Leadership Is No Longer Optional: Reframing the Surgeon’s Professional Obligation

The contemporary healthcare landscape is unforgiving toward organizations that lack strong, adaptable leadership.
The combination of financial volatility, labor shortages, demographic changes, and increasing public expectations has exposed the limitations of conventional governance paradigms. Academic health systems now function at the convergence of clinical intricacy, educational obligation, and research advancement, all while navigating limited financial margins. In this situation, leadership is not an administrative indulgence; it is a critical imperative.

Surgeons occupy a unique and often underleveraged position within this leadership landscape. Their training emphasizes accountability, decisiveness, situational awareness, and team coordination under pressure. These competencies are forged through years of practice in environments where uncertainty is the norm and consequences are immediate. Yet despite this alignment, surgeons remain underrepresented in enterprise leadership roles,
particularly at the level of health-system governance.

This gap is not due to a lack of capability or ambition. Rather, it reflects a systemic failure to prepare surgeons for leadership beyond the operating room. Surgical education has historically focused on technical excellence and clinical judgment, but it has not treated leadership as a professional competency requiring the same rigor and intentionality.

The result is a predictable mismatch. Surgeons are often promoted into leadership roles based on clinical reputation or seniority and then expected to learn leadership on the job. Finance, strategy, workforce management, and organizational change are treated as ancillary rather than essential domains of surgical professionalism.

Contemporary healthcare leadership necessitates proficiency in navigating ambiguity, accepting measured risks, and unifying disparate stakeholders around common objectives. Surgeons possess the necessary skills for this task, provided their clinical instincts are intentionally adapted to business environments.

For academic surgery, the implications are profound. Leadership development must be reframed as a longitudinal responsibility rather than an episodic opportunity. Residency and fellowship programs should introduce leadership concepts early, normalize system-level thinking, and provide experiential exposure to organizational decision-making.

Leadership must be reclaimed as a core element of surgical professionalism. It is not an alternative career path but an extension of the surgeon’s obligation to steward resources, develop future generations, and ensure the long-term viability of the systems in which care is delivered.

Disaster Committee

Burn Mass Casualty Incident: How do we manage them?

Written by: Natalie DeWitte, DO and Lori Rhodes, MD

Burn disasters are rare occurrences but when they do happen, they can be catastrophic and can be challenging to manage for those who may be unfamiliar with burn care. Burn disasters over the last hundred years have occurred in the setting of large fires, explosions, natural disasters, or acts of terrorism. Worsening global climate change, rise in industrialization and increased incidence of terrorism calls attention to the need for better preparation for these mass casualty events.

A burn mass casualty incident occurs when the number of burn victims exceeds the capacity of local burn centers. Surge capacity, the balance of staff, supplies, and space, becomes critical in managing the influx. Established triage criteria guide treatment decisions and determine the need for burn center transfer. Initial management includes stabilizing airway, breathing, and circulation. Burn size should be estimated using the rule of nines or the palm method, followed by resuscitation if indicated.

Often in mass burn casualty incidents, patients can have concomitant traumatic injuries making triage complex. In almost all situations, traumatic injuries will take priority over burn injuries such as uncontrolled hemorrhage, airway compromise, or traumatic brain injury as these are life-threatening. Patients with severe trauma and major burns should be considered for early transfer to tertiary care centers.

If a burn mass casualty event occurs, there are several organizations that provide resources. The ABA can provide disaster plans, hotlines with direct access to burn experts, and educational materials to help you respond to these events. The ASPR Tracie program under HHS provides guidance on triage, assessment and treatment. Lastly, the WHO has their own set of guidelines for managing these mass casualty events and has these available online for no cost. The following links can be found on AAST disaster committee website

Resources:

1. ABA: Disaster Response – American Burn Association
2. ASPR Tracie Program: ASPR TRACIE | Healthcare Emergency Preparedness Information Gateway
3. WHO: Mass Casualty Management

