Outcomes relate to surgeon, hospital volume
Data helps predict progress of NAFLD to NASH
Final data for PROVE1 and R.E.V.E.A.L.-HBV studies reported
GIs gain lifelong learning tools
Translational Symposium reveals research about how gut flora affects behavior
Novices gain insights to capsule endoscopy
Session sheds light on P4P
Presidential Profile



Outcomes relate to surgeon, hospital volume

SSAT launched a double plenary session Monday morning with a standing-room-only audience. Key topics included assessments on the effect of surgical volume on liver resection outcomes and sleeve gastrectomies.

“Numerous studies have found that surgical outcomes may be related to surgeon and hospital volume,” said Shimul Shah, MD, department of surgery, University of Massachusetts Medical School, Worcester, MA. “What was not clear were the effects of surgeon volume, center volume and patient characteristics.”

Dr. Shah and his colleagues analyzed all liver resections recorded in the National Inpatient Sample between 1998 and 2005, which covers about 20 percent of all U.S. hospitals. The group used 10 liver resections annually as a cutoff for high- versus low-volume surgeons. The cut point for high- versus low-volume centers was 20 liver resections annually. Most centers in the database performed one or two liver resections yearly, he noted.

While high surgical volume has been associated with improved outcomes for many procedures, only high-volume surgeons working in high-volume centers produced superior liver resection outcomes. Other combinations of surgeon and center volume had no effect on outcomes, Dr. Shah reported. The primary outcome measure was in-hospital mortality.

Patients who were white, had private insurance, higher incomes and elective admission were more likely to be treated in high-volume centers. But, when adjusted for race, insurance status and income, center volume had no effect on outcome.

The only statistically significant predictors for surgical outcomes were elective admission, fewer comorbidities, and treatment by a high-volume surgeon at a high-volume center.

“Volume may be a surrogate for other factors of patient care,” he concluded. “We need to define those processes of care that come into play with high-volume centers and high-volume surgeons.”

Paul Cirangle, MD, FACS, Laparoscopic Associates of San Francisco, California Pacific Medical Center, San Francisco, reported results from 1,000 vertical sleeve gastrectomies performed since 2002. Overall, the vertical sleeve offers shorter operative time, shorter length of stay and comparable weight loss to the Roux-en-Y gastric bypass with lower long term morbidity.

The vertical sleeve procedure limits the gastric pouch to the lesser curvature of the stomach.

One key advantage of the vertical sleeve is that it maintains more normal anatomic relationships than the gastric bypass, including access to the bile duct. Dr. Cirangle also noted that the vertical sleeve offers weight loss and complication rates similar to the adjustable gastric band without the need to leave the band in place.

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Data helps predict progress of NAFLD to NASH

An overview of the latest information about the predictors, prognosis and treatment of non-alcoholic fatty liver disease (NAFLD) was presented Monday in an AASLD State-of-the-Art Lecture.

Zobair M. Younossi MD, MPH, focused on the clinical assessment of the disease, including the impact of type II diabetes and metabolic syndrome, and how NAFLD can progress to nonalcoholic steatohepatitis (NASH), cirrhosis and liver cancer.

NAFLD is common, especially in patients with metabolic syndrome, and its victims are at risk of cardiovascular disease, said Dr. Younossi, director of the Center for Liver Diseases at Inova Fairfax Hospital and executive director of research, Inova Health System.

“At the moment, establishing diagnosis of NASH requires careful clinical and pathologic criteria,” Dr. Younossi said. “No single intervention has convincingly improved all important outcomes in NAFLD.”

No drugs for the treatment of NAFLD have been approved by the FDA, so treatment should focus on NASH by reversing contributing factors such as metabolic syndrome, type II diabetes and insulin resistance, he said.

Dr. Younossi walked attendees through the growing knowledge on NAFLD, presenting evidence of factors that affect its progress into other diseases — specifically NASH.

That evidence begins with the fact that the growth of NAFLD has mirrored that of obesity in the U.S. — defined as a body mass index of 30 or greater — which includes 30 percent of adults in the U.S. Still, NAFLD growth is affecting nations around the world, with the greatest percentage in Taiwan, where almost 37 percent of the population is affected.

