Brigham and Women's Hospital Department of Surgery Harvard Medical School External Review 2017-2021

Department of Surgery Harvard Medical School Review 2016-2021

TABLE OF CONTENTS Department Chair’s Narrative A. Executive Summary..........................................................................................................1 B. Department History and Background ..............................................................................1 C. Governance and Organizational Structure ......................................................................5 D. Goals and Objectives........................................................................................................8 E. Areas of Excellence/Major Accomplishments .................................................................8 F. Challenges and Barriers to Success................................................................................11 G. Opportunities Over the Next Five Years ........................................................................13 Clinical Services A. Overview and Organization ...........................................................................................15 B. Clinical Operations…………………………………………………………………………………………………….20 C. Clinical Volume……………………………... .............................................................................26 D. Relationship to Hospital Goals and Initiatives ...............................................................28 E. Relationship to Activities/Needs of Other Departments...............................................31 F. Quality and Safety..........................................................................................................33 G. Network Affiliations and Programs................................................................................35 H. Constraints and Challenges to Success ..........................................................................39 Division Reports A. Breast Surgery................................................................................................................42 B. Cardiac Surgery ..............................................................................................................49 C. General and Gastrointestinal Surgery............................................................................57 D. Oral Medicine.................................................................................................................67 E. Otolaryngology—Head and Neck Surgery .....................................................................72 F. Plastic and Reconstructive Surgery................................................................................79 G. Surgical Oncology...........................................................................................................84 H. Thoracic Surgery ............................................................................................................93 I. Transplant Surgery.......................................................................................................100 J. Trauma, Burn and Surgical Critical Care ......................................................................106 K. Urology.........................................................................................................................115 L. Vascular and Endovascular Surgery………………………………………………………………………… 124

Research A. Overview ......................................................................................................................131 B. Research Funding.........................................................................................................134 C. Resources.....................................................................................................................139 D. Clinical Research ..........................................................................................................142 E. Research Centers .........................................................................................................146 F. Research Programs ......................................................................................................153 G. Junior Faculty ...............................................................................................................161 H. Resident Research........................................................................................................170 I. Current Challenges.......................................................................................................173 J. Future Goals.................................................................................................................173 Surgical Education A. Overview and Organization .........................................................................................175 B. Education Leadership...................................................................................................176 C. Major Accomplishments ..............................................................................................177 D. Neil and Elise Wallace STRATUS Center for Medical Simulation .................................180 E. Medical Student Teaching........................................................................................... 181 F. Current Residency Programs………………………………………………………………………………..... 188 G. Current Fellowship Programs ......................................................................................189 H. Continuing Medical Education.....................................................................................189 I. Visiting Professors........................................................................................................191 J. Constraints and Challenges..........................................................................................194 Faculty, Leadership, and Administration A. Overview ......................................................................................................................197 B. Process for Decision-Making........................................................................................203 C. Faculty Affairs ..............................................................................................................204 D. Communication with Faculty .......................................................................................216 E. Named Chairs...............................................................................................................217 F. Faculty Honors/Awards................................................................................................218

Department Finances A. Overview……………………………………………………………………………...................................... 223 B. BWPO Operating Performance………………………………………………………………………………. 223 C. BWH Operating Support ..............................................................................................226 D. Capital Expenses ..........................................................................................................228 E. Harvard Medical School Funding……………………………………………………………………………. 229 F. Research Finances………………………………………………………………………………………………….. 229 G. Physician Compensation Plan…………………………………………………………………………………. 229 Resources A. Space: Clinical, Research, Admin .................................................................................233 B. Major Equipment .........................................................................................................235 C. Fundraising...................................................................................................................236 D. Communications/Marketing/Media Relations ............................................................238 Strategic Plans A. Clinical Strategy............................................................................................................243 B. Research Strategy ........................................................................................................246 C. Educational Strategy ....................................................................................................247 D. Department of Surgery Environment Strategy……………………………………………………….. 248 APPENDIX 1. Faculty List 2. Residency Program Descriptions 3. Fellowship Program Descriptions 4. ACGME Surveys 5. Department of Surgery Annual Reports

Department Chair’s Narrative A. EXECUTIVE SUMMARY The Department of Surgery (DOS) centered at Brigham and Women’s Hospital and Brigham and Women’s Physician Organization (BWPO) is a large, multidisciplinary group of 176 faculty members who have diverse specialty interests and varying balances of clinical, research and teaching effort. For a full list of the faculty, please refer to Appendix 1. The DOS includes all surgical specialties except for orthopedics, neurosurgery and OB/Gyn. Our clinicians work in a variety of settings, including not only the primary settings in the Longwood Medical Area but at network and training affiliates throughout Massachusetts and Rhode Island: • Brigham and Women’s Faulkner Hospital • Patriot Place in Foxborough • VA Boston Healthcare System • South Shore Hospital • Boston Medical Center • Cape Cod Hospital • Southcoast Health • Milford Regional Medical Center • Steward Healthcare • Care New England in Rhode Island B. DEPARTMENT HISTORY AND BACKGROUND The Department of Surgery’s clinical history begins in 1913 with the opening of the Peter Bent Brigham Hospital, across the street from Harvard Medical School. Shortly thereafter, the trustees of the hospital appointed Harvey Cushing, MD, to be their first surgeon-in-chief. Following Dr. Cushing, Elliott Cutler, MD, Francis Moore, MD, John Mannick, MD and Michael Zinner MD were surgeons-in-chief at the Brigham. The unique contributions of these leaders created a strong foundation for our department. The Brigham remained a small 250-bed hospital until 1980, when Brigham and Women’s Hospital welcomed patients to its new, state-of-the-art facility, resulting from the merger of three prominent hospitals: Boston Hospital for Women, the Peter Bent Brigham Hospital and the Robert Breck Brigham Hospital. 1

