific for antimicrobial products,” Dr. Gottlieb announced. The FDA intends to use the information gained from clinicians and others in its creation of guidance documents and recommendations to streamline the antibiotic development process. He also cited the FDA’s ongoing support of partnerships with public and private organizations such as the Clinical Trials Transformation Initiative, which focuses on drug development for severe bacterial infections with current unmet medical need.

“We need to harness science and policy to help our public health systems and researchers become nimbler in the battle against drug-resistant pathogens,” Dr. Gottlieb concluded. 

In a panel discussion following the briefing, several experts offered perspective on the FDA’s goals and on the challenges of AMR. 

William Flynn, DVM, deputy director of science policy for the Center of Veterinary Medicine, noted some goals for reducing the use of antibiotics in the veterinary arena. 

“We are trying to focus on the driver: What are the disease conditions that drive use of the product,” he said. Ideally, better management of disease conditions can reduce reliance on antibiotics, he added. 

Also in the panel discussion, Steven Gitterman, MD, deputy director of the division of microbiology devices at the Center for Devices and Radiological Health, emphasized the value of sustainable trial databases so AMR research can continue on an ongoing basis. Finally, Carolyn Wilson, PhD, associate director of research at the Center for Biologics Evaluation and Research, noted that the FDA’s research and development efforts include antibiotic alternatives, including live biotherapeutic products, fecal microbiota transplantation, and bacteriophage therapy.

Visit www.fda.gov for a transcript of Dr. Gottlieb’s talk, and for the updated FDA website page with more details on the agency’s plans to combat antimicrobial resistance. 

Dr. Gottlieb and the panelists had no financial conflicts to disclose.

Surgeons have a time-honored institution of reflection, learning, and responsibility in the Morbidity & Mortality conference. The M&M is unique in the medical profession and we should look critically at efforts by hospitals and bureaucracies to change its character and its purpose.

A story in this issue (“Little overlap between surgical M&M and AHRQ” on adverse events, p. xx) covers a published study (Anderson J et al. J Am Coll Surg. 2018 Jul 5. doi: 10.1016/j.jamcollsurg.2018.06.008) of the ways in which surgeon-reported M&M cases do (but mostly, do not) overlap with those captured in the ubiquitous Patient Safety Indicators (PSIs).

I am reminded once again of the long road we have traveled from the M&M conference of my student and resident days in the 1970s to today’s version of this event.

At our institution, the M&M has evolved over the years to serve not only an educational venue from which all in attendance learn from the misadventures of others and (hopefully) avoid similar errors in the future, but also as a component of the institution’s overall patient safety and quality improvement program. The authors point out the inherent difference between the clinician-generated M&M cases, which may possess selection bias in the cases they identify as complications, and the strictly defined PSIs that are captured from an administrative database and often include cases overlooked by the clinicians as not relevant to the surgical M&M process.

Both kinds of data are valuable, but for surgeons, the M&M is the one venue where they can focus in the company of their colleagues on those instances where the best intentions go off the rails: erroneous decisions, faulty assessments, and unanticipated complications.

The surgical M&M conference traces its origins to the admirable practice of early 20th century Boston surgeon Ernest Codman, who tracked the treatment outcome of all of his patients on “End Result Cards” for at least a year with the goal of identifying errors to improve the care of his future patients. He established the first M&M conference at Harvard and was one of the founders of the American College of Surgeons and the forerunner of the Joint Commission. His idea that surgeon and hospital outcomes should be made public so that patients could make an informed choice about where and from whom to seek care was, however, vigorously resisted by Harvard and Dr. Codman lost his privileges there.

I would offer that the M&M conference and the PSIs are apples and oranges: both good, but different. Each serves a different purpose. But too much integration of the PSI into the M&M format could end up creating a formulaic adverse events conference that answers to bureaucratic needs of the hospital, but loses some of its value as a forum for learning.

It is worth reflecting on how and why the traditional M&M has such value to surgeons.

To begin with, the quality of the leadership matters. A good leader knows how to avoid blaming, shaming, or embarrassing the presenter, who likely feels bad enough about the complication without being tortured about it. The goal is that all salient factors that contributed to the complication are elicited and that everyone present comes away from the conference armed with alternative ways to prevent a repeat of the same complication.

As a resident I learned more at the Saturday morning M&M than I did at any other conference. I was there every Saturday morning almost without fail for 15 years as a medical student, resident, and faculty member. There I learned not only how to avoid errors and benefit from the accumulated wisdom of many gray hairs in the audience, but also how to present an embarrassing complication both honestly and even with some self-deprecating humor.

Chief residents such as Don Trunkey, Brent Eastman, and Theodore Schrock were gifted in being accountable for mistakes while simultaneously deflecting ire with some well-chosen props. I remember one vivid example: Ted Schrock stepping up to the podium to present a “case gone bad” while holding a garbage-can lid in front of his chest like a shield, ready to defend himself. I don’t remember the case, but the picture is still etched in my mind 45 years later.

Our chairman, Dr. J. Englebert Dunphy, was a master at zeroing in on the critical errors in decision-making or operative conduct that had led to a poor outcome. When the presenter was honest and well-meaning but lacking in sophisticated insight, Dr. Dunphy would calmly ask probing questions that guided the resident to understand why a complication had occurred and how it might have been avoided. If the complication was exceptionally egregious, or the resident was not forthright or was evasive in his “mea culpa,” Dr. Dunphy would turn to one of his staunch faculty allies in the front row and inquire, “Brodie, what do you think about that?” to which Brodie Stephens would typically reply, “Bert, I thought we were here to CURE disease, not CAUSE it!” (To add some colorful football lore to the story, Howard Brodie Stephens was the All-American end who caught a 53-yard pass from “Brick” Muller in the 1921 Rose Bowl victory of Cal Berkeley over Ohio State, the Pacific Coast Conference’s last win against a Big Ten team until 1953.)

Certain resident shortcomings were sure to raise Dr. Dunphy’s ire. These included failing to take responsibility for your mistake and attempting to blame the error on someone else or on another discipline or not adequately supervising an intern or junior resident if you were the chief resident. The latter crime was the subject of one of the most clever and resourceful chief resident M&M presentations of all time, that of past ACS President Brent Eastman as his final presentation from his vascular surgery rotation, the last of his chief year. This one took some moxie, considerable preparation, and the involvement of colleagues near and far. Brent enlisted his good friend and later distinguished cardiac surgeon Dr. Larry Cohn, then junior faculty at Harvard, to find a list of Dr. Dunphy’s complications while he was a resident in Boston in the 1930s. Although records were no longer available, Dr. Cohn mentioned the issue to Dr. Hartwell Harrison, who had been chief resident at the Peter Bent Brigham Hospital when Dr. Dunphy was a junior resident. Dr. Harrison remembered a case that Dr. Dunphy had performed in the outpatient clinic without supervision in which he encountered uncontrolled bleeding.

Armed with the perfect case to present, Brent coached Dr. Edwin (Jack) Wylie to be his “plant” in the audience. At M&M, Brent sheepishly admitted that the case he had to present was that of an unsupervised junior resident who incurred uncontrolled bleeding in the outpatient setting. On cue, Dr. Wylie asked, “Who the hell WAS that resident?” Dr. Eastman then shuffled through his papers to find the correct sheet and announced, “Dr. John E. Dunphy, Peter Bent Brigham Hospital, 1937.” The room exploded in uproarious laughter, joined heartily by Dr. Dunphy.

That was then, and this is now. I can’t envision such a spectacle ever occurring these days. The M&M conference of 2018 has become far more standardized and endowed with greater scientific rigor. Its evolution has likely made M&M more precise and valuable as an educational tool for surgeons to learn from the mistakes of others, but of course, it has lost an element of surprise and hilarity that kept all of us sleep-deprived residents awake and alert. The lessons learned from the traditional M&M lasted this surgeon’s lifetime, and we should consider preserving some of the give-and-take, admission of failure, and reflection that made the M&M so unforgettable.
 

Dr. Deveney is professor of surgery and vice chair of education in the department of surgery at Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

Surgeons have a time-honored institution of reflection, learning, and responsibility in the Morbidity & Mortality conference. The M&M is unique in the medical profession and we should look critically at efforts by hospitals and bureaucracies to change its character and its purpose.