The disease also varies greatly among different ethnic groups, ranging from 44.7 percent among Caucasians, 28.3 percent for Hispanics, 17 percent among Asians, and 3.1 percent for African-Americans.

Moving from the growing prevalence of NAFLD, Dr. Younossi discussed outcomes of patients in studies around the world. The first included a group of 132 patients at eight years. The follow-up study, 10 years later, included many of the earlier patients in a new, larger cohort of 174 patients.

In those patients, liver disease was the third leading cause of death, following malignancy and cardiovascular disease. In those cases that progressed from NAFLD to NASH, the liver-related mortality rate was 17.5 percent in NASH compared with 2.7 percent in non-NASH patients.

Among the predictors of liver-related mortality were diabetes, older age, lower albumin and higher alkaline phosphatase.

Some of the outcomes of the research of the progression of NAFLD into NASH are that cryptogenic cirrhosis patients resemble NASH patients because of diabetes and obesity, cryptogenic cirrhosis patients are older than NASH patients by 10 years and patients receiving a transplant for cryptogenic cirrhosis develop NAFLD/NASH after orthotopic liver transplant, Dr. Younossi said.

NAFLD also has strong ties to hepatocellular carcinoma (HCC), he said, because studies show that 47 percent of patients with cryptogenic cirrhosis and HCC had clinical or histologic evidence of NAFLD. In addition, cryptogenic cirrhotics with HCC were less likely to have undergone HCC surveillance and had larger tumors.

Among the histologic predictors of the progression, Dr. Younossi said, are a higher grade of fibrosis independently associated with the presence of hepatocyte ballooning, Mallory bodies on the liver biopsy and a higher AST/ALT ratio.

Clinical predictors of progression were hypertension and type II diabetes, he said. Hypertension has less affect than diabetes, but when both are combined the progression to NASH increased.

Among those who should be considered for treatment are patients with histologic NASH who are at risk for progressive liver disease, especially those with metabolic disease, such as insulin resistance or type II diabetes, Dr. Younossi said.

In addition, because data suggest that NAFLD is a predictor of cardiovascular disease, all NAFLD patients should be considered for treatment to prevent the risk of cardiovascular disease, he said.

Diagnostic modalities in NAFLD include liver biopsy and noninvasive options such as radiologic tests, a predictive panel for fibrosis and serum biomarkers for NASH, Dr. Younossi said.

Still, problems with diagnosing NAFLD and identifying patients with NASH persist because patients are generally asymptomatic, and clinical presentations and current radiologic modalities cannot distinguish NASH or accurately detect fibrosis

“Therefore, in 2008, liver biopsy remains ‘the imperfect gold standard’ to diagnose and stage NASH,” Dr. Younossi said.

Data show that the best treatment of NAFLD now is weight loss, medication and following management recommendations, he said, because sustained weight loss improves ALT, but data do not show improvement for other important outcomes.

Finally, insulin-sensitizing agents, such as thiazolidinediones seem to improve both liver enzymes and histology, but the improvement seems to be temporary and the safety of long-term use remains an important issue, Dr. Younossi said.

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Final data for PROVE1 and R.E.V.E.A.L.-HBV studies reported

Gregory T. Everson, MD, presented final data for the Investigation of HCV PROtease Inhibition for Viral Evaluation (PROVE1) study to Monday morning’s AASLD Presidential Plenary II session, showing that adding telaprevir to standard therapy significantly improved virologic responses in treatment-naïve patients with hepatitis C. The study compared the efficacy of telaprevir (T), pegylated-interferon alfa (P) and ribavarin (R) versus PR given to patients with genotypye 1 hepatitis C.

The PROVE1 study randomized 250 patients into four groups: the control group (n=75) received PR for 48 weeks (PR48 group); 175 patients in the treatment arm received TPR for 12 weeks followed by PR for 0 (T12/PR12 group; n=17), 12 (T12/PR24 group; n=79) or 36 (T12/PR48 group; n=79) weeks.

