The American College of Veterinary Surgeons The Second 25 Years

Abstract

The American College of Veterinary Surgeons (ACVS) has evolved to meet the needs of its members, the veterinary profession and the public since its inception 50 years ago. The founding and establishment of the College during the first 25 years are well documented by Dr. Ghery Pettit, a Charter ACVS Diplomate, in an excellent article commemorating the 25th anniversary.1 As we celebrate the 50th anniversary of the ACVS, understanding the events and lessons since 1990 is essential to the College moving confidently into the future. Possibly the most significant changes occurring over the past 25 years are the dramatic increase in Diplomate numbers and the migration of members to private practice. In 1989, there were 384 Diplomates of whom 10% were women, the majority were in academic practice and all Regents and officers were men.2 By 2014, there were 1,763 members of whom 35% were women, 84% small animal surgeons and 64% in private practice. During these years, the membership elected three female presidents (Fig 1);3 approximately 11% had attained emeritus status; and the title “Chairman” had officially been amended to “Chair” in the Constitution and Bylaws. The changes in the professional environment are also profound. In 2014, there were more than 11,000 veterinarians with Diplomate status in 22 AVMA recognized veterinary specialties.4 The European specialty colleges have flourished, with 21 veterinary specialty colleges including 2,304 specialists identified by 2006.4 Intense competition occurs for name and certification recognition, which translates into clients and income. Because practices are more lucrative, a significant number of Diplomates at universities migrate to the private sector due to salary differentials.5 Private practice surgeons are affiliated with large, well equipped multispecialty referral practices and increase their recognition as leaders in surgical innovation. This change in dynamics is affecting residency programs as residents, focused on developing the skills to excel in private practice, migrate to private practice residency programs. The advent of the digital age of websites and instant access to information has enhanced communications and documentation processes. The ACVS practices and policies affected by these changes include administration and governance, mission and objectives, public relations, residency programs, credentialing requirements and examination protocols. The evolution from a mostly volunteer administrative force headquartered in Dr. Al and Carolyn Schiller's basement to a professional office staff marked a significant change. In 1990, Past President and long-time Executive Secretary, Dr. Schiller retired from administration of the organization (Fig 2). He and Carolyn long provided a personal touch to the College and its members. The transition to a management company, PAI Management, was difficult, as the officers and Regents had concerns regarding the cost of management and the issues involving sharing an Executive Director with other organizations. However, when Ann Loew, an employee of the management company, was assigned to the ACVS, the right chemistry was achieved. By 1998, the ACVS had established an independent office, hired Ann Loew as Executive Director (Fig 3) and hired a part-time employee. As a sign of the continuing evolution of the College, by 2014 the ACVS had 10 employees, the Executive Director's title changed to Chief Executive Officer and the office was housed in a purchased office condominium. With professional staff in place, responsibility for some portions of College governance was absorbed internally. While the College was still governed by a Board of Regents consisting of 6 elected Regents and 3 elected officers, along with non-voting members including an Executive Secretary, Treasurer and Recorder each appointed for 3-year terms, 2 appointed positions were eliminated. Dr. Ann L. Johnson was the last Recorder and the Executive Secretary position was eliminated when Dr. Alan Lipowitz retired in 2010 (Fig 4). Other administrative changes occurred as the College grew. Because newer Diplomates were less aware of the current issues, criteria were established for member eligibility for Regent (5 years as a member) and President-elect (10 years as a member and previous service as a member of the Board of Regents). Nominations for Regents and officers became species-specific to insure equal representation for large animal surgeons, despite the overwhelming majority of small animal Diplomates. The unwieldy committee structure was streamlined by limiting the number of standing committees and forming ad hoc committees as needed. Additionally, the protocols for standing committees were removed from the Bylaws, where changes required a vote by the membership and replaced by documents that could be modified by the Board of Regents. Similarly, the method of raising dues changed from requiring an affirmative vote by the members to the Board of Regents determining dues rate as needed, not to exceed an increase of 3.5% per year. Opportunities for member involvement have also evolved. When the Annual Meeting and Surgical Forum were combined into 1 meeting, the requirement that all members attend 1 of the yearly meetings became impossible to enforce and still allow for coverage at surgical practices. The Constitution and Bylaws were amended to allow more member participation in governance from afar. Voting by mail which was established for elections and approving changes in the Constitution and Bylaws has evolved to electronic voting. The quorum for the Annual Business Meeting decreased