Portal de Periódicos da CAPES

For the Care of the Underserved

2014; Lippincott Williams & Wilkins; Volume: 77; Issue: 5 Linguagem: Inglês

10.1097/ta.0000000000000440

2163-0763

Robert C. Mackersie,

Diversity and Career in Medicine

Thank you very much, and thank you Dr. Cioffi for that great introduction. I have to say, I did not expect in a million years to be standing up here, and it is an honor and rare privilege to be able to do so. The American Association for the Surgery of Trauma (AAST) has been part of my professional life and part of my culture since I was a young and very anxious junior resident presenting my first article here so many years ago. The title of an alternate subject that I had considered for this address was "The Company You Keep," in reflection of the fact that there is not a day that goes by when I do not think about the value of the professional and personal relationships that exist among my colleagues and among so many people in this room. This community of surgeons that shares the same ideals, commitment, and dedication is extraordinary. I feel incredibly fortunate to have shared my professional life with so many special persons—those who have been a source of great support, encouragement, and camaraderie over the years. As a young medical student, I landed a summer job working for a group of surgeons here in San Francisco that included Bill Blaisdell, Don Trunkey, Frank Lewis, George Sheldon, Bob Lim, Art Thomas, Jack McAninch, and others who were or were to become household names in American surgery. Don Trunkey, with his "love of the sport," humor, and quick wit, and Frank Lewis, with his piercing intellect and analytic approach to problems, helped to convince me that surgery is where I wanted to be. My "Forrest Gump" experience continued when I accepted my first faculty position with two young surgeons, Steve Shackford and David Hoyt, joined 2 years later by Jim Davis. You are all probably tired of looking at this picture (Fig. 1), as it has been shown so many times on occasions such as this. To the young persons in the room, this is what happens to trauma surgeons after 23 years (Fig. 2), a little heavier perhaps (except for Shackford), a little grayer, but still sharing the same ideals and aspirations and still lifelong colleagues and friends.FIGURE 1: From left to right: Drs. Mackersie, Hoyt, Shackford, Davis (1988).FIGURE 2: Twenty-three years later: Drs. Mackersie, Hoyt, Shackford, Davis (2011).Trauma of course is a team sport. We share the thrill of victory and the agony of defeat on a daily basis with other members of our clinical family. Our "family" at the San Francisco General Hospital (SFGH) includes Drs. Bill Schecter, Andre Campbell, Peggy Knudson, Mike West, Jan Horn, Mitch Cohen, Rochelle Dicker, Rachael Callcut, and Art Hill. I value their partnership and friendship greatly and appreciate their support (and patience) over the years. My wife Katherine is sitting here in the front row. She is the most important person and the best thing in my life. The importance of most everything else in our lives pales by comparison with someone who provides the love, support, and encouragement that is truly sustaining over a career and over a lifetime. Thank you Katherine so very, very much. The focus of the talk this morning is on the care of the underserved in relation to their needs for emergency surgical care (ESC). We have seen amazing advances in clinical science, practice models, and the effectiveness of care of the critically ill and injured. At the same time however, access to this care for a significant proportion of patients, the underserved, continues to be threatened. The basic premise of this discourse today is that improving timely access to a system of optimal trauma and ESC may be one of the most effective means of reducing the overall "burden of disease" for critical surgical illness in the United States. The basic message is that we are uniquely qualified and positioned to do this and it is an integral part of our academic and clinical future. Before discussing the underserved and on the occasion of the AAST's 75th anniversary, it is worth reflecting briefly on some of the major developments and milestones we have seen in this eventful 75 years. Distilled from the milestones cited by the section authors of the AAST 75th anniversary commemorative book and from interviews with the AAST past presidents,1 I present to you an abbreviated listing of what are regarded as being some of the most important developments that have occurred during the last 75 years: □ Trauma systems: regional trauma performance improvement, large-scale trauma registries, risk-adjusted analytic techniques □ Imaging: computed tomography, computed tomography angiography, ultrasound □ Surgical critical care: specialty training, patterns of practice and staffing □ Critical care techniques: monitoring, management of organ failure, protocols and guidelines, goal-directed therapy □ Resuscitation: all aspects □ Selective operative management for solid organ injuries □ Damage-control surgery and delayed primary abdominal closure □ Intra-abdominal compartment syndrome and related pathophysiology □ Optimal resource standards for trauma centers and a formalized review process □ Primary and secondary injury prevention □ The concept of "acute care surgery" and the development of related training programs □ Endovascular techniques for trauma □ Improvement in nutritional support techniques □ Evidence-based practices and definitions of levels of evidence □ Expansion of clinical management guidelines and practice algorithms In a