Commentary

Senior staff of the Division of Advocacy and Health Policy was recently approached and asked to consider contributing a monthly column for ACS Surgery News. Unanimously, we agreed that it was imperative to do so and with this inaugural column, we embark on such an endeavor.

As many Fellows may be unfamiliar with the College’s Washington, DC, office and the Division of Advocacy and Health Policy, we thought it might be instructive with our first contribution to provide an overview of the office. However, being mindful of the proximity to the November elections, I will also refer Fellows to Election 2014: Issue-based considerations from a surgeon’s perspective in the Sept. 30th edition of the ACS Advocate for a quick refresher on some of the cogent issues expected to impact surgeons and their patients in the 114th Congress.

The ACS offices in Washington, DC, are located at 20 F St., NW, on the “Senate side” of Capitol Hill. The Division of Advocacy and Health Policy consists of 20 staff members working in the following areas: Legislative and Political Affairs, Quality Affairs, and Regulatory Affairs and State Affairs.

The Legislative and Political Affairs section currently consists of a Deputy Director, John Hedstrom, JD; as well as Manager of Political Affairs, Sara Morse; and lobbyists Matt Coffron and Heather Smith. Obviously, their focus is upon working toward the passage of legislation that furthers the College’s objectives of assuring access to quality surgical care. In the course of doing so, ACS staff routinely interface and work with not only individual members of Congress but also with congressional staff representing those individual members as well as the committee staff of the major committees of jurisdiction for our issues: 1) House Committee on Energy and Commerce; 2) House Ways and Means Committee; and 3) Senate Finance Committee. This section supports the College’s Legislative Committee.

ACSPA-SurgeonsPAC and the ACSPA-SurgeonsVoice platform of the Health Policy Advisory Council are managed by this section as well. The access to legislators facilitated by SurgeonsPAC enables us to have an opportunity to frame the argument on the issues affecting surgical patients and the practice of surgery. SurgeonsVoice provides resources for Fellows to develop relationships with their individual senators and representatives such that they too can actively participate in advocacy both at home via in-district meetings and here on Capitol Hill.

Though legislation and its attendant politics frequently garner more attention, it is the sections of Quality Affairs and Regulatory Affairs that concentrate on the effects of that successful legislation that becomes law and thus impacts surgeons and their patients. Staffing these sections are Manager of Regulatory Affairs, Vinita Ollapaly, JD; Manager of Quality Affairs, Jill Sage, MPH; as well as Sana Gokak, MPH; Neha Agrawal and Sarah Kurusz. Specific activities of this section include support of the General Surgery Coding and Reimbursement Committee and the annual ACS response to the Medicare Physician Fee Schedule proposed rule. This year that rule included proposals to eliminate 10- and 90-day global codes and to eliminate an exemption in the Open Payments (“Sunshine Act”) for physicians who serve as speakers at accredited CME programs. These areas of the ACS also assist Fellows in understanding and maintaining compliance with the Physician Quality Reporting System (PQRS). An excellent example of their work product can be found in the September issue of the ACS Bulletin entitled, “The benefits of PQRS participation and what the College is doing on your behalf (p. 28).

The State Affairs section moved to the Washington, DC, office from Chicago just over a year ago. Jon Sutton, who has been with ACS for 16 years, heads up this section and is assisted by Justin Rosen and Tara Leystra, MPH. Current active projects on which Jon and his team are engaged include obtaining coverage for bariatric surgery in the essential benefit packages of the various state exchanges, passage of the Uniform Emergency Volunteer Health Practitioners Act, as well as supporting the legislative and regulatory advocacy efforts of state chapters. The State Affairs section also supports the ACS delegation to the AMA House of Delegates and administers the State Lobby Day grant program.

The Director of the Division of Advocacy and Health Policy is Christian Shalgian, who has been with ACS for more than 16 years. Frank Opelka, MD, FACS (Medical Director for Quality and Health Policy) and I (Medical Director for Advocacy) are extremely pleased to have joined him this past June and look forward to assisting our Fellows and the College with challenges facing healthcare in the near and long-term future. We also look forward to contributing to ACS Surgery News as a means by which to communicate with you about our efforts relative to same.

Until next month …..

Dr. Bailey is a Pediatric Surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.

Senior staff of the Division of Advocacy and Health Policy was recently approached and asked to consider contributing a monthly column for ACS Surgery News. Unanimously, we agreed that it was imperative to do so and with this inaugural column, we embark on such an endeavor.

As many Fellows may be unfamiliar with the College’s Washington, DC, office and the Division of Advocacy and Health Policy, we thought it might be instructive with our first contribution to provide an overview of the office. However, being mindful of the proximity to the November elections, I will also refer Fellows to Election 2014: Issue-based considerations from a surgeon’s perspective in the Sept. 30th edition of the ACS Advocate for a quick refresher on some of the cogent issues expected to impact surgeons and their patients in the 114th Congress.

The ACS offices in Washington, DC, are located at 20 F St., NW, on the “Senate side” of Capitol Hill. The Division of Advocacy and Health Policy consists of 20 staff members working in the following areas: Legislative and Political Affairs, Quality Affairs, and Regulatory Affairs and State Affairs.

The Legislative and Political Affairs section currently consists of a Deputy Director, John Hedstrom, JD; as well as Manager of Political Affairs, Sara Morse; and lobbyists Matt Coffron and Heather Smith. Obviously, their focus is upon working toward the passage of legislation that furthers the College’s objectives of assuring access to quality surgical care. In the course of doing so, ACS staff routinely interface and work with not only individual members of Congress but also with congressional staff representing those individual members as well as the committee staff of the major committees of jurisdiction for our issues: 1) House Committee on Energy and Commerce; 2) House Ways and Means Committee; and 3) Senate Finance Committee. This section supports the College’s Legislative Committee.

ACSPA-SurgeonsPAC and the ACSPA-SurgeonsVoice platform of the Health Policy Advisory Council are managed by this section as well. The access to legislators facilitated by SurgeonsPAC enables us to have an opportunity to frame the argument on the issues affecting surgical patients and the practice of surgery. SurgeonsVoice provides resources for Fellows to develop relationships with their individual senators and representatives such that they too can actively participate in advocacy both at home via in-district meetings and here on Capitol Hill.

Though legislation and its attendant politics frequently garner more attention, it is the sections of Quality Affairs and Regulatory Affairs that concentrate on the effects of that successful legislation that becomes law and thus impacts surgeons and their patients. Staffing these sections are Manager of Regulatory Affairs, Vinita Ollapaly, JD; Manager of Quality Affairs, Jill Sage, MPH; as well as Sana Gokak, MPH; Neha Agrawal and Sarah Kurusz. Specific activities of this section include support of the General Surgery Coding and Reimbursement Committee and the annual ACS response to the Medicare Physician Fee Schedule proposed rule. This year that rule included proposals to eliminate 10- and 90-day global codes and to eliminate an exemption in the Open Payments (“Sunshine Act”) for physicians who serve as speakers at accredited CME programs. These areas of the ACS also assist Fellows in understanding and maintaining compliance with the Physician Quality Reporting System (PQRS). An excellent example of their work product can be found in the September issue of the ACS Bulletin entitled, “The benefits of PQRS participation and what the College is doing on your behalf (p. 28).

The State Affairs section moved to the Washington, DC, office from Chicago just over a year ago. Jon Sutton, who has been with ACS for 16 years, heads up this section and is assisted by Justin Rosen and Tara Leystra, MPH. Current active projects on which Jon and his team are engaged include obtaining coverage for bariatric surgery in the essential benefit packages of the various state exchanges, passage of the Uniform Emergency Volunteer Health Practitioners Act, as well as supporting the legislative and regulatory advocacy efforts of state chapters. The State Affairs section also supports the ACS delegation to the AMA House of Delegates and administers the State Lobby Day grant program.

The Director of the Division of Advocacy and Health Policy is Christian Shalgian, who has been with ACS for more than 16 years. Frank Opelka, MD, FACS (Medical Director for Quality and Health Policy) and I (Medical Director for Advocacy) are extremely pleased to have joined him this past June and look forward to assisting our Fellows and the College with challenges facing healthcare in the near and long-term future. We also look forward to contributing to ACS Surgery News as a means by which to communicate with you about our efforts relative to same.

Until next month …..

Dr. Bailey is a Pediatric Surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.

Senior staff of the Division of Advocacy and Health Policy was recently approached and asked to consider contributing a monthly column for ACS Surgery News. Unanimously, we agreed that it was imperative to do so and with this inaugural column, we embark on such an endeavor.

As many Fellows may be unfamiliar with the College’s Washington, DC, office and the Division of Advocacy and Health Policy, we thought it might be instructive with our first contribution to provide an overview of the office. However, being mindful of the proximity to the November elections, I will also refer Fellows to Election 2014: Issue-based considerations from a surgeon’s perspective in the Sept. 30th edition of the ACS Advocate for a quick refresher on some of the cogent issues expected to impact surgeons and their patients in the 114th Congress.