About Brigham and Women’s Hospital Brigham and Women’s Hospital is a world-class academic medical center based in Boston, Massachusetts. The Brigham serves patients from New England, as well as from across the United States and from 120 countries around the world. A major teaching hospital of Harvard Medical School, Brigham and Women’s Hospital has a legacy of clinical excellence that continues to grow year after year. The Brigham network includes 1,200 doctors throughout New England, working across 150 outpatient practices. An international leader in virtually every area of medicine, the Brigham has led numerous medical and scientific breakthroughs that have improved lives around the world. U.S. News & World Report ranks Brigham and Women’s Hospital among the best hospitals in many specialty areas, including cancer, cardiology and heart surgery, diabetes and endocrine disorders, ear, nose and throat, gastroenterology and GI surgery, geriatric care, gynecology, neurology and neurosurgery, orthopedics, pulmonology, rheumatology and urology. Mass General Brigham: An Integrated Health Care System Brigham and Women’s Hospital is part of Mass General Brigham, an integrated health care system that consists of 16 member institutions encompassing a range of health care organizations. (Mass General Brigham was formerly known as Partners HealthCare, when it was founded in 1994 by Brigham and Women’s Hospital and Massachusetts General Hospital.) In addition to our academic medical centers, these member institutions include top-tier specialty hospitals, community hospitals, a rehabilitation network, a health insurance plan, a physician network, a teaching organization and many locations for urgent and community care. Working together as one system, our health care organizations can leverage their collective expertise, resources and compassion to better serve patients and the community. 2

Department of Surgery: Historical Milestones Brigham and Women’s Hospital surgeons are international leaders in every surgical specialty. They have been, and continue to be, innovators who create pioneering breakthroughs that improve lives around the world. 2016 – The Brigham performs a life-changing bilateral arm transplant on retired Marine Sergeant John Peck, who became a quad amputee in 2010 after he stepped on an improvised explosive device (IED) in Afghanistan. 2016 – The Brigham performs the first-of-its-kind Ewing amputation. Named after the patient, Jim Ewing, the procedure helps him perform complex actions and feel sensation by allowing his brain to interact with the robotic prosthetic. 2013 – Brigham researchers found that using checklists in the operating room improve performance during a crisis; teams using checklists were 74% less likely to miss key life-saving steps than those working from memory alone. 2012 – The Brigham performs the first total artificial heart implant in New England. 2011 – The Advanced Multimodality Image-Guided Operating (AMIGO) suite opens so that multidisciplinary medical teams can access any of the advanced imaging and surgical technologies available, whether before, during or after a procedure. 2011 – Surgeons at the Brigham perform the first successful bilateral hand transplant in New England. 2009 – The Brigham completes the second partial facial transplant in the United States. 2005 – The Brigham establishes the Center for Surgery and Public Health (CSPH), a joint program of Harvard Medical School (HMS) and the Harvard School of Public Health (HSPH). The center’s connectivity to these rich academic environments provides essential access to interdisciplinary expertise and resources, both inside and outside of surgery. 2005 – The Brigham completes its 500th heart transplant, the most for any New England hospital. According to the United Network of Organ Sharing (UNOS), this historic operation adds the Brigham to an exclusive nationwide list of hospitals that have reached this mark. 2004 – The Brigham performs the nation's first implant of the new Intrinsic dual-chamber implantable cardioverter-defibrillator (ICD). The Intrinsic ICD is the world's first ICD with a pacing mode designed to promote natural heart activity and reduce unnecessary pacing in the lower right chamber of the heart. 2004 – The Brigham achieves another transplant first in the United States—five lung transplants in 36 hours. Hundreds of staff members — including doctors, nurses and intensive care staff — come in during their weekend time off to assist. 2000 – In what is believed to be a first in organ transplantation, the Brigham performs a quadruple transplant, harvesting four organs from a single donor—a kidney, two lungs and a heart—and transplanting them into four patients. 1999 – The Brigham is the first in New England to perform implantation of a left ventricular assist device (LVAD) for long-term treatment. 1998 – Then known as Peter Bent Brigham Hospital, Brigham and Women’s Hospital became one of the first hospitals worldwide to dedicate a postoperative unit to the critical care of surgical patients. The Department of Surgery reformulated its multidisciplinary intensive care unit team and started the 3

Brigham surgical intensive care service consisting of general surgeons, anesthesiologists, pulmonologists and thoracic surgeons. 1996 – The Brigham becomes one of only 10 hospitals in the country to perform minimally invasive aortic valve surgery. 1995 – The Brigham performs the first minimally invasive adrenalectomy in New England. 1994 – The Brigham unveils the world's first intraoperative magnetic resonance imaging (iMRI) system. This invention, which enables clinicians to take images of the body's interior during surgery, makes it possible to cure patients with brain tumors that previously were considered inoperable. 1992 – The Brigham performs the first heart-lung transplant in Massachusetts. 1984 – The Brigham performs the first heart transplant in New England. 1979 – U.S. trials of cadaver renal transplantation with the first use of the immunosuppressant drug cyclosporine A, now standard therapy for organ transplant patients, begin at the Peter Bent Brigham Hospital and the University of Colorado. 1977 – Introduction of EEG-guided carotid surgery. 1972 – Introduction of cardiac-output guided aortic surgery. 1969 – Early work begins on Extracorporeal Membrane Oxygenation (ECMO), also known as extracorporeal life support (ECLS). 1960s – Dwight Harken, MD, the chief of Thoracic Surgery at the Peter Bent Brigham Hospital from 1948 to 1970, implants the first \"demand\" pacemaker and pioneers the use of the first pacemakers at the Peter Bent Brigham Hospital. 1962 – Joseph Murray, MD, the chief of Plastic Surgery at the Peter Bent Brigham Hospital from 1964 to 1986, performs the world’s first successful kidney transplantation from an unrelated cadaver donor. The procedure included the first clinical use of the immunosuppressive drug azathioprine. 1960 – Dwight Harken, MD, inserts the first prosthetic aortic valve directly into a human heart at the site of the biological valve; the prosthesis was the first of several designed by Dr. Harken throughout his career. 1954 – The first successful human organ transplant — a kidney transplanted from one identical twin to another — is accomplished by Joseph Murray, MD, at the Peter Bent Brigham Hospital. In 1990, Dr. Murray receives the Nobel Prize in physiology or medicine for this work, and the subsequent development of immunosuppressive drugs. 1950s – Out of concern for the survival of patients during the critical hours after surgery, Dwight Harken, MD, develops the concept of an intensive care unit at the Peter Bent Brigham Hospital. His approach was an important innovation in medicine, extending beyond cardiac cases to the care of all patients with life-threatening conditions. 1949-1959 – Dr. Francis D. Moore’s research, carried out between the physiology laboratory and the patient’s bedside, culminates in two classic books: Metabolic Response to Surgery, co-written with Margaret R. Ball (1949), and Metabolic Care of the Surgical Patient (1959). These masterpieces changed the thinking of surgeons. 1949 – Carl Walter, MD, invents and perfects a way to collect, store and transfuse blood at the Peter Bent Brigham Hospital. He devised new materials and equipment for collecting, storing and transfusing blood that replaced fragile glass bottles with plastic bags, thus preventing losses from breakage. 4