February Faculty Article

Leadership Is No Longer Optional: Reframing the Surgeon’s Professional Obligation

Written By: 

Jason W. Smith, MD, PhD, MBA, FACS
Chief Executive Officer and Executive Vice President
UofL Health The Hiram C. Polk Jr., Department of Surgery University of Louisville

The contemporary healthcare landscape is unforgiving toward organizations that lack strong, adaptable leadership. The convergence of financial volatility, labor shortages, demographic change, and rising public expectations has exposed the limitations of conventional governance paradigms. Academic health systems now operate at the intersection of clinical intricacy, educational obligation, and research advancement, all while navigating increasingly constrained financial margins. In this environment, leadership is not an administrative indulgence; it is a critical imperative.

Surgeons occupy a unique and often underleveraged position within this leadership landscape, particularly at the level of enterprise decision-making. Their representation remains limited across senior executive roles, system-level operational leadership, and board governance, even though these forums increasingly shape clinical strategy, capital allocation, workforce policy, and quality infrastructure. Surgical training emphasizes accountability, decisiveness, situational awareness, and team coordination under pressure. These competencies are not incidental; they are forged through years of practice in environments where uncertainty is the norm and consequences are immediate. Yet, despite this alignment, surgeons remain underrepresented in the very leadership spaces where clinical insight is most needed.

This gap is not due to a lack of capability or ambition. Rather, it reflects a systemic failure to prepare surgeons for leadership beyond the operating room. Surgical education has historically—and appropriately—prioritized technical excellence and clinical judgment. What it has consistently failed to do is treat leadership as a professional competency requiring the same rigor, intentionality, and assessment as operative skill. As a result, leadership development is often left to chance, mentorship variability, or post hoc executive training rather than being integrated into the core professional identity of the surgeon.

The result is a predictable mismatch. Surgeons are frequently elevated into leadership roles based on clinical reputation or seniority and then expected to “learn leadership on the job.” While some succeed, many struggle—not because they lack aptitude, but because the role demands skills they were never trained to develop. Finance, strategy, workforce management, and organizational change are treated as ancillary rather than essential domains of surgical professionalism. This approach is no longer tenable. As healthcare systems grow more complex and interdependent, leadership competency can no longer be assumed to emerge organically from clinical excellence alone.

At the enterprise level, the consequences of this gap are not theoretical. Decisions regarding capital deployment, service-line growth, workforce stabilization, and academic investment increasingly occur in environments where clinical nuance matters. In my experience, these discussions rarely present clean choices. Determining whether limited capital should support trauma capacity expansion, workforce retention, deferred infrastructure replacement, or academic investment is not a purely financial exercise. Each option carries downstream implications for patient access, training pipelines, and community trust. Leaders who understand care delivery at the bedside are often best positioned to frame these tradeoffs honestly, even when the answers are imperfect or incomplete.

Recognizing this reality necessitates a clearer articulation of the competencies required for contemporary healthcare leadership. Effective leaders must be comfortable navigating ambiguity, accepting measured risk, and aligning diverse stakeholders around shared objectives. Surgeons possess many of the foundational skills for this work, provided their clinical instincts are intentionally recalibrated for enterprise environments. The ethical obligation to minimize harm—central to surgical practice—must be balanced against the necessity of innovation and transformation. Strategic leadership often requires acting with incomplete information and accepting short-term disruption in service of long-term sustainability. This shift is not intuitive, and it is not automatic.

Equally important is the transition from hierarchical authority to distributed leadership. Surgical culture has long relied on explicit hierarchies—an approach that serves patients well in acute, time-sensitive settings but can inhibit collaboration, innovation, and shared ownership within complex healthcare organizations. Effective surgeon leaders must learn to distinguish when command-and-control leadership is essential and when empowerment and collective problem-solving are more appropriate. Organizational success increasingly depends on shared intelligence rather than individual expertise, and leadership effectiveness is defined by the ability to cultivate that intelligence at scale. This is a learned skill, and it takes practice.