The ACS offices in Washington, DC, are located at 20 F St., NW, on the “Senate side” of Capitol Hill. The Division of Advocacy and Health Policy consists of 20 staff members working in the following areas: Legislative and Political Affairs, Quality Affairs, and Regulatory Affairs and State Affairs.

The Legislative and Political Affairs section currently consists of a Deputy Director, John Hedstrom, JD; as well as Manager of Political Affairs, Sara Morse; and lobbyists Matt Coffron and Heather Smith. Obviously, their focus is upon working toward the passage of legislation that furthers the College’s objectives of assuring access to quality surgical care. In the course of doing so, ACS staff routinely interface and work with not only individual members of Congress but also with congressional staff representing those individual members as well as the committee staff of the major committees of jurisdiction for our issues: 1) House Committee on Energy and Commerce; 2) House Ways and Means Committee; and 3) Senate Finance Committee. This section supports the College’s Legislative Committee.

ACSPA-SurgeonsPAC and the ACSPA-SurgeonsVoice platform of the Health Policy Advisory Council are managed by this section as well. The access to legislators facilitated by SurgeonsPAC enables us to have an opportunity to frame the argument on the issues affecting surgical patients and the practice of surgery. SurgeonsVoice provides resources for Fellows to develop relationships with their individual senators and representatives such that they too can actively participate in advocacy both at home via in-district meetings and here on Capitol Hill.

Though legislation and its attendant politics frequently garner more attention, it is the sections of Quality Affairs and Regulatory Affairs that concentrate on the effects of that successful legislation that becomes law and thus impacts surgeons and their patients. Staffing these sections are Manager of Regulatory Affairs, Vinita Ollapaly, JD; Manager of Quality Affairs, Jill Sage, MPH; as well as Sana Gokak, MPH; Neha Agrawal and Sarah Kurusz. Specific activities of this section include support of the General Surgery Coding and Reimbursement Committee and the annual ACS response to the Medicare Physician Fee Schedule proposed rule. This year that rule included proposals to eliminate 10- and 90-day global codes and to eliminate an exemption in the Open Payments (“Sunshine Act”) for physicians who serve as speakers at accredited CME programs. These areas of the ACS also assist Fellows in understanding and maintaining compliance with the Physician Quality Reporting System (PQRS). An excellent example of their work product can be found in the September issue of the ACS Bulletin entitled, “The benefits of PQRS participation and what the College is doing on your behalf (p. 28).

The State Affairs section moved to the Washington, DC, office from Chicago just over a year ago. Jon Sutton, who has been with ACS for 16 years, heads up this section and is assisted by Justin Rosen and Tara Leystra, MPH. Current active projects on which Jon and his team are engaged include obtaining coverage for bariatric surgery in the essential benefit packages of the various state exchanges, passage of the Uniform Emergency Volunteer Health Practitioners Act, as well as supporting the legislative and regulatory advocacy efforts of state chapters. The State Affairs section also supports the ACS delegation to the AMA House of Delegates and administers the State Lobby Day grant program.

The Director of the Division of Advocacy and Health Policy is Christian Shalgian, who has been with ACS for more than 16 years. Frank Opelka, MD, FACS (Medical Director for Quality and Health Policy) and I (Medical Director for Advocacy) are extremely pleased to have joined him this past June and look forward to assisting our Fellows and the College with challenges facing healthcare in the near and long-term future. We also look forward to contributing to ACS Surgery News as a means by which to communicate with you about our efforts relative to same.

Until next month …..

Dr. Bailey is a Pediatric Surgeon and Medical Director, Advocacy for the Division of Advocacy and Health Policy in the ACS offices in Washington, DC.

In my recent travels to ACS state chapter gatherings and in my meeting with rural surgeons in a variety of settings, I have heard on many occasions a particular theme of concern: the lack of resources, in particular, personnel resources available in rural hospitals. A shortage of nurses, assistants, and support staff of all kinds has emerged as a serious, continuing challenge for surgeons who work in small communities.

Rural surgery still “gets it done” in spite of resource challenges. Actually, rural surgeons perform more procedures per year with more variety in procedure types than did their urban peers, in spite of limited resources (J. Am. Coll. Surg. 2005;201:732-6).

Courtesy of Dr. Caropreso

Resource shortage for rural practices is a common subject on the rural surgery Listserv. Rural surgeons might exclaim, “We have done so much with so little for so long that we are now expected to do everything with nothing forever!” Nursing and support personnel are key resources that can be in short supply.

The rural surgery Listserv has hosted a contest inviting rural surgeons to complete the following statement: “You know you are a rural surgeon if … (YKYAARSI).” At a recent rural surgery dinner at a scientific meeting, we had a little fun amidst all of the serious topics. The winner surgeon read his winning entry: “You know you are a rural surgeon if your first OR assistant is also the OR director, the director of nursing, the DRG coordinator, the director of QA for the ER, the coordinator of emergency preparedness, the committee coordinator for the annual hospital Christmas party, the chairwoman of the committee for quality measures, the best enema nurse, and the best interpreter of the local jargon, such as ‘casophagus’ (esophagus), ‘whistle’ (penis), ‘physic’ (enema), ‘hepmotoma’ (hematoma ), and ‘toodinitis’ (vaginal infection).” Laughter and cheers followed.

Is this hyperbole? The winning YKYAARSI entry is likely closer to reality for many rural surgeons than might be supposed by those who practice in institutions with abundant personnel resources. In small community hospitals, one dedicated staff nurse can have many roles and many jobs.

Early in my career, I practiced with a true team. Individuals had specific roles. My physician assistants assisted me during operations and on rounds. The OR head nurse “ran the board.” The director of surgical services coordinated all functions of the OR from an office. The emergency room was under the management of a veteran emergency nurse. Patients received outstanding bedside nursing care on the surgical floors and in the ICU. IV teams developed and provided valuable services. Skilled lab techs drew blood. An administrative assistant coordinated social events and fund raising. Clearly, trained individuals focused on their areas of expertise.

Gradually, this structure changed. Individuals had to assume many different roles and fill positions that were otherwise unfamiliar to them. The nursing and support personnel resources available for surgery started to diminish significantly.

Today, the concept of team is reduced to single individuals “wearing many hats.” They have all accepted the additional roles to support their hospitals and then made sincere efforts to perform well. The added responsibilities have stressed these well-intentioned nurses, technicians, and assistants both physically and emotionally. Frequently circumstances prevented them from being resources for surgery, straining surgical performance and patient care. I have experienced such situations firsthand, and I have no doubt many readers have as well.

The YKYAARSI winning entry came to life at my critical access hospital. The OR charge nurse became the director for surgical services, ob.gyn., and the emergency department. Previously, this capable nurse would either circulate my cases or be the first assistant. She also took call. She had the greatest skill starting IVs. With the additional duties outside of the OR, this “resource” nearly disappeared, depriving the practice of her abilities and experience. Providing overall quality care became even more challenging. The new “director of almost everything” also led efforts to raise funds for the hospital building campaign. In addition, she developed and coordinated a half-marathon to lift spirits and get pledges for the hospital. In spite of being encouraged to the contrary by hospital administration, even this smart, determined nurse fell behind, and was no longer a resource for surgery.

Like other rural surgeons in similar circumstances, I persisted and adapted to working with less, but I recognize that this situation is not ideal, and perhaps in the long run, not sustainable.

The root of the problem of limited personnel resources for rural surgery is multifactorial and the topic for another column. If you have experienced a personnel shortage or a situation of critical staff “wearing many hats” and would like to contribute to this discussion, please feel free to e-mail me.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

In my recent travels to ACS state chapter gatherings and in my meeting with rural surgeons in a variety of settings, I have heard on many occasions a particular theme of concern: the lack of resources, in particular, personnel resources available in rural hospitals. A shortage of nurses, assistants, and support staff of all kinds has emerged as a serious, continuing challenge for surgeons who work in small communities.

Rural surgery still “gets it done” in spite of resource challenges. Actually, rural surgeons perform more procedures per year with more variety in procedure types than did their urban peers, in spite of limited resources (J. Am. Coll. Surg. 2005;201:732-6).

Courtesy of Dr. Caropreso

Resource shortage for rural practices is a common subject on the rural surgery Listserv. Rural surgeons might exclaim, “We have done so much with so little for so long that we are now expected to do everything with nothing forever!” Nursing and support personnel are key resources that can be in short supply.

The rural surgery Listserv has hosted a contest inviting rural surgeons to complete the following statement: “You know you are a rural surgeon if … (YKYAARSI).” At a recent rural surgery dinner at a scientific meeting, we had a little fun amidst all of the serious topics. The winner surgeon read his winning entry: “You know you are a rural surgeon if your first OR assistant is also the OR director, the director of nursing, the DRG coordinator, the director of QA for the ER, the coordinator of emergency preparedness, the committee coordinator for the annual hospital Christmas party, the chairwoman of the committee for quality measures, the best enema nurse, and the best interpreter of the local jargon, such as ‘casophagus’ (esophagus), ‘whistle’ (penis), ‘physic’ (enema), ‘hepmotoma’ (hematoma ), and ‘toodinitis’ (vaginal infection).” Laughter and cheers followed.