The primary endpoint of PROVE1 was to determine sustained virologic response rates (SVR), defined as undetectable HCV RNA 24 weeks after the end of dosing. Patients on the T12PR12 and T12PR24 arms of the study were also required to achieve rapid virologic responses (RVR) at week 4 and maintain undetectable HCV RNA (<10 IU/mL) level through the end of their assigned dosing.

Eighty-one percent, 71 percent and 41 percent of patients on the T12PR48, T12PR24, T12PR12 and control arms achieved RVR at 4 weeks. Correspondingly, HCV RNA was undetected in 80 percent, 68 percent, 71 percent and 45 percent of patients at 12 weeks. Compared with patients on the control arm (PR48 group) of the study, significantly more patients on the T12/PR24 (61 versus 41 percent) and T12/PR48 (67 versus 41 percent) groups achieved SVR.

Relapse rates were markedly higher than patients on the T12PR24 and T12PR48 arms of the study.

Virologic failure, determined based on virologic breakthroughs, was low in patients receiving telaprevir, most occurring in the first four weeks of treatment. According to Dr. Everson these observations suggest that “firstly, addition of standard therapy to telaprevir lowers relapse rates. Secondly, in the short duration arms of the study, 12 weeks of standard therapy added to telaprevir is not sufficient for achieving sustained responses.”

Rash, gastrointestinal toxicity and anemia were adverse events more frequently seen in patients receiving telaprevir. In particular, maculopapular rash of more severe grades occurred in patients who received telaprevir. Fifteen percent and 7 percent of patients receiving telaprevir were reported to have rash of moderate and severe grades, respectively. Decreases seen in hemoglobin levels with 12 weeks of telaprevir were restored after 12 weeks, when patients no longer received telaprevir.

Dr. Everson concluded, “Telaprevir, when combined with at least 24 weeks of standard therapy with pegylated interferon and ribavarin achieved higher SVR rates compared with 48 weeks of PR treatment, suggesting the potential to halve treatment duration in most patients. In addition, in patients who achieve RVR, treatment beyond 24 weeks may not provide added benefits and would expose patients to potential risks.”

In another presentation, Uchenna Iloeje, MD, MPH, of Bristol-Myers Squibb, presented new data on the R.E.V.E.A.L.-HBV study that showed high viral loads and ALT levels at baseline and follow-up were significant risk factors for predicting hepatocellular carcinoma (HCC). The R.E.V.E.A.L.-HBV study was a population-based, prospective cohort study with a mean follow-up of 11.4 years. Analyses were presented on a subgroup of HBsAg seropositive patients and patients with confirmed HCC. Patients (n=1564) with high viral loads were compared with those with low viral loads (n=2020). Dr. Iloeje showed that patients with high ALT levels (=45 U/mL) at baseline and follow-up were approximately twice as likely to get HCC compared with patients with normal ALT levels (<15 U/mL). In addition, patients with viral loads of greater than one million at baseline and follow-up had up to an eight times higher risk for getting HCC. These data confirmed and extended earlier observations: that increasing HBV DNA level remains a very significant predictor of HCC after taking follow-up HBV DNA and change in serum ALT into account.

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GIs gain lifelong learning tools

AGA members now have the means to enhance their clinical performance with a unique interactive online educational tool — GI LEARN, the GI Lifelong Education And Resource Network. The AGA Institute developed this tool as part of its efforts to spearhead lifelong learning for members.

Champions of such learning gave DDW® attendees a glimpse of the robust nature of this and other online tools, which go far beyond just providing one-way educational programs.

Sponsored by the AGA Institute Education and Training Committee, presenters showcased Internet resources designed to assist gastroenterologists with developing goals for improving their clinical competence and tracking their CME and Maintenance of Certification (MOC) progress.

James B. (J.B.) McGee Jr., MD, AGA Institute editor for online education, looked at the effectiveness of interactive learning. While didactic interventions help people pass multiple-choice tests, this form of learning is poor in its ability change the manner in which someone teaches, treats patients and improves patient outcomes, he said.

