Open letter to the American College of Surgeons

I have been a member of The American College of Surgeons since the mid 1970s, and have watched many decisions by this body that have lessened the professional standing of surgeons in our nation (American College of Surgeons, Where are you?,Mychasecuts,March 2009), but the current health care debate has revealed, unfortunately, another mistake in leadership of our organization that will have far reaching consequences for our collective futures as surgeons.

The College has recently acknowledged that they are supporting this "reform" because they need to have a "seat at the table." Apparently the College is afraid that if it is not "at the table" Congress will not hear its opinions on issues it believes are vitally important. It seems that the College does not understand or value history. First of all, what makes us believe that we can trust the Congress? History proves otherwise. The first paragraph of the Medicare law has a title: "Prohibition Against Any Federal Interference." Does anyone believe that the Federal Government has not interfered with the practice of medicine? Of course they have, and they intend, or rather they MUST continue to do so for Congress has no choice.

In order to stay in office, Congress makes rash promises to voters. This forces them to tell half-truths, and twist ideas while they promise these "gifts." There is no way they can afford these "gifts" as their promises, especially on health care, are economically unsustainable. They promise, however, because they wish to stay in power. In a sense, they are "forced" to lie! I cannot understand why the College fails to see this fundamental truth.

It is clear that our government is tampering with the lives and sweat, in essence the freedoms, of highly trained surgeons, and not considering the details of the "surgical lifestyle," market forces, work environment and need for a surgeon's hope for the future. Surgeons are small minority in this BIG problem of medical care delivery, and the Congress is certainly going to roll over our rights. They will do it slowly, but THEY ARE GOING TO DO IT! After all, is the ruthless intimidation that has been used to "force" us to come to their table the work of a group that will listen to our position?

The College should have refused to sit at a table with this bunch of bureaucrats that, history has shown, are going to smile, and wish us well, and then do exactly what they want to. They have flagrantly violated the promise of "prohibition against any Federal interference."

Does the American College of Surgeons really want to be part of this fiasco? The American people are not and have not been told the truth. Once this plan is in, and time exposes the certain draconian consequences, we will fare better if we are not a part the original planning. Won't we be blamed also if we are "at the table?"

The College surely knows that there are only two ways to control the distribution of any resource: price or availability. In countries where price is excluded by politics, and there is a nationalized system, availability is the means of control of expenditures. That explains why it takes three months to have a MRI in Canada. Do we want the same? It would be appreciated if our representatives would at least admit publicly that we will have to have many objectionable ways to control costs in their incipient system.

Finally, I cannot understand how the College is so far distant from my personal understanding of this movement (appropriate term). I have been a practicing surgeon for almost 40 years now, and have an excellent feel for the essence of medical practice. Where does the leadership get their understanding of the desires of the members? A survey would be helpful. Do they believe that they know so much more than the membership that they can diverge completely from the desires and understandings of the group?

Surgeons, in the past, have been trained to persevere and approach obstacles with quiet courage and unshakable fortitude. Where is this attitude in our current leadership? Have they stood before the Congress and told the TRUTH? I do not believe so. Is the palace of government so intimidating that we cannot articulate the necessity of our personal God given rights to this bunch of charlatans? If the College cannot do it, who then, will? How many of our personal rights are we going to sacrifice by slobbering up to the government trough of handouts? This will inevitably affect our behavior with our patients and with that our professionalism. May God help us all.

James P. Weaver, M.D.,FACS

Motorcycling and Surgery

I'm afraid to write this because it might cut into my credibility, but the internet is a "safe" place to write, so here goes.

I am a surgeon, and I also ride a motorcycle. I have ridden off and on for forty years! I rode for a while while I lived in Cleveland, Ohio, but it was too cold, and the children were too young, and it wasn't very safe in a big city. So I sold the bike (a 1969 Triumph tiger) and quit for about 20 years.

In my early 40's I picked up the bug again, and bought a Yahama Virago, and living in North Carolina then, I decided to ride the length of the Blue Ridge Parkway. If you have never ridden on this road it is a must. Probably one of the most beautiful roads in the United States.

