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Valley Surgical Specialists

General Surgery

Clovis Community Medical Center SpotlightThe Evolution of General Surgery: A DiscussionWINTER SYMPOSIUM 2017

General Surgery

“Surgery is a profession defined by its authority to cure bymeans of bodily invasion. The brutality and risks of openinga living person’s body have long been apparent, thebenefits only slowly and haltingly worked out. Nonetheless,over the past two centuries, surgery has become radicallymore effective, and its violence substantially reduced –changes that have been proved central to the developmentof mankind’s abilities to heal the sick.”

Atul Gawande, MD, MPH - “Two Hundred Years of Surgery”

HELLO,LET ME INTRODUCE MYSELF…

• Raised in Vancouver, British Columbia, Canada

• Attended the University of British Columbia• Bachelors of Science in Microbiology• Medical degree at U.B.C.

• Completed general surgical residency at UCSF – Fresno in 1999

• Completed additional training in advanced laparoscopic, thoracic, and robotic surgery

• Fellow of the Royal College of Physicians and Surgeons-Canada and the American College of Surgeons

• Board certified in general surgery in both Canada and the United States

Ming LeeM.D., FACS, FRCS(C)

ANDMY COLLEAGUE…

• Medical school at the St. Louis University School of Medicine in St. Louis, Missouri

• Surgical training at the University of California, San Francisco Medical Education Program in Fresno

• Board Certified in General Surgery and Surgical Critical Care.

• Completed fellowship in Surgical Critical Care

• Fellow of the American College of Surgeons

• Served on the faculty as an Assistant Clinical Professor of Surgery (1997-2002)

• In private practice since 2002

Mark CunninghamM.D., FACS

Agenda

The Evolution of General Surgery

The Modern General Surgeon

What the Future HoldsValley Surgical SpecialistsClovis Community Medical Center

– General Surgery Programs

1812 1846 18671860s

New England Journal of Medicine and

Surgery

Ether AnesthesiaCarbolic Acid

Introduced as Antiseptic

Hysterectomy and Bilateral Ovariotomy

Milestones

Liston, like many other surgeons,

proceeded in his usual lightning-quick and bloody way.

Spectators in the operating-theater gallery would still get out their

pocket watches to time him. The butler’s operation, for

instance, took an astonishing 25 seconds from incision

to wound closure.

Liston operatedso fast that he once

accidentally amputated an assistant’s fingers along with a patient’s leg. The patient and

the assistant both died of sepsis, and a spectator reportedly died

of shock, resulting in the only known procedure with a

300% mortality.

Surgery was all about Speed…..

Milestones

1880

• Brain Tumor Removal• Chest Surgery• Joint Repair

1912 1920s1913

• Blood Vessel Suturing• Surgical Grafts

• Surgery Accounts for 50% of NEJM

Articles

• American College of Surgeons

Milestones

1940s

Dominant Force in Medical Advancement

• 1948 - Open Heart Surgery

Milestones

1950s• 1952 - Open Heart Surgery

using Hypothermia• 1953 - Carotid Endarterectomy• 1954 - Kidney Transplant• 1955 - Artificial Cardiac

Pacemaker• 1955 - Separation of Conjoined

Twins

Dominant Force in Medical Advancement

Milestones

• 1961 - Cochlear Implant• 1961 - Fogarty Embolectomy

Catheter• 1962 - LFA Hip Replacement

Surgery• 1963 - Liver Transplant• 1964 - Laser Scalpel Invented• 1967 - Heart Transplant• 1967 - Coronary Artery Bypass

Surgery

1960s

• The Halcyon Years• Attracted the Best

• High Professional Satisfaction• Good Financial Compensation

• Low Administrative & Overhead Costs• Minimal Red Tape

Dominant Force in Medical Advancement

Milestones Dominant Force in Medical Advancement

1970s

• Subspecialties and Non-Surgical Options Emerge

• Inflection Point for the Contraction of General Surgery

• 1972 - CT Scan Perfected• 1974 - Tommy John Surgery• 1974 - Blunt Tunneling Liposuction