“On the other hand, case solving, role playing and group discussions change the way we practice, and they improve our clinical outcomes,” Dr. McGee said. “It’s problem-based and reflective.”

Just as Wikipedia, Flickr, YouTube, MySpace and Facebook allow users to direct content, Dr. McGee said that gastroenterologists can share information and expertise with each others via GI LEARN (www.gilearn.org).

Those visiting these personal or “Web 2.0” sites direct the content through their own contributions rather than relying only on experts.

With GI LEARN, users can search both AGA Institute and external educational sources for content that matches their learning goals and build upon their already--created Personal Learning Portfolio (PLP).

The PLP allows AGA members to:
• Build their PLP, track CME credits earned through the AGA Institute — which are -automatically added to their PLP — and other meetings and activities.
• Create personalized educational plans based on their individual needs and learning interests.
• Link CME activities to their state licensure requirements.
• Track progress toward ABIM MOC.

In the next phase, planners hope to expand the self-assessment modules, connect members with common interests and tools via social networking, and allow members to guide other members through ratings and recommendations.

“Ongoing self monitoring is a process we go through every day to be the most effective physicians we can be,” said John F. Kuemmerle, MD, AGAF, AGA Institute editor for online self-assessment. “Once we have assessment of ourselves and our practices, we want some way to validate our efforts and our actions.”

Beyond relying on online point-of-care and evidence-based resources, gastroenterologists can assess themselves via the online self-assessment and MOC resources of GI SAM, which will launch in October.

GI SAM is specific to GIs in its case-based tests and practice improvement modules. Conforming to the principles of adult education, Dr. Kuemmerle said that GI SAM will allow users to identify weakness and then use resources to improve themselves and how they care for their patients.

Dr. McGee is assistant dean for medical education technology in the division of gastroenterology, hepatology and nutrition, director of the laboratory for educational technology, and an associate professor of medicine at the University of Pittsburgh School of Medicine. Dr. Kuemmerle is a professor of medicine and physiology and associate chair of GI research at the Medical College, Virginia Commonwealth University, Richmond.

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Translational Symposium reveals research about how gut flora affects behavior

Behavior has always been a suspect in GI symptoms, but recent research indicates that gut flora affects behavior as well. Presenting evidence to support the gut flora-behavior link was Stephen M. Collins, MBBS, during his presentation on “Bug-Brain Crosstalk: Implications for Functional GI Disorders and Beyond” in Sunday’s AGA Institute Translational Symposium.

“While gut microbiology does play a role in gut dysfunction and functional disorders, alterations in the delicate gut microbial balance may contribute to expression of primary behavioral problems such as depression,” said Dr. Collins, associate dean for research at McMaster University Faculty of Health Sciences, Hamilton, Ontario.

Dr. Collins identified the two seemingly polarizing processes as the “bottom-up model” versus the “top-down model.”

The bottom-up model is where acute gastroenteritis serves as a trigger for the dysfunctional disorders. Antibiotics may be linked to the development of these disorders, inducing an imbalance of the relationship of not only the good and bad bacteria but also between the consortium and the host, Dr. Collins noted. This leads to GI symptom generation and psychiatric co-morbidities.

The top-down model is characterized by behavioral changes that induce alterations in gut flora, resulting in dysbiotsis, low-grade inflammation gut dysfunction and GI symptom generation, according to Dr. Collins.

“For years, this field was dominated by the notion that functional disorders such as irritable bowel were primarily a behavior abnormality that resulted in reporting symptoms to the health-care system,” Dr. Collins noted.

In recent years, scientists began to theorize that gut microbiota affected behavior. They put this hypothesis to the test in recent studies on laboratory mice. Investigators altered gut microbial content through orally administrating neomycin, bacitracin and primaricin to laboratory mice for 10 days. What researchers found was that the mice lost their timidity and acted “almost psychotic” in their newfound boldness, according to Dr. Collins.

In still another study, laboratory mice were placed under the stress of maternal separation, which did cause changes in the flora content of these mice, Dr. Collins said.