perfect world, every victim of injury and every patient experiencing acute surgical illness would be able to benefit from all that we have learned over these many years. In an imperfect world, there will be those groups whose demographic, geographic, or economic characteristics impede or prevent access to optimal trauma and ESC. In the context of our discussion today, these are the underserved. Geographic Factors in Access to Care The geographically underserved are people who do not have timely access to care by virtue of living in remote places. You have all seen the studies and diagrams from the American Trauma Society, illustrating populations that live within 1 hour of helicopter or ground access to designated trauma centers.2 Much of the United States remains outside this window even by helicopter, and if you look at 1-hour ground transport accessibility, the situation is even worse. Brent Eastman spoke about this in his Scudder Oration of 2009,3 with the idea of filling in all of these gaps in our trauma systems and improving access to care for everyone, regardless of geographic location. We forget sometimes that trauma systems are a relatively new development. Beginning with the first trauma centers in the early 1960s that provided reliable, timely access to surgical care, seminal work examining preventable deaths provided further impetus for the development of trauma centers and early trauma systems in the 1970s and 1980s.4,5 More formalized structures for trauma systems were provided through the American College of Surgeons' optimal resources guide (1976), the Development of Trauma Systems (DOTS) course by the National Highway Traffic Safety Administration (1986), the Model Trauma Care Systems Plan by the Health Resources Services Administration (1992), and the initial Consultation for Trauma Systems by the ACS (1996). The ideal characteristics for trauma systems were subsequently defined and tabulated, and many in this room contributed to the 2006 Health Resources and Services Administration Model Trauma System Planning and Evaluation Guidelines6 and to the revised ACS "grey book" for trauma systems consultation.7 Despite the gradual but continuous growth of trauma systems in the United States, access to care is still far from perfect. In a 2004 study, Nathans et al.8 showed that more than one third of patients with major injury were not making it to a trauma center. Here in California, we seem to be doing a little bit better, with a steady increase in the number of high Injury Severity Score (ISS) patients reaching trauma centers to just less than 50% by 2006.9 Since 2006, we have seen a steady increase in the number of trauma centers filling in some geographic gaps, but the establishment of trauma centers in areas of need continues to present a challenge. The underserved in our trauma systems lack timely access for reasons beyond the simple lack of a local trauma center. These include the failure to use available trauma centers with more seriously injured patients being deliberately kept at nontrauma center facilities; delayed access caused by initial undertriage; delayed retriage (secondary triage) from a nontrauma center emergency department (ED), and delayed care caused by a failure to use management guidelines either in the field or at lower-level facilities. Protocol-driven care should begin at the scene, and basic prehospital practice management guidelines such as those for traumatic brain injury are often not being used at all or being delayed. We know how to reduce the number of underserved and expand emergency care systems access. We have the expertise, and we continue to work to do this with trauma. The key elements include upgrades in the level of care—from nontrauma centers to Level IV or Level III and from Level III to Level II, developing inclusivity in existing systems by promoting data sharing and participation in regional performance improvement, developing better triage and retriage (ED to ED) processes, and using outreach programs and regional education to promote protocol-driven management. In the context of a trauma system, the question has been raised: should regionalization similar to that for trauma be extended to include all critical surgical emergency care? It is a central question and one we are becoming positioned to address. A glimpse into what might be the magnitude of the problem is provided in a study by Santry et al.10 The authors compared the outcomes of patients with critical surgical illness who were transferred into a definitive acute care surgery center with a similar group of those who were admitted directly. Patients being transferred into an acute care surgery hospital had more than four times the mortality and a longer stay. While we do not have a definitive answer to the broader regionalization question yet, formulating a solution will be a recurring theme and a direction we will need to take. Let us say our next step will be to build a regionalized system of emergency surgical care—I will just call it ESC for short—that is not limited to emergency general surgery but includes other subspecialty surgical services as well. This ESC system would presumably be built on the backbone of existing trauma systems and would incorporate the same elements used in a trauma system: ESC data registries, ESC disease scaling, ESC resources standards, ESC triage and transfer criteria, and ESC outcomes measures and analytic methods. Some of this will sound familiar because we have already started to move in this direction, and limited ESC regionalization has begun to occur in a few areas. We should now