Any serious discussion of surgeon leadership must also acknowledge the practical barriers that complicate leadership development. Time constraints within clinical practice, compensation models that undervalue leadership work, and institutional resistance to redefining traditional roles all limit surgeons’ ability to pursue and sustain leadership growth. These barriers are not trivial, nor are they solely individual challenges. They reflect structural choices within healthcare organizations that often prioritize short-term productivity over long-term leadership capacity. In retrospect, some of these choices are understandable; many are no longer defensible.

For academic surgery, the implications are substantial. Leadership development must be reframed as a longitudinal responsibility rather than an episodic opportunity. Residency and fellowship programs should introduce leadership concepts early, normalize system-level thinking, and provide experiential exposure to organizational decision-making. Faculty development pathways must include progressive leadership responsibility, mentorship, and accountability for outcomes beyond the clinical domain. Institutions, in turn, must accept their role in cultivating leadership capacity. Elevating surgeons into nominal leadership positions without real authority or developmental support undermines both the individual and the organization. Authentic leadership pipelines—grounded in transparency, mentorship, and measurable responsibility—are essential to building a sustainable bench of future leaders.

The objective is not to dissuade surgeons from patient care nor to suggest that all surgeons should pursue executive leadership roles. Rather, it is to recognize that leadership competence strengthens the profession as a whole. Surgeons who understand system dynamics advocate more effectively for patients, trainees, and care teams. Organizations led by clinically grounded executives are better positioned to align mission and margin, quality and sustainability. From where I sit, leadership is not a departure from surgical professionalism; it is one of its natural extensions.

Leadership is no longer optional. In the decades ahead, the success of academic surgery will be measured not only by technical innovation, but by the ability of surgeons to lead organizations through complexity and change. Preparing surgeon leaders is an ethical, professional, and institutional imperative—and ultimately one that determines our ability to deliver safe, effective, and equitable care to the patients who depend on us.

Healthcare Economics Committee

CMS Updates in 2026 that may affect your practice

Written By: Author, Co-Editor: Raeanna C. Adams, MD, MBA, FACS, Co-Editor: Samir M. Fakhry, MD, FACS

Increase in Medicare Conversion Factor (CF): 3.26% for most physicians (if not in advanced alternative payment models)

(wRVUs + Practice Expense RVUs + Malpractice RVUs) x CF = Final Payment

“Efficiency adjustment” beginning January 2026, unless legislative changes: 2.5% decrease

• 2.5% decrease in wRVUs and intra-service time for almost all non-time-based codes
  • Based on no new data or physician input. 

• • Affects nearly 7,000 physician services and 91% of services provided by physicians. 
  • It is predicted that 53% of general surgeons will see a 5-10% reduction in total RVUs; 28% will see a 2-5% reduction. Vs ~50% of primary care will see a 5-10% increase. 
  • CMS assumes physician time and intensity has decreased for all procedures.
  • Procedure times are steady or increasing (average 3.1% increase in time, thought to be due to increasing complexity, obesity, comorbidities, etc)
  • Primary care is advocating for this change, as those who will not see the Efficiency Adjustment will only get the increased reimbursement from the Conversion Factor increase.

• 50% cut to indirect Practice Expense (PE) RVUs for all facility-based services
  • CMS assumes allocation of indirect costs for PE RVUs in facility setting at same rate as non-facility setting is “double counting” for facility-based indirect PE when hospitals employ physicians
  • Indirect PE costs still exist for employed physicians and hospitals (not doctors) are true recipients of any double payments.
  • Specialists who primarily see pts in an office will see pay increase. Physician payment for services in a facility will decrease ~7%.

*Upshot: Lower RVUs for same procedures - Applies across the board, even for newer codes that were already adjusted and based on recent data. Physicians with salaries based on RVUs should negotiate for appropriate adjustments of targets/benchmarks.