Is this hyperbole? The winning YKYAARSI entry is likely closer to reality for many rural surgeons than might be supposed by those who practice in institutions with abundant personnel resources. In small community hospitals, one dedicated staff nurse can have many roles and many jobs.

Early in my career, I practiced with a true team. Individuals had specific roles. My physician assistants assisted me during operations and on rounds. The OR head nurse “ran the board.” The director of surgical services coordinated all functions of the OR from an office. The emergency room was under the management of a veteran emergency nurse. Patients received outstanding bedside nursing care on the surgical floors and in the ICU. IV teams developed and provided valuable services. Skilled lab techs drew blood. An administrative assistant coordinated social events and fund raising. Clearly, trained individuals focused on their areas of expertise.

Gradually, this structure changed. Individuals had to assume many different roles and fill positions that were otherwise unfamiliar to them. The nursing and support personnel resources available for surgery started to diminish significantly.

Today, the concept of team is reduced to single individuals “wearing many hats.” They have all accepted the additional roles to support their hospitals and then made sincere efforts to perform well. The added responsibilities have stressed these well-intentioned nurses, technicians, and assistants both physically and emotionally. Frequently circumstances prevented them from being resources for surgery, straining surgical performance and patient care. I have experienced such situations firsthand, and I have no doubt many readers have as well.

The YKYAARSI winning entry came to life at my critical access hospital. The OR charge nurse became the director for surgical services, ob.gyn., and the emergency department. Previously, this capable nurse would either circulate my cases or be the first assistant. She also took call. She had the greatest skill starting IVs. With the additional duties outside of the OR, this “resource” nearly disappeared, depriving the practice of her abilities and experience. Providing overall quality care became even more challenging. The new “director of almost everything” also led efforts to raise funds for the hospital building campaign. In addition, she developed and coordinated a half-marathon to lift spirits and get pledges for the hospital. In spite of being encouraged to the contrary by hospital administration, even this smart, determined nurse fell behind, and was no longer a resource for surgery.

Like other rural surgeons in similar circumstances, I persisted and adapted to working with less, but I recognize that this situation is not ideal, and perhaps in the long run, not sustainable.

The root of the problem of limited personnel resources for rural surgery is multifactorial and the topic for another column. If you have experienced a personnel shortage or a situation of critical staff “wearing many hats” and would like to contribute to this discussion, please feel free to e-mail me.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

In my recent travels to ACS state chapter gatherings and in my meeting with rural surgeons in a variety of settings, I have heard on many occasions a particular theme of concern: the lack of resources, in particular, personnel resources available in rural hospitals. A shortage of nurses, assistants, and support staff of all kinds has emerged as a serious, continuing challenge for surgeons who work in small communities.

Rural surgery still “gets it done” in spite of resource challenges. Actually, rural surgeons perform more procedures per year with more variety in procedure types than did their urban peers, in spite of limited resources (J. Am. Coll. Surg. 2005;201:732-6).

Courtesy of Dr. Caropreso

Resource shortage for rural practices is a common subject on the rural surgery Listserv. Rural surgeons might exclaim, “We have done so much with so little for so long that we are now expected to do everything with nothing forever!” Nursing and support personnel are key resources that can be in short supply.

The rural surgery Listserv has hosted a contest inviting rural surgeons to complete the following statement: “You know you are a rural surgeon if … (YKYAARSI).” At a recent rural surgery dinner at a scientific meeting, we had a little fun amidst all of the serious topics. The winner surgeon read his winning entry: “You know you are a rural surgeon if your first OR assistant is also the OR director, the director of nursing, the DRG coordinator, the director of QA for the ER, the coordinator of emergency preparedness, the committee coordinator for the annual hospital Christmas party, the chairwoman of the committee for quality measures, the best enema nurse, and the best interpreter of the local jargon, such as ‘casophagus’ (esophagus), ‘whistle’ (penis), ‘physic’ (enema), ‘hepmotoma’ (hematoma ), and ‘toodinitis’ (vaginal infection).” Laughter and cheers followed.

Is this hyperbole? The winning YKYAARSI entry is likely closer to reality for many rural surgeons than might be supposed by those who practice in institutions with abundant personnel resources. In small community hospitals, one dedicated staff nurse can have many roles and many jobs.

Early in my career, I practiced with a true team. Individuals had specific roles. My physician assistants assisted me during operations and on rounds. The OR head nurse “ran the board.” The director of surgical services coordinated all functions of the OR from an office. The emergency room was under the management of a veteran emergency nurse. Patients received outstanding bedside nursing care on the surgical floors and in the ICU. IV teams developed and provided valuable services. Skilled lab techs drew blood. An administrative assistant coordinated social events and fund raising. Clearly, trained individuals focused on their areas of expertise.

Gradually, this structure changed. Individuals had to assume many different roles and fill positions that were otherwise unfamiliar to them. The nursing and support personnel resources available for surgery started to diminish significantly.

Today, the concept of team is reduced to single individuals “wearing many hats.” They have all accepted the additional roles to support their hospitals and then made sincere efforts to perform well. The added responsibilities have stressed these well-intentioned nurses, technicians, and assistants both physically and emotionally. Frequently circumstances prevented them from being resources for surgery, straining surgical performance and patient care. I have experienced such situations firsthand, and I have no doubt many readers have as well.

The YKYAARSI winning entry came to life at my critical access hospital. The OR charge nurse became the director for surgical services, ob.gyn., and the emergency department. Previously, this capable nurse would either circulate my cases or be the first assistant. She also took call. She had the greatest skill starting IVs. With the additional duties outside of the OR, this “resource” nearly disappeared, depriving the practice of her abilities and experience. Providing overall quality care became even more challenging. The new “director of almost everything” also led efforts to raise funds for the hospital building campaign. In addition, she developed and coordinated a half-marathon to lift spirits and get pledges for the hospital. In spite of being encouraged to the contrary by hospital administration, even this smart, determined nurse fell behind, and was no longer a resource for surgery.

Like other rural surgeons in similar circumstances, I persisted and adapted to working with less, but I recognize that this situation is not ideal, and perhaps in the long run, not sustainable.

The root of the problem of limited personnel resources for rural surgery is multifactorial and the topic for another column. If you have experienced a personnel shortage or a situation of critical staff “wearing many hats” and would like to contribute to this discussion, please feel free to e-mail me.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

Thanksgiving will soon be here and celebrated joyfully with food, friends, and family in many homes around the country. Football, as well, has become a big part of this tradition on the fourth Thursday of November, an official holiday proclaimed by Abraham Lincoln in 1863. The first Thanksgiving was at Plymouth Plantation in 1621. It is unknown if any rural surgeons were present then. During this holiday, many rural surgeons will be giving thanks for more than food, friends, family, and football.

Twenty-five percent of the population is rural and fewer than 10% of surgeons practice in rural locations. This fact is complicated by the advanced age of the surgeons (~55 y/o) with more than 60% of them planning to retire in less than 10 years. The changes to all aspects of health care today, such as the Affordable Care Act, ACOs, and EMRs, affect the rural health care environment more profoundly and actually promote the deterioration of rural surgical practices. In recent years, rural surgeons have had few reasons to give thanks for the trajectory of their professional situation and fewer yet for the degree of acknowledgment of their challenges by the profession as a whole.

Courtesy of Dr. Caropreso

In the past 2 years, thanks to the tireless efforts of a few activists and enlightened leadership in the College, the ACS is now reaching out to rural surgeons, to recognize and to represent them. An important first step was the establishment of the Advisory Council on Rural Surgery, with its pillars for member services, education, quality, advocacy, as well as communication. The Council is chaired by Dr. Tyler Hughes.

Some critics might conclude that this council is just another group of surgeons more concerned about appearances and prominent positions than making an impact on the professional lives of rural surgeons. But such a conclusion would be wrong. Since its inception, the ACRS has worked relentlessly to identify and address the needs of rural surgeons. Efforts of all the pillars have involved education, along with local and national engagement of rural surgeons with emphasis on training, recruitment, and retention. The ACRS has stressed and promoted the value and quality found in rural surgical practices. Members of the Council have generously given their time and enthusiasm to advance these goals.

One of the major roles played by ACRS members has been contributing articles on the realities of a rural practice for the ACS Bulletin’s regular column, “Dispatches from rural surgeons.” Member services chair Dr. Mike Sarap wrote the initial article “The value of chapter membership: The rural surgeon’s perspective,” detailing chapter membership benefits. It concluded that patient care would benefit from a united, networked surgical community. Local ACS chapters can be a foundation of community and professional support among rural surgeons.

Dr. Mark Savarise, advocacy chair, wrote the feature article, “CPT 2012 brings with it new codes and code changes,” that provided invaluable information to rural surgeons, who otherwise would have struggled to secure it. Recently, Dr. Savarise wrote “ACS intervenes to resolve questions about the 96-hour rule” on an issue of great concern to rural surgeons. These efforts to raise awareness, articulate concerns, advocate for change, and inform members about issues are among the most important tasks of the ACRS.