1939 – Elliott Cutler, MD, co-authors the book The Atlas of Surgical Operations with Robert M. Zollinger, MD. The book remained a standard surgery textbook throughout the 20th century. 1931 – Harvey Cushing, MD, the father of modern neurosurgery, performs his 2,000th brain surgery while serving as chief of surgery at the Peter Bent Brigham Hospital. 1929 – The first polio victim is saved using the newly developed Drinker respirator (iron lung) at the Peter Bent Brigham Hospital in collaboration with Children's Hospital Medical Center and the Harvard School of Public Health. 1926 – Harvey Cushing, MD, performs the first surgery using an electrosurgical generator in an operating room at the Peter Bent Brigham Hospital. 1923 – Elliott Cutler, MD, performs the world's first successful heart valve surgery at the Peter Bent Brigham Hospital. C. GOVERNANCE AND ORGANIZATIONAL STRUCTURE The Department of Surgery is led by the chair, Gerard Doherty, MD, who reports jointly to the Brigham and Women’s Hospital president, Robert Higgins, MD, MSHA, and the Brigham and Women’s Physician Organization (BWPO) president, Giles Boland, MD. Dr. Doherty joined the DOS on October 1, 2016, as the sixth chair of surgery in Brigham history, serving as surgeon-in-chief for both Brigham and Women’s Hospital and Dana-Farber Cancer Institute (DFCI). He joined a highly successful department with a well- established, centralized management structure that also had key relationships with DFCI and a group of network hospitals. Over the past five years, the DOS has been restructured in important ways to reflect the current values and functions and to involve more members in the faculty leadership team. This was done deliberately to improve decision-making by increasing the number of people with input as well as increasing the diversity of the leadership group. The division structure of the DOS was reformed, and the funds-flow responsibilities were redefined. Formal role descriptions and decision-making rights and responsibilities were established for the various leadership roles. 5

Exhibit 1: Department Missions and Structure A representation of the missions and functions of the DOS, which dictate the DOS structure, was established within the initial months, and this has been reiterated and refined repeatedly since then (see Exhibit 1). The four basic missions —clinical care, education, research and career development — intersect with one another and are supported by the DOS administration. Roles were defined for faculty members with interest and talent to lead within each of these areas. Placement of the DOS administration at the bottom of the graphic was deliberate, to show that the purpose of the administration is to enable and support the missions, rather than the inverse. The faculty is arranged into 11 divisions, each with a division chief and a paired division administrator (Exhibit 2). These divisions were restructured in 2018 to achieve better balance with respect to faculty numbers and specialty focus. The divisions are now the fundamental business units of the DOS, with each containing its own revenue and expense accounting and annual financial and activity budgets. (Previously, individual surgeons were the focus of revenue and expense accounting, as well as clinical activity budgets, and most division chiefs had limited management input.) Open division chief roles have been filled through national searches; five of the 11 division chiefs are new to their roles in the last five years (Drs. King, Pusic, Raut, Tavakkoli and Uppaluri). 6

The central DOS office budget includes the functions that cut across divisions, such as managing recruiting costs, faculty development, funded faculty leaves and research infrastructure. Charging each division chief and division administrator with the efficient management of their group has proved very effective at expense management and annual planning, and takes the best advantage of this pool of talented leaders. Exhibit 2: Department of Surgery Faculty Leadership Eight vice chair positions were also established to lead topical work that crosses divisions (Exhibit 2) and which also map to the DOS missions (Exhibit 1). Examples include vice chairs for Quality & Patient Safety, Clinical Operations, Research, Education and others. These new positions were filled through an internal DOS application process, with open calls for interested applicants. There is also an executive vice chair role, which shares some of the chair responsibilities. All nine of these faculty members are new to these roles over the last five years. The ongoing management of the department occurs through a series of decision-making and information-sharing meetings, which include faculty meetings, Advisory Committee meetings, and DOS Operations Committee meetings. All meetings can be attended in-person or remotely, prior to and throughout the COVID interruptions. Faculty meetings occur monthly. One faculty meeting per year is designated the Annual Meeting, and it focuses on a summary of the prior year (through key performance indicators across the DOS missions) and a review of goals for the next year. The Advisory Committee includes the chair, vice chairs, division chiefs and lead administrators. This group meets twice per month and is the main policy-making and major decision-making group for the DOS; an Extended Advisory Committee was crafted during the COVID response and includes the 7