consider how to systematically broaden our existing trauma systems into systems for treating all critical surgical emergencies. The Poor, Disenfranchised, Uninsured This is the population classically thought of as underserved: the poor, the disenfranchised, and the uninsured. What do we know about this group? In 2002, the Institution of Medicine (IOM) published the report "Care Without Coverage, Too Little, Too Late."11 This report noted that uninsured trauma patients were less likely to be admitted to the hospital, had fewer services provided when they were admitted, and had a higher mortality when compared with insured patients. This was a very disturbing report, and the underlying reasons for the findings were not well defined. My friend and colleague, Bill Schecter, speaks of the "surgery of poverty."12 Caring for this patient population requires the consideration of many factors: occult comorbidities and higher overall mortality rates; the health impact of marginal housing resulting in poor nutrition, infection, and increased exposure to violence; alcohol and drug dependence coupled with depression and other mental health problems; increased risks of heart disease and cancer; and the general lack of access to basic health care. Was the IOM correct? A growing literature suggests so. There seems to be an association between hospitals caring for large numbers of minority patients and increased mortality;13,14 an association between lack of insurance coverage and the mortality from gunshot wounds;15 increased trauma mortality, even in the pediatric population, for those uninsured minorities;16 and a particularly disturbing disparity seen in uninsured minorities even at a public Level 1 trauma center.17 Those of us working in large public trauma centers, with a "take all comers" approach, have trouble imagining that we are part of an environment that results in treatment or outcome disparities based on race and insurance. Yet, this seems to be the case even for our most important safety net hospitals. What are the explanations for this? Investigators have explored a number of possibilities. Are disparities related to occult, undiagnosed medical comorbidities? We know that this may be a significant problem, a premise corroborated by one study reporting an adverse effect of undiagnosed comorbidities on trauma outcomes in the uninsured.18 Do disparities in diagnosis and treatment that could affect outcome exist? At least one study addressed this, suggesting that fewer diagnostic tests are conducted for uninsured patients with pelvic fractures.19 This next one really hurts—a report of significantly higher orchiectomy rates for uninsured and minority patients sustaining testicular trauma.20 Where is Dr. McAninch when we need him? Another explanation for the observed disparities is suggested by a report from the Hopkins Outcomes Research group that found that minority patients seem to receive their trauma treatment at hospitals with worse-than-expected mortality figures.21 Disparity is the condition or fact of being unequal. The observed outcome differences seem to be real, and they seem to be multifactorial. However, trauma is or should be the most egalitarian of medical care systems, and these disparities are fundamentally unsettling. We can enumerate the possible underlying causes but remain unsure of their impact. □ The physiologic effects of poverty □ Occult, undiagnosed medical comorbidities □ Underresourced and/or overcrowded safety net hospitals □ Disparities in medical errors related to less time and less senior supervision □ Financial barriers, real or imposed □ Actual treatment bias based on altered perception of benefit The potential for physicians to consciously or unconsciously categorize patients into sex, age, ethnic, or socioeconomic groups and actually modify treatment based on the perception of differences in benefit among these groups has been described as part of a "social categorization" process. The degree to which this is a factor in trauma disparities remains to be seen, but there is clearly much to sort out before we really understand and can modify the root causes of treatment and improve on these outcome disparities. The Underserved Elderly The next group of underserved I will talk about is the elderly. That is going to be everybody in this room at some point, and many of us are getting close now. The increasing prevalence of injury in the elderly is reflected in the US Health, Burden of Disease report examining the top diseases and conditions based on disability-adjusted life year ranks.22 Based on these data, falls moved from a rank of 24th to a rank of 15th. At the same time, road injuries declined in rank from fourth to ninth. Self-harm and interpersonal violence declined also. Care of the elderly trauma patient is clearly a growth industry. There is increasing age, and there is increasing frailty. There are worsening comorbidities. The incidence trajectory for the injured elderly is skyrocketing relative to the younger population.23 There seem to be true disparities in access, and there is probably provider treatment bias. There is also a clear need for integrated programs to better care for this population. To this end, last year, I appointed Steve Shackford to chair a new ad hoc Committee on Geriatric Trauma. It is remarkable how fast and with what enthusiasm this group has taken off. The provision of optimal care to the underserved geriatric trauma population is clearly of great interest to this association and a very important opportunity for future development. Other organizations, notably the ACS and its Trauma