The ACRS also emphasizes continuing education for rural surgeons. Rural surgery symposiums and skills courses over the years attest to that fact and acknowledge the ACRS connection with the Mithoefer Center, Cooperstown, NY, and the Nora Institute in Chicago, IL. ACRS council member, Dr. David Borgstrom, “Rural surgical practice requires a new training model, offers great opportunities” in another Bulletin rural surgery dispatch. The article describes the existing and emerging training programs, ranging from rural surgery rotations and dedicated rural surgery tracks to immersion and fellowship opportunities. The ACS has hosted a series of regional meetings such as the ACS Surgical Healthcare Quality Forum Iowa in June 2014 to engage the surgical community to share ideas on training and workforce needs, maintenance of quality care, and staff retention. In addition, ACS has introduced the Transition to Practice Program in General Surgery, which has been established in several institutions to help residents move into rural surgical practice. This program offers clinical training but also practice management training tailored to rural surgery.

ACRS quality chair, Dr. Don Nakayama, professor and chair at West Virginia University, Morgantown, has collected standards criteria for rural surgery centers of excellence and is composing a verification document for rural surgical practices. This document will assist rural surgeons and be instrumental in maintaining resources and quality in their practices. Once implemented by the ACS, the verification process for rural surgery, like the well-established program for trauma, will enable the highest standards required for the inspiring quality and for better outcomes. This new verification process and its standards give the rural surgeon a basis for the best practice.

The College has stepped up its advocacy efforts to have an impact on policy and legislation to support all surgeons. The ACS Washington office is vital and Dr. Pat Bailey, ACS medical director of advocacy, has worked with the ACRS to make sure the concerns of rural surgeons are incorporated into the advocacy strategy.

One of the four pillars of the ACRS is communication. The rural surgeons listserv was developed in by the ACRS in 2012 and has been a great success. With more than 1,000 members, and several million emails exchanged, the listserv has become meeting place for the community of rural surgeons. During the numerous rural listserv discussions and threads, many of the emails expressed thanks and appreciation. One rural surgeon volunteered, “This is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.” The conversation continued with this sentiment, “I am terrifically gratified to find that the guilt I have suffered all these years (30+) is misplaced.” As the thread continued, the word thanks appeared multiple times. The communication mission of the ACRS will continue with the development of the ACS Communities platform.

The ACS support for rural surgeons came at an ideal time. And for many in the community, this support is a cause for thankfulness.

In participating in the listserv, rural surgeons identified many topics of interest and some actual concerns to them. Call and locum tenens coverage were the most prominent potential issues. The ACS leadership is aware of both subjects and is currently investigating each one. These matters are vital to rural surgeons, and this publication, ACS Surgery News, invites rural surgeons (or any reader) to respond with any additional information. A productive dialogue could follow and be useful to the ACS. Regardless, the ACS will continue without interruption the process of support rural surgeons.

By its actions, the ACS gives living proof to its motto – “inspiring quality, highest standards, better outcomes” – which now have improved chances for surgeons to continue their work in rural communities. Rural surgeons have experienced the true meaning of ACS Fellowship. Indeed, during this Thanksgiving, rural surgeons will be giving thanks for food, friends, family, and the calling to the surgical profession. Rural surgeons will also be grateful for their College and its personal support of their profession and their practices. Thank you and Happy Thanksgiving to everyone.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

Thanksgiving will soon be here and celebrated joyfully with food, friends, and family in many homes around the country. Football, as well, has become a big part of this tradition on the fourth Thursday of November, an official holiday proclaimed by Abraham Lincoln in 1863. The first Thanksgiving was at Plymouth Plantation in 1621. It is unknown if any rural surgeons were present then. During this holiday, many rural surgeons will be giving thanks for more than food, friends, family, and football.

Twenty-five percent of the population is rural and fewer than 10% of surgeons practice in rural locations. This fact is complicated by the advanced age of the surgeons (~55 y/o) with more than 60% of them planning to retire in less than 10 years. The changes to all aspects of health care today, such as the Affordable Care Act, ACOs, and EMRs, affect the rural health care environment more profoundly and actually promote the deterioration of rural surgical practices. In recent years, rural surgeons have had few reasons to give thanks for the trajectory of their professional situation and fewer yet for the degree of acknowledgment of their challenges by the profession as a whole.

Courtesy of Dr. Caropreso

In the past 2 years, thanks to the tireless efforts of a few activists and enlightened leadership in the College, the ACS is now reaching out to rural surgeons, to recognize and to represent them. An important first step was the establishment of the Advisory Council on Rural Surgery, with its pillars for member services, education, quality, advocacy, as well as communication. The Council is chaired by Dr. Tyler Hughes.

Some critics might conclude that this council is just another group of surgeons more concerned about appearances and prominent positions than making an impact on the professional lives of rural surgeons. But such a conclusion would be wrong. Since its inception, the ACRS has worked relentlessly to identify and address the needs of rural surgeons. Efforts of all the pillars have involved education, along with local and national engagement of rural surgeons with emphasis on training, recruitment, and retention. The ACRS has stressed and promoted the value and quality found in rural surgical practices. Members of the Council have generously given their time and enthusiasm to advance these goals.

One of the major roles played by ACRS members has been contributing articles on the realities of a rural practice for the ACS Bulletin’s regular column, “Dispatches from rural surgeons.” Member services chair Dr. Mike Sarap wrote the initial article “The value of chapter membership: The rural surgeon’s perspective,” detailing chapter membership benefits. It concluded that patient care would benefit from a united, networked surgical community. Local ACS chapters can be a foundation of community and professional support among rural surgeons.

Dr. Mark Savarise, advocacy chair, wrote the feature article, “CPT 2012 brings with it new codes and code changes,” that provided invaluable information to rural surgeons, who otherwise would have struggled to secure it. Recently, Dr. Savarise wrote “ACS intervenes to resolve questions about the 96-hour rule” on an issue of great concern to rural surgeons. These efforts to raise awareness, articulate concerns, advocate for change, and inform members about issues are among the most important tasks of the ACRS.

The ACRS also emphasizes continuing education for rural surgeons. Rural surgery symposiums and skills courses over the years attest to that fact and acknowledge the ACRS connection with the Mithoefer Center, Cooperstown, NY, and the Nora Institute in Chicago, IL. ACRS council member, Dr. David Borgstrom, “Rural surgical practice requires a new training model, offers great opportunities” in another Bulletin rural surgery dispatch. The article describes the existing and emerging training programs, ranging from rural surgery rotations and dedicated rural surgery tracks to immersion and fellowship opportunities. The ACS has hosted a series of regional meetings such as the ACS Surgical Healthcare Quality Forum Iowa in June 2014 to engage the surgical community to share ideas on training and workforce needs, maintenance of quality care, and staff retention. In addition, ACS has introduced the Transition to Practice Program in General Surgery, which has been established in several institutions to help residents move into rural surgical practice. This program offers clinical training but also practice management training tailored to rural surgery.

ACRS quality chair, Dr. Don Nakayama, professor and chair at West Virginia University, Morgantown, has collected standards criteria for rural surgery centers of excellence and is composing a verification document for rural surgical practices. This document will assist rural surgeons and be instrumental in maintaining resources and quality in their practices. Once implemented by the ACS, the verification process for rural surgery, like the well-established program for trauma, will enable the highest standards required for the inspiring quality and for better outcomes. This new verification process and its standards give the rural surgeon a basis for the best practice.

The College has stepped up its advocacy efforts to have an impact on policy and legislation to support all surgeons. The ACS Washington office is vital and Dr. Pat Bailey, ACS medical director of advocacy, has worked with the ACRS to make sure the concerns of rural surgeons are incorporated into the advocacy strategy.

One of the four pillars of the ACRS is communication. The rural surgeons listserv was developed in by the ACRS in 2012 and has been a great success. With more than 1,000 members, and several million emails exchanged, the listserv has become meeting place for the community of rural surgeons. During the numerous rural listserv discussions and threads, many of the emails expressed thanks and appreciation. One rural surgeon volunteered, “This is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.” The conversation continued with this sentiment, “I am terrifically gratified to find that the guilt I have suffered all these years (30+) is misplaced.” As the thread continued, the word thanks appeared multiple times. The communication mission of the ACRS will continue with the development of the ACS Communities platform.

The ACS support for rural surgeons came at an ideal time. And for many in the community, this support is a cause for thankfulness.

In participating in the listserv, rural surgeons identified many topics of interest and some actual concerns to them. Call and locum tenens coverage were the most prominent potential issues. The ACS leadership is aware of both subjects and is currently investigating each one. These matters are vital to rural surgeons, and this publication, ACS Surgery News, invites rural surgeons (or any reader) to respond with any additional information. A productive dialogue could follow and be useful to the ACS. Regardless, the ACS will continue without interruption the process of support rural surgeons.