administrative chief residents from the four embedded residencies and the lead physician assistant. The extended group is now included for appropriate Advisory Committee topics, about once every two months. The DOS Operations Committee meets for two hours weekly. This group includes the chair, executive vice chair (Dr. Keith Ozaki), the vice chairs for Clinical Operations (Dr. Malcolm Robinson) and Education (Dr. Douglas Smink), and the director of the Center for Surgery and Public Health (Dr. Zara Cooper), as well as the DOS lead administrators (executive administrator, communications director, finance director, network director, operations director and research director). This group reviews and determines the ongoing details of DOS operations — faculty offer letter approval, performance-against-budget reviews, network negotiation updates, agenda planning for upcoming faculty and advisory meetings, and other day-to-day functions. An intended part of the inclusion of the selected faculty members at this meeting, beyond benefiting from their input and review of ongoing decisions, is to teach them the operational functions of department management as a part of their career development. D. GOALS AND OBJECTIVES The goals of the department are to fulfill its missions of providing exceptional clinical care, advancing the field of surgery through investigation, teaching students and training clinical and research residents and fellows, and establishing a platform through which faculty members can build their career. E. AREAS OF EXCELLENCE AND MAJOR ACCOMPLISHMENTS Clinical Activity The DOS clinical work has continued to grow over the past five years — whether measured by case counts, net patient service revenue or RVUs — and includes development of new programs and expansion of existing ones. We have achieved that through the recruitment of surgeons without adding physical space. We have also placed particular emphasis on improving the efficiency of our operating room resource use, especially by moving more secondary care out of the highly specialized Longwood campus to other sites. Nearly every service has increased in its volume of clinical work and number of clinical faculty members. The growth of the clinical faculty has been deliberate; the DOS codified recruitment processes for all new faculty members immediately upon Dr. Doherty joining. Importantly, all faculty members must be recruited through an open search process, and no faculty members can be added through the “Harvard exception.” According to Harvard Medical School policy, there are well-defined search requirements that must be documented for a new member of the medical staff to receive an HMS appointment. However, there is an exception if the new member is recruited directly from a training program at an HMS-affiliate institution. In that case, the new member can be appointed at HMS without a search. The “Harvard exception” has not been used by the DOS. Instead, we have chosen to optimize the opportunity to recruit the best new faculty members from around the country, thus adding to the visible 8

and invisible diversity of the group, including aspects of race, gender, ethnicity, training background, life experience and others. This change has facilitated the growth of the faculty, including their clinical work, with an extremely talented group of new members. To create clinical space for this increase, without adding physical space, the ongoing work to address OR efficiency has focused on major rearrangements in the assignment of OR areas (“pods”) to surgical services. The space for each service has been right-sized to limit the amount of time that a service spends operating “out of pod” — in rooms and with nursing teams and equipment that are designed around a different service. OR block time was re-oriented from being assigned to individual surgeons, to being assigned to services, and the service block time assignments have been coordinated across operative room assets (the Brigham, Brigham and Women’s’ Faulkner Hospital-BWFH and Foxborough). This change has engaged the service leaders in the work of fully utilizing their assigned OR resources. These changes have also enabled planned migration of some secondary care services to less intensive and less expensive care sites. For example, the majority of breast surgery, bariatric surgery and benign gynecologic surgery procedures were moved from the Brigham to BWFH. This has had the desired effects of filling ORs at BWFH that had previously suffered lower utilization, as well as enabling performance of more complex care at the Brigham, allowing the growth of the thoracic surgery, hepatopancreaticobiliary surgery and neurosurgery practices. We have begun the process of organizing some work as multidisciplinary service lines within the institution. The best-developed of these to date is Oncology, with Dana-Farber Cancer Institute as our exclusive oncologic partner. The 11 long-standing multidisciplinary programs are arranged around disease sites, such as Breast Oncology, Gastrointestinal Oncology and Genitourinary Oncology. More recently, other non-cancer programs have been oriented to this approach. The Center for Weight Management and Wellness is arranged around patients for whom weight loss is an important health goal, and includes endocrinologists, surgeons and gastroenterologists who can wield all the potential approaches to the patients’ benefit. Similar work is ongoing in the cardiovascular service line, and more work is anticipated in the future for urology, trauma care and others. Research The DOS maintains an active and varied research portfolio (through the Brigham, DFCI and VA Boston) which has increased over the last five years as measured by sponsored research dollars and funding per square foot of allocated space. There are several highly successful individual investigator laboratory efforts, such as those run by Drs. Mittendorf, Uppaluri, Bueno, Lederer, Orgill and Sinha. In addition, there are six multi-investigator platforms attached to the DOS that provide opportunities for faculty members and trainees to link their research efforts. 9