from 1/3 of all members to the members present at the Annual Business Meeting. The Annual Business Meeting transformed from unstructured, often contentious experiences to tightly scheduled informational opportunities that included messages from meeting sponsors. With the advent of the digital age of websites and social media, the printed newsletter, which had gained importance as a primary communication vehicle, was replaced with information delivered through the ACVS website, email, a monthly e-bulletin Cut to the Point and Facebook. In 1990, according to Article III of the ACVS Constitution, the objectives of the College were the “advancement of the art and science of surgery and protection of the public against incompetence by developing methods of graduate teaching in veterinary surgery with particular reference to the resident system, establishing an agency to certify veterinarians as specialists in surgery and encouraging its members to pursue original investigations and contribute to the veterinary literature.” The mandate to protect the public was interpreted by many members of the College to mean taking a leadership role in defining the standards of veterinary surgery for the profession by providing excellent continuing education to veterinarians. At the same time, with the growth of Diplomates in private practice, educating the public about the roles of the surgeon and the referring veterinarian was an emerging priority. To an extent these two issues have been competitive; some Diplomates question the practice of providing detailed surgical education to referring veterinarians. However, by 2000 additional objectives defining the role of the ACVS in setting the standards for surgical education for the veterinary profession and in providing positive public relations for its Diplomates were added to the Constitution. A stated objective is to provide surgical education not only for ACVS Diplomates, but also for other members of the veterinary profession and the public. The concerns about protection of the public are restated by emphasizing the role of the College in providing excellent service to the public. Continuing surgical education for veterinarians provided by Diplomates has been a part of the ACVS almost from the beginning. According to Dr. Pettit, “The first Veterinary Surgical Forum, held November 1-2, 1973, at the Hyatt Regency O'Hare Hotel near Chicago, attracted nearly 400 veterinarians” and “From its inception, the Veterinary Surgical Forum has been the most comprehensive continuing education program on veterinary surgery in the world, with a justified reputation for excellence”.1 Initially, Diplomates were not compensated for speaking at the Forum, considering presenting at the Forum a membership obligation. Since the Forum was designed to provide continuing education for all veterinarians, the ACVS Annual Scientific Meeting, held in February, was designed for Diplomates and their residents, serving as a venue for research presentations, the Annual Business Meeting and the examination. In 1990, the meetings were combined to become the Surgical Symposium held in the fall at varying locations. Administration of the examination continued to be in February at various locations until a snowstorm in Reno, NV, affected arrival of examiners and examinees alike. Subsequently, the examination moved to Las Vegas and eventually to San Diego, free from winter weather woes. In 2004 and 2005, an attempt was made to reintroduce a “Diplomates-only” meeting, held in resort settings, but the concept succumbed to low attendance and budget issues. Since the Forum's inception, the development of the educational program and administration was performed by a committee of volunteers headed by a conference Chair, a position which evolved into a 3-year rotation. Drs. Nancy O. Brown and Ron D. Montgomery served as Chairs and dedicated stewards of the early Symposia. As the competition for continuing education dollars and the ACVS's dependence on Symposium income for College operations increased, continuity of leadership became paramount. In 1997, the Board of Regents established a longer-term Symposium Director position and Dr. Nathaniel White II, Past President and Chair of the Symposium Committee, was appointed as Symposium Director (Fig 5). Under his guidance, the popularity of the Symposium has grown with attendance reaching more than 1,700.6 The programing has also evolved to include more research presentations, seminars by allied medicine specialists, laboratories and over 140 exhibitors. In 2014, the name of the meeting changed to the ACVS Surgery Summit to better represent the highest level of continuing education and research results in veterinary surgery. Also in keeping with the objectives in the constitution, the ACVS has enhanced its support for research (i.e., original investigations) by increasing opportunities for funding and recognition. In 1990, small amounts of funding were available only for a few resident research projects and the awards were limited to the Resident Presentation Award and Resident Publication Award. Funding increased significantly with the establishment of the ACVS Research and Education Foundation in 1992 (Fig 6), which was later renamed the ACVS Foundation. As an independently-chartered nonprofit philanthropic organization, the Foundation is devoted to the advancement of surgical care of all animals through funding of educational and research opportunities for veterinary surgical residents and board-certified veterinary surgeons. Surgeon-in-Training Research Grants were offered to candidates in ACVS residency programs and Diplomate Clinical Research Grants were designed to fund projects