By its actions, the ACS gives living proof to its motto – “inspiring quality, highest standards, better outcomes” – which now have improved chances for surgeons to continue their work in rural communities. Rural surgeons have experienced the true meaning of ACS Fellowship. Indeed, during this Thanksgiving, rural surgeons will be giving thanks for food, friends, family, and the calling to the surgical profession. Rural surgeons will also be grateful for their College and its personal support of their profession and their practices. Thank you and Happy Thanksgiving to everyone.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

Thanksgiving will soon be here and celebrated joyfully with food, friends, and family in many homes around the country. Football, as well, has become a big part of this tradition on the fourth Thursday of November, an official holiday proclaimed by Abraham Lincoln in 1863. The first Thanksgiving was at Plymouth Plantation in 1621. It is unknown if any rural surgeons were present then. During this holiday, many rural surgeons will be giving thanks for more than food, friends, family, and football.

Twenty-five percent of the population is rural and fewer than 10% of surgeons practice in rural locations. This fact is complicated by the advanced age of the surgeons (~55 y/o) with more than 60% of them planning to retire in less than 10 years. The changes to all aspects of health care today, such as the Affordable Care Act, ACOs, and EMRs, affect the rural health care environment more profoundly and actually promote the deterioration of rural surgical practices. In recent years, rural surgeons have had few reasons to give thanks for the trajectory of their professional situation and fewer yet for the degree of acknowledgment of their challenges by the profession as a whole.

Courtesy of Dr. Caropreso

In the past 2 years, thanks to the tireless efforts of a few activists and enlightened leadership in the College, the ACS is now reaching out to rural surgeons, to recognize and to represent them. An important first step was the establishment of the Advisory Council on Rural Surgery, with its pillars for member services, education, quality, advocacy, as well as communication. The Council is chaired by Dr. Tyler Hughes.

Some critics might conclude that this council is just another group of surgeons more concerned about appearances and prominent positions than making an impact on the professional lives of rural surgeons. But such a conclusion would be wrong. Since its inception, the ACRS has worked relentlessly to identify and address the needs of rural surgeons. Efforts of all the pillars have involved education, along with local and national engagement of rural surgeons with emphasis on training, recruitment, and retention. The ACRS has stressed and promoted the value and quality found in rural surgical practices. Members of the Council have generously given their time and enthusiasm to advance these goals.

One of the major roles played by ACRS members has been contributing articles on the realities of a rural practice for the ACS Bulletin’s regular column, “Dispatches from rural surgeons.” Member services chair Dr. Mike Sarap wrote the initial article “The value of chapter membership: The rural surgeon’s perspective,” detailing chapter membership benefits. It concluded that patient care would benefit from a united, networked surgical community. Local ACS chapters can be a foundation of community and professional support among rural surgeons.

Dr. Mark Savarise, advocacy chair, wrote the feature article, “CPT 2012 brings with it new codes and code changes,” that provided invaluable information to rural surgeons, who otherwise would have struggled to secure it. Recently, Dr. Savarise wrote “ACS intervenes to resolve questions about the 96-hour rule” on an issue of great concern to rural surgeons. These efforts to raise awareness, articulate concerns, advocate for change, and inform members about issues are among the most important tasks of the ACRS.

The ACRS also emphasizes continuing education for rural surgeons. Rural surgery symposiums and skills courses over the years attest to that fact and acknowledge the ACRS connection with the Mithoefer Center, Cooperstown, NY, and the Nora Institute in Chicago, IL. ACRS council member, Dr. David Borgstrom, “Rural surgical practice requires a new training model, offers great opportunities” in another Bulletin rural surgery dispatch. The article describes the existing and emerging training programs, ranging from rural surgery rotations and dedicated rural surgery tracks to immersion and fellowship opportunities. The ACS has hosted a series of regional meetings such as the ACS Surgical Healthcare Quality Forum Iowa in June 2014 to engage the surgical community to share ideas on training and workforce needs, maintenance of quality care, and staff retention. In addition, ACS has introduced the Transition to Practice Program in General Surgery, which has been established in several institutions to help residents move into rural surgical practice. This program offers clinical training but also practice management training tailored to rural surgery.

ACRS quality chair, Dr. Don Nakayama, professor and chair at West Virginia University, Morgantown, has collected standards criteria for rural surgery centers of excellence and is composing a verification document for rural surgical practices. This document will assist rural surgeons and be instrumental in maintaining resources and quality in their practices. Once implemented by the ACS, the verification process for rural surgery, like the well-established program for trauma, will enable the highest standards required for the inspiring quality and for better outcomes. This new verification process and its standards give the rural surgeon a basis for the best practice.

The College has stepped up its advocacy efforts to have an impact on policy and legislation to support all surgeons. The ACS Washington office is vital and Dr. Pat Bailey, ACS medical director of advocacy, has worked with the ACRS to make sure the concerns of rural surgeons are incorporated into the advocacy strategy.

One of the four pillars of the ACRS is communication. The rural surgeons listserv was developed in by the ACRS in 2012 and has been a great success. With more than 1,000 members, and several million emails exchanged, the listserv has become meeting place for the community of rural surgeons. During the numerous rural listserv discussions and threads, many of the emails expressed thanks and appreciation. One rural surgeon volunteered, “This is the most tangible, personally applicable arm of the College I have been exposed to in nearly 40 years as a Fellow.” The conversation continued with this sentiment, “I am terrifically gratified to find that the guilt I have suffered all these years (30+) is misplaced.” As the thread continued, the word thanks appeared multiple times. The communication mission of the ACRS will continue with the development of the ACS Communities platform.

The ACS support for rural surgeons came at an ideal time. And for many in the community, this support is a cause for thankfulness.

In participating in the listserv, rural surgeons identified many topics of interest and some actual concerns to them. Call and locum tenens coverage were the most prominent potential issues. The ACS leadership is aware of both subjects and is currently investigating each one. These matters are vital to rural surgeons, and this publication, ACS Surgery News, invites rural surgeons (or any reader) to respond with any additional information. A productive dialogue could follow and be useful to the ACS. Regardless, the ACS will continue without interruption the process of support rural surgeons.

By its actions, the ACS gives living proof to its motto – “inspiring quality, highest standards, better outcomes” – which now have improved chances for surgeons to continue their work in rural communities. Rural surgeons have experienced the true meaning of ACS Fellowship. Indeed, during this Thanksgiving, rural surgeons will be giving thanks for food, friends, family, and the calling to the surgical profession. Rural surgeons will also be grateful for their College and its personal support of their profession and their practices. Thank you and Happy Thanksgiving to everyone.

Dr. Caropreso is a general surgeon at Keokuk (Iowa) Area Hospital and Clinical Professor of Surgery at the University of Iowa Carver College of Medicine. He has practiced surgery in the rural communities of Mason City, Iowa; Keokuk, Iowa; and Carthage, Ill., for 37 years.

In the wake of the grand jury’s decision not to indict Officer Darren Wilson for the death of Michael Brown in Ferguson, Mo., an artist/comedian named Joe Veix made a brilliant fake mock-up of what the New York Times’ banner page would look like the following day. The fake headline says, “Everything’s ... Awful,” (expletive deleted) and it calls out the endlessly scatological nature of the opinion pages. It captured the bleakness of the moment. The world-on-fire sentiment is one that I often feel, particularly when calamities, man-made or otherwise, strike.

So the Thanksgiving holiday was a welcome break from the world. It was a time to retreat from the world.

Starting with the peaceful drive from Providence, R.I., to New York, we insulated ourselves briefly from the 24-hour news cycle, the bad news, the critics and thought pieces, and the criticisms of the thought pieces. We managed to tune out our phones, those instruments of endless mind-numbing connectivity, and enjoy each other’s company. We listened to music, told stories, spent time together in the kitchen making old family favorites. We talked about our anxieties and aspirations. We shared stories of our childhood and sibling rivalry, and the curious relationship of parents and children. We had dinner with friends of a friend, strangers who welcomed us into their home. We made new friends, got well fed, and drank plenty of hot apple cider and whiskey. We basked in love and affection, and went to bed that night content as pigs in a very warm blanket.

The holiday was enough, for the briefest of moments, to be at peace with the mess of the human condition.

This left me thinking of the ultimate big-level picture of the condition we are in. In 1990, the spacecraft Voyager 1 left our atmosphere, and when it was about 4 billion miles away, it took a snapshot of Earth, seen here.

It is this image that inspired Carl Sagan to write the following passage. Every reading of it leaves me with different measures but always the same combination of conflicting emotions: of sadness, and insignificance, of awe, and gratitude, and hope.

“From this distant vantage point, the Earth might not seem of any particular interest. But for us, it’s different. Consider again that dot. That’s here, that’s home, that’s us. On it everyone you love, everyone you know, everyone you ever heard of, every human being who ever was, lived out their lives. The aggregate of our joy and suffering, thousands of confident religions, ideologies, and economic doctrines, every hunter and forager, every hero and coward, every creator and destroyer of civilization, every king and peasant, every young couple in love, every mother and father, hopeful child, inventor and explorer, every teacher of morals, every corrupt politician, every “superstar,” every “supreme leader,” every saint and sinner in the history of our species lived there – on the mote of dust suspended in a sunbeam.”

Dr. Chan practices rheumatology in Pawtucket, R.I.

