American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

As a young surgeon, have you had the opportunity to advocate for your profession or for a patient and needed to garner bipartisan support for your cause? Similarly, how has working together “across the aisle” so to speak worked for you in your surgery career?

The Young Fellows Association of the American College of Surgeons (YFA-ACS) annually hosts an essay contest to encourage members to think about the profession from a particular lens. In 2020, the lens focused on garnering bi-partisan support when advocating for your patients.

2020 YFA Advocacy Essay Winner

Below is the winning essay. Enjoy!

That Which Unites Us Is Greater Than That Which Divides Us

Eric Grossman, MD, FACS

Eric Grossman, MD, FACSIn 1952, Adlai Stevenson conceded the presidential election to Dwight D. Eisenhower and called for unity among all Americans. Sadly, in today's extremely divisive political environment, it is nearly impossible to imagine such generous and magnanimous words being spoken. Fortunately, the extreme antagonism seen in today's political arena does not exist in the hospital; however, there are definitely challenges that require bipartisan support and working across the aisle.

Over the last few years, I have had the opportunity to identify and spearhead a solution to such a challenge. As a busy pediatric surgeon, the most common operation I perform is a laparoscopic appendectomy. This statistic is no different than any of my peers across the country. Despite the prevalence of this disease, the diagnosis methodologies, operative techniques, and postoperative management differ enormously among providers. These variations are first uncovered in the emergency department where the diagnosis of appendicitis may be confirmed using ultrasound, CT scan, or MRI. And although most surgeons now perform appendectomies laparoscopically, the surgical techniques differ in stapler choice, energy devices, and removal bags. Finally, there exists great variation in antibiotic choice and duration.

Ironically, every practitioner firmly believes that their approach to this malady is both the most effective course of action; yet it is the nature of this variability and duplication of resources that prohibits efficient delivery of care. To streamline and optimize care for our pediatric patients with appendicitis, I was tasked by my hospital to create an appendectomy pathway beginning with the work up in the emergency department and continuing to postoperative management. My first course of action was to meet with emergency room physicians and identify practice patterns as well as barriers they perceive in their evaluation of children. Our hope was to decrease the use of CT scans and optimize the use of ultrasound.

In this phase of the project, the bipartisan support required took the form of working with our electronic medical record provider to create pediatric appendicitis specific order-sets that would make ordering and obtaining abdominal ultrasounds easier and more user-friendly. Secondly, we set up work groups with radiology and radiology technicians to help facilitate using ultrasound in the evaluation for pediatric appendicitis. My second order of business was to create a uniform operative preference card to decrease cost among surgeons performing this common procedure. This phase of the project definitely required the most tact and willingness to work across the aisle.

As you might imagine, getting a group of surgeons to alter their preference cards on an operation like an appendectomy required significant diplomacy. I met with all our pediatric surgeons and reviewed their instrument choices including staplers, energy devices, and other suture material. In order to reach a consensus and develop a uniform OR set, I discussed how such a pathway would decrease our costs and streamline operating room functionality. Additionally, I was able to show data demonstrating equivalent outcomes with the proposed universal methodology, thereby allaying some of my colleagues concerns. Overall, my success in this aspect of the project was due in large part to my willingness to understand and acknowledge everyone's point of view.

Finally, I created a postoperative pathway regarding antibiotic duration. This was also met with some resistance. Fortunately, our infectious disease and antibiotic stewardship team was a wonderful resource in helping establish this pathway. Thanks to their expertise and guidance, our surgeons were able to review data and understand the rationale for unifying our appendectomy antibiotic pathway. During this phase of my project, I realized that utilizing third-party experts is an invaluable tool in reaching bipartisan support.

In conclusion, after a year of work, our hospital had a streamlined pathway for all children presenting with presumed appendicitis that was evidence-based, cost-efficient, and aimed at providing the best care. I was able to succeed in creating such a pathway by first listening to everyone's concerns and learning how to best overcome these hurdles and deficiencies. I then succeeded by appealing to the common goal of providing the best care in the most efficient manner. The utilization of experts such as the infectious disease team was extremely helpful in bringing everyone together. This endeavor has been invaluable in my surgical career—both in the establishment of an efficient and cost-effective pathway for pediatric appendicitis, but also in my professional maturation in learning how to work with multiple different providers in our health care system. I frequently use these problem-solving and team-building strategies as I approach novel problems.

About the Author

Eric Grossman, MD, FACS, is a pediatric surgeon at Cottage Hospital, Santa Barbara, CA. Dr. Grossman is the director of pediatric trauma and actively involved in hospital and surgical leadership.