Milestones Dominant Force in Medical Advancement

1980s

• Sub-Specialization Erodes General Surgery• Chief Residents Flock to Sub-Specialty Training

• Financial Compensation Remains Strong• Red Tape Increasingly Burdensome

• Physician Shortages Predicted

• 1982 - Jarvik-7 Artificial Heart • 1983 - Robot-Assisted Surgery• 1985 - Laparoscopic

Cholecystectomy• 1985 - Positron Emission

Tomography Invented• 1987 - Heart-Lung Transplant

Milestones Dominant Force in Medical Advancement

1990s - 2000s

• Changes to Residency Work Hours• Re-Evaluation of the Typical 90-100 Hour Work

Week• Assumed that “Rites Of Passage” Critical for

Developing Clinical Acumen • Long and Unpredictable Work Hours Has Been

Staple of Medical Training for Centuries• Little Attention Paid to Potential Patient Safety

Effects of Fatigue Among Residents

• 1998 - Stem Cell Therapy• 2000 - Da Vinci Surgical System

Approved by FDA• 2001 - Self-Contained Artificial

Heart• 2001 - ZEUS for Remote

Surgery

Milestones

2003

ACGME Introduces Rule to Limit Resident Work Hours • No More than 80 Hours per Week or 24 Consecutive

Hours on Duty• “On-call” No More than Every-Third Night• 1 Day Off per Week

Milestones Dominant Force in Medical Advancement

• 2005 - Partial Face Transplant• 2008 - Full Face Transplant• 2011 - Double Leg Transplant• 2012 - Mother-Daughter Womb

Transplant• 2012 - Human Hand Transplant • 2012 - Double Arm Transplant • 2013 - Virtual Surgery Using

Google Glass• 2013 - Growing of Replacement

Nose

2004

Impact of Duty Hour Regulations Mixed Since Introduction• No Clear Cause – Effect on Patient Safety• No Landmark Study Demonstrating Clear Benefit of DHRs on

Decreasing Medical Error or Improving Patient Outcomes• No Difference in Resident Well Being• Residents' Educational Experience Adversely Affected;

Fewer Cases?• Faculty Have Less Time for Teaching• Residents Have Less Time to Attend Educational Activities

Milestones Dominant Force in Medical Advancement

• 2014 - Penis Transplant • 2015 - Skull and Scalp Transplant • 2016 - Uterus Transplant in the US • 2016 - HIV-to-HIV Liver Transplant

2014

• First Trial Results• Started In 2014 – Results 2016• Flexible Duty Hour Rules:

• Better Care• Better Continuity• Better Education• No Difference in Patient Safety• No Difference in Resident Well Being

FIRST TRIAL

RESULTS

The Modern General Surgeon

THE MODERN GENERAL SURGEON

DEFINITION OF GENERAL SURGERY (American Board of Surgery)General Surgery includes:• A central core of knowledge embracing anatomy, physiology, metabolism,

immunology, nutrition, pathology, wound healing, shock and resuscitation, intensive care, and neoplasia

• Specialized knowledge and skill relating to the diagnosis, preoperative, operative, and postoperative management in the following areas of primary responsibility:

• Alimentary tract• Abdomen and its contents• Breast, skin, and soft tissue• Head and neck• Vascular system, excluding the intracranial vessels, the heart, and those vessels

intrinsic and immediately adjacent thereto• Comprehensive management of trauma. The responsibility of all phases of

care of the injured patient is an essential component of general surgery• Complete care of critically ill patients with underlying surgical conditions, in

the emergency room, intensive care unit, and trauma/burn units

The Modern General SurgeonA specialist with known expertise in soft tissue disorders, abdominal conditions and emergencieswho may have also picked additional highly specialized clinical area(s) to compliment his/her practice

• One of the last “complete physicians” • Breadth of training encourages us to embrace the patient in totality, from the beginning of care to

the end of the patient’s journey and final recovery• Completed at least 5 years of broad residency training in a diverse set of disciplines• Certified by the American Board of Surgery (ABS)• The largest surgical subspecialty group; 18,000 Actively Practicing in the United States• Vital to the function of any hospital and emergency department• Crucial part of any rural/urban medical community