A story in this issue (“Little overlap between surgical M&M and AHRQ” on adverse events, p. xx) covers a published study (Anderson J et al. J Am Coll Surg. 2018 Jul 5. doi: 10.1016/j.jamcollsurg.2018.06.008) of the ways in which surgeon-reported M&M cases do (but mostly, do not) overlap with those captured in the ubiquitous Patient Safety Indicators (PSIs).

I am reminded once again of the long road we have traveled from the M&M conference of my student and resident days in the 1970s to today’s version of this event.

At our institution, the M&M has evolved over the years to serve not only an educational venue from which all in attendance learn from the misadventures of others and (hopefully) avoid similar errors in the future, but also as a component of the institution’s overall patient safety and quality improvement program. The authors point out the inherent difference between the clinician-generated M&M cases, which may possess selection bias in the cases they identify as complications, and the strictly defined PSIs that are captured from an administrative database and often include cases overlooked by the clinicians as not relevant to the surgical M&M process.

Both kinds of data are valuable, but for surgeons, the M&M is the one venue where they can focus in the company of their colleagues on those instances where the best intentions go off the rails: erroneous decisions, faulty assessments, and unanticipated complications.

The surgical M&M conference traces its origins to the admirable practice of early 20th century Boston surgeon Ernest Codman, who tracked the treatment outcome of all of his patients on “End Result Cards” for at least a year with the goal of identifying errors to improve the care of his future patients. He established the first M&M conference at Harvard and was one of the founders of the American College of Surgeons and the forerunner of the Joint Commission. His idea that surgeon and hospital outcomes should be made public so that patients could make an informed choice about where and from whom to seek care was, however, vigorously resisted by Harvard and Dr. Codman lost his privileges there.

I would offer that the M&M conference and the PSIs are apples and oranges: both good, but different. Each serves a different purpose. But too much integration of the PSI into the M&M format could end up creating a formulaic adverse events conference that answers to bureaucratic needs of the hospital, but loses some of its value as a forum for learning.

It is worth reflecting on how and why the traditional M&M has such value to surgeons.

To begin with, the quality of the leadership matters. A good leader knows how to avoid blaming, shaming, or embarrassing the presenter, who likely feels bad enough about the complication without being tortured about it. The goal is that all salient factors that contributed to the complication are elicited and that everyone present comes away from the conference armed with alternative ways to prevent a repeat of the same complication.

As a resident I learned more at the Saturday morning M&M than I did at any other conference. I was there every Saturday morning almost without fail for 15 years as a medical student, resident, and faculty member. There I learned not only how to avoid errors and benefit from the accumulated wisdom of many gray hairs in the audience, but also how to present an embarrassing complication both honestly and even with some self-deprecating humor.

Chief residents such as Don Trunkey, Brent Eastman, and Theodore Schrock were gifted in being accountable for mistakes while simultaneously deflecting ire with some well-chosen props. I remember one vivid example: Ted Schrock stepping up to the podium to present a “case gone bad” while holding a garbage-can lid in front of his chest like a shield, ready to defend himself. I don’t remember the case, but the picture is still etched in my mind 45 years later.

Our chairman, Dr. J. Englebert Dunphy, was a master at zeroing in on the critical errors in decision-making or operative conduct that had led to a poor outcome. When the presenter was honest and well-meaning but lacking in sophisticated insight, Dr. Dunphy would calmly ask probing questions that guided the resident to understand why a complication had occurred and how it might have been avoided. If the complication was exceptionally egregious, or the resident was not forthright or was evasive in his “mea culpa,” Dr. Dunphy would turn to one of his staunch faculty allies in the front row and inquire, “Brodie, what do you think about that?” to which Brodie Stephens would typically reply, “Bert, I thought we were here to CURE disease, not CAUSE it!” (To add some colorful football lore to the story, Howard Brodie Stephens was the All-American end who caught a 53-yard pass from “Brick” Muller in the 1921 Rose Bowl victory of Cal Berkeley over Ohio State, the Pacific Coast Conference’s last win against a Big Ten team until 1953.)

Certain resident shortcomings were sure to raise Dr. Dunphy’s ire. These included failing to take responsibility for your mistake and attempting to blame the error on someone else or on another discipline or not adequately supervising an intern or junior resident if you were the chief resident. The latter crime was the subject of one of the most clever and resourceful chief resident M&M presentations of all time, that of past ACS President Brent Eastman as his final presentation from his vascular surgery rotation, the last of his chief year. This one took some moxie, considerable preparation, and the involvement of colleagues near and far. Brent enlisted his good friend and later distinguished cardiac surgeon Dr. Larry Cohn, then junior faculty at Harvard, to find a list of Dr. Dunphy’s complications while he was a resident in Boston in the 1930s. Although records were no longer available, Dr. Cohn mentioned the issue to Dr. Hartwell Harrison, who had been chief resident at the Peter Bent Brigham Hospital when Dr. Dunphy was a junior resident. Dr. Harrison remembered a case that Dr. Dunphy had performed in the outpatient clinic without supervision in which he encountered uncontrolled bleeding.

Armed with the perfect case to present, Brent coached Dr. Edwin (Jack) Wylie to be his “plant” in the audience. At M&M, Brent sheepishly admitted that the case he had to present was that of an unsupervised junior resident who incurred uncontrolled bleeding in the outpatient setting. On cue, Dr. Wylie asked, “Who the hell WAS that resident?” Dr. Eastman then shuffled through his papers to find the correct sheet and announced, “Dr. John E. Dunphy, Peter Bent Brigham Hospital, 1937.” The room exploded in uproarious laughter, joined heartily by Dr. Dunphy.

That was then, and this is now. I can’t envision such a spectacle ever occurring these days. The M&M conference of 2018 has become far more standardized and endowed with greater scientific rigor. Its evolution has likely made M&M more precise and valuable as an educational tool for surgeons to learn from the mistakes of others, but of course, it has lost an element of surprise and hilarity that kept all of us sleep-deprived residents awake and alert. The lessons learned from the traditional M&M lasted this surgeon’s lifetime, and we should consider preserving some of the give-and-take, admission of failure, and reflection that made the M&M so unforgettable.
 

Dr. Deveney is professor of surgery and vice chair of education in the department of surgery at Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

Surgeons have a time-honored institution of reflection, learning, and responsibility in the Morbidity & Mortality conference. The M&M is unique in the medical profession and we should look critically at efforts by hospitals and bureaucracies to change its character and its purpose.

A story in this issue (“Little overlap between surgical M&M and AHRQ” on adverse events, p. xx) covers a published study (Anderson J et al. J Am Coll Surg. 2018 Jul 5. doi: 10.1016/j.jamcollsurg.2018.06.008) of the ways in which surgeon-reported M&M cases do (but mostly, do not) overlap with those captured in the ubiquitous Patient Safety Indicators (PSIs).

I am reminded once again of the long road we have traveled from the M&M conference of my student and resident days in the 1970s to today’s version of this event.

At our institution, the M&M has evolved over the years to serve not only an educational venue from which all in attendance learn from the misadventures of others and (hopefully) avoid similar errors in the future, but also as a component of the institution’s overall patient safety and quality improvement program. The authors point out the inherent difference between the clinician-generated M&M cases, which may possess selection bias in the cases they identify as complications, and the strictly defined PSIs that are captured from an administrative database and often include cases overlooked by the clinicians as not relevant to the surgical M&M process.

Both kinds of data are valuable, but for surgeons, the M&M is the one venue where they can focus in the company of their colleagues on those instances where the best intentions go off the rails: erroneous decisions, faulty assessments, and unanticipated complications.

The surgical M&M conference traces its origins to the admirable practice of early 20th century Boston surgeon Ernest Codman, who tracked the treatment outcome of all of his patients on “End Result Cards” for at least a year with the goal of identifying errors to improve the care of his future patients. He established the first M&M conference at Harvard and was one of the founders of the American College of Surgeons and the forerunner of the Joint Commission. His idea that surgeon and hospital outcomes should be made public so that patients could make an informed choice about where and from whom to seek care was, however, vigorously resisted by Harvard and Dr. Codman lost his privileges there.

I would offer that the M&M conference and the PSIs are apples and oranges: both good, but different. Each serves a different purpose. But too much integration of the PSI into the M&M format could end up creating a formulaic adverse events conference that answers to bureaucratic needs of the hospital, but loses some of its value as a forum for learning.

It is worth reflecting on how and why the traditional M&M has such value to surgeons.