Quality Improvement Program (TQIP) program, are working along the same lines.24 Despite the increasing importance of geriatric trauma, as we might have suspected, it seems that the elderly do not have the kind of access to trauma that we hoped they would. In a report from California, Hsia et al.25 found that age was an inverse independent predictor for access to designated trauma center care. A similar result was found by Lane et al.26 in a study of the Pennsylvania trauma system. Possible reasons for disparities in trauma center access were further explored in two reports of systematic undertriage of elderly patients to designated trauma centers, suggesting that lack of specific training related to the elderly and age bias may be important factors.27,28 A particularly disturbing study was one by Kirkman et al.29 who suggested that the presence of an underlying age-related treatment bias, where elderly patients were more likely to be managed by less-experienced health care providers, resulted in the poor outcomes observed. Access to Rehabilitation Those with limited access to good rehabilitation may be another underserved population. In 2011, the injury prevention group at Harborview published a study examining the long-term outcomes from traumatic injury as a function of patient disposition.30 The disturbing thing is the finding that the cumulative mortality for those patients discharged to a skilled nursing facility (SNF), even after controlling for injury severity and comorbidities, was dramatically higher than for those discharged home or to a rehabilitation facility (34% 3-year mortality for SNF vs. 12% for rehabilitation facility). This was a retrospective study and cannot really determine the underlying causes for the observed disparities. However, the suspicion is that we are "warehousing" trauma survivors in SNFs based on the lack of insurance or other factors, thereby depriving them of the opportunity for optimal rehabilitation therapy and optimal recovery. We seem to be, in effect, compromising the optimal care that we provide at our trauma centers by the lack of postdischarge follow through. The presence of a rehabilitation disparity has been corroborated by a number of other studies looking at the outcome differences related to discharge venue. Ethnic minority patients and those who are uninsured seem to be less likely placed in rehabilitation facilities, further exacerbating the acute care disparities already described.31–33 In a study by Shafi et al.,34 the authors found that, even accounting for insurance status, ethnic minorities were less likely to be discharged to rehabilitation. Given that brain injury is a primary cause of death and disability in a lot of our trauma centers, we now recognize the efficacy of rehabilitation for these patients and we know where these patients should ideally receive their postdischarge care.35–38 Again, the disturbing fact seems to be that access to rehabilitation, even for this vulnerable population, may be lacking.39,40 Even for patients with traumatic brain injuries, the lack of insurance is detrimental to their recovery. Many of these patients are not getting the type of neurorehabilitation that they need, despite numerous studies showing that this is of benefit. Rehabilitation is a critical part of our trauma system, but rehabilitation programs have never been well integrated into the continuum of care, for a lot of reasons. Long-term outcomes are a critical measure of overall systems performance, but our existing systems structures are not well informed by these measures—most clinical databases are not inclusive of long-term functional recovery data. Access to optimal rehabilitation, in all its forms, seems to be particularly prone to occult treatment bias that may encompass age, insurance, injury type, sex, and maybe other factors, creating, again, a large and mostly invisible, underserved population. Work Force Issues The discussion thus far has focused on the "demand" side—the underserved populations. I am now going to examine part of the "supply" side, that is, the work force and hospitals that will be part of the solution to providing access to care for the underserved. Several of the key studies on surgical work force come from the late George Sheldon who did so much to underscore this important aspect of our future. Most are familiar with the looming population "bubble" of elderly patients and the work force demands this will create. In a recent study published just this year by Dr. Sheldon and his group, a dynamic stock and flow model was used to project the surgical work force beginning with 2009 numbers.41 We are now at a point where the work force has dropped by 30,000 since 2009. Based on various modeling assumptions and different work force growth rates, it seems that we are in trouble with the surgical work force almost any way you slice it. For the trauma, surgical critical care, and emergency general surgery work force, we can examine the surgical critical care applicants (most of whom complete trauma or acute care surgery fellowships). There is good news and bad news. The good news is the numbers are going up, with a 50% increase in fellowship applicants since 2009. The bad news is the slope of the curve (only approximately 12% per year) and the height of the curve (142 applicants in 2013) are not yet what they need to be.42 It seems that we are not going to be able to solve the work force problem for ESC simply by increased throughput in acute care surgery training programs. This problem will require a long-term solution—we are not going to be able to turn the