Unifying force upon which all other surgical specialties depend…

General Surgery Case Examples

29 Year-Old Patient (Hysterectomy)• Develops expanding retroperitoneal

hematoma requiring massive transfusion• GS called to consult and manage this

case

40 Year-Old Patient with Laryngospasm in OR• Not able to establish airway• GS called for emergency tracheostomy

Multi-trauma Patient with Flail Chest, Multiple Rib Fractures, Pneumothorax and Multiple Orthopedic Injuries• GS called to stabilize patient and

direct care of complex trauma patient

57 Year-Old Male with Fournier’s Gangrene• GS called to address necrotizing

infection, manage resuscitation and ICU care of patient

• GS to direct long term wound care and skin grafting

The Present State of General Surgery

The Present State of General Surgery• The largest surgical subspecialty group; 18,000 Actively Practicing in the United States

• Unifying force upon which all other surgical specialties depend

• Vital to the function of any hospital and emergency department

• Crucial part of any rural/urban medical community

• Surgeons have > 2500 procedures in their arsenal

• Focus has shifted from inventing new procedures to perfecting or improving upon existing ones

• Minimally invasive surgery has most recently revolutionized our field and will continue to dictate advances in the foreseeable future of surgery

However…

Negative Perceptions

Contribute to a High-Attrition Rate

Long Hours…..often unpredictable

Specialty is poorly and inadequately defined: “Jack of All Trades; Master of None”

Poor Compensation…..income not high enough to support desired lifestyle

High Stress

Early Burn Out

Dissatisfaction seen in general surgery mentors; lack of mentorship opportunities?

“General” = Dumping Ground

Dr. Claude Organ: “time restricted or geographical apartheid credentialing”

Resulting in a Dramatic Shift to Sub-Specialization…..

The Present State of General Surgery

The Present State of General SurgeryCurrently >85% of Graduating Chief Residents Pursue Subspecialty Fellowship Training

Reasons Include:

• Perception that additional training provides a competitive advantage

• Perception that subspecialty training results in better financial remuneration

• >33% of graduating chief residents do not feel confident in their skills

• Perception that subspecialty training will improve their lifestyle

• It is better to be a master of a narrow focus of practice

• Lack of mentorship in general surgery

Currently > 85% of graduating chief residents in general surgery pursue subspecialty fellowship training

Majority of Available Jobs Do Not Require Fellowship Training

Couching…

MULTI-SPECIALITY PATIENT-FOCUSED COORDINATED CARE

VSS: Integrity.

Compassion. Commitment.

A Multi-specialty Surgical Group, Built on a Firm Belief in:

• Patient-focused care

• That quality and compassionate care is not only just, it is the only advertising you will ever need

• That the patient always comes first….no matter what

• That division of interests internally, and “doubling up” on cases increases exposure to complex procedures, and encourages “sub-specialization” within the group; best surgeon = best outcome

• A strong work ethic and a healthy esprit de corps

• A strong imprinting of these values is vital to the groups continued success

VSS: Integrity. Compassion. Commitment.• Multi-Specialty Surgical Group - “founded” in 1995 as Mid Valley Surgical

• Board Certified with extensive experience in respective areas of expertise

• Guiding philosophy based on Patient-Focused Care: “the patient always comes first no matter what”

• Patients benefit from combined knowledge and experience of a dedicated team

• Strong Commitment to Coordination of Care

• ”Pragmatic Realists” - evolution & growth mirrors that of the greater surgical landscape

• 100+ Years of Combined Surgical Experience

• Successfully navigated substantial changes to the field of general surgery

The Future of General

Surgery

• As relevant and critical to patient care as ever before

• Economics demand continuing evolution of general surgery / alignment with Clovis Community Medical Center

• General surgery continues to evolve, opening new opportunities:

• Acute Care Surgery

• Elective Surgery

• Robotic Surgery / MIS

• Oncologic Surgery

• Continuity of Care

Acute Care Surgery• Came from a realization that with the increasing burden of ER and inpatient surgical

emergencies and consultations, there is a need for acute surgical care services

• We are committed to the development of an independently functioning “Surgicalist” program that is fully aligned with Community’s quality measures and metrics