To begin with, the quality of the leadership matters. A good leader knows how to avoid blaming, shaming, or embarrassing the presenter, who likely feels bad enough about the complication without being tortured about it. The goal is that all salient factors that contributed to the complication are elicited and that everyone present comes away from the conference armed with alternative ways to prevent a repeat of the same complication.

As a resident I learned more at the Saturday morning M&M than I did at any other conference. I was there every Saturday morning almost without fail for 15 years as a medical student, resident, and faculty member. There I learned not only how to avoid errors and benefit from the accumulated wisdom of many gray hairs in the audience, but also how to present an embarrassing complication both honestly and even with some self-deprecating humor.

Chief residents such as Don Trunkey, Brent Eastman, and Theodore Schrock were gifted in being accountable for mistakes while simultaneously deflecting ire with some well-chosen props. I remember one vivid example: Ted Schrock stepping up to the podium to present a “case gone bad” while holding a garbage-can lid in front of his chest like a shield, ready to defend himself. I don’t remember the case, but the picture is still etched in my mind 45 years later.

Our chairman, Dr. J. Englebert Dunphy, was a master at zeroing in on the critical errors in decision-making or operative conduct that had led to a poor outcome. When the presenter was honest and well-meaning but lacking in sophisticated insight, Dr. Dunphy would calmly ask probing questions that guided the resident to understand why a complication had occurred and how it might have been avoided. If the complication was exceptionally egregious, or the resident was not forthright or was evasive in his “mea culpa,” Dr. Dunphy would turn to one of his staunch faculty allies in the front row and inquire, “Brodie, what do you think about that?” to which Brodie Stephens would typically reply, “Bert, I thought we were here to CURE disease, not CAUSE it!” (To add some colorful football lore to the story, Howard Brodie Stephens was the All-American end who caught a 53-yard pass from “Brick” Muller in the 1921 Rose Bowl victory of Cal Berkeley over Ohio State, the Pacific Coast Conference’s last win against a Big Ten team until 1953.)

Certain resident shortcomings were sure to raise Dr. Dunphy’s ire. These included failing to take responsibility for your mistake and attempting to blame the error on someone else or on another discipline or not adequately supervising an intern or junior resident if you were the chief resident. The latter crime was the subject of one of the most clever and resourceful chief resident M&M presentations of all time, that of past ACS President Brent Eastman as his final presentation from his vascular surgery rotation, the last of his chief year. This one took some moxie, considerable preparation, and the involvement of colleagues near and far. Brent enlisted his good friend and later distinguished cardiac surgeon Dr. Larry Cohn, then junior faculty at Harvard, to find a list of Dr. Dunphy’s complications while he was a resident in Boston in the 1930s. Although records were no longer available, Dr. Cohn mentioned the issue to Dr. Hartwell Harrison, who had been chief resident at the Peter Bent Brigham Hospital when Dr. Dunphy was a junior resident. Dr. Harrison remembered a case that Dr. Dunphy had performed in the outpatient clinic without supervision in which he encountered uncontrolled bleeding.

Armed with the perfect case to present, Brent coached Dr. Edwin (Jack) Wylie to be his “plant” in the audience. At M&M, Brent sheepishly admitted that the case he had to present was that of an unsupervised junior resident who incurred uncontrolled bleeding in the outpatient setting. On cue, Dr. Wylie asked, “Who the hell WAS that resident?” Dr. Eastman then shuffled through his papers to find the correct sheet and announced, “Dr. John E. Dunphy, Peter Bent Brigham Hospital, 1937.” The room exploded in uproarious laughter, joined heartily by Dr. Dunphy.

That was then, and this is now. I can’t envision such a spectacle ever occurring these days. The M&M conference of 2018 has become far more standardized and endowed with greater scientific rigor. Its evolution has likely made M&M more precise and valuable as an educational tool for surgeons to learn from the mistakes of others, but of course, it has lost an element of surprise and hilarity that kept all of us sleep-deprived residents awake and alert. The lessons learned from the traditional M&M lasted this surgeon’s lifetime, and we should consider preserving some of the give-and-take, admission of failure, and reflection that made the M&M so unforgettable.
 

Dr. Deveney is professor of surgery and vice chair of education in the department of surgery at Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.

The American College of Surgeons (ACS) hosted a Capitol Hill briefing July 23 featuring a panel of experts on military surgical care—John H. Armstrong, MD, FACS; Arthur Kellerman, MD, MPH; CAPT Eric Elster, MD, FACS, USN; and COL Frederick Lough, MD, FACS, USA. The panelists focused on themes from the recent publication, Out of the Crucible: How the U.S. Military Transformed Combat Casualty Care in Iraq and Afghanistan, and the role military-civilian trauma partnerships play in maintaining trauma care readiness.

Attendees learned that the prolonged conflicts in Operation Iraqi Freedom and Operation Enduring Freedom saw an unprecedented improvement in military combat casualty care and the creation of the Joint Trauma System (JTS), allowing for the development and dissemination of best trauma practices across the Department of Defense. Preserving the JTS and establishing a fully integrated military-civilian trauma system are among the primary efforts of the Military Health System Strategic Partnership American College of Surgeons.

For more information about this briefing, contact Carrie Zlatos, ACS Senior Congressional Lobbyist, at [email protected] or 202-672-1508.
 

The American College of Surgeons (ACS) hosted a Capitol Hill briefing July 23 featuring a panel of experts on military surgical care—John H. Armstrong, MD, FACS; Arthur Kellerman, MD, MPH; CAPT Eric Elster, MD, FACS, USN; and COL Frederick Lough, MD, FACS, USA. The panelists focused on themes from the recent publication, Out of the Crucible: How the U.S. Military Transformed Combat Casualty Care in Iraq and Afghanistan, and the role military-civilian trauma partnerships play in maintaining trauma care readiness.

Attendees learned that the prolonged conflicts in Operation Iraqi Freedom and Operation Enduring Freedom saw an unprecedented improvement in military combat casualty care and the creation of the Joint Trauma System (JTS), allowing for the development and dissemination of best trauma practices across the Department of Defense. Preserving the JTS and establishing a fully integrated military-civilian trauma system are among the primary efforts of the Military Health System Strategic Partnership American College of Surgeons.

For more information about this briefing, contact Carrie Zlatos, ACS Senior Congressional Lobbyist, at [email protected] or 202-672-1508.
 

The American College of Surgeons (ACS) hosted a Capitol Hill briefing July 23 featuring a panel of experts on military surgical care—John H. Armstrong, MD, FACS; Arthur Kellerman, MD, MPH; CAPT Eric Elster, MD, FACS, USN; and COL Frederick Lough, MD, FACS, USA. The panelists focused on themes from the recent publication, Out of the Crucible: How the U.S. Military Transformed Combat Casualty Care in Iraq and Afghanistan, and the role military-civilian trauma partnerships play in maintaining trauma care readiness.

Attendees learned that the prolonged conflicts in Operation Iraqi Freedom and Operation Enduring Freedom saw an unprecedented improvement in military combat casualty care and the creation of the Joint Trauma System (JTS), allowing for the development and dissemination of best trauma practices across the Department of Defense. Preserving the JTS and establishing a fully integrated military-civilian trauma system are among the primary efforts of the Military Health System Strategic Partnership American College of Surgeons.

For more information about this briefing, contact Carrie Zlatos, ACS Senior Congressional Lobbyist, at [email protected] or 202-672-1508.
 

If you are not already a member of the American College of Surgeons (ACS) or you know an interested non-member colleague who is attending the Clinical Congress 2018 in Boston, MA, visit the Become a Member booth to apply for ACS membership. The membership application fee will be waived for individuals who apply at the meeting.

The Become a Member booth will be located in the Registration Area of the Boston Convention & Exhibition Center and will be open the same hours as registration, which are as follows:



• Sunday, October 21: 7:00 am–6:00 pm

• Monday, October 22: 6:30 am–5:00 pm

• Tuesday, October 23: 7:00 am–4:00 pm

• Wednesday, October 24: 7:00 am–4:00 pm

• Thursday, October 25: 7:00–10:00 am



Plan ahead to apply at the meeting for one of the following membership categories and have access to the documents listed to support and speed up your application process:



• Fellows (U.S. and Canada): Copy of board certification document, current curriculum vitae (CV), and names of five ACS Fellows to serve as references. Watch the video about the domestic application process at www.youtube.com/watch?v=2VUqvveNYf8&.