work force deficit around on a dime. The ACS, through its division of Advocacy and Health Policy, has for years recognized the growing crisis in patient access to ESC, nicely summarized in its 2006 report.43 The impact of this crisis is illustrated by superimposing a map of age-adjusted death rates per 100,000 population and the number of surgeons by county.44 The image has been used in a number of previous studies and talks, and the message is clear: the more surgeons there are, the lower the mortality is; the fewer surgeons there are, the higher the mortality is. I would like to comment briefly on what I think are a couple of important trends: the trend toward employed general surgeons and a trend toward having these surgeons function as shift workers. While the employed surgeon might be part of a contracted group, in many cases, they are hospital based. From another study by George Sheldon's group, there has been a relative increase in the surgeon-employee (from 50.2% in 2001 to 66.1% in 2010) and the relative decrease in the self-employed surgeon (from 49.8% in 2001 to 33.9% in 2010).45 At the same time, we see job advertisements seeking general surgeons willing to work in shift schedules to fill some of these new "employed" positions. Call them "surgicalists" or "hospitalists" or "surgical hospitalists"—I am not particularly fond of the terms, but the trends suggest that there is a great potential for this group of general surgeons to help meet ESC needs. These are not fellowship-trained acute care surgeons practicing trauma and surgical critical care at Level 1 or Level 2 designated centers. They may not have the same scope of emergency practice that we do. They are, however, a potentially important part of the surgical work force, and we need to consider how to incorporate them into our models for ESC. As academic surgical educators, our role is to ensure the future and consistency of emergency surgical and critical care training, both within fellowships and for the general surgical residency. As clinicians, our role is to design and work within a system providing the highest level of integrated ESC. However, the fellowship-trained acute care surgery work force, as I mentioned before, is not going to be sufficient to cover all trauma and emergency surgery. So what other options do we have? We can consider new practice models involving an expanded use of midlevel providers (physician assistants and nurse practitioners), recognizing that most of us have to some degree incorporated midlevel providers into our practices. We can better integrate our medical hospitalists and geriatricians as collaborators into models for providing inpatient care. We can explore how an employed general surgeon might be best used within a regional system to make it more "inclusive" and improve ESC. We can begin to design these inclusive systems of comprehensive ESC that are patterned after and built on our existing trauma systems. While we do not yet have data that would compel the regionalization of all ESC, most of us in this room, based on our experiences with trauma and other critical surgical illness, believe that there is surely a survival benefit to regionalization that extends to more severe or complex nontrauma surgical conditions. I would like to take note of our AAST history with respect to ensuring the future of the trauma surgeon and now the acute care surgeon. Dr. Arthur Metz in his AAST presidential address in 1952 opined that the future of trauma "was to organize a Board for the Surgery of Trauma," and "develop in the Department of Surgery, a sub-department for the teaching of the surgery of trauma."46 Dr. Elsie Asbury in his 1954 AAST presidential address stated that the AAST's goal was to "assist the General Surgical Board in setting up a method of high level certification of surgeons in the field of trauma."47 Subsequently, there was an ad hoc AAST committee formed to do this, working with the American Board of Surgery. Unfortunately, no progress was made in this collaboration, for a variety of reasons. We now find ourselves 60 years later, with a work force crisis threatening to create an even greater number of underserved, pursuing almost the same thing. The Fate of the Safety Net Hospital Following the creation of Medicaid and Medicare in 1965, the demise of the public (safety net) hospital was predicted since all patients would have health insurance. In his 1991 presidential address, Dr. William Blaisdell focused on the pre-Medicare role of these city/county hospitals, stating that there "…will always be those who have problems with access to health care and that there is a need for hospitals that will provide for the neglected patients and neglected diseases."48 Dr. Blaisdell was correct; many but not all public hospitals survived but did so with budgetary impediments that continue to run the risk of creating a two-tiered system of care. We now have a large array of safety net hospitals, including public hospitals, whose future is again uncertain with health care funding under the Affordable Care Act (ACA). We are in uncharted waters now despite the promise of expanded health care coverage for millions of Americans. It is projected that as many as 30 million persons will remain uninsured even with the ACA, that disproportionate share income is likely to decrease by up to 75%, that regulatory requirements will grow, and that the impact of adverse selection for the underserved poor, homeless, and those with mental health problems will remain a threat.49,50 On the positive side, the ACA defines qualifications for trauma centers and specifically