• VSS provides oversight, assistance, coverage and mentorship

• We envision a total of at least 4 acute care surgeons working with 1-2 Physician Extenders in anticipation of

• A new bed tower • Comprehensive cancer program

• This program will allow for the continuity of care of patients from both outpatient practice and inpatient care

Acute Care Surgery• Use of National Burden to Define Operative Emergency General Surgery – JAMA; 2016; 15(16) –

John W Scott, et al • Retrospective review of 2008-2011 National Inpatient Sample • Adults > 18 with primary EGS diagnoses consistent with the AAST definition, admitted urgently or

emergently, who underwent an operative procedure within 2 days of admission were included in the analysis

• 7 procedures account for most surgical admissions, deaths, complications and inpatient costsattributable to the 512,079 EGS procedures performed in the US each year:

• Partial colectomy• Small bowel resection• Cholecystectomy• Operative management of PUD• Lysis of peritoneal adhesions• Appendectomy• Laparotomy

Acute Care SurgeryCONCLUSION

Analysis of the largest nationally representative database demonstrates that more than half a million patients undergo urgent or emergent general surgery operations annually in the US that account for more than $6 billion in annual costs. Only 7 representative procedures account for approximately 80% of all admissions, deaths, complications, and inpatient costs attributable to operative EGS nationwide

National quality benchmarks and cost reduction efforts should focus on these common, complicated, and costly EGS procedures

• VSS is establishing benchmarks for emergency cholecystectomy• Other benchmarks forthcoming with analysis of quality data and outcome analysis• Potential for Surgical CCG Pathways?

Elective SurgeryWe have enjoyed and continue to have a robust elective surgical practice, both on the ambulatory and inpatient departments

TOP 6 AMBULATORY SURGERIES:

• Laparoscopic cholecystectomy• Laparoscopic inguinal hernia repair – TEP

and robotic TAPP• Umbilical hernia repair• Ventral hernia repair – open, lap, robotic

lap • Skin, soft tissue and lymphatic procedures• Diagnostic laparoscopy

TOP 6 INPATIENT SURGERIES:

• Colorectal resections• Complex incisional or ventral hernia – open,

lap, robotic lap• Surgery for bowel obstruction or non-GI

tumors• Foregut surgery – para-esophageal hernia,

gastrectomy, Anti-reflux procedure• Thoracic – pulmonary, esophageal, chest

wall• Thyroid and parathyroid

Elective SurgeryA 10 YEAR SYNOPSIS OF ONE SURGEON’S EXPERIENCE

1229

Inguinal Hernias(928 lap; 301 open)

1149

LaparoscopicCholecystectomies

941

Ventral / Incisional / Umbilical hernia

repairs

320

Colorectal resections (70% oncologic)

196

Thoracic / pulmonary resections

(70% oncologic)

141

Small bowel resections

128

Appendectomies

124

Gastric resections (90% oncologic)

104

Pancreatic resections

(90% oncologic)

88

Hiatal hernia / Fundoplication

78

Thyroid / Parathyroid

56

Splenectomy

36

Bile duct surgeries

(60% oncologic)

37

Mediastinoscopy

25

Adrenalectomy

24

Liver resections

(90% oncologic)

712Skin / Soft tissue / Muscle procedures / Amputations / Tracheostomy / Vascular / Breast procedures

TRENDS in Elective Surgery

More Outpatient Procedures:• Open ventral / inguinal hernia• Robotic / MIS ventral / inguinal

hernia• Mastectomy• Appendectomy• Cholecystectomy

23 Hour Hold Procedures: (admission denied by insurance)

• Thyroid / Parathyroid• Mastectomy• Splenectomy • Adrenalectomy

Minimally Invasive Surgery (MIS):• Continuing rise in MIS

procedures- Colorectal- Foregut- Thoracic

• Advanced laparoscopic• Robotic surgery

THE ROBOTIC SURGERY PROGRAM AT CLOVIS COMMUNITY

Revolutionary Anatomical Access

Crystal-clear 3D HD vision

Platform for Advanced Technologies

PN 1006780 R

ev A 3/14

Robotic Surgery• VSS entered the program in mid 2014 with few – and uncertain – expectations…