• International Fellows: Copy of medical license, board/country certification document, current CV, and names of three ACS Fellows to serve as references. Watch the video about the international application process at www.youtube.com/watch?v=djoMUAUTA4I.

• Associate Fellows: Copy of residency completion document or an official board/country certification document.

• Residents: Letter verifying training status.

• Medical Students: Letter verifying educational status.

• Affiliate Members: The name of a Fellow as a reference.



Familiarize yourself with the ACS Member Benefits (facs.org/member-services/benefits) and make time to apply for membership while at the meeting. For additional information, contact Member Services at [email protected] or 800-621-4111. We look forward to assisting you.

If you are not already a member of the American College of Surgeons (ACS) or you know an interested non-member colleague who is attending the Clinical Congress 2018 in Boston, MA, visit the Become a Member booth to apply for ACS membership. The membership application fee will be waived for individuals who apply at the meeting.

The Become a Member booth will be located in the Registration Area of the Boston Convention & Exhibition Center and will be open the same hours as registration, which are as follows:



• Sunday, October 21: 7:00 am–6:00 pm

• Monday, October 22: 6:30 am–5:00 pm

• Tuesday, October 23: 7:00 am–4:00 pm

• Wednesday, October 24: 7:00 am–4:00 pm

• Thursday, October 25: 7:00–10:00 am



Plan ahead to apply at the meeting for one of the following membership categories and have access to the documents listed to support and speed up your application process:



• Fellows (U.S. and Canada): Copy of board certification document, current curriculum vitae (CV), and names of five ACS Fellows to serve as references. Watch the video about the domestic application process at www.youtube.com/watch?v=2VUqvveNYf8&.

• International Fellows: Copy of medical license, board/country certification document, current CV, and names of three ACS Fellows to serve as references. Watch the video about the international application process at www.youtube.com/watch?v=djoMUAUTA4I.

• Associate Fellows: Copy of residency completion document or an official board/country certification document.

• Residents: Letter verifying training status.

• Medical Students: Letter verifying educational status.

• Affiliate Members: The name of a Fellow as a reference.



Familiarize yourself with the ACS Member Benefits (facs.org/member-services/benefits) and make time to apply for membership while at the meeting. For additional information, contact Member Services at [email protected] or 800-621-4111. We look forward to assisting you.

If you are not already a member of the American College of Surgeons (ACS) or you know an interested non-member colleague who is attending the Clinical Congress 2018 in Boston, MA, visit the Become a Member booth to apply for ACS membership. The membership application fee will be waived for individuals who apply at the meeting.

The Become a Member booth will be located in the Registration Area of the Boston Convention & Exhibition Center and will be open the same hours as registration, which are as follows:



• Sunday, October 21: 7:00 am–6:00 pm

• Monday, October 22: 6:30 am–5:00 pm

• Tuesday, October 23: 7:00 am–4:00 pm

• Wednesday, October 24: 7:00 am–4:00 pm

• Thursday, October 25: 7:00–10:00 am



Plan ahead to apply at the meeting for one of the following membership categories and have access to the documents listed to support and speed up your application process:



• Fellows (U.S. and Canada): Copy of board certification document, current curriculum vitae (CV), and names of five ACS Fellows to serve as references. Watch the video about the domestic application process at www.youtube.com/watch?v=2VUqvveNYf8&.

• International Fellows: Copy of medical license, board/country certification document, current CV, and names of three ACS Fellows to serve as references. Watch the video about the international application process at www.youtube.com/watch?v=djoMUAUTA4I.

• Associate Fellows: Copy of residency completion document or an official board/country certification document.

• Residents: Letter verifying training status.

• Medical Students: Letter verifying educational status.

• Affiliate Members: The name of a Fellow as a reference.



Familiarize yourself with the ACS Member Benefits (facs.org/member-services/benefits) and make time to apply for membership while at the meeting. For additional information, contact Member Services at [email protected] or 800-621-4111. We look forward to assisting you.

The American Medical Association (AMA) Annual House of Delegates (HOD) meeting took place June 9–13 in Chicago, IL. Approximately 600 delegates representing state medical societies, national specialty societies, and national medical societies gathered to discuss a variety of policies and issues that affect patients and physicians.

The American College of Surgeons (ACS) sent a six-member delegation to the meeting (see sidebar, page 84). In addition to serving on the College’s delegation, some of the ACS delegates serve in other capacities in the HOD, on the AMA Council on Medical Education, in the AMA Young Physicians Section, and in the AMA Resident and Fellow Section. All three of these entities convene during the broader HOD meeting, providing further opportunities to influence the adoption of health care policy.

Issue highlights

During the HOD meeting, delegates discuss and adopt policies as presented in reports and resolutions. The HOD considered more than 64 reports and 200 resolutions at the June meeting, including the following:

• Colorectal cancer screening: A joint report of the Council on Medical Service and the Council on Science and Public Health focused on policy updates related to coverage for colorectal cancer screening. As adopted, this report directs the AMA to seek to eliminate cost-sharing in all health care plans for the full range of colorectal cancer screening and all associated costs, including colonoscopies that include a diagnostic intervention (such as the removal of a polyp or biopsy of a mass), as defined by Medicare. In addition, the AMA now recognizes colon cancer as a leading cause of cancer deaths in the U.S. and encourages appropriate screening programs to detect colorectal cancer.

• Obesity treatment: The ACS cosponsored Resolution 201, Barriers to Obesity Treatment, which the HOD adopted. It directs the AMA to work with appropriate stakeholders to remove out-of-date restrictions at the state and federal level that prohibit health care providers from providing the accepted standard of care to patients affected by obesity.

• Kidney transplantation: The ACS cosponsored Resolution 219, which asked the AMA to work with professional and patient-centered organizations to advance patient- and physician-directed coordinated care for end-stage renal disease (ESRD) patients and to actively oppose the Dialysis Patient Access to Integrated-care, Empowerment, Nephrologists, and Treatment Services (PATIENTS) Demonstration Act of 2017. The College and other organizations opposed this federal legislation as introduced, partly due to infringement on the patient-physician relationship and the disruption of care by prohibiting nephrologists who are not part of preferred networks from caring for their patients receiving care in units owned by an ESRD integrated care organization participating in the model. The resolution was referred to the AMA Board of Trustees.

The HOD also amended AMA policy regarding living organ donation. The amended policy supports removing financial barriers to living organ donation, such as provisions for expenses incurred after the donation as a consequence of donation, and prohibiting the use of living donor status to limit disability and long-term care coverage. In addition, the AMA will advocate that live organ donation operations be classified as a serious health condition under the Family and Medical Leave Act.

• Firearms: After extensive debate, the HOD adopted a new policy regarding firearms. The new policy supports a ban on the sale of firearms and ammunition from licensed and unlicensed dealers to those younger than 21 years old (excluding certain categories of individuals, such as military and law enforcement personnel); opposes “concealed carry reciprocity” federal legislation; and supports a ban on the sale and ownership of all assault-type weapons, bump stocks and related devices, high-capacity magazines, and armor-piercing bullets.

• Prostate cancer screening: Resolution 226 proposed that the AMA develop model state legislation for screening asymptomatic men ages 55–69 for prostate cancer after informed discussion between patients and their physician without annual deductible or copayment. Testimony both for and against this resolution was offered, and the HOD referred the resolution so that the various facets of the issue can be studied.

• Maintenance of Certification: The AMA Council on Medical Education submitted its annual report on Maintenance of Certification (MOC), detailing the status of revisions by specialty boards to the MOC process and discussing council interactions with the boards and the American Board of Medical Specialties. The HOD adopted this report.



Two additional MOC-related resolutions were introduced. Resolution 320 asked the AMA to support young physician involvement in MOC, and Resolution 316 asked the AMA to oppose the Part 4 Improvement in Medical Practice requirement for MOC. The HOD adopted Resolution 320 and referred Resolution 316.
 

AMA elections

During the annual meeting of the HOD, officers and councils are elected. Patrice Harris, MD, a psychiatrist from Atlanta, GA, was elected president-elect, and Russell Kridel, MD, FACS, a facial plastic surgeon from Houston, TX, who was endorsed by the ACS, was reelected to the Board of Trustees. Following the conclusion of the HOD, Dr. Kridel also was elected to serve as Secretary of the Board. For a summary of the AMA election results, go to the AMA Wire article at wire.ama-assn.org/ama-news/patrice-harris-md-wins-office-ama-president-elect.
 