recognizes trauma centers for their unique expertise. The ACA also offers conditional grants to offset the decreases in disproportionate share income for safety net hospitals. When taking everything into account, it seems that funding will remain uncertain, that the amount of uncompensated care may have been substantially underestimated, and that the ultimate survival of safety net trauma hospitals will be determined largely by individual state governments. The Growing Public Need I am going to try and summarize. There is a clearly a growing public need for ESC and a growing population of underserved. Most everyone recognizes this, and it is a problem we have been committed to for decades in our work with trauma care. We are at a pivotal point in this organization. Having embraced acute care surgery as a training paradigm, we are now beginning to take the next steps to embrace acute care surgery (trauma, emergency general surgery, surgical critical care) as an overarching approach to a system of care that will help meet these growing public health care needs. Many of the advances in trauma care, so nicely illustrated in the 75th anniversary commemorative book, and emergency surgery are not always available to significant portions of our population. This situation will likely get worse, and the seemingly simple matter of improving access to care may be one of the most effective means of reducing the overall burden of disease for critical surgical illness and injury that we will see in the coming years. What should our response be as an organization and as a community of practitioners? We have already begun—extending our expertise and lessons learned in trauma to a broader scope of practice. To establish extended systems of ESC and corresponding practice models, we need leadership. Surgical leadership provides the foundation of our trauma systems and can also provide the foundation for a broader system covering all ESC. To set benchmarks for optimal care for all critical surgical illnesses, we need highly trained, expert clinicians with experience in doing this. I am looking at them in this room. To continue to improve outcomes and reduce disparities, we need talented researchers and an established data infrastructure. Almost everyone here today has devoted their careers to capturing and analyzing data and disseminating the results. These efforts are part of the core mission of the AAST and can now be expanded to include emergency surgery. To ensure the future work force, we need mentors and educators; we need certified training programs; and we need to incorporate the true general surgeon into this work force. You are the group to do this. Looking forward, we have set a path to extend our expertise in trauma surgery and trauma systems to encompass a broad scope of emergency surgery. Trauma care now morphs and expands to ESC. Injury severity and trauma scoring expands to ESC scoring, with Dr. Shafi's AAST committee now leading this effort. The TQIP may, at some point, become ESCQIP or something similar. Optimal resource and process standards for hospitals and systems of care for trauma will expand to include ESC, a process already begun under Dr. Rotondo's leadership of the Committee on Trauma. An expanded scope of scholarship for the AAST was promoted last year under Dr. Meredith's leadership with the development of a research agenda for emergency surgery. At the same time, we continue to develop acute care surgery programs that will train the next generation of leaders that reflect this extension of trauma expertise to a broader scope of ESC. While we have taken these initial steps to expand our scope of expertise and establish a new training paradigm, it will be critical for us to also demonstrate that outcomes from nontrauma surgical emergencies will benefit from a similar application of a systems approach to that used for trauma. I am guessing that most everyone in this room believes this to be true, but that is not going to be good enough. Just like we did for trauma, we will need to demonstrate the cost and outcomes effectiveness of a broader system of care for ESC. We have just scratched the surface in terms of doing this. I think that it has become clear that the public needs for ESC will not be met within the confines of general surgery. Additional commitment on our part is needed: a commitment to long-term data acquisition and outcomes analysis for ESC, a commitment to develop an inclusive system for ESC that also uses smaller hospitals and the skills of the hospital-based general surgeon, and a commitment to establish formal training certification for the next generation of acute care surgeons. Acute care surgery (trauma, surgical critical care, and emergency general surgery) is much more than a training paradigm. It is an extension of our philosophy, an extension of our acquired expertise, and an extension of our model system of care that we have so painstakingly developed over the last several decades for trauma. Look at the AAST committee work and listen to the committee reports that will be given at the business meeting tomorrow. We have already begun to extend our philosophy and expertise, with a commitment to a systems-based approach designed to meet public needs for the surgically underserved. This is our future, and we will be working to ensure it. It has been such a privilege to serve as your president and an honor to be cherished beyond measure. Thank you for coming here to San Francisco, thank you for having me as your president, and thank you for listening. DISCLOSURE The author declares no conflict of interest.