that utilized either clinical case material or experimental projects to address a clinically-oriented surgical problem. Not only have donations from Diplomates supported the grants, but industry has also provided significant research grant funding. As of 2014, more than 90 research projects have received funding totaling over $930,000. Similarly, recognition of Diplomate and non-Diplomate contributions to veterinary surgery became prominent with the advent of the ACVS Founders' Award for Career Achievement and the ACVS Merit Award. The ACVS Foundation has also sponsored the Legends Award, Outstanding Surgical Resident Awards and the Student Proficiency in Surgery Awards. The ACVS promotes contributions to the literature by publishing Veterinary Surgery, a scientific journal, which disseminates surgical information and the results of surgical research. When Dr. Ghery D. Pettit became Editor-in-Chief in 1987, he guided the journal to its acceptance by the National Library of Medicine for indexing and inclusion in Index Medicus and its database. Subsequent Editors-in-Chief Drs. Phil Vassuer and John Pascoe continued to provide excellent leadership, overseeing Assistant Editors and reviewers. Together they have contributed to the development of an outstanding journal, which has grown in readership, citations and prominence. Reflecting the increasing time commitment to steward the journal, upon John Pascoe's retirement as Editor-in-Chief in 2014, the Board established Co-Editors-in-Chief positions, with Drs. Linda Dahlgren and Giselle Hosgood assuming these roles. In 2000, the ACVS entered the digital age of disseminating surgical information by providing electronic access to Veterinary Surgery (Fig 7). In 2003, the journal changed publishers from Elsevier to Wiley Blackwell and, in 2012, the number of issues published annually increased from 6 to 8. The journal increased its scope to become the official journal for the European College of Veterinary Surgeons (ECVS) and the Veterinary Endoscopy Society. The policies of the ACVS were not only developed to ensure that the public is protected from false claims of competence, but also to promote accurate representation of specific skills and focused education. As the training programs and examination procedures continued to diverge into large and small animal specific areas, the College voted, in 1999, to issue species specific diplomas. This decision triggered the American Board of Veterinary Specialties (ABVS) to request that the ACVS formally establish two recognized veterinary specialties within the ACVS, the parent recognized specialty organization for veterinary surgery. Subsequently, a pathway to dual certification was developed. Additionally, to recognize Diplomates who have chosen to focus on a specific area of surgery, the ACVS established the concept of fellowship programs. In 2013, the first fellowship program, the ACVS Fellowship in Surgical Oncology, was formally recognized. To conform to ABVS initiatives and continue to assure the public that ACVS Diplomates provide the ultimate in surgical expertise for their patients, maintenance of certification requirements will be implemented in 2016. Although protection of the public against incompetence by developing methods of graduate teaching in veterinary surgery has been one of the objectives of the ACVS since the College was formed, active involvement in public relations has been a recent initiative. The emergence of specialty practices and the increased number of ACVS Diplomates in private practice compelled the College to increase public awareness of the benefits of referral to board certified surgeons for both the patient and the client. Initiated in 1996, the ACVS website primarily served the Diplomate community. But after two major redesigns, the website is also used effectively to inform animal owners about the value of a board certified surgeon as a member of their animal's care team. Information about the process of board certification, frequently asked questions about surgery and concise descriptions of common diseases treated best with surgery and the surgical procedures used are all available to the public. In addition, the Diplomate directory provides instant access to the closest ACVS surgeon for both owners and referring veterinarians. Brochures are available for Diplomates to distribute to animal owners and referring veterinarians and the ACVS publishes a column, “Surgery STAT” in DVM Newsmagazine. Despite some changes in the mission and objectives of the ACVS, the core purpose of educating and certifying surgeons is still paramount. Over the past 25 years, the total number of residency programs has increased with a shift from almost exclusively academic-based to a combination of academic- and private practice-based programs. The program guidelines and requirements have been refined with an increase in documentation and the elimination of many inconsistencies and loopholes. The goals are to standardize training experiences and assure consistently adequate preparation for admission to the College. In 1989, the Board of Regents developed a new concept for residency programs based on the resident documenting his or her training activities. The Regents also proposed that all residency programs, whether academia or private practice, would incorporate the same basic requirements. The resident had to complete 3 years (156 weeks) of documented training under the supervision of at least 1 Diplomate, but that training could occur in smaller segments of time spread out over many years (in 2004, a time limit of 6 years for a residency was instituted). This flexibility was proposed to meet the ABVS requirement