• Realization early on – “It’s all about the team”

• VSS would drive the program...with unexpected consequences

• Surgeons wanted to be trained in robotics – inertia was overcome• Younger partners wanted to incorporate into acute care and elective surgery• Senior partner wanted to expand skill set; potentially lengthen surgical career - ergonomics• Competing surgeon(s) had renewed interest in revisiting robotic surgery • Surgeons from other subspecialties wanted to be trained in robotics

• Block time issues...could grant requests for new block time / The robot was wearing out...

• Last 2 quarters in 2015...busiest single robot hospital in the world

• 2016...top 5 busiest ambulatory robotic hospital in the United States

• 2017...corporate office visit to CCMC...considering hospital as ambulatory robotic surgery reference site

Robotic Surgery

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2014 2015 2016 2017

ONCOLOGIC SURGERY

"Surgical oncology is the branch of surgery applied to oncology; it focuses on the surgical management of tumors, especially cancerous tumors.”

The majority of all cancer operations are done by general surgeons

Oncologic Surgery

THE MARJORIE-RADIN BREAST CARE CENTER AT

CLOVIS COMMUNITYDr. Vassi Gardikas, MD, FACS / Dr.

Deborah Gumina, MD, FACS

Spoke last year at the winter symposium: “The Team approach to Breast Cancer

Care, the Radin Way”

• Inception: 2006 – has been a beacon of success in comprehensive oncology care

• Mission Statement: Early Detection • Advanced Treatment • Comprehensive Care

• “All in one place and all at one time” – one place, multidisciplinary team, comprehensive consultation

• Patient focused care > Navigation > Efficient patient through put = Timely care

• Designated a Center of Excellence by: - The National Quality Measures for Breast Centers™

(NQMBC) - American College of Radiology (ACR)

• State of the art facility on the Clovis Community campus

85% of breast surgeons are general surgeons (non-fellowship trained)In 2016:

• Radin - 350 breast cancer procedures; 648 breast surgeries – 2 private practice surgeons • UCSF – 379 breast cancer procedures - academic department• Stanford – 525 breast cancer procedures - academic department

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400

500

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2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Clovis Community: Breast Surgeries Performed 2007-2016Dr. Gardikas, MD, FACS / Dr. Gumina, MD, FACS

Oncologic Surgery

• University of Louisville – Medical School• University of Maryland Medical Center – General Surgery

Residency• NIH – Bethesda – 2 year Surgical Oncology Research

Fellow • Moffitt Cancer Center and Research Institute – Fellowship in

Complex General Surgical Oncology• Board Certified in General Surgery • Board Certified in Complex General Surgical Oncology• Certificate # 82

DR. CHENWI AMBE, MD

• Melanoma• Sarcoma• Adrenal• Esophagus• Stomach

• Liver• Pancreas• Small bowel• Colorectal malignancy

C L I N I C A L I N T E R E S T S :

Oncologic SurgeryNAVIGATOR:

• Definition: A person who directs the route or course of a vessel (ship)• Traditional: Private practice Physician and staff • Radin: 2 navigators for Breast Cancer patients• Community Cancer Center at Clovis:

• How many needed• for what service lines• How to coordinate with the needs of the system

Continuity of Care

• It is what we have always done at VSS…• The patient comes first no matter what = Patient-Focused Care

• Better patient outcomes…• Navigation efficient throughput timely care

• Limit communication errors • Patient ownership (practice and practitioner)

• Reduce cost to the system – develop best practice pathways• Not limited to a schedule – 24/7 on call surgical hospitalists• Critical to success of cancer center and beyond

Good for the Patient.

Good for the Hospital.

General Surgery Key Takeaways

Rural/UrbanMedical

Community

One of the Last “Complete Physicians”

In Need of Re-Vitalization

Hospital and Emergency Department

Unifying Force

Largest Surgical Subspecialties

Must Continueto Evolve

Quality Mentorship

Thank you!