Surgical Caucus

Founded almost 30 years ago, the Surgical Caucus gives surgeon delegates and alternates the opportunity to meet to discuss HOD business from the surgical perspective. Part of the regular business of the caucus involves sponsoring an educational session. Titled Ready or Not, Here We Come: Transitioning to Practice in a Modern Healthcare System, this program focused on the transition from surgical residency to practice and how the profession can enhance this process, as well as the effects of current training program requirements on preparedness for independent practice.

Future meeting

The Interim Meeting of the HOD will take place November 10–13 at National Harbor, MD, and the ACS delegation will be well-prepared to represent surgical perspectives. Surgeons with thoughts about potential resolutions or questions about the HOD may contact [email protected] or visit the HOD web page at www.ama-assn.org/hod-annual-overview.
 

ACS Delegation at the AMA HOD

• Patricia L. Turner, MD, FACS (Delegation Chair), general surgery, Chicago, IL; Director, ACS Division of Member Services; member and immediate past-chair, AMA Council on Medical Education

• David B. Hoyt, MD, FACS, general surgery, Chicago, IL; ACS Executive Director

• Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH

• Jacob Moalem, MD, FACS, general surgery, Rochester, NY

• Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Chair, ACS Board of Regents

• Naveen F. Sangji, MD (also Resident and Fellow Section delegate), general surgery resident, Boston, MA



Dr. Turner is Director, ACS Division of Member Services, Chicago, IL.

Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy, Washington, DC.
 

The American Medical Association (AMA) Annual House of Delegates (HOD) meeting took place June 9–13 in Chicago, IL. Approximately 600 delegates representing state medical societies, national specialty societies, and national medical societies gathered to discuss a variety of policies and issues that affect patients and physicians.

The American College of Surgeons (ACS) sent a six-member delegation to the meeting (see sidebar, page 84). In addition to serving on the College’s delegation, some of the ACS delegates serve in other capacities in the HOD, on the AMA Council on Medical Education, in the AMA Young Physicians Section, and in the AMA Resident and Fellow Section. All three of these entities convene during the broader HOD meeting, providing further opportunities to influence the adoption of health care policy.

Issue highlights

During the HOD meeting, delegates discuss and adopt policies as presented in reports and resolutions. The HOD considered more than 64 reports and 200 resolutions at the June meeting, including the following:

• Colorectal cancer screening: A joint report of the Council on Medical Service and the Council on Science and Public Health focused on policy updates related to coverage for colorectal cancer screening. As adopted, this report directs the AMA to seek to eliminate cost-sharing in all health care plans for the full range of colorectal cancer screening and all associated costs, including colonoscopies that include a diagnostic intervention (such as the removal of a polyp or biopsy of a mass), as defined by Medicare. In addition, the AMA now recognizes colon cancer as a leading cause of cancer deaths in the U.S. and encourages appropriate screening programs to detect colorectal cancer.

• Obesity treatment: The ACS cosponsored Resolution 201, Barriers to Obesity Treatment, which the HOD adopted. It directs the AMA to work with appropriate stakeholders to remove out-of-date restrictions at the state and federal level that prohibit health care providers from providing the accepted standard of care to patients affected by obesity.

• Kidney transplantation: The ACS cosponsored Resolution 219, which asked the AMA to work with professional and patient-centered organizations to advance patient- and physician-directed coordinated care for end-stage renal disease (ESRD) patients and to actively oppose the Dialysis Patient Access to Integrated-care, Empowerment, Nephrologists, and Treatment Services (PATIENTS) Demonstration Act of 2017. The College and other organizations opposed this federal legislation as introduced, partly due to infringement on the patient-physician relationship and the disruption of care by prohibiting nephrologists who are not part of preferred networks from caring for their patients receiving care in units owned by an ESRD integrated care organization participating in the model. The resolution was referred to the AMA Board of Trustees.

The HOD also amended AMA policy regarding living organ donation. The amended policy supports removing financial barriers to living organ donation, such as provisions for expenses incurred after the donation as a consequence of donation, and prohibiting the use of living donor status to limit disability and long-term care coverage. In addition, the AMA will advocate that live organ donation operations be classified as a serious health condition under the Family and Medical Leave Act.

• Firearms: After extensive debate, the HOD adopted a new policy regarding firearms. The new policy supports a ban on the sale of firearms and ammunition from licensed and unlicensed dealers to those younger than 21 years old (excluding certain categories of individuals, such as military and law enforcement personnel); opposes “concealed carry reciprocity” federal legislation; and supports a ban on the sale and ownership of all assault-type weapons, bump stocks and related devices, high-capacity magazines, and armor-piercing bullets.

• Prostate cancer screening: Resolution 226 proposed that the AMA develop model state legislation for screening asymptomatic men ages 55–69 for prostate cancer after informed discussion between patients and their physician without annual deductible or copayment. Testimony both for and against this resolution was offered, and the HOD referred the resolution so that the various facets of the issue can be studied.

• Maintenance of Certification: The AMA Council on Medical Education submitted its annual report on Maintenance of Certification (MOC), detailing the status of revisions by specialty boards to the MOC process and discussing council interactions with the boards and the American Board of Medical Specialties. The HOD adopted this report.



Two additional MOC-related resolutions were introduced. Resolution 320 asked the AMA to support young physician involvement in MOC, and Resolution 316 asked the AMA to oppose the Part 4 Improvement in Medical Practice requirement for MOC. The HOD adopted Resolution 320 and referred Resolution 316.
 

AMA elections

During the annual meeting of the HOD, officers and councils are elected. Patrice Harris, MD, a psychiatrist from Atlanta, GA, was elected president-elect, and Russell Kridel, MD, FACS, a facial plastic surgeon from Houston, TX, who was endorsed by the ACS, was reelected to the Board of Trustees. Following the conclusion of the HOD, Dr. Kridel also was elected to serve as Secretary of the Board. For a summary of the AMA election results, go to the AMA Wire article at wire.ama-assn.org/ama-news/patrice-harris-md-wins-office-ama-president-elect.
 

Surgical Caucus

Founded almost 30 years ago, the Surgical Caucus gives surgeon delegates and alternates the opportunity to meet to discuss HOD business from the surgical perspective. Part of the regular business of the caucus involves sponsoring an educational session. Titled Ready or Not, Here We Come: Transitioning to Practice in a Modern Healthcare System, this program focused on the transition from surgical residency to practice and how the profession can enhance this process, as well as the effects of current training program requirements on preparedness for independent practice.

Future meeting

The Interim Meeting of the HOD will take place November 10–13 at National Harbor, MD, and the ACS delegation will be well-prepared to represent surgical perspectives. Surgeons with thoughts about potential resolutions or questions about the HOD may contact [email protected] or visit the HOD web page at www.ama-assn.org/hod-annual-overview.
 

ACS Delegation at the AMA HOD

• Patricia L. Turner, MD, FACS (Delegation Chair), general surgery, Chicago, IL; Director, ACS Division of Member Services; member and immediate past-chair, AMA Council on Medical Education

• David B. Hoyt, MD, FACS, general surgery, Chicago, IL; ACS Executive Director

• Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH

• Jacob Moalem, MD, FACS, general surgery, Rochester, NY

• Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Chair, ACS Board of Regents

• Naveen F. Sangji, MD (also Resident and Fellow Section delegate), general surgery resident, Boston, MA



Dr. Turner is Director, ACS Division of Member Services, Chicago, IL.

Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy, Washington, DC.
 

The American Medical Association (AMA) Annual House of Delegates (HOD) meeting took place June 9–13 in Chicago, IL. Approximately 600 delegates representing state medical societies, national specialty societies, and national medical societies gathered to discuss a variety of policies and issues that affect patients and physicians.

The American College of Surgeons (ACS) sent a six-member delegation to the meeting (see sidebar, page 84). In addition to serving on the College’s delegation, some of the ACS delegates serve in other capacities in the HOD, on the AMA Council on Medical Education, in the AMA Young Physicians Section, and in the AMA Resident and Fellow Section. All three of these entities convene during the broader HOD meeting, providing further opportunities to influence the adoption of health care policy.