for alternative training pathways for those practitioners who could not enter a sequential 3-year program. Residents maintained a surgical case log listing all procedures performed as primary or assistant surgeon on elective or emergency basis, a weekly activity log documenting clinical service rotations, rounds, seminars, lectures attended and other professional activities and a presentation log documenting 6 scientific seminars presented by the resident. Residents were also responsible for documenting anesthesiology, pathology and radiology training rotations. Over the years, the criteria for residency training administration have developed into a rigid structure of documentation and verification in an attempt to standardize the training experiences. The Program Director became responsible for verifying pre-residency training and assuring suitable facilities and resources for the program while the Resident Advisor performed semi-annual progress evaluations and reviewed logs prior to submission. Meanwhile the Diplomate supervisors, who must have the appropriate expertise for species and procedure, are responsible for the day-to-day education and supervision of the resident. The Program Director, Resident Advisor and Diplomate Supervisor can be the same person. Since 2004, the Program Director and Resident Advisor have been required to be in the same location as the resident for the majority of the residency. After 2005, a new requirement mandating at least 12 weeks of training with a second Diplomate eventually led to the requirement established in 2014 that all programs have at least two full-time Diplomates working in the same location as the resident. The ACVS, through the Residency Program Committee, assumed responsibility for evaluating each resident's progress and communicating deficiencies to that resident. The concept was to help residents identify and remedy deficiencies early in their training. What followed were ever increasing requirements and an explosion of forms. Requirements for case log documentation included identifying assisting and primary surgeons, listing only major surgical cases (e.g., no routine neutering, declaw or dental prophylaxis procedures) and logging research surgical procedures separately. The Residency Program Committee also recommended that 1st year residents perform at least 50% of their surgical procedures under the supervision of a Diplomate. Standardized log forms, along with summary and cover sheets and a documentation form for ancillary specialty training, were developed. In 1997, the Residency Program and Credentialing Committees were combined to form the Resident Credentialing Committee to streamline oversight of residency programs and credentialing. At that time there were 11 official forms, including a Program Director's Statement to initiate a resident's training, a Resident Advisor Assignment form and a Resident Advisor's Statement of satisfactory progress in the program. By 2000, the ACVS Information Brochure detailed the requirements and included all required forms and in 2003 tabs were inserted to help access pertinent information. The forms for documentation and verification of the ACVS residency program were available electronically in 2002. However, because verification signatures were needed, all documents were printed and submitted along with the electronic file to the ACVS office each year, resulting in the annual August ritual of numerous large boxes of resident program documentation arriving at the ACVS office. The documentation was collated and mailed to the Committee for review. Following the 2005 residency program strategic planning meeting, a web-based documentation system was developed, eliminating submission of printed logs (Fig 8). Although the documentation became more intensive, the breakdown of the requirements by number of weeks remained virtually the same: 94 weeks of clinical training (defined as receiving, daily management of cases, clinical teaching, clinical service and communication and emergency duty) supervised by an ACVS Diplomate and 31 weeks (special rotations) in graduate studies, research, visiting a human hospital, writing manuscripts, doing ancillary training, attending conferences, or external veterinary rotations with the advisor's approval. Activities during the remaining 31 weeks were not dictated by the ACVS, and in 1993, those weeks were specified as Program Director's choice time. Also in 1993, the ACVS officially recognized neurosurgery rotations supervised by an American College of Veterinary Internal Medicine Neurology Diplomate could fulfill any of the 156 activity weeks of the residency. By 2004, surgical rotations in ophthalmology and dentistry supervised respectively by Diplomates of the American College of Veterinary Ophthalmologists and the American Veterinary Dental College also counted as Diplomate supervised rotations. Vacation was always an issue and initially vacation time was required to come from either special rotation or Program Director's choice rotation time, but later was limited to Program Director's choice time. In 1995, the requirements for training in related specialties changed to 80 hours in anesthesiology, pathology and radiology, as well as 80 hours of internal medicine training. By 1997, in an attempt to simplify the logs, residents were asked to classify weekly activity as either Diplomate supervised rotations, non-Diplomate supervised rotations, special rotations or vacation. As the number of residencies in private practice increased, those Diplomate supervisors criticized the residency program guidelines for limiting the on-service operating time, while the Resident Credentialing Committee