Center for Surgery and Public Health (CSPH) CSPH is a health services research platform founded in 2005 to coordinate and support our large- database research focused on making surgery safer, more patient-centered, and more accessible in the U.S. and around the world. The center is led by Dr. Zara Cooper and supports the Health Services Research of any DOS faculty member by enabling collaboration through the CSPH platform of data- servers, data scientists, programmers and project managers. The center holds weekly work-in-progress meetings and offers in-depth technical HSR training through research fellowships for trainees from the DOS and elsewhere. Patient Reported Outcomes, Value and Experience Center (PROVE) PROVE is a research and implementation center intended to expand the collection, analysis and utilization of patient-reported outcome measures (PROMs). Led by Dr. Andrea Pusic, the PROVE Center focuses on using innovative methods to study outcomes that matter the most to patients and their caregivers. The center provides a platform for clinicians, researchers, patient advocates, health informatics experts and policymakers to amplify the patient voice in research, health care decision- making and patient care delivery, and provides a venue for trainees interested in learning these approaches. Ariadne Labs Ariadne Labs is a joint center for health systems innovation at the Brigham and the Harvard T. H. Chan School of Public Health. Though not contained within the DOS, Ariadne was founded by faculty member Atul Gawande, MD, MPH, who remained chair of the Governance Council until his recent appointment as the assistant administrator for Global Health at USAID in the Biden administration. Ariadne Labs has focused its implementation science efforts on scalable solutions to strategic, high-impact health episodes, including childbirth, surgery and end-of-life care. Ariadne Labs provides a venue for faculty members and trainees from the DOS and elsewhere to pursue research interests in these areas. DOS faculty members have been particularly engaged in the safe surgery work. The Gillian Reny Stepping Strong Center for Trauma Innovation The Stepping Strong Center was born out of the tragedy of the Boston Marathon bombing. Led by co- medical director, Dr. Ali Salim and director of Strategy and Innovation, Matthew Carty, MD, along with Mitchel Harris, MD, the mission of the center is to catalyze multidisciplinary collaborations that inspire groundbreaking innovation, effective prevention, and compassionate intervention to transform care for civilians and military heroes who endure traumatic injuries and events. The center provides a platform for research within the DOS, focusing mainly on innovative approaches to functional restoration after lower extremity amputation, as well as injury prevention and trauma education. Alliance for Clinical Trials in Oncology Led by group chair, Monica Bertagnolli, MD, the Alliance is part of the National Clinical Trials Network (NCTN) sponsored by the National Cancer Institute (NCI), which serves as a research base for the NCI Community Research Oncology Program (NCORP). The Alliance is comprised of nearly 10,000 cancer specialists at hospitals, medical centers, and community clinics across the United States and Canada. The Office of the Group Chair is within the Brigham DOS and is responsible for Alliance administrative and 10

fiscal affairs, including support for scientific leadership, administrative committees, membership services, regulatory compliance/audits, travel, meetings, financial services and grants administration. The Alliance provides a platform for DOS members to become involved in the design and administration of multicenter clinical cancer trials. Laboratory for Surgical and Metabolic Research (LSMR) Originally founded by Dr. Francis Moore after World War II, the LSMR is currently led by Ali Tavakkoli, MD, and is a basic and translational research laboratory platform now focused mainly on investigations of obesity and its treatments. The laboratory links together investigators who are invested in these areas and provides a platform for research and research training for faculty members and trainees in the DOS. Education The education efforts of the DOS are organized through the vice chair for Education, Dr. Smink, who oversees the Surgical Education Office, the residency and fellowship program directors, the student clerkship leadership, and Jamie Robertson, PhD, MPH, the director for Innovation in Surgical Education. The DOS houses four categorical training programs and participates in a fifth. Categorical training programs include general surgery, plastic surgery, thoracic surgery, and urology, which is based at the Brigham but also includes MGH. The department also participates in the otolaryngology-head and neck surgery program based at Massachusetts Eye and Ear. In addition, the DOS offers several advanced fellowships, such as colorectal surgery, endocrine surgery, surgical oncology, surgical critical care, thoracic surgery, and vascular surgery, some of which also include MGH as a part of the fellowship curriculum structure. Finally, the DOS provides the surgery rotation for the Primary Clinical Experience (PCE) for about one- third of each Harvard Medical School class. This 12-week rotation is overseen by Reza Askari, MD, and includes didactic and experiential education in surgery, including selected subspecialties and anesthesiology. F. CHALLENGES AND BARRIERS TO SUCCESS Space Space is a limitation for each mission except research; this is not solely a DOS issue, as it affects each department of the BWPO. • Clinical space to practice in ambulatory, inpatient and operating room settings have each absorbed increased volume but are running short; they are now reaching the point of inefficient function due to being over capacity. Some of this has been situational due to the COVID-19 11

pandemic and its effects on inpatient census, staffing shortages and competing care demands. However, the limitations were present prior to 2020 and persist outside of COVID surges. • Academic office space is a limit now for most divisions, with doubling up of faculty members becoming routine where the physical design permits. • Inpatient working space is a significant issue for house staff to accomplish their clinical duties, and thus affects their learning environment and the working environment for the PA staff. • Education space was a substantial issue prior to the pandemic and the move to remote lectures and conferences; it is not yet clear whether this will be a limit in the future. Transition Work in Mass General Brigham Integration Our health care system is undertaking a significant reorganization of clinical planning, decision-rights, funds flow and governance of functions such as marketing, communications and foundational enterprise services (imaging, pathology, anesthesiology and emergency medicine). In the medium- to long-term, this will be beneficial in diminishing the significant energy that has gone into internal competition, particularly between the Brigham and Mass General, and should redirect that work to the benefit of our faculty, staff and patients. In the short-term, there is a tremendous amount of effort necessary to design and execute the reorganization, which necessarily distracts from the primary missions of the DOS, as leadership across the department is involved to support this work. Aging Infrastructure Though the Brigham has added new buildings over the last decade (the Shapiro building housing mainly cardiovascular services, including some new operating rooms, and the Hale building housing mainly neurosciences and musculoskeletal services), the core of the hospital is the Braunwald Tower, an aging facility. This imposes clinical space inconveniences, with mostly semiprivate patient rooms, smaller operating rooms with intermittent infrastructure challenges, and workspaces designed for a different era (construction was completed in 1980). This places some limits on the work that can be done and the options for DOS growth on the Longwood campus. Faculty Satisfaction Faculty member burnout and professional satisfaction have been significant issues across academic medicine and have received extensive attention nationally and locally over the last decade. The tensions that create this are real; the pressures of the quantity and pace of work, faculty member autonomy, control of the work environment and management of the electronic health record may all differ from what faculty members believed that their career would be. Added to this, life in a compensation system that includes a productivity component, during a time when external forces may limit productivity in a community with a relatively high cost of living, can only increase faculty stress. While we continue to work on this as a department, this is also critical work for the BWPO and our health care system. 12