“It is possible to unify these two polarized ideas of the top-down model and the bottom-up model in our functional GI disorders,” Dr. Collins said. “There is a bug-brain axis, and it is bidirectional.”

Another symposium speaker, Michael T. Bailey, PhD, the Institute for Behavioral Medicine Research, Ohio State University, Columbus, OH, hypothesized that exposure to stressors significantly affects the stability of the intestinal microflora during his presentation “The Impact of Early Life Stress on Bacteria Colonization of the Gut.”

“Stressors can activate the central nervous system, resulting in an endocrine response and behavioral changes, and how much these factors interact with each other increases susceptibility to disease or increases the severity of existing diseases,” Dr. Bailey said.

The effects of microflora on the host are no small matter, Dr. Bailey noted. Microflora metabolizes many substrates to produce multiple metabolites, produces vitamins and absorbs ions, influences epithelia cell proliferation, maintains immune homeostasis and serves as a barrier to pathogens.

“Exposure to a stressor would significantly affect the stability of the intestinal microflora, which would be manifest as a reduction of ‘protective’ microflora,” Dr. Bailey said.

To test his hypothesis, Dr. Bailey conducted several studies. For this experiment, “protective” microflora were identified as members of the genera lactobacillus and bifidobacterium.

In one experiment, infant rhesus monkeys were separated from their mothers when they came of age. The separation led to increased cortisol levels, altered mean levels of shed microflora and significantly reduced lactobacilli levels in the infant monkeys. In another study, pregnant rhesus monkeys were exposed to acoustical startle stress (random beeps) up to 147 days. The acoustical stress significantly increased circulating cortisol in pregnant females. The prenatal stress of this experiment affected the development of anaerobic microflora during the first 24 weeks of life.

“The number of bacteria shed in the stool is significantly affected upon stressor exposure early in the life span,” Dr. Bailey said. “Stressor-induced alterations in bacterial levels may enhance susceptibility to enteric infection.”

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Novices gain insights to capsule endoscopy

The use of capsule endoscopy has gained rapid favor in recent years, leaving physicians eager to test the waters. Capsule endoscopy novices got that opportunity during an Interactive Education Session Monday.

The course was designed to give attendees a thorough overview of the procedure, thus preparing them for further investigations.

Led by Christopher J. Gostout, MD, FASGE, the course reviewed basic types of pathology, interpretation of findings and assimilation of those findings into a basic management plan.

“The first thing in reading cases is managing your time. Do you read them all at once or chip away at your cases? When I open up a case, I try to determine the length of the small bowel study. I ignore everything in the stomach because imaging in the stomach is radically different than what you see in a flexible endoscope,” said Dr. Gostout, director of endoscopy research and development at the Mayo Clinic College of Medicine, Rochester, MN.

While he can “knock out” studies two to four hours in length, he takes a chip-away approach if they are six to seven hours in duration.

Dr. Gostout recommends that endoscopists use general bowel preps and interpret studies in four-quad imaging, which can be magnified.

“Preps will enable your ability to interpret, especially in early phases,” he added.

Designed to slowly deteriorate over 30 to 60 hours, the capsule by and large will pass through the stomach relatively well. However, if the capsule remains in the gut for more than two weeks, then capsule retention has occurred. While the predominant causes are NSAID use, Crohn’s disease and radiation enteritis, other indicators include small bowel tumors and surgical anastomotic strictures.

“The patency system took a long time to develop. It’s slick and it works. It will help you identify problems with retention,” Dr. Gostout added.

With regard to patients with implantable cardioverter-defibrillators, more data is needed. Although small bowel capsule endoscopy can be safely performed in a patient with an ICD, it is recommended that the procedure be done in the hospital under continuous monitoring with support from the cardiologist.

“We follow this to the letter, and now our cardiologists want to expel all our capsule patients from their monitored areas,” Dr. Gostout said.

This course was supported, in part, by educational grants from Given Imaging, Inc. and Olympus America.