Well, I practiced, took the Motorcycle Safety Foundation course on safety, and took a 10 day vacation and took the trip. It was beautiful. I stayed with friends along the way, and had a ball. I had intended to sell the bike after the trip, but I didn't and that was over 20 years ago. Since then, I have been up to Ohio to the Vintage Motorcycle Days meeting, ridden across the USA twice, and traveled up the northeast part of the country besides taken numerous smaller trips of a few days in the surrounding vicinity. Finally, I took a once in a lifetime 10 day trip over to Europe and traveled through the alps. It just never left my blood, and I still yearn for more travels.

But why do I do this, and for that matter, what can it possibly have to do with surgery? More that most of you folks that do not ride a motorcycle can imagine.

To get right to the point, motorcycling is like surgery because you have to know what you are doing or you get your butt in a jam. You have to know the rules, be careful, and watch our for unexpected circumstances. The major difference is that when you ride a motorcycle, you get a full sense of freedom and a deep appreciation of the nature of your surroundings.

It hurts me to go to a state (like Arizona) where there are no helmet laws, and see riders biking without a helmet. That makes me immediately think they do not understand the depth of the risk. They are being foolish as far as I can see. When I see someone drinking alcohol, and biking, I get the same feeling. I guess that's why they are not surgeons. There are more effective ways to demonstrate the idea of individual freedom. Our heads are fragile at 25mph, and it's just not worth it.

Because I do what I do, I feel at home on a bike. The best part is that even though I am in familiar surroundings, I can get the additional benefit of the feeling of freedom. I don't get that in the operating room.

So when you ride, I would advise you to ride safe. Wear good clothing, helmets, and shoes, and enjoy the experience. I have enjoyed it for years, and hopefully can continue to enjoy it for many more.

James P. Weaver, M.D., FACS

Safety and Liberty, always competing

Safety and Liberty, two ideals which are constantly competing for primacy in our tempestuous lives. Most of us do not even see this battle, but it is going on in many venues. We just have to look for it.

I became aware of this struggle, and ordered my priorities in the battle over motorcycle helmet laws. I wanted more liberty, because I believe liberty strengthens us to face life as confident people. Liberty gives us the essence of our yearning to be a whole person. To have liberty, to be free, is an instinct infused into our souls at creation. We continue to search for it.

With the motorcycle helmet laws, the "safety people" want everyone to wear a helmet at all times- it's safer. The "liberty people" want to have the freedom to choose. Yes, they are safer, and I always wear one when I ride, but safety is not the only, or for that matter, the most important issue to consider.

The safety people want to preserve life-their priority- by being safe. Understood. But in the choice between life and liberty, which is the most important? My assessment is liberty! It is certain that many of us have sacrificed life to preserve liberty. Isn't that why many of us have died in war? In a multitude of circumstances, liberty easily trumps safety.

I can think of many examples where this battle rages on lesser levels: bicycle laws about helmets, seat belts in cars, walking up a hill with your 8 year old child, playing high school sports, and almost anything where their is a danger to life or limb. I believe that a child raised without liberty and all safety will lack essential attributes to succeed in the world: self confidence, ambition, and creativity to name a few. But again, from my perspective, liberty is most important.

The latest area in medical care which illustrates this conflict is the area of "patient safety." I don't have anything against patient safety, but it can go too far. Currently, it has become such a craze, that it is threatening to remove any semblance of professional liberty from the practice of medicine. Not only do we surgeons talk to the patients about their surgery, and have them sign a "request" for surgery, but we have to mark the site of the surgery before the patient enters the operating room, and then do a "time out" and repeat it all over again. The latest potential addition to this liturgy is a World Health Organization check list that the followers of this movement are potentially going to lay on us!

In surgery, this control came about because of "wrong patient or wrong site surgery." But how many of these occur (the numerator) and how many surgeries are there anyway (the denominator)? Isn't there a little bit of throwing out the baby with the bath water here?

I do not think we have carefully thought this through. "Safety uber allis," and to hell with liberty. There is no understanding or concern of the culture that this oppressive system is creating.

Do the safety people believe that physicians cannot create a safe environment or that they do not think patient safety is laudable? We have been thinking about it since the Oath was first spoken.

Physicians, especially surgeons, are a motivated group. We have succeeded in elementary school, high school, college, and have gone through rigorous training to reach a high level of societal responsibility. This is the essence of the "professional liberty" that society previously granted for completing this training. For me, and many others, this quest for liberty, is one of the motivations that propelled us along this arduous road. Is it wise to take this liberty away?