Service Dependence on Limited House Staff As our clinical services have grown, the house staff and PA support staff have remained relatively fixed. In addition, we have had a significant vacancy rate among our PA staff. The combination of these factors impacts the training satisfaction of the house staff and the job satisfaction of the PA staff. To their credit, neither of these highly motivated, professional groups has allowed this to affect the quality of patient care. However, it is reflected in the house staff evaluations of the training programs. Impact of COVID-19 on Work and Learning Environment The pandemic has affected our work and learning environment in a substantial way. All the necessary adjustments that we have engineered to respond to this societal challenge have affected our faculty and trainees. While we have worked to protect the trainees from the disruptions (for example, by redeploying PAs from their primary services to COVID support care and maintaining the resident staff on their primary duties), there have been inevitable effects on their training experience. G. OPPORTUNITIES OVER THE NEXT FIVE YEARS Dana-Farber Relationship The Brigham and DFCI recently completed a renewed, long-term agreement governing the Dana- Farber/Brigham Cancer Center as the platform for our oncology practices. Clinically, DFCI employs medical oncologists and houses ambulatory multidisciplinary cancer care in DFCI buildings. The remainder of the clinicians (surgeons, pathologists, radiologists, etc.) are BWPO employees, and the Dana-Farber inpatient beds are embedded within and leased from the Brigham. The new agreement updates our approach to multidisciplinary care and marketing and will incent growth of cancer care provided by the DOS at Longwood and in our network. This is a tremendous opportunity to continue high-quality care and increase our oncology-focused research and training. About 40% of the clinical activity of the DOS is oncology-focused, spread through every division, and so this provides a great chance to advance our fields. Gender-Affirmation Program This recently established program is co-led by Devin O’Brien-Coon, MD, from Plastic and Reconstructive Surgery, and Shalender Bhasin, MD, from Endocrinology, and includes several services designed to provide wraparound support for these patients. This is an opportunity to grow a new line of care for an underserved community, and by including leading researchers in the field, will provide guidance for other interested clinicians around the country. 13

Minimally Invasive Surgery Minimally invasive surgery is an area of longstanding interest for the DOS that is being advanced along multiple paths. We anticipate increasing innovative application of minimally invasive approaches in areas where that was not possible until recently: • The Division of General and Gastrointestinal Surgery has active collaborations with GI Medicine to work on new approaches to address primary and revision weight loss care • The thoracic surgery service has obtained a dedicated Xi robotic platform and is in negotiations to acquire an SP platform from Intuitive to support clinical research with novel approaches to diseases in the chest and neck • Our surgical oncology group has an ongoing, funded program to study complex upper abdominal resections, including pancreaticoduodenectomy and hepatic lobectomy using robotic platforms. Cross-System Collaboration Platforms The evolution of Mass General Brigham from a holding company to an integrated academic health care system provides increased opportunity for cross-system collaboration. This is especially intriguing for rare problems or programs that would be small if confined to one academic medical center. The first steps in this direction for the DOS have come through the MGB liver transplant service, which has a distributed model for ambulatory and inpatient care, with concentrated care for the liver transplant episode at MGH. Cardiac surgery has also begun to organize across the Brigham and MGH, first to harmonize the processes of care, but soon to develop concentrated experience with some rare issues. Similar approaches in vascular surgery, urology and bariatric surgery have the potential to bring great service and concentrated expertise to our patients and research. Research Program Maturation Some of our multi-investigator platforms have the opportunity to transform over the coming years to realize their potential as highly impactful research centers. For example, the Center for Surgery and Public Health has redefined its missions and processes under Dr. Cooper’s leadership, with a goal of becoming more directly involved in public policy discourse. The PROVE Center is just reaching its stride under Dr. Pusic, with its interactive patient-reporting module that enhances breast cancer care. The Stepping Strong Center is supporting research in lower extremity amputation that creates the ability of the limb to control a dynamic prosthesis. As these research programs mature in their impact, our patients and patients around the world will benefit. 14

Clinical Services A. OVERVIEW AND ORGANIZATION The Department of Surgery (DOS) at Brigham and Women’s Hospital provides some of the most highly regarded surgical services in the world. Our internationally renowned surgeons create pioneering breakthroughs that make a difference for patients today, as well as for generations to come. We are committed to delivering world-class, collaborative patient care while advancing scientific research and training the surgical innovators of tomorrow. Description of Services Each year, the department performs nearly 30,000 operations and conducts more than 175,000 office visits. Operative services are delivered in 45 Main ORs, one Hybrid OR, one Image Guided OR at the main Brigham campus, 16 ORs at Brigham and Women’s Faulkner Hospital and 4 ORs at the Brigham’s Foxborough campus. In addition, care is provided at numerous network locations throughout eastern Massachusetts. (See Network Affiliations section for more information on our strategic relationships.) The Brigham is home to a Level I Trauma Center, an Advanced Multimodality Image-Guided Operating (AMIGO) suite and the STRATUS Center for Medical Simulation. The Department of Surgery collaborates with the Dana-Farber Cancer Institute to care for patients at The Dana-Farber Brigham Cancer Center, a premier surgical oncology center. The DOS is also well known for its pioneering transplant programs and has one of the largest robotic-assisted surgery programs in the world. 15