In the wake of the grand jury’s decision not to indict Officer Darren Wilson for the death of Michael Brown in Ferguson, Mo., an artist/comedian named Joe Veix made a brilliant fake mock-up of what the New York Times’ banner page would look like the following day. The fake headline says, “Everything’s ... Awful,” (expletive deleted) and it calls out the endlessly scatological nature of the opinion pages. It captured the bleakness of the moment. The world-on-fire sentiment is one that I often feel, particularly when calamities, man-made or otherwise, strike.

So the Thanksgiving holiday was a welcome break from the world. It was a time to retreat from the world.

Starting with the peaceful drive from Providence, R.I., to New York, we insulated ourselves briefly from the 24-hour news cycle, the bad news, the critics and thought pieces, and the criticisms of the thought pieces. We managed to tune out our phones, those instruments of endless mind-numbing connectivity, and enjoy each other’s company. We listened to music, told stories, spent time together in the kitchen making old family favorites. We talked about our anxieties and aspirations. We shared stories of our childhood and sibling rivalry, and the curious relationship of parents and children. We had dinner with friends of a friend, strangers who welcomed us into their home. We made new friends, got well fed, and drank plenty of hot apple cider and whiskey. We basked in love and affection, and went to bed that night content as pigs in a very warm blanket.

The holiday was enough, for the briefest of moments, to be at peace with the mess of the human condition.

This left me thinking of the ultimate big-level picture of the condition we are in. In 1990, the spacecraft Voyager 1 left our atmosphere, and when it was about 4 billion miles away, it took a snapshot of Earth, seen here.

It is this image that inspired Carl Sagan to write the following passage. Every reading of it leaves me with different measures but always the same combination of conflicting emotions: of sadness, and insignificance, of awe, and gratitude, and hope.

“From this distant vantage point, the Earth might not seem of any particular interest. But for us, it’s different. Consider again that dot. That’s here, that’s home, that’s us. On it everyone you love, everyone you know, everyone you ever heard of, every human being who ever was, lived out their lives. The aggregate of our joy and suffering, thousands of confident religions, ideologies, and economic doctrines, every hunter and forager, every hero and coward, every creator and destroyer of civilization, every king and peasant, every young couple in love, every mother and father, hopeful child, inventor and explorer, every teacher of morals, every corrupt politician, every “superstar,” every “supreme leader,” every saint and sinner in the history of our species lived there – on the mote of dust suspended in a sunbeam.”

Dr. Chan practices rheumatology in Pawtucket, R.I.

In the wake of the grand jury’s decision not to indict Officer Darren Wilson for the death of Michael Brown in Ferguson, Mo., an artist/comedian named Joe Veix made a brilliant fake mock-up of what the New York Times’ banner page would look like the following day. The fake headline says, “Everything’s ... Awful,” (expletive deleted) and it calls out the endlessly scatological nature of the opinion pages. It captured the bleakness of the moment. The world-on-fire sentiment is one that I often feel, particularly when calamities, man-made or otherwise, strike.

So the Thanksgiving holiday was a welcome break from the world. It was a time to retreat from the world.

Starting with the peaceful drive from Providence, R.I., to New York, we insulated ourselves briefly from the 24-hour news cycle, the bad news, the critics and thought pieces, and the criticisms of the thought pieces. We managed to tune out our phones, those instruments of endless mind-numbing connectivity, and enjoy each other’s company. We listened to music, told stories, spent time together in the kitchen making old family favorites. We talked about our anxieties and aspirations. We shared stories of our childhood and sibling rivalry, and the curious relationship of parents and children. We had dinner with friends of a friend, strangers who welcomed us into their home. We made new friends, got well fed, and drank plenty of hot apple cider and whiskey. We basked in love and affection, and went to bed that night content as pigs in a very warm blanket.

The holiday was enough, for the briefest of moments, to be at peace with the mess of the human condition.

This left me thinking of the ultimate big-level picture of the condition we are in. In 1990, the spacecraft Voyager 1 left our atmosphere, and when it was about 4 billion miles away, it took a snapshot of Earth, seen here.

It is this image that inspired Carl Sagan to write the following passage. Every reading of it leaves me with different measures but always the same combination of conflicting emotions: of sadness, and insignificance, of awe, and gratitude, and hope.

“From this distant vantage point, the Earth might not seem of any particular interest. But for us, it’s different. Consider again that dot. That’s here, that’s home, that’s us. On it everyone you love, everyone you know, everyone you ever heard of, every human being who ever was, lived out their lives. The aggregate of our joy and suffering, thousands of confident religions, ideologies, and economic doctrines, every hunter and forager, every hero and coward, every creator and destroyer of civilization, every king and peasant, every young couple in love, every mother and father, hopeful child, inventor and explorer, every teacher of morals, every corrupt politician, every “superstar,” every “supreme leader,” every saint and sinner in the history of our species lived there – on the mote of dust suspended in a sunbeam.”

Dr. Chan practices rheumatology in Pawtucket, R.I.

Last year, there were five predictions made that appeared to be on the money – but there is more to the story!

1. The approach to diagnosis and treatment of influenza was essential knowledge for clinicians. Last year, we started seeing influenza activity early – with disease confirmed in mid-November, peaking during the week ending December 28, 2013 and trending downward in early January 2014. Hospitalizations were most common in young and middle aged adults and the 2009 H1N1 virus predominated.

This year, again we are seeing influenza early – with nearly all states reporting at least sporadic and local activity, and several states (Alaska, Florida, Louisiana, Massachusetts, and Texas) reporting regional activity as of the week ending November 24, 2014. At my institution, we’ve already tested over 500 children and over 100 were positive – influenza A (H3N2) strains are predominating. That may be important for the two reasons you’ll read below.

2. Invasive staphylococcal disease caused by methicillin-susceptible Staphylococcus aureus (MSSA) was more common than methicillin-resistant Staphylococcus aureus (MRSA), as the national burden of MRSA disease decreased (JAMA 2014;311:1438-9). The rates of clindamycin resistance continue to be pretty steady at approximately 15%-18%, but higher for MSSA than for MRSA – a point that is important to consider when empirically treating suspected invasive staphylococcal infection.

3. Multidrug resistant uropathogens took an increasingly prominent role in 2014, requiring careful approach to diagnosis (every child treated for urinary tract infection should have an appropriately obtained urine culture with an identified pathogen) and treatment (the drug used should be based on antibiotic susceptibility testing results). Particularly concerning is the emergence of carbapenem-resistant Enterobacteriaceae, which cause infection more commonly in hospitalized patients, those with indwelling devices, and those who have received long courses of antibiotics.

4. It was an outbreak year for parechovirus (HPeV), a viral pathogen causing meningitis in very young infants. Such infants present with signs and symptoms of meningitis but rarely show CSF pleocytosis. Diagnosis relies on the detection of the virus by polymerase chain reaction testing in CSF – a test which is not routinely available in many laboratories. At my institution this season, we saw nearly as many cases of parechovirus meningitis (n = 43) as we saw cases of enterovirus meningitis (n = 63). The parechovirus virus we detected was HPeV type 3, which can cause particularly severe disease in neonates.

5. Data confirmed that making human papillomavirus (HPV) vaccine a standard recommendation increased vaccine uptake and coverage. In February of 2014, a “Dear Colleague” letter that was endorsed by six leading medical organizations encouraged providers to promote HPV vaccination by giving a strong recommendation, citing data based on research conducted by the Centers for Disease Control and Prevention. We still have a long way to go as HPV vaccine coverage for teens remains at 35% for the three-dose series while meningococcal and Tdap vaccine (both vaccines that generally receive a standard recommendation by physicians) coverage is at nearly 90%.

So for 2015, I’ll start the discussion by saying there are five major developments I did not see coming for this past year, but that will remain relevant for the year 2015!

1. In June of 2014, live attenuated influenza vaccine (LAIV) was announced by the Advisory Committee on Immunization Practices to be the preferred vaccine in children aged 2-8 years. The American Academy of Pediatrics followed with a recommendation that either inactivated influenza vaccine (IIV) or LAIV be used for children, including children aged 2-8 years – the key being to give the vaccine as soon as one had it available. What was not known then and I did not predict was that newer data would confirm that in children aged 2-8 years who received LAIV last year when 2009 H1N1 strains predominated, there was essentially no coverage against 2009 H1N1 virus. This was in contrast to data from the prior 2 years and is as yet unexplained. The AAP continues to recommend that either vaccine be given and all children be immunized. That may be especially important this year as the influenza season started early. Disease will likely have been widespread by Christmas in many parts of the United States, and it looks like influenza A H3N2 strains will be most commonly noted. So the good news for young children who received LAIV is that 2009 H1N1 strains so far have not been seen this year. The bad news is that there are two H3N2 strains circulating, and potentially only one will be covered by the 2014-2015 seasonal vaccine. Staffing your office and hospital for a likely high census respiratory viral season is going to be essential.