"We hold these truths to be self evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, LIBERTY, and the pursuit of Happiness." These words were written by wise men. They were chosen because they understood the importance of liberty as essential to a full life. They didn't say "life, safety, and the pursuit of happiness." Many of them died in defense of their philosophy.

Patient safety must develop limits to its protocols. The continued erosion of professional liberty will not promote the excellence in medical care that we all strive for. Further equitable cooperation between practicing physicians and regulators must occur to preserve professional liberty and produce the optimal outcome for patient care that we all covet.


James P. Weaver, M.D.,FACS

American College of Surgeons, Where Are You?

I have been a member of the American College of Surgeons for 30+ years, and I am still disappointed in its ability to defend the profession. Surgeons have lost any control of their work environment, and with that any true sense of a functioning professional. Where is the ACS on this issue?

In a previous article on this blog-A Problem with Patient Safety, Feb. 28, 2009- I explained how "patient safety" has taken a chunk out of professional freedom but that is not the only opportunity that has been squandered by the ACS (American College of Surgeons). In terms of "patient safety" I do not expect to hear a peep out of the ACS over the fact that I have discussed the absence of limits to the regulations over patient safety. In 2004, there were about 70 reports of "wrong site surgery" by the Joint Commission. My guess is that they included even wrong site anaesthetic blocks that were discovered and corrected prior to the surgery. They probably included "near misses." But the critical question is how many surgeries were done in the United States in 2004, and how far are we to go with the regulation of surgeons because of these few mistakes. My guess is that there is a baseline number of "wrong site surgeries" that will be done each year no matter how much control these many organizations impose. I do not condone mistakes, but I don't agree with regulations that are securing jobs for the regulators either. Where is the ACS on this issue?

Another area that illustrates the lack of attention to our professional freedom, is the ACS continued endorsement of regulations that disparage the profession. What does "pay for profession" mean anyway? I thought we were a profession, and that means that we do the best we can ALWAYS! Are they going to pay us more of we preform well? Does that mean that we don't do things well some of the time and we won't be paid as much for those procedures? The ACS should not agree to "pay for performance." Agreeing to this concept is disparaging to the principles of professionalism which the ACS is supposed to represent and protect. Where is the ACS?

Another example of "lack of fortitude" are the recent "should never happen" Medicare rules. Medicare is only looking for reasons not to pay for the work of physicians. Now, I can understand they will not pay for an instrument left in the patient, that makes sense. But what about mediastinal infection after heart surgery? This is clearly an attempt to enter a new area of "denial of payment." Where is the ACS?

I have been involved in hundreds of operations, and infections just happen. The rules are strict, and carefully applied, and IN SPITE of all the precautions, infections occur. It's clear that Medicare has added this exclusion to test our response. The ACS response should have been the same as mine: "Infections can occur in spite of rigorous precautions, and it is unacceptable to include mediastinal infection after heart surgery in this scheme." The ACS should mention the fact that Medicare attempts to withhold payment mainly because of their own budgetary constraints, but history predicts it will not be part of the discussion because the ACS will not bring it up. Where is the ACS?

I could add more, but finally, the Medicare reimbursement system. The ACS should go to Washington and tell them that there is no integrity in this system. The resource based relative value scale does not contain any mention of "value" to the patient. It's value that people pay for when they purchase any product. The RBRVS is a blatant lie, used to control the costs of the promises that the government cannot afford. The ACS should let Washington know that physicians have no trust in the determination of the "value" of their services because the government has a conflict of interest in determining this "value." Currently it has enslaved physicians, and is ruining the profession. It does not look good for the future of patient care under Medicare. Where is the ACS?

Another area that has had "no comment" from the ACS has been re-certification. Physicians are re-certified at all levels these days. The hospitals, the insurance companies, our societies, the state boards, the specialty boards all have a part in re-certification. Isn't that enough? Has the ACS stood up for surgeons, and stated that we have so many organizations and review groups watching us that re-certification is not necessary anymore. Where is the ACS?

American College of Surgeons, please reevaluate, and begin to take an active role in defending our profession.

James P. Weaver, M.D., FACS