grew more concerned that research time was being neglected. In response to these and other concerns, the first major shift in time requirements for resident training since the inception of the program occurred in 2013 when the number of Diplomate supervised surgical rotations increased to 110 weeks (a 10% increase). Additionally, the 31 weeks in the special rotations category was divided into more specific components: 18 weeks for research and manuscript preparation; 8 weeks for training in other specialties; and the remaining 20 weeks left to the program's discretion. Additionally, since the needs for training in ancillary specialties of large animal residents differed from that of small animal residents, the required training in other specialties became species specific. Over the years the concept of changing to program approval based on documentation submitted by the Diplomates rather than a resident responsibility to verify the programs has been hotly debated. Many of the participants in the 2005 residency program strategic planning favored moving to a program approval system replacing the need for resident logs. Although not implemented at that time, the issue continued to generate discussion. New Residency Training Standards and Requirements now mandate that, starting in 2015, training programs must submit documentation for evaluation by the Residency Program Compliance Committee to become an ACVS-registered training program, which must be renewed annually. However, documentation of training by the resident will continue to be a vital part of the training evaluation. The publication requirement has also provoked hours of debate about both its necessity and role in the evaluation process. The requirement stems from the College's mission to pursue original investigations and contribute to the veterinary literature. In 1991, 2 publications resulting from the resident's research or practice of surgery published no more than 5 years before credentials submission in which the resident was sole or senior author were required. The papers had to be surgically relevant, “above the level of a case report” and at least fully accepted for publication in a refereed journal with an established editorial board. Responsibility for evaluating the quality and accepting the publication rested with the Credentials Committee. Often the committee found at least 1 of the 2 required papers did not meet the requirements. The Board of Regents responded to consistent concerns vocalized about the difficulties in developing 2 acceptable scientific papers during a 3-year training program by dramatically changing the publication requirement in 1993. The new requirement was 1 scientific publication that followed the scientific method, including an introductory statement, a hypothesis or objective, a description of techniques, results, discussion and conclusion and was fully accepted by a refereed journal. Clinical studies fulfilling the above criteria were acceptable. The expectation was that each resident would learn about scientific methodology by conducting a project and writing a scientific paper. Because this change in publication requirement could be applied retrospectively if the resident wished, there was a sudden increase in the number of residents applying for examination as the lack of 2 acceptable papers had prevented many individuals from applying earlier. In 1995, the Board of Regents continued to facilitate credentialing by developing a list of approved journals for a manuscript. The concept was that if the paper followed the scientific method and was accepted by an approved refereed journal then that paper should fulfill the ACVS's requirements. Residents seeking to publish in a journal not on the list must petition to add the publication to the approved list. In 2003, the Resident Credentialing Committee began offering an early review process to accept manuscripts. Despite these changes, controversy occurs yearly about the definition of scientific method and discussions continue regarding the relevance of the publication requirement. Prior to 1996 there were no requirements for the resident to submit documentation of the number and type of surgeries performed during their programs. In 1995, residents were asked to categorize and record the numbers of cases operated in each organ system and the next year the ACVS membership voted to require that small animal residents perform a minimum of 380 surgeries and large animal residents perform a minimum of 250 surgeries. By 1997, the Board of Regents had more specifically defined the core curriculum to identify required numbers of cases in each system category. The large animal core curriculum was further divided into equine emphasis and general large animal emphasis. In contrast to the specific procedures required in the large animal curriculum, the small animal curriculum encompassed broad categories along regional and organ system lines. By 2000, the required cases increased to 400 for small animal residents and 300 for large animal residents. Residents were also required to be directly supervised by a Diplomate (defined as having a Diplomate at the surgery table or in the operating room) for half of the cases in each category. As the numbers of yearly submitted logs and the complexity of reviewing the logs increased so did the number of Diplomates on the Resident Credentialing Committee. A tremendous amount of time was required for log review, verification of case numbers and response to the residents. The Resident Credentialing Committee continues to recommend changes to the case requirements as new surgical procedures are developed and techniques are mastered, insuring that residents