Issue highlights

During the HOD meeting, delegates discuss and adopt policies as presented in reports and resolutions. The HOD considered more than 64 reports and 200 resolutions at the June meeting, including the following:

• Colorectal cancer screening: A joint report of the Council on Medical Service and the Council on Science and Public Health focused on policy updates related to coverage for colorectal cancer screening. As adopted, this report directs the AMA to seek to eliminate cost-sharing in all health care plans for the full range of colorectal cancer screening and all associated costs, including colonoscopies that include a diagnostic intervention (such as the removal of a polyp or biopsy of a mass), as defined by Medicare. In addition, the AMA now recognizes colon cancer as a leading cause of cancer deaths in the U.S. and encourages appropriate screening programs to detect colorectal cancer.

• Obesity treatment: The ACS cosponsored Resolution 201, Barriers to Obesity Treatment, which the HOD adopted. It directs the AMA to work with appropriate stakeholders to remove out-of-date restrictions at the state and federal level that prohibit health care providers from providing the accepted standard of care to patients affected by obesity.

• Kidney transplantation: The ACS cosponsored Resolution 219, which asked the AMA to work with professional and patient-centered organizations to advance patient- and physician-directed coordinated care for end-stage renal disease (ESRD) patients and to actively oppose the Dialysis Patient Access to Integrated-care, Empowerment, Nephrologists, and Treatment Services (PATIENTS) Demonstration Act of 2017. The College and other organizations opposed this federal legislation as introduced, partly due to infringement on the patient-physician relationship and the disruption of care by prohibiting nephrologists who are not part of preferred networks from caring for their patients receiving care in units owned by an ESRD integrated care organization participating in the model. The resolution was referred to the AMA Board of Trustees.

The HOD also amended AMA policy regarding living organ donation. The amended policy supports removing financial barriers to living organ donation, such as provisions for expenses incurred after the donation as a consequence of donation, and prohibiting the use of living donor status to limit disability and long-term care coverage. In addition, the AMA will advocate that live organ donation operations be classified as a serious health condition under the Family and Medical Leave Act.

• Firearms: After extensive debate, the HOD adopted a new policy regarding firearms. The new policy supports a ban on the sale of firearms and ammunition from licensed and unlicensed dealers to those younger than 21 years old (excluding certain categories of individuals, such as military and law enforcement personnel); opposes “concealed carry reciprocity” federal legislation; and supports a ban on the sale and ownership of all assault-type weapons, bump stocks and related devices, high-capacity magazines, and armor-piercing bullets.

• Prostate cancer screening: Resolution 226 proposed that the AMA develop model state legislation for screening asymptomatic men ages 55–69 for prostate cancer after informed discussion between patients and their physician without annual deductible or copayment. Testimony both for and against this resolution was offered, and the HOD referred the resolution so that the various facets of the issue can be studied.

• Maintenance of Certification: The AMA Council on Medical Education submitted its annual report on Maintenance of Certification (MOC), detailing the status of revisions by specialty boards to the MOC process and discussing council interactions with the boards and the American Board of Medical Specialties. The HOD adopted this report.



Two additional MOC-related resolutions were introduced. Resolution 320 asked the AMA to support young physician involvement in MOC, and Resolution 316 asked the AMA to oppose the Part 4 Improvement in Medical Practice requirement for MOC. The HOD adopted Resolution 320 and referred Resolution 316.
 

AMA elections

During the annual meeting of the HOD, officers and councils are elected. Patrice Harris, MD, a psychiatrist from Atlanta, GA, was elected president-elect, and Russell Kridel, MD, FACS, a facial plastic surgeon from Houston, TX, who was endorsed by the ACS, was reelected to the Board of Trustees. Following the conclusion of the HOD, Dr. Kridel also was elected to serve as Secretary of the Board. For a summary of the AMA election results, go to the AMA Wire article at wire.ama-assn.org/ama-news/patrice-harris-md-wins-office-ama-president-elect.
 

Surgical Caucus

Founded almost 30 years ago, the Surgical Caucus gives surgeon delegates and alternates the opportunity to meet to discuss HOD business from the surgical perspective. Part of the regular business of the caucus involves sponsoring an educational session. Titled Ready or Not, Here We Come: Transitioning to Practice in a Modern Healthcare System, this program focused on the transition from surgical residency to practice and how the profession can enhance this process, as well as the effects of current training program requirements on preparedness for independent practice.

Future meeting

The Interim Meeting of the HOD will take place November 10–13 at National Harbor, MD, and the ACS delegation will be well-prepared to represent surgical perspectives. Surgeons with thoughts about potential resolutions or questions about the HOD may contact [email protected] or visit the HOD web page at www.ama-assn.org/hod-annual-overview.
 

ACS Delegation at the AMA HOD

• Patricia L. Turner, MD, FACS (Delegation Chair), general surgery, Chicago, IL; Director, ACS Division of Member Services; member and immediate past-chair, AMA Council on Medical Education

• David B. Hoyt, MD, FACS, general surgery, Chicago, IL; ACS Executive Director

• Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH

• Jacob Moalem, MD, FACS, general surgery, Rochester, NY

• Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Chair, ACS Board of Regents

• Naveen F. Sangji, MD (also Resident and Fellow Section delegate), general surgery resident, Boston, MA



Dr. Turner is Director, ACS Division of Member Services, Chicago, IL.

Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy, Washington, DC.
 

LAS VEGAS – More than half of patients tested for prescription drug compliance last year misused their medications, often supplementing them with nonprescribed and illicit drugs in dangerous combinations.

sdominick/iStock/Getty Images

Of almost 4 million urine screens examined, 52% were discordant for the screen-ordered drugs, Jeffrey Gudin, MD, said at the annual PAINWeek. Most common was the combination of opioids and benzodiazepines, which accounted for 21% of the discordant samples – and, in 64% of these cases, at least one of the drugs was not prescribed.

“Drug testing is a standard of care in pain management, and it’s the only objective way to know what patients are really taking,” said Dr. Gudin, director of pain and palliative care at Englewood (N.J.) Hospital and Medical Center. “What this tells us is that, if we just ask our patients, half the time they won’t tell you the whole story. More than 50% of the time things don’t match up. To me this is just unbelievable.”

Quest Diagnostics compiled these data, and many more, in its “Health Trends Report: Drug Misuse in America 2018.”

The report examines 3.9 million routine drug screens ordered by primary care and pain physicians during 2011-2017. It not only looks at prescription drug use and misuse but also tracks illicit drugs in both general and substance abuse patient populations. The findings reported at PAINWeek were based on 456,675 screens from 276,953 patients conducted in 2017. These results were included in the Quest Diagnostics medMATCH reports, which indicated what tested drugs were prescribed and whether these drugs were detected in the specimen.

The following were found among the discordant screens identified in 2017:

• 45% were positive for nonprescribed or illicit drugs in addition to all the prescribed drugs.
• 34% did not show all the drugs they had been prescribed, or any other tested drug.
• 22% did not show all the drugs they had been prescribed but were positive for other illicit or nonprescribed drugs.

The tests were ordered as a part of routine care – an important point, Dr. Gudin said in an interview. “These are not ‘gotcha tests,’ ” intended to catch patients unawares. “These are regularly ordered screens that are standard of care in pain management.”

The report found that men and women were equally likely to misuse medications (52% each). There were some age-related differences, with misuse peaking in young adulthood: 60% of 18- to 24-year-olds and 56% of 25- to 45-year-olds. Misuse dropped off in those aged 55-64 years (52%) and in those 65 years and older (43%). But even children showed evidence of medication misuse, with about 41% of samples from children aged 10 years and younger being discordant.

The rates of misuse were about 50% in Medicare and private pay patients, but around 65% in Medicaid patients.

There was some good news: In the general patient population, opioid use was down by 12% from 2016 – the largest annual decrease Quest has noted since 2012. Several factors probably contributed to that decline, including shifts in clinical care and payer reimbursement, as well as regulatory and legislative restrictions.

“This shows that we’re doing better on the pain management front,” Dr. Gudin said. “But in substance use disorder settings, we saw 400% increases for both fentanyl and heroin. The addiction front it out of control.”

More than 27% of all specimens that came from substance abuse treatment centers were positive for nonprescribed fentanyl and 10% were positive for heroin. “We also saw that, in 2016, 45% of those heroin-positive samples had fentanyl in them, and in 2017, 83% did.”

Although not discussed at PAINWeek, the report also noted a rise in gabapentin misuse. The antiepileptic is now the 10th most commonly prescribed drug in the United States, the report noted, with 68 million prescriptions dispensed last year. The report found that 9.5% of tests showed nonprescription gabapentin. In the subset of samples obtained from substance abuse treatment centers, gabapentin misuse increased by 800% from 2016 – the most dramatic increase of any of the tracked drugs.