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Session sheds light on P4P

The alphabet soup of pay-for-performance (P4P) was turned into words of explanation Monday during the ASGE Special Session Quality Indicators in Endoscopy: How it Affects Your Practice.

P4P has become a hot topic because health-care spending in the U.S. is expected to reach $4.3 trillion by 2017 with Medicare and Medicaid accounting for half of those costs, said Brian C. Jacobson, MD, MPH, FASGE, Boston University Medical Center.

“You have to look at the dollars to understand why this has become an issue in the forefront,” he said.

Dr. Jacobs reviewed the history of the movement to improve quality in health care, which led to the development of the CMS Quality Improvement Roadmap in 2005. The roadmap established quality measures, reimbursement guidelines to reward quality improvement and avoidance of unnecessary costs, and the greater use of electronic health records (EHS).

The alphabet soup comes from the many “relevant players” involved in P4P:
• PCPI — the AMA’s Physician Consortium for Performance Improvement that works with subspecialty groups to develop relevant quality measures.
• NCQA — the National Committee for Quality Assurance that maintains Health Plan Employer Data and Information Set (HEDIS) to monitor performance measures in health plans.
• NQF — the National Quality Forum, which “endorses” quality measures deemed valid and evidence-based on the advice of experts, but all members vote on proposed measures.
• AQA — the Ambulatory Care Quality Alliance, a joint venture of medical associations the Agency for Healthcare Research and Quality (AHRQ), and America’s Health Insurance Plans (AHIP) to adopt quality measures and promote uniformity in measures.
• QIO — Quality improvement organizations that work under contract with CMS in each state to help practitioners identify and implement improvements in health-care delivery and develop quality measures for public reporting.
• PQRI — the Physician Quality Reporting Initiative created by the Tax Relief and Health Care Act of 2006 to halt physician reimbursement cuts in 2007.

Physicians participating in P4P will submit PQRI information to CMS for payments, Dr. Jacobson said, adding that the measures are expected to remain the same in 2009.

Addressing P4P in the private sector was Tom Deas Jr., MD, FASGE, Gastroenterology Associates of North Texas, Fort Worth. who said that even though many physicians are unhappy with P4P, it has driven electronic medical records, e-prescribing and other measures that may very well become part of medical practice in coming years.

“Try to make yourself more efficient and add quality. That is the way we will be measured,” Dr. Deas said.

Program to promote quality in endoscopy
ASGE launched a program Monday designed to promote quality in endoscopy in all settings where it is practiced in the U.S.

The ASGE Endoscopy Unit Recognition Program will recognize endoscopy units that follow the ASGE guidelines on priveleging, quality assurance, endoscopy reprocessing and CDC infection control guidelines.

The first course that is part of the program, “Improving Quality and Safety in Your Endoscopy Unit,” is scheduled for Oct. 17 to 18 in Oak Brook, IL.

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Presidential Profile

In his life, John Bowen, MD, has faced crises as a surgeon in the Vietnam War and in the long weeks on call at the largest medical center open in New Orleans after Hurricane Katrina swamped the city.

So, he had the background to deal with the problems that could have surfaced during his term as SSAT president. Fortunately, Dr. Bowen didn’t have to deal with crises and was able to steer the society through a positive year.

“My number-one goal was to manage the organization in a way to take advantage of the talent that we have,” said Dr. Bowen, chairman emeritus of the department of surgery at the Ochsner Clinic Foundation, New Orleans. “We have several very active, productive committees, and I got to oversee the fruits of their work.”

The SSAT president has many obligations, but at the top of the list is to offer educational opportunities to members, especially by developing a strong program for DDW®.

“The Program Committee has put together one of the best programs I’ve seen since I’ve been a member, which is almost 30 years,” Dr. Bowen said. “We have an excellent program with great balance among clinical, translational and research papers, down to basic science.”

“We’ve also been working on putting together multidisciplinary, topical programs,” he said. “We have a lot of new video programming, which I think has become very attractive to attendees.”

Another priority is the continued growth of the SSAT Foundation, which is dedicated to funding research and educational activities related to principles established by the SSAT.