Our surgical subspecialties — organized into 11 divisions — provide a full complement of surgical services at multiple locations throughout Massachusetts and Rhode Island. The department’s divisions, services and programs integrate as one strong multidisciplinary team, providing collaborative care for patients, using powerful and precise diagnostic and treatment technologies. The department is committed to continuously improving the surgical pathways, including Enhanced Recovery After Surgery (ERAS) protocols. Clinical Leadership • Gerard M. Doherty, MD, Surgeon-in-Chief, Brigham and Women’s Hospital & Dana-Farber Cancer Institute • Douglas S. Smink, MD, MPH, Chief of Surgery, Brigham and Women’s Faulkner Hospital • Ronald Bleday, MD, Vice Chair for Quality and Patient Safety • Louis L. Nguyen, MD, MPH, MBA, Vice Chair for Digital Health Systems • Tari A. King, MD, Vice Chair for Multidisciplinary Oncology • Malcolm K. Robinson, MD, Vice Chair for Clinical Operations • Ali Salim, MD, Vice Chair for Surgical Critical Care • Jennifer Beatty, PA-C, Director of Clinical Operations and Surgical Physician Assistants Exhibit 3: Department of Surgery Division Chiefs Clinical Division Division Chief Breast Surgery Tari A. King, MD General and Gastrointestinal Surgery Ali Tavakkoli, MD Oral Medicine Nathaniel Treister, DMD, DMSc Otolaryngology—Head and Neck Surgery Ravindra Uppaluri, MD, PhD Plastic and Reconstructive Surgery Andrea L. Pusic, MD, MHS Surgical Oncology Chandrajit P. Raut, MD, MSc Thoracic and Cardiac Surgery Raphael Bueno, MD Trauma, Burn and Surgical Critical Care Ali Salim, MD Transplant Surgery Stefan Tullius, MD, PhD Urology Adam S. Kibel, MD Vascular and Endovascular Surgery Michael Belkin, MD 16

Major Accomplishments Many of our major clinical accomplishments and new clinical programs over the past five years are discussed in detail in the Division Reports section. A couple of exceptional clinical accomplishments from the past five years can be found below. Agonist-Antagonist Myoneural Interface (AMI) – Ewing Amputation In 2016, a BWH clinical team invented a new type of lower-limb amputation procedure known as the Ewing amputation. Led by Matthew J. Carty, MD, a surgeon in the Division of Plastic and Reconstructive Surgery, in collaboration with Hugh Herr, PhD, of the Center for Extreme Bionics in the MIT Media Lab, this new procedure preserves normal signaling between the muscles and the brain, so amputees feel as if they are controlling their physiological limb, even though it’s been replaced by a prosthesis. Matthew J. Carty, MD, of BWH (left), confers with Hugh Herr, Emerging research led by Dr. Carty shows that PhD (center), and Tyler Clites of MIT, as Jim Ewing (foreground) the Ewing amputation provides better outcomes tests their newly developed prosthetic device. than a conventional amputation. In a study that compared outcomes in below-knee Ewing amputees with people who had standard amputations, the Ewing procedure improved mobility and offered amputees more control over prosthetic devices. Research also shows that patients who undergo a Ewing operation lose less muscle than standard amputees and experience less phantom and residual limb pain. Nearly all patients’ quality of life improved dramatically after the Ewing operation. As of 2022, the below-knee operation has been performed on more than 30 patients, including four which were bilateral. In more recent groundbreaking clinical research, Dr. Carty and colleagues at MIT are now applying principles of the Ewing amputation to above- and below-elbow amputation. This reengineered Ewing procedure is designed to provide patients with more functionality and use of their prosthesis following an arm amputation. Thus far, four upper extremity amputations have been performed by Dr. Carty’s team. 17

COVID-19 Response The last two years presented an unforeseen and unique challenge as we navigated the COVID-19 pandemic. As Brigham and Women’s Hospital began to plan for the surge of COVID-19 patients and the postponement of all elective surgeries, it became clear that the Department of Surgery would play a critical role in responding to this unprecedented crisis. Some highlights during the first wave include: • Created six new teams, with three staffed as surgical critical care teams. • Started a “line team”— a team of surgeons on call to do the labor-intensive task of placing arterial and central lines to free up ICU staff for other duties. • Surgeons and advanced practitioners volunteered for home hospital duty, where they took off- hours calls from COVID patients recovering at home. o Others, focused on teaching and assisting COVID ICU staff with proper donning and doffing of personal protection equipment (PPE)—a task very familiar to surgeons but much less familiar to clinicians in the ICU and emergency department. • Adapted to digital health and used virtual visits to keep seeing patients safely from their homes. With COVID restrictions, virtual visits grew by over 3,000%. • Secured philanthropic support to secure additional ECMO machines that provided lifesaving breathing support to patients in critical care. • Developed a priority schema to get 4,500 previously deferred surgery patients back on the OR schedule. Faculty and staff were not trained to respond to this crisis, but rose to the occasion, over and over again. Everyone found or invented ways to help, and it was inspiring to watch. We are very proud of the varied ways that every member of the department found to contribute when society needed us most. New Programs Over the last five years the Department of Surgery has launched several new programs, many of which are highlighted in the Division Reports section. Following are some highlights. Breast Cancer Personalized Risk Assessment, Education and Prevention Program (B-PREP) Launched in 2017, the B-PREP Program is comprised of a multidisciplinary team of breast specialists, including breast surgeons, medical oncologists, breast imagers, physician assistants and nurse practitioners, as well as a social worker and patient navigator, who collaborate to deliver expert individualized evaluation and care. The program is led by Tari A. King, MD, chief of the Division of Breast Surgery and vice chair for Multidisciplinary Oncology. 18