CPT Codes/Revisions Accepted (listed on public agenda, active January 2027) more details after finalized:

• Skin cell suspension autograft (SCSA) -Accepted addition of codes 15X19-15X22 for reporting ; revision of SCSA guidelines; and deletion of codes 15011-15018.
• Diaphragmatic hernia repair - Accepted addition of codes 39XX3-39X12 for repair of diaphragmatic hernia; addition of add-on code 39X13 for mesh implantation; revision of codes 39540, 39541 to reflect “via laparotomy” for diaphragmatic hernia repair.

References

• American Medical Association (AMA) — “AMA releases CPT 2026 code set” (Sept 11, 2025) (American Medical Association)
• MLN14315 Medicare Physician Fee Schedule Final Rule Schedule CY 2026. https://www.cms.gov/files/document/mm14315-medicare-physician-fee-schedule-final-rule-summary-cy-2026.pdf
• Centers for Medicare & Medicaid Services (CMS) — “CY 2026 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies” (Final Rule 2025) (Federal Register)
• Childers, Christopher P; Foe, Lauren M; Mujumdar, Vinita; Mabry, Charles D; Selzer, Don; Senkowski, Christopher K; Ko, Clifford Y; Tsai, Thomas C. Longitudinal Trends in Efficiency and Complexity of Surgical Procedures: Analysis of 1.7 Million Operations Between 2019 and 2023. Journal of the American College of Surgeons. 241(5):p 741-744, November 2025. | DOI: 10.1097/XCS.0000000000001588

Diversity, Equity, and Inclusion Committee

Critical Appraisal of SCORE’s Diversity, Equity, and Inclusion Curriculum for General Surgery Residents

Written By: Megan T. Quintana, MD FACS

The SCORE Curriculum has made deliberate progress in expanding DEI-focused educational offerings for general surgery residents, and the six currently available modules represent a notable step toward embedding equity principles into core surgical training. Collectively, these resources span foundational concepts such as cultural awareness, language barriers, communication norms, allyship, and the socio-structural forces shaping the surgical workforce. Still, amount of content, content depth, pedagogical strategy, and integration vary widely across modules, revealing some strengths and many more opportunities for further development.

Strengths of the Current SCORE DEI Portfolio

Several modules demonstrate impressive scholarly rigor and contemporary relevance. Diversity in the U.S. Surgical Workforce provides a rich, data-driven overview of representation gaps and trends across training and academic leadership. Its explicit use of updated UIM definitions, pipeline data, and institutional barriers (e.g., minority tax, biased promotion structures) gives learners a robust foundation for understanding structural inequities that shape surgical training and practice. The Allyship and Bystander Intervention module similarly stands out for providing concrete frameworks such as the “Five Ds” and real-world behavioral taxonomies that allow residents to identify, interpret, and respond to disruptive behavior—a critical skill given the well-documented links between psychological safety, communication failures, and adverse patient outcomes.

The PACTS module extends the curriculum’s cross-cultural competence by emphasizing trust-building, trauma-informed communication, and optimizing encounters with patients with limited English proficiency. Its incorporation of informed consent as an iterative, culturally influenced process is particularly valuable for surgical residents who often navigate high-stakes decisions in compressed timelines.

SCORE also attempts to integrate DEI concepts into modules not explicitly branded as DEI content. For example, Communicating Medical Errors incorporates cultural dimensions of apology, acknowledgement, and trust—an important reminder that equity is inseparable from core professional competencies.

Gaps and Opportunities for Enrichment

Despite the existing content, the curriculum varies in sophistication. Some modules, especially Working Through Language Barriers and Differing Customs, present culturally relevant scenarios but rely heavily on lists, definitions, and broad principles without offering nuanced discussion of intersectionality, systems-based inequities, or the sociopolitical context influencing patient-physician interactions. Guidance for using interpreters is practical but remains focused on mechanics rather than deeper issues of power dynamics, health literacy, or institutional responsibilities in mitigating inequitable communication practices.