The combination of gabapentin and opioids is risky, the report noted. Opioid-related deaths are 49% more common among those taking both than those taking opioids only.
 

[email protected]

SOURCE: Gudin J et al. PAINWeek 2018, abstract 44.

LAS VEGAS – More than half of patients tested for prescription drug compliance last year misused their medications, often supplementing them with nonprescribed and illicit drugs in dangerous combinations.

sdominick/iStock/Getty Images

Of almost 4 million urine screens examined, 52% were discordant for the screen-ordered drugs, Jeffrey Gudin, MD, said at the annual PAINWeek. Most common was the combination of opioids and benzodiazepines, which accounted for 21% of the discordant samples – and, in 64% of these cases, at least one of the drugs was not prescribed.

“Drug testing is a standard of care in pain management, and it’s the only objective way to know what patients are really taking,” said Dr. Gudin, director of pain and palliative care at Englewood (N.J.) Hospital and Medical Center. “What this tells us is that, if we just ask our patients, half the time they won’t tell you the whole story. More than 50% of the time things don’t match up. To me this is just unbelievable.”

Quest Diagnostics compiled these data, and many more, in its “Health Trends Report: Drug Misuse in America 2018.”

The report examines 3.9 million routine drug screens ordered by primary care and pain physicians during 2011-2017. It not only looks at prescription drug use and misuse but also tracks illicit drugs in both general and substance abuse patient populations. The findings reported at PAINWeek were based on 456,675 screens from 276,953 patients conducted in 2017. These results were included in the Quest Diagnostics medMATCH reports, which indicated what tested drugs were prescribed and whether these drugs were detected in the specimen.

The following were found among the discordant screens identified in 2017:

• 45% were positive for nonprescribed or illicit drugs in addition to all the prescribed drugs.
• 34% did not show all the drugs they had been prescribed, or any other tested drug.
• 22% did not show all the drugs they had been prescribed but were positive for other illicit or nonprescribed drugs.

The tests were ordered as a part of routine care – an important point, Dr. Gudin said in an interview. “These are not ‘gotcha tests,’ ” intended to catch patients unawares. “These are regularly ordered screens that are standard of care in pain management.”

The report found that men and women were equally likely to misuse medications (52% each). There were some age-related differences, with misuse peaking in young adulthood: 60% of 18- to 24-year-olds and 56% of 25- to 45-year-olds. Misuse dropped off in those aged 55-64 years (52%) and in those 65 years and older (43%). But even children showed evidence of medication misuse, with about 41% of samples from children aged 10 years and younger being discordant.

The rates of misuse were about 50% in Medicare and private pay patients, but around 65% in Medicaid patients.

There was some good news: In the general patient population, opioid use was down by 12% from 2016 – the largest annual decrease Quest has noted since 2012. Several factors probably contributed to that decline, including shifts in clinical care and payer reimbursement, as well as regulatory and legislative restrictions.

“This shows that we’re doing better on the pain management front,” Dr. Gudin said. “But in substance use disorder settings, we saw 400% increases for both fentanyl and heroin. The addiction front it out of control.”

More than 27% of all specimens that came from substance abuse treatment centers were positive for nonprescribed fentanyl and 10% were positive for heroin. “We also saw that, in 2016, 45% of those heroin-positive samples had fentanyl in them, and in 2017, 83% did.”

Although not discussed at PAINWeek, the report also noted a rise in gabapentin misuse. The antiepileptic is now the 10th most commonly prescribed drug in the United States, the report noted, with 68 million prescriptions dispensed last year. The report found that 9.5% of tests showed nonprescription gabapentin. In the subset of samples obtained from substance abuse treatment centers, gabapentin misuse increased by 800% from 2016 – the most dramatic increase of any of the tracked drugs.

The combination of gabapentin and opioids is risky, the report noted. Opioid-related deaths are 49% more common among those taking both than those taking opioids only.
 

[email protected]

SOURCE: Gudin J et al. PAINWeek 2018, abstract 44.

LAS VEGAS – More than half of patients tested for prescription drug compliance last year misused their medications, often supplementing them with nonprescribed and illicit drugs in dangerous combinations.

sdominick/iStock/Getty Images

Of almost 4 million urine screens examined, 52% were discordant for the screen-ordered drugs, Jeffrey Gudin, MD, said at the annual PAINWeek. Most common was the combination of opioids and benzodiazepines, which accounted for 21% of the discordant samples – and, in 64% of these cases, at least one of the drugs was not prescribed.

“Drug testing is a standard of care in pain management, and it’s the only objective way to know what patients are really taking,” said Dr. Gudin, director of pain and palliative care at Englewood (N.J.) Hospital and Medical Center. “What this tells us is that, if we just ask our patients, half the time they won’t tell you the whole story. More than 50% of the time things don’t match up. To me this is just unbelievable.”

Quest Diagnostics compiled these data, and many more, in its “Health Trends Report: Drug Misuse in America 2018.”

The report examines 3.9 million routine drug screens ordered by primary care and pain physicians during 2011-2017. It not only looks at prescription drug use and misuse but also tracks illicit drugs in both general and substance abuse patient populations. The findings reported at PAINWeek were based on 456,675 screens from 276,953 patients conducted in 2017. These results were included in the Quest Diagnostics medMATCH reports, which indicated what tested drugs were prescribed and whether these drugs were detected in the specimen.

The following were found among the discordant screens identified in 2017:

• 45% were positive for nonprescribed or illicit drugs in addition to all the prescribed drugs.
• 34% did not show all the drugs they had been prescribed, or any other tested drug.
• 22% did not show all the drugs they had been prescribed but were positive for other illicit or nonprescribed drugs.

The tests were ordered as a part of routine care – an important point, Dr. Gudin said in an interview. “These are not ‘gotcha tests,’ ” intended to catch patients unawares. “These are regularly ordered screens that are standard of care in pain management.”

The report found that men and women were equally likely to misuse medications (52% each). There were some age-related differences, with misuse peaking in young adulthood: 60% of 18- to 24-year-olds and 56% of 25- to 45-year-olds. Misuse dropped off in those aged 55-64 years (52%) and in those 65 years and older (43%). But even children showed evidence of medication misuse, with about 41% of samples from children aged 10 years and younger being discordant.

The rates of misuse were about 50% in Medicare and private pay patients, but around 65% in Medicaid patients.

There was some good news: In the general patient population, opioid use was down by 12% from 2016 – the largest annual decrease Quest has noted since 2012. Several factors probably contributed to that decline, including shifts in clinical care and payer reimbursement, as well as regulatory and legislative restrictions.

“This shows that we’re doing better on the pain management front,” Dr. Gudin said. “But in substance use disorder settings, we saw 400% increases for both fentanyl and heroin. The addiction front it out of control.”

More than 27% of all specimens that came from substance abuse treatment centers were positive for nonprescribed fentanyl and 10% were positive for heroin. “We also saw that, in 2016, 45% of those heroin-positive samples had fentanyl in them, and in 2017, 83% did.”

Although not discussed at PAINWeek, the report also noted a rise in gabapentin misuse. The antiepileptic is now the 10th most commonly prescribed drug in the United States, the report noted, with 68 million prescriptions dispensed last year. The report found that 9.5% of tests showed nonprescription gabapentin. In the subset of samples obtained from substance abuse treatment centers, gabapentin misuse increased by 800% from 2016 – the most dramatic increase of any of the tracked drugs.

The combination of gabapentin and opioids is risky, the report noted. Opioid-related deaths are 49% more common among those taking both than those taking opioids only.
 

[email protected]

SOURCE: Gudin J et al. PAINWeek 2018, abstract 44.

Doctors’ dismay at the proposed flattening of evaluation and management (E/M) payments seems to be falling on deaf ears.

More than 170 medical societies and organizations expressed their concern about the new payment structure for E/M codes proposed as part of the 2019 Medicare Physician Fee Schedule (PFS) in comments on the draft rule.

Yet, in the final days of the comment period, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, took to Twitter to defend her agency’s plan.

[email protected]

Doctors’ dismay at the proposed flattening of evaluation and management (E/M) payments seems to be falling on deaf ears.

More than 170 medical societies and organizations expressed their concern about the new payment structure for E/M codes proposed as part of the 2019 Medicare Physician Fee Schedule (PFS) in comments on the draft rule.

Yet, in the final days of the comment period, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, took to Twitter to defend her agency’s plan.