are educated to be competent in all current surgical areas. The ACVS has been largely silent regarding the didactic curriculum of a residency program. Each program is responsible for insuring the didactic program enables residents to learn all aspects of surgery. In many programs this is accomplished with didactic lectures, literature reviews, journal clubs and reading assignments. Consideration has been given to developing a model curriculum or online information modules that could be accessed by all programs. The change in 2014 to a 2-phase examination process and in 2015 to a greater emphasis on educational events are first steps in further evolution in this area. Credentialing components completed before application have also changed over the past 25 years. The 5 year, 3-phase training program developed during the first 25 years of the ACVS gave way to a more streamlined 3 year residency program, eliminating what some saw as a waiting period before submitting credentials. Although the particular requirements for residency training programs and publications have varied over the years, credentialing has stabilized at the successful completion and approval of all Resident Training Requirements, acceptance of 1 scientific manuscript in an approved journal and submission and acceptance of a Credentials Application. The examination has improved significantly over the past 25 years in both content validation and standardization of delivery. Initially the examination included written questions, interpretation of slides and radiographs and oral questions about the literature and the field of the candidate's interest. Large and small animal candidates took the same examination. Candidates who failed 1 or 2 parts of the examination could repeat those parts, but only 3 attempts were permitted. As the training programs for large and small animal surgeons diverged so did the examination. Separate examinations composed of 3 sections, practical, case-based and written, were developed for large and small animal examinees, although approximately 25% of the written questions were general in nature and appeared on both the examinations. The general content and the weight of each content area for all 3 test components were determined by analysis of the veterinary surgeon's activities in practice. On occasion there were significant concerns about the defensibility of the examination process. In the late 1980s, an examination service was hired to help the Examination Committee improve the examination construction, delivery and scoring process. In 2004, the oral examination, considered too subjective, variable and stressful, was replaced with a case-based written examination. The examination continues to evolve as a 2-phase format is instituted for residents whose training started in 2014. The motivation for the change is to strengthen surgical training in all ACVS residency programs by encouraging the earlier learning of fundamental surgical principles that would immediately benefit residents in clinical training. Residents will be eligible to take the Phase-I Surgical Knowledge examination during the 2nd year of their residency and the Phase II Surgical Competency examination after completing all residency training and credentialing requirements. In 1991, the ACVS was joined by the ECVS as a specialty College dedicated to the advancement of surgery. The 2 Colleges have maintained an excellent relationship over the past 20 years. The collaboration between the 2 Colleges started in 1993 as the first examinations were organized for charter ECVS members using experienced ACVS Diplomates with close European ties as examiners. Since then, outgoing members of the ACVS Examination Committee have been invited to be part of the ECVS Examination Committee for the following year. ACVS Diplomates who meet the criteria for ECVS membership may petition that Board of Regents for membership. Veterinary Surgery is the official journal of the ECVS. The ECVS logo appears on the cover, ECVS members serve on the Editorial Review Board and there is a European Associate Editor. Another formal tie has been the ritual invitation for the president of each group to attend the other groups' annual business meeting and address the College membership (Fig 9). The ACVS matured during its second 25 years into a robust, well-administered organization whose leadership role in veterinary surgery is recognized worldwide. Contributing to this distinction are thousands of volunteer hours provided by Diplomates out of loyalty to the ACVS and a strong passion for accomplishing the College's mission and objectives. Over the past 25 years, there have been at least 25 President-elects, Presidents and Chairs of the Board of Regents, 1 Executive Secretary, 3 Treasurers, 50 Regents, numerous committee chairs and myriad committee members who have given freely of their time and talents. This devotion, in combination with a skilled and dedicated office staff, has propelled the ACVS into the 21st century and laid a secure foundation for continuing to demonstrate an unwavering commitment to excellence in veterinary surgery. Obviously, only a very small percentage of all of these dedicated Diplomates have been identified by name in this document due to limitations in space. Diplomates present at key transitions in the ACVS organization were more likely to be identified; however, a sincere “Thank You” goes to all Diplomates for contributing significantly to the evolution of the College. Because of these contributions, the ACVS is well positioned to lead the veterinary profession for the next 25 years. Ann L. Johnson, DVM, MS, Diplomate ACVS ACVS Past President University of Illinois