2. The largest U.S. outbreak ever of enterovirus (EV) D-68 respiratory infection occurred between August and October of 2014. This virus – which had been identified in 1962 but was rarely described over the next 36 years except in small clusters of disease – was reported in nearly every state and characterized by unusually severe respiratory tract infection. Many, but not all children, had a history of asthma or prior wheezing, and the clinical presentation was that of severe bronchospasm that was generally resistant to standard bronchodilator therapy. The spectrum of infection likely ranged from mild upper respiratory infection to severe bronchospasm with respiratory failure, and the burden of disease resulting in hospitalization was substantial at many children’s hospitals. The big question now is what will enterovirus season 2015 bring us? The good news here is that we now have a test to rapidly diagnose EV D-68, which will allow us to more clearly understand the burden of disease – and potentially to define antiviral treatment (none of the current antivirals is effective) and prevention (there is no vaccine against EV D-68).

3. The etiology of the neurologic illness, which appeared to mimic polio and presented during the same time frame during which EV D-68 was circulating, is as yet unknown. As of Nov. 26, 2014, the CDC has received reports of 90 children in 32 states who meet a case definition consistent with acute flaccid myelitis. While certain viruses – including West Nile virus, herpes virus, adenovirus, and certain enterovirus types (for example, enterovirus 71, and the classic being polio) – may cause acute flaccid paralysis and can be confirmed by detecting the virus in cerebrospinal fluid and stool, to date virus testing for all viruses, including EV D-68, has been negative in all of the patients reported. Hopefully, 2015 will be the year that will allow us to more clearly understand this neurologic illness – and this is important because so far most children have shown minimal recovery of function.

4. If you see a child (or adult) who recently traveled to the Caribbean and returns with fever, rash, and joint pain, especially with severe pain of the hands and feet, think chikungunya virus infection. As of the end of October 2014, local transmission had been identified in 37 countries or territories in the Caribbean (including Puerto Rico and the U.S. Virgin Islands), with a total of 780,206 suspected cases and over 15,000 confirmed cases reported from these areas. Consider this in contrast to the numbers from 2006 through 2011, when 117 cases of chikungunya fever were reported in returning travelers. As of Dec. 2, a total of 1,911 chikungunya virus disease cases have been reported to ArboNET from U.S. states. The mosquito that transmits chikungunya virus can bite in day and night, and prevention relies on appropriate use of mosquito repellents. Physicians should be prepared to discuss the risks of this virus with travelers who plan a trip to the Caribbean, especially those at high risk, including those with underlying medical conditions, preexisting arthritis diagnoses, and pregnant women (because of the potential risk to newborns whose mothers develop intrapartum infection).

5. And lastly, Ebola. While there were reports that Ebola virus disease had emerged in West Africa as early as December of 2013, the scope of the outbreak and extent of loss of human life has been unbelievably huge. Dr. Carrie Byington, who is the current chair of the AAP Committee on Infectious Diseases, wrote an article in AAP News in October 2014 describing the needs of children who have been impacted by Ebola virus disease (EVD). She noted that UNICEF estimated there were at that time, over 4,000 Ebola orphans in the countries most affected by EVD, including Sierra Leone, Liberia, and Guinea, and that these countries urgently needed medical infrastructure for treatment and prevention of this disease. It appears that at least two Ebola vaccines will be deployed in West Africa in 2015, and it is not a moment too soon. While cases in Liberia seemed to be decreasing, it looks like Sierra Leone cases continue to mount.

Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled “Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions,” but said she had no other conflicts of interest to disclose. E-mail her at [email protected].

Last year, there were five predictions made that appeared to be on the money – but there is more to the story!

1. The approach to diagnosis and treatment of influenza was essential knowledge for clinicians. Last year, we started seeing influenza activity early – with disease confirmed in mid-November, peaking during the week ending December 28, 2013 and trending downward in early January 2014. Hospitalizations were most common in young and middle aged adults and the 2009 H1N1 virus predominated.

This year, again we are seeing influenza early – with nearly all states reporting at least sporadic and local activity, and several states (Alaska, Florida, Louisiana, Massachusetts, and Texas) reporting regional activity as of the week ending November 24, 2014. At my institution, we’ve already tested over 500 children and over 100 were positive – influenza A (H3N2) strains are predominating. That may be important for the two reasons you’ll read below.

2. Invasive staphylococcal disease caused by methicillin-susceptible Staphylococcus aureus (MSSA) was more common than methicillin-resistant Staphylococcus aureus (MRSA), as the national burden of MRSA disease decreased (JAMA 2014;311:1438-9). The rates of clindamycin resistance continue to be pretty steady at approximately 15%-18%, but higher for MSSA than for MRSA – a point that is important to consider when empirically treating suspected invasive staphylococcal infection.

3. Multidrug resistant uropathogens took an increasingly prominent role in 2014, requiring careful approach to diagnosis (every child treated for urinary tract infection should have an appropriately obtained urine culture with an identified pathogen) and treatment (the drug used should be based on antibiotic susceptibility testing results). Particularly concerning is the emergence of carbapenem-resistant Enterobacteriaceae, which cause infection more commonly in hospitalized patients, those with indwelling devices, and those who have received long courses of antibiotics.

4. It was an outbreak year for parechovirus (HPeV), a viral pathogen causing meningitis in very young infants. Such infants present with signs and symptoms of meningitis but rarely show CSF pleocytosis. Diagnosis relies on the detection of the virus by polymerase chain reaction testing in CSF – a test which is not routinely available in many laboratories. At my institution this season, we saw nearly as many cases of parechovirus meningitis (n = 43) as we saw cases of enterovirus meningitis (n = 63). The parechovirus virus we detected was HPeV type 3, which can cause particularly severe disease in neonates.

5. Data confirmed that making human papillomavirus (HPV) vaccine a standard recommendation increased vaccine uptake and coverage. In February of 2014, a “Dear Colleague” letter that was endorsed by six leading medical organizations encouraged providers to promote HPV vaccination by giving a strong recommendation, citing data based on research conducted by the Centers for Disease Control and Prevention. We still have a long way to go as HPV vaccine coverage for teens remains at 35% for the three-dose series while meningococcal and Tdap vaccine (both vaccines that generally receive a standard recommendation by physicians) coverage is at nearly 90%.

So for 2015, I’ll start the discussion by saying there are five major developments I did not see coming for this past year, but that will remain relevant for the year 2015!

1. In June of 2014, live attenuated influenza vaccine (LAIV) was announced by the Advisory Committee on Immunization Practices to be the preferred vaccine in children aged 2-8 years. The American Academy of Pediatrics followed with a recommendation that either inactivated influenza vaccine (IIV) or LAIV be used for children, including children aged 2-8 years – the key being to give the vaccine as soon as one had it available. What was not known then and I did not predict was that newer data would confirm that in children aged 2-8 years who received LAIV last year when 2009 H1N1 strains predominated, there was essentially no coverage against 2009 H1N1 virus. This was in contrast to data from the prior 2 years and is as yet unexplained. The AAP continues to recommend that either vaccine be given and all children be immunized. That may be especially important this year as the influenza season started early. Disease will likely have been widespread by Christmas in many parts of the United States, and it looks like influenza A H3N2 strains will be most commonly noted. So the good news for young children who received LAIV is that 2009 H1N1 strains so far have not been seen this year. The bad news is that there are two H3N2 strains circulating, and potentially only one will be covered by the 2014-2015 seasonal vaccine. Staffing your office and hospital for a likely high census respiratory viral season is going to be essential.

2. The largest U.S. outbreak ever of enterovirus (EV) D-68 respiratory infection occurred between August and October of 2014. This virus – which had been identified in 1962 but was rarely described over the next 36 years except in small clusters of disease – was reported in nearly every state and characterized by unusually severe respiratory tract infection. Many, but not all children, had a history of asthma or prior wheezing, and the clinical presentation was that of severe bronchospasm that was generally resistant to standard bronchodilator therapy. The spectrum of infection likely ranged from mild upper respiratory infection to severe bronchospasm with respiratory failure, and the burden of disease resulting in hospitalization was substantial at many children’s hospitals. The big question now is what will enterovirus season 2015 bring us? The good news here is that we now have a test to rapidly diagnose EV D-68, which will allow us to more clearly understand the burden of disease – and potentially to define antiviral treatment (none of the current antivirals is effective) and prevention (there is no vaccine against EV D-68).

3. The etiology of the neurologic illness, which appeared to mimic polio and presented during the same time frame during which EV D-68 was circulating, is as yet unknown. As of Nov. 26, 2014, the CDC has received reports of 90 children in 32 states who meet a case definition consistent with acute flaccid myelitis. While certain viruses – including West Nile virus, herpes virus, adenovirus, and certain enterovirus types (for example, enterovirus 71, and the classic being polio) – may cause acute flaccid paralysis and can be confirmed by detecting the virus in cerebrospinal fluid and stool, to date virus testing for all viruses, including EV D-68, has been negative in all of the patients reported. Hopefully, 2015 will be the year that will allow us to more clearly understand this neurologic illness – and this is important because so far most children have shown minimal recovery of function.