We’ve been raising money to fund research fellowships and the invited lectureships for the meeting,” said Dr. Bowen, who also served four years as SSAT treasurer. “We continue to raise money and spend it appropriately. We’ve worked quite a bit during the year on funding,” he added.

Dr. Bowen is quick to make it clear that running the SSAT is a team effort and that the president and chairman of the board head that team together. The chairman is the past president of the society, a position Dr. Bowen will assume after DDW.

“I’ve just tried to support people and to get everything done,” he said. “The society’s leadership is set up so you can grow into the job and gain more responsibility as you learn more about the organization. You gain maturity and perspective as you learn that.”

“I think that Bill Traverso, the past president and the chairman of the board, has shown a tremendous amount of leadership, and I just hope I can do the same next year. It is a tradition to hand down responsibility as you learn about the organization and the people in it,” he said.

Among the positive steps the society took during his term, Dr. Bowen included advancing some of the society’s nontraditional goals. For example, the SSAT developed a program to film 10 operations performed according to generally accepted standard procedures.

“We are doing this so there is a record of how these things were done when there was open surgery, and the procedures were not all laparoscopic,” he said. “We have a lot of history about surgery in our organization, so we are trying to record it for the future.”

While the SSAT’s emphasis is education, Dr. Bowen has strong personal feelings about the future of surgery as quality issues and reduced reimbursements change the culture of the profession.

“The reimbursement issue is almost a stepchild. It is my opinion that reimbursement is a big problem for surgeons,” he said. “The extent of the problem is not fully recognized, because as we are into declining reimbursements for surgery, what happens is that it begins to affect who goes into surgery and the choice of specialties. People begin to make decisions about so-called quality-of-life issues that, in the final analysis, often come back to remuneration in one form or another.”

“Surgery is not a life of comfort. You go into it because you love it and because you want to do it. But I can tell you that it is going to be a sacrifice in terms of quality of life, and you are going to make a lousy living if that trend continues,” Dr. Bowen said.

It is important that those in health care only look to make a fair living and not get greedy, he said.

Reimbursement issues are also important because so many physicians graduate from medical school with great education loans to pay.

“What does quality of life mean? It is how you live and interact with your family, certainly. But it also means that if I can’t make a good living, I can’t do what I want to do. I am concerned about that, and I hope that in the future, American medicine confronts this issue.”

SSAT President John C. Bowen, MD
John C. Bowen, MD, is chairman emeritus of the department of surgery at the Ochsner Clinic Foundation, New Orleans, where he has been on staff for more than 30 years.

After earning his medical degree from Columbia College of Physicians and Surgeons, New York, in 1967, Dr. Bowen was an intern, junior assistant resident, senior assistant resident, teaching fellow and chief resident in general surgery at the University Hospitals of Cleveland and Case Western Reserve University-Affiliated hospitals. Between these appointments he served in the U.S. Army as a clinical surgeon with the rank of captain in Vietnam. While in Vietnam, he was awarded the Bronze Star Medal for meritorious achievement or service. When he returned to the U.S., Dr. Bowen joined the division of surgery at Walter Reed Army Institute of Research, Washington, where he was appointed to the rank of major.

In 1973, Dr. Bowen moved to Houston, where he was a fellow in gastrointestinal physiology under Eugene D. Jacobson, MD, and then an assistant professor of surgery and physiology at the University of Texas Medical School. In 1976, he joined the Ochsner Clinic, where he became director of surgical education and research and chairman of the department of surgery. Dr. Bowen also has held the post of program director for two departments — general surgery and vascular surgery — for the Ochsner Foundation Hospital. Dr. Bowen has been the recipient of three NIH R01 grants.

Since 2001, he also has been president and chairman of the Board of South Louisiana Medical Associates, a medical group that provides professional staffing to one of Louisiana’s teaching hospitals.

Dr. Bowen has contributed to a number of surgical organizations, including as a member of the Board of Governors for the American College of Surgeons (ACS), president of the ACS Louisiana Chapter, president of the New Orleans Surgical Society, treasurer of DDW® and treasurer of SSAT.

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