The lack of structured assessment tools represents another lost opportunity. None of the reviewed modules include validated evaluation instruments, reflective prompts, or entrustable professional activity-aligned competencies. Without mechanisms to measure learner growth, DEI training risks becoming theoretical rather than transformative.

Additionally, although the modules highlight the lack of UIM representation and the persistence of microaggressions, they provide limited exploration of antiracist praxis, systems-level redesign, or concrete programmatic strategies that residency programs can implement. The curriculum would be strengthened by expanding its focus to include structural competency, restorative approaches to conflict, and institutional accountability frameworks.

SCORE’s DEI-related offerings provide the start of a foundation for resident learning but could better reflect the surgical community’s growing commitment to equity and inclusion. The content is strongest when it integrates DEI principles into essential surgical competencies (communication, trust-building, patient safety) and weakest where it remains largely descriptive rather than action-oriented. As the field continues to evolve, future iterations would benefit from deeper structural analysis, competency-based assessments, richer scenario-based learning, and stronger integration of DEI content across all clinical modules, not as supplemental material, but as core to the practice of safe, effective, and human-centered surgery.

Palliative Care Committee

Perioperative DNAR

Author: Melanie Bobbs, MD FACS

We’ve all been there. It’s two in the morning, and you are on call. A patient comes into the Emergency Department with abdominal pain. They are septic, altered, and you are informed they have a pre-existing “Do Not Attempt Resuscitation” (DNAR) order.

Historically, undergoing surgery was an informal agreement between patients and their providers. This implied contract suggested patients will accept life-saving treatment necessary for survival in the perioperative period. Thus, many institutions and clinicians developed a culture of automatic suspension for any existing DNAR orders if a patient was proceeding to the operating room. This process is very different from individualized treatment plans based on goals of care. For many, automatic suspension of DNAR orders was an effort to practice nonmaleficence, a core principle to our profession. Many have felt that not attempting resuscitation following a perioperative complication, whether due to therapeutic effort or error, violates our duty to do no harm. However, automatic suspension of DNAR orders does not sufficiently address a patient’s right to self-determination and autonomy. The American College of Surgeons (ACS) published its last Statement on the Advanced Directives by Patients: “Do Not Resuscitate” in the Operating Room in 2013, revised from 1994, advising “required reconsideration” for patients undergoing an operation with an existing DNAR order. While this should not be confused as mandating the patient reconsider their wishes, it does imply that surgeons have a duty to understand the patient’s goals of care in the time constraints of the clinical situation.

In circumstances with limited time, it is important to have a clear algorithm to address and understand these goals. There are three peri-operative plans to help guide the discussion, and you should ask questions to delineate which of them match your patient’s values. These three options are: temporarily suspend the DNAR order; conditionally suspend/modify the DNAR order; do not suspend the DNAR order. Try to obtain and review the pre-existing DNAR and record it in the patient’s medical record. Assess whether your patient has capacity to discuss their DNAR order, and if not, attempt to reach out to a surrogate decision maker. Next is to understand the patient’s values, preferences and goals that originated the DNAR order. Questions to consider asking the patient include, “Are there states you find unacceptable?” and “What is currently most important to you?” After gathering this information from the patient or surrogate, then an informed consent discussion ensues, which includes disclosing potential adverse scenarios and perioperative complications, and whether the planned operation or procedure will enhance, maintain, or diminish the patient’s quality of life. It is critically important to understand if any potential outcomes do not align with states the patient would find unacceptable. Avoiding or aborting a procedure may be more concordant with the patient’s goals of care. Clearly document your discussion in the medical record.

To help simplify discussions on perioperative plans, use levels of care to distinguish life sustaining treatments (LSTs) that best fit the patient’s goals while undergoing general anesthesia. This can also help avoid unrealistic “checklists” with certain treatment. (Table 1) If you and your patient decide to modify or suspend the DNAR order, it is critically important to clearly define the “perioperative period,” document if/when the DNAR order modification will end, and communicate this clearly with all stakeholders, including the operating room, recovery, and bedside staff. Well-defined time trials should also be considered if a DNAR order is suspended, ideally every 24-48 hours to assess whether the treatment plan and progress is consistent with the patient’s goals of care.