[email protected]

Doctors’ dismay at the proposed flattening of evaluation and management (E/M) payments seems to be falling on deaf ears.

More than 170 medical societies and organizations expressed their concern about the new payment structure for E/M codes proposed as part of the 2019 Medicare Physician Fee Schedule (PFS) in comments on the draft rule.

Yet, in the final days of the comment period, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, took to Twitter to defend her agency’s plan.

[email protected]

Physicians experiencing burnout are twice as likely to be associated with patient safety issues and deliver a lower quality of care from low professionalism and are three times as likely to be rated poorly among patients because of depersonalization of care, according to recent research published in JAMA Internal Medicine.

olm26250/Thinkstock

“The primary conclusion of this review is that physician burnout might jeopardize patient care,” Maria Panagioti, PhD, from the National Institute for Health Research (NIHR) School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre at the University of Manchester (United Kingdom) and her colleagues wrote in their study. “Physician wellness and quality of patient care are critical [as are] complementary dimensions of health care organization efficiency.”

Dr. Panagioti and her colleagues performed a search of the MEDLINE, EMBASE, CINAHL, and PsycInfo databases and found 47 eligible studies on the topics of physician burnout and patient care, which altogether included data from a pooled cohort of 42,473 physicians. The physicians were median 38 years old, with 44.7% of studies looking at physicians in residency or early career (up to 5 years post residency) and 55.3% of studies examining experienced physicians. The meta-analysis also evaluated physicians in a hospital setting (63.8%), primary care (13.8%), and across various different health care settings (8.5%).

The researchers found physicians with burnout were significantly associated with higher rates of patient safety issues (odds ratio, 1.96; 95% confidence interval, 1.59-2.40), reduced patient satisfaction (OR, 2.28; 95% CI, 1.42-3.68), and lower quality of care (OR, 2.31; 95% CI, 1.87-2.85). System-reported instances of patient safety issues and low professionalism were not statistically significant, but the subgroup differences did reach statistical significance (Cohen Q, 8.14; P = .007). Among residents and physicians in their early career, there was a greater association between burnout and low professionalism (OR, 3.39; 95% CI, 2.38-4.40), compared with physicians in the middle or later in their career (OR, 1.73; 95% CI, 1.46-2.01; Cohen Q, 7.27; P = .003).

“Investments in organizational strategies to jointly monitor and improve physician wellness and patient care outcomes are needed,” Dr. Panagioti and her colleagues wrote in the study. “Interventions aimed at improving the culture of health care organizations, as well as interventions focused on individual physicians but supported and funded by health care organizations, are beneficial.”

Researchers noted the study quality was low to moderate. Variation in outcomes across studies, heterogeneity among studies, potential selection bias by excluding gray literature, and the inability to establish causal links from findings because of the cross-sectional nature of the studies analyzed were potential limitations in the study, they reported.

The study was funded by the United Kingdom NIHR School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre. The authors report no relevant conflicts of interest.

SOURCE: Panagioti M et al. JAMA Intern Med. 2018 Sept 4. doi: 10.1001/jamainternmed.2018.3713.

Physicians experiencing burnout are twice as likely to be associated with patient safety issues and deliver a lower quality of care from low professionalism and are three times as likely to be rated poorly among patients because of depersonalization of care, according to recent research published in JAMA Internal Medicine.

olm26250/Thinkstock

“The primary conclusion of this review is that physician burnout might jeopardize patient care,” Maria Panagioti, PhD, from the National Institute for Health Research (NIHR) School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre at the University of Manchester (United Kingdom) and her colleagues wrote in their study. “Physician wellness and quality of patient care are critical [as are] complementary dimensions of health care organization efficiency.”

Dr. Panagioti and her colleagues performed a search of the MEDLINE, EMBASE, CINAHL, and PsycInfo databases and found 47 eligible studies on the topics of physician burnout and patient care, which altogether included data from a pooled cohort of 42,473 physicians. The physicians were median 38 years old, with 44.7% of studies looking at physicians in residency or early career (up to 5 years post residency) and 55.3% of studies examining experienced physicians. The meta-analysis also evaluated physicians in a hospital setting (63.8%), primary care (13.8%), and across various different health care settings (8.5%).

The researchers found physicians with burnout were significantly associated with higher rates of patient safety issues (odds ratio, 1.96; 95% confidence interval, 1.59-2.40), reduced patient satisfaction (OR, 2.28; 95% CI, 1.42-3.68), and lower quality of care (OR, 2.31; 95% CI, 1.87-2.85). System-reported instances of patient safety issues and low professionalism were not statistically significant, but the subgroup differences did reach statistical significance (Cohen Q, 8.14; P = .007). Among residents and physicians in their early career, there was a greater association between burnout and low professionalism (OR, 3.39; 95% CI, 2.38-4.40), compared with physicians in the middle or later in their career (OR, 1.73; 95% CI, 1.46-2.01; Cohen Q, 7.27; P = .003).

“Investments in organizational strategies to jointly monitor and improve physician wellness and patient care outcomes are needed,” Dr. Panagioti and her colleagues wrote in the study. “Interventions aimed at improving the culture of health care organizations, as well as interventions focused on individual physicians but supported and funded by health care organizations, are beneficial.”

Researchers noted the study quality was low to moderate. Variation in outcomes across studies, heterogeneity among studies, potential selection bias by excluding gray literature, and the inability to establish causal links from findings because of the cross-sectional nature of the studies analyzed were potential limitations in the study, they reported.

The study was funded by the United Kingdom NIHR School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre. The authors report no relevant conflicts of interest.

SOURCE: Panagioti M et al. JAMA Intern Med. 2018 Sept 4. doi: 10.1001/jamainternmed.2018.3713.

Physicians experiencing burnout are twice as likely to be associated with patient safety issues and deliver a lower quality of care from low professionalism and are three times as likely to be rated poorly among patients because of depersonalization of care, according to recent research published in JAMA Internal Medicine.

olm26250/Thinkstock

“The primary conclusion of this review is that physician burnout might jeopardize patient care,” Maria Panagioti, PhD, from the National Institute for Health Research (NIHR) School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre at the University of Manchester (United Kingdom) and her colleagues wrote in their study. “Physician wellness and quality of patient care are critical [as are] complementary dimensions of health care organization efficiency.”

Dr. Panagioti and her colleagues performed a search of the MEDLINE, EMBASE, CINAHL, and PsycInfo databases and found 47 eligible studies on the topics of physician burnout and patient care, which altogether included data from a pooled cohort of 42,473 physicians. The physicians were median 38 years old, with 44.7% of studies looking at physicians in residency or early career (up to 5 years post residency) and 55.3% of studies examining experienced physicians. The meta-analysis also evaluated physicians in a hospital setting (63.8%), primary care (13.8%), and across various different health care settings (8.5%).

The researchers found physicians with burnout were significantly associated with higher rates of patient safety issues (odds ratio, 1.96; 95% confidence interval, 1.59-2.40), reduced patient satisfaction (OR, 2.28; 95% CI, 1.42-3.68), and lower quality of care (OR, 2.31; 95% CI, 1.87-2.85). System-reported instances of patient safety issues and low professionalism were not statistically significant, but the subgroup differences did reach statistical significance (Cohen Q, 8.14; P = .007). Among residents and physicians in their early career, there was a greater association between burnout and low professionalism (OR, 3.39; 95% CI, 2.38-4.40), compared with physicians in the middle or later in their career (OR, 1.73; 95% CI, 1.46-2.01; Cohen Q, 7.27; P = .003).

“Investments in organizational strategies to jointly monitor and improve physician wellness and patient care outcomes are needed,” Dr. Panagioti and her colleagues wrote in the study. “Interventions aimed at improving the culture of health care organizations, as well as interventions focused on individual physicians but supported and funded by health care organizations, are beneficial.”

Researchers noted the study quality was low to moderate. Variation in outcomes across studies, heterogeneity among studies, potential selection bias by excluding gray literature, and the inability to establish causal links from findings because of the cross-sectional nature of the studies analyzed were potential limitations in the study, they reported.

The study was funded by the United Kingdom NIHR School for Primary Care Research and the NIHR Greater Manchester Patient Safety Translational Research Centre. The authors report no relevant conflicts of interest.

SOURCE: Panagioti M et al. JAMA Intern Med. 2018 Sept 4. doi: 10.1001/jamainternmed.2018.3713.