4. If you see a child (or adult) who recently traveled to the Caribbean and returns with fever, rash, and joint pain, especially with severe pain of the hands and feet, think chikungunya virus infection. As of the end of October 2014, local transmission had been identified in 37 countries or territories in the Caribbean (including Puerto Rico and the U.S. Virgin Islands), with a total of 780,206 suspected cases and over 15,000 confirmed cases reported from these areas. Consider this in contrast to the numbers from 2006 through 2011, when 117 cases of chikungunya fever were reported in returning travelers. As of Dec. 2, a total of 1,911 chikungunya virus disease cases have been reported to ArboNET from U.S. states. The mosquito that transmits chikungunya virus can bite in day and night, and prevention relies on appropriate use of mosquito repellents. Physicians should be prepared to discuss the risks of this virus with travelers who plan a trip to the Caribbean, especially those at high risk, including those with underlying medical conditions, preexisting arthritis diagnoses, and pregnant women (because of the potential risk to newborns whose mothers develop intrapartum infection).

5. And lastly, Ebola. While there were reports that Ebola virus disease had emerged in West Africa as early as December of 2013, the scope of the outbreak and extent of loss of human life has been unbelievably huge. Dr. Carrie Byington, who is the current chair of the AAP Committee on Infectious Diseases, wrote an article in AAP News in October 2014 describing the needs of children who have been impacted by Ebola virus disease (EVD). She noted that UNICEF estimated there were at that time, over 4,000 Ebola orphans in the countries most affected by EVD, including Sierra Leone, Liberia, and Guinea, and that these countries urgently needed medical infrastructure for treatment and prevention of this disease. It appears that at least two Ebola vaccines will be deployed in West Africa in 2015, and it is not a moment too soon. While cases in Liberia seemed to be decreasing, it looks like Sierra Leone cases continue to mount.

Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled “Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions,” but said she had no other conflicts of interest to disclose. E-mail her at [email protected].

Last year, there were five predictions made that appeared to be on the money – but there is more to the story!

1. The approach to diagnosis and treatment of influenza was essential knowledge for clinicians. Last year, we started seeing influenza activity early – with disease confirmed in mid-November, peaking during the week ending December 28, 2013 and trending downward in early January 2014. Hospitalizations were most common in young and middle aged adults and the 2009 H1N1 virus predominated.

This year, again we are seeing influenza early – with nearly all states reporting at least sporadic and local activity, and several states (Alaska, Florida, Louisiana, Massachusetts, and Texas) reporting regional activity as of the week ending November 24, 2014. At my institution, we’ve already tested over 500 children and over 100 were positive – influenza A (H3N2) strains are predominating. That may be important for the two reasons you’ll read below.

2. Invasive staphylococcal disease caused by methicillin-susceptible Staphylococcus aureus (MSSA) was more common than methicillin-resistant Staphylococcus aureus (MRSA), as the national burden of MRSA disease decreased (JAMA 2014;311:1438-9). The rates of clindamycin resistance continue to be pretty steady at approximately 15%-18%, but higher for MSSA than for MRSA – a point that is important to consider when empirically treating suspected invasive staphylococcal infection.

3. Multidrug resistant uropathogens took an increasingly prominent role in 2014, requiring careful approach to diagnosis (every child treated for urinary tract infection should have an appropriately obtained urine culture with an identified pathogen) and treatment (the drug used should be based on antibiotic susceptibility testing results). Particularly concerning is the emergence of carbapenem-resistant Enterobacteriaceae, which cause infection more commonly in hospitalized patients, those with indwelling devices, and those who have received long courses of antibiotics.

4. It was an outbreak year for parechovirus (HPeV), a viral pathogen causing meningitis in very young infants. Such infants present with signs and symptoms of meningitis but rarely show CSF pleocytosis. Diagnosis relies on the detection of the virus by polymerase chain reaction testing in CSF – a test which is not routinely available in many laboratories. At my institution this season, we saw nearly as many cases of parechovirus meningitis (n = 43) as we saw cases of enterovirus meningitis (n = 63). The parechovirus virus we detected was HPeV type 3, which can cause particularly severe disease in neonates.

5. Data confirmed that making human papillomavirus (HPV) vaccine a standard recommendation increased vaccine uptake and coverage. In February of 2014, a “Dear Colleague” letter that was endorsed by six leading medical organizations encouraged providers to promote HPV vaccination by giving a strong recommendation, citing data based on research conducted by the Centers for Disease Control and Prevention. We still have a long way to go as HPV vaccine coverage for teens remains at 35% for the three-dose series while meningococcal and Tdap vaccine (both vaccines that generally receive a standard recommendation by physicians) coverage is at nearly 90%.

So for 2015, I’ll start the discussion by saying there are five major developments I did not see coming for this past year, but that will remain relevant for the year 2015!

1. In June of 2014, live attenuated influenza vaccine (LAIV) was announced by the Advisory Committee on Immunization Practices to be the preferred vaccine in children aged 2-8 years. The American Academy of Pediatrics followed with a recommendation that either inactivated influenza vaccine (IIV) or LAIV be used for children, including children aged 2-8 years – the key being to give the vaccine as soon as one had it available. What was not known then and I did not predict was that newer data would confirm that in children aged 2-8 years who received LAIV last year when 2009 H1N1 strains predominated, there was essentially no coverage against 2009 H1N1 virus. This was in contrast to data from the prior 2 years and is as yet unexplained. The AAP continues to recommend that either vaccine be given and all children be immunized. That may be especially important this year as the influenza season started early. Disease will likely have been widespread by Christmas in many parts of the United States, and it looks like influenza A H3N2 strains will be most commonly noted. So the good news for young children who received LAIV is that 2009 H1N1 strains so far have not been seen this year. The bad news is that there are two H3N2 strains circulating, and potentially only one will be covered by the 2014-2015 seasonal vaccine. Staffing your office and hospital for a likely high census respiratory viral season is going to be essential.

2. The largest U.S. outbreak ever of enterovirus (EV) D-68 respiratory infection occurred between August and October of 2014. This virus – which had been identified in 1962 but was rarely described over the next 36 years except in small clusters of disease – was reported in nearly every state and characterized by unusually severe respiratory tract infection. Many, but not all children, had a history of asthma or prior wheezing, and the clinical presentation was that of severe bronchospasm that was generally resistant to standard bronchodilator therapy. The spectrum of infection likely ranged from mild upper respiratory infection to severe bronchospasm with respiratory failure, and the burden of disease resulting in hospitalization was substantial at many children’s hospitals. The big question now is what will enterovirus season 2015 bring us? The good news here is that we now have a test to rapidly diagnose EV D-68, which will allow us to more clearly understand the burden of disease – and potentially to define antiviral treatment (none of the current antivirals is effective) and prevention (there is no vaccine against EV D-68).

3. The etiology of the neurologic illness, which appeared to mimic polio and presented during the same time frame during which EV D-68 was circulating, is as yet unknown. As of Nov. 26, 2014, the CDC has received reports of 90 children in 32 states who meet a case definition consistent with acute flaccid myelitis. While certain viruses – including West Nile virus, herpes virus, adenovirus, and certain enterovirus types (for example, enterovirus 71, and the classic being polio) – may cause acute flaccid paralysis and can be confirmed by detecting the virus in cerebrospinal fluid and stool, to date virus testing for all viruses, including EV D-68, has been negative in all of the patients reported. Hopefully, 2015 will be the year that will allow us to more clearly understand this neurologic illness – and this is important because so far most children have shown minimal recovery of function.

4. If you see a child (or adult) who recently traveled to the Caribbean and returns with fever, rash, and joint pain, especially with severe pain of the hands and feet, think chikungunya virus infection. As of the end of October 2014, local transmission had been identified in 37 countries or territories in the Caribbean (including Puerto Rico and the U.S. Virgin Islands), with a total of 780,206 suspected cases and over 15,000 confirmed cases reported from these areas. Consider this in contrast to the numbers from 2006 through 2011, when 117 cases of chikungunya fever were reported in returning travelers. As of Dec. 2, a total of 1,911 chikungunya virus disease cases have been reported to ArboNET from U.S. states. The mosquito that transmits chikungunya virus can bite in day and night, and prevention relies on appropriate use of mosquito repellents. Physicians should be prepared to discuss the risks of this virus with travelers who plan a trip to the Caribbean, especially those at high risk, including those with underlying medical conditions, preexisting arthritis diagnoses, and pregnant women (because of the potential risk to newborns whose mothers develop intrapartum infection).

5. And lastly, Ebola. While there were reports that Ebola virus disease had emerged in West Africa as early as December of 2013, the scope of the outbreak and extent of loss of human life has been unbelievably huge. Dr. Carrie Byington, who is the current chair of the AAP Committee on Infectious Diseases, wrote an article in AAP News in October 2014 describing the needs of children who have been impacted by Ebola virus disease (EVD). She noted that UNICEF estimated there were at that time, over 4,000 Ebola orphans in the countries most affected by EVD, including Sierra Leone, Liberia, and Guinea, and that these countries urgently needed medical infrastructure for treatment and prevention of this disease. It appears that at least two Ebola vaccines will be deployed in West Africa in 2015, and it is not a moment too soon. While cases in Liberia seemed to be decreasing, it looks like Sierra Leone cases continue to mount.

Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled “Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions,” but said she had no other conflicts of interest to disclose. E-mail her at [email protected].