Goals of resuscitation in the event of perioperative complications should be with communication and agreement between anesthesia colleagues and others. Ideally, the anesthesia team should participate during discussion of LSTs, however, this is not always feasible. Regardless, it is the surgeon’s responsibility to clearly articulate potential findings of an operation and the plan for resuscitation based on the perioperative discussion. Use the surgical time-out to reinforce this communication. For example, during the time-out the surgeon might say “patient consents to Level 2 resuscitation. We will not perform chest compressions or defibrillation under any circumstance.”

Finally, document and articulate your understanding of their goals and how that supports your plan of care. This includes documenting a pre-determined time to discuss the patient’s progress, ongoing goals of care, and potential reinstatement of the DNAR order. In the setting of an imminent, life-threatening emergency, or with an inability to contact a surrogate decision-maker for a patient without decision-making capacity, unilateral suspension of a DNAR order may be the most appropriate option. In this setting, you must give consideration to resuscitation in the context of any previously documented wishes and the presenting disease process. If you proceed to the OR emergently, every effort should be made to contact the patient’s surrogate postoperatively. In this situation, it is recommended to utilize a time trial of 24-48 hours to re-evaluate the suspension of the DNAR order.

There are still indications for unilateral suspension of DNAR orders, and there is considerable difficulty and pressure to gather information regarding goals of care when time is limited. However, we must adopt patterns and systems that encourage self-determination with individualized perioperative plans. With cultural change, improved documentation, and focused questions to delineate goals and values, we can maintain our duty to do no harm, allow patient autonomy, and provide the highest level of compassionate care.

The AAST Palliative Trauma Committee has created a Goals of Care One-Pager that summarizes this information. Please download it from the website, and hang in the ICU, the resident workroom and other spaces where it can be referenced.

Table 1

8^th World Trauma Congress

Written By: Raul Coimbra, MD, PhD

Despite initial challenges in organizing the 8^th World Trauma Congress, the combined scientific program has been finalized and looks strong. The meeting will be held in Stockholm, Sweden, April 26-28, 2026.

We are confident it will be a great conference, with ample opportunity for superb learning, updates on current concepts of trauma care, and, very importantly, networking.

The WCT abstract submission remains open. Please see information about abstract submission and the meeting venue, registration, and hotel reservations below:

• WTC ABSTRACT SUBMISSION: (opened on 10/27/2025, and CLOSES on 1/15/2026)
• Abstracts may be accepted for Oral presentation, Quickshot (mini-oral presentation), or Posters, depending on space availability at the meeting. 
• The best 15-20 abstracts will be invited to submit a full manuscript for publication in the journal Trauma Surgery and Acute Care Open, open access, and free of charge.
• Link for Abstract Submission:

 https://aastscholarships.communityforce.com/Funds/Search.aspx#4371597136646D517975544F5976596D4E73384E69673D3D

MEETING INFORMATION

Venue 
Kistamässan
Arne Beurlings Torg 5
64 40 Kista, Schweden

Registration Information
https://estes-congress.org/registration

Hotel
There are many hotels in the area but the ones where rooms have been blocked for the congress are: 
Victoria Tower (in junction to the venue): https://www.scandichotels.com/sv/hotell/scandic-victoria-tower
Voco: https://www.ihg.com/voco/hotels/us/en/kista/stokt/hoteldetail?cm_mmc=GoogleMaps-_-VX-_-SE-_-STOKT

I hope you will be able to submit your research to the 8^th WTC.

See you all in Stockholm.

Raul Coimbra, MD, PhD, FACS
Executive Director – World Coalition for Trauma Care
President – 8^th World Trauma Congress