Patient-Reported Outcomes, Value & Experience (PROVE) Center In 2018, Brigham and Women’s Hospital took our longstanding commitment to patient-centered care to a new level with the launch of the Patient-Reported Outcomes, Value & Experience (PROVE) Center. Led by Andrea Pusic, MD, MHS, chief of the Division of Plastic and Reconstructive Surgery, the mission of the PROVE Center is to expand the collection, analysis and utilization of patient-reported outcome measures (PROMs). The PROVE Center focuses on using innovative methods to study outcomes that matter the most to patients and their caregivers. Through collaboration with clinicians, researchers, patient advocates, health informatics experts and policymakers, they seek to amplify the patient voice in research, health care decision-making and patient care delivery. The multidisciplinary PROVE Center team consists of clinicians and researchers with expertise in qualitative and quantitative methods relevant to PROM development, evaluation and implementation. We have several ongoing and completed projects to support the use of PROMs in clinical care across the Mass General Brigham community. Lung Center In 2019, the Brigham opened a new state-of-the-art Lung Center. As a Center of Excellence and an exceptional model of multidisciplinary clinical care, the Lung Center provides care for all lung-based diagnoses by bringing together more than 30 clinical and research programs. Raphael Bueno, MD, chief of the Division of Thoracic and Cardiac Surgery, serves as the co-director of the Lung Center. Center for Weight Management and Wellness Launched in 2020, the Center for Weight Management and Wellness at Brigham and Women’s Hospital is a multidisciplinary center that brings together leading experts in surgical and non-surgical methods of weight management. The center is co-led by Ali Tavakkoli, MD, chief of the Division of General and Gastrointestinal Surgery at the Brigham. Hernia Center Formed in 2020, this new center draws on the expertise of members from the Division of General and Gastrointestinal Surgery and Plastic and Reconstructive Surgery. The goal of the center is to provide interdisciplinary care for patients with complex and recurrent hernias. We have partnered with clinicians in Radiology, Infectious Disease, Wound Care, Endocrinology and Weight Management to address the many medical and surgical issues faced by these complex patients. The center is led by Douglas S. Smink, MD, MPH (General and Gastrointestinal Surgery), and Simon G. Talbot, MD (Plastic and Reconstructive Surgery). Mass General Brigham Liver Transplant Program Launched in 2021, the newly formed Mass General Brigham Liver Transplant Program is an integrated and comprehensive program comprised of Massachusetts General Hospital and Brigham and Women’s 19

Hospital clinicians. The program greatly expands options for patients with acute or chronic liver disease by enhancing and streamlining access. Susan and Stewart Satter Robotic Whipple Surgery Program Founded in 2021, this comprehensive program for robotic pancreatic surgery is the first of its kind in Boston. The program is led by Thomas Clancy, MD, from the Division of Surgical Oncology, who also serves as the co-director of the Pancreatic and Biliary Tumor Center at Dana-Farber Brigham Cancer Center. Center for Transgender Health Founded in 2021, the Center for Transgender Health (CTH) at Brigham and Women’s Hospital provides comprehensive clinical services to transgender patients. The CTH unites staff and faculty within the Brigham and Mass General Brigham to advance research, education and advocacy for this patient group. The CTH is co-led by Devin O’Brien Coon, MD, MSE. Dr. Coon joined the Brigham from Johns Hopkins University, where he served as the founding chief medical director of the Johns Hopkins Center for Transgender Health. At Hopkins, he developed a multidisciplinary service line across eight departments that has become one of the largest academic programs in the U.S. Within the DOS, the Division of Plastic and Reconstructive Surgery plans to establish itself as a leader in the field of transgender health. B. CLINICAL OPERATIONS The Department of Surgery chair, Gerard M. Doherty, MD, also serves as surgeon-in-chief at both Brigham and Women’s Hospital and Dana-Farber Cancer Institute. In this role, he sits on the Perioperative Leadership Group (PLG) at the Brigham. The PLG meets weekly and is responsible for OR operations at Brigham and Women’s Hospital and at Brigham and Women’s Faulkner Hospital. Joining Dr. Doherty as members of the PLG are Douglas Smink, MD, MPH, chief of surgery at Brigham and Women’s Faulkner Hospital, and Malcolm Robinson, MD, vice chair of clinical operations. The Department of Surgery Clinical Operations Team leads a bi-weekly Surgical Clinical Operations Workgroup meeting, which includes members from Nursing, the Analysis, Planning, Strategy, and Improvement (APSI) team, and others. The purpose of this meeting is to focus on improving patient progression, reducing length of stay, improving patient safety, and ensuring clinician wellness. This group has developed workflows and processes to increase early discharges, both on the floor and in the extended recovery unit. This work will likely be replicated across all units within the hospital to help with patient progression. 20

Brigham and Women’s Surgical Facilities Brigham and Women’s Hospital ORs At the main BWH campus, the operating rooms are located inside a single operative suite which extends on the L1 underground floor under the Main Tower, the Shapiro Building and Francis Street. The 44 ORs are clustered into several areas (called pods) by surgical specialty. There are: • four rooms dedicated to robotic surgery • one room for hybrid cardiovascular, or other image-guided, procedures • six rooms for thoracic surgery • six rooms for neurosurgery • six rooms for orthopedic surgery • three rooms for cardiac surgery • two rooms for vascular surgery The rest of the rooms are utilized for general surgery and for all other surgical specialties. The OR suite also contains a pre-operative/arrival area and the post anesthesia care unit (PACU). Brigham and Women’s Faulkner Hospital ORs Brigham and Women's Faulkner Hospital (BWFH) is a 171-bed community teaching hospital located in Jamaica Plain, just 3.4 miles from the Longwood medical area. BWFH has 16 ORs where the following DOS services operate: Breast Surgery, General Surgery, Plastic and Reconstructive Surgery, Otolaryngology—Head and Neck Surgery, Thoracic Surgery, Urology and Vascular and Endovascular surgery. BWFH has a single robotic platform, and is also a high-volume orthopedics center. Brigham and Women’s Hospital Surgical Center at Foxborough The Brigham and Women’s Foxborough ambulatory surgical center is located in a medical building as part of the Brigham and Women's/Mass General Health Care Center, Foxborough. The facility has four ORs for day surgery procedures. Currently, the following DOS services operate in Foxborough: Plastic surgery, including cosmetic procedures, General surgery and Urology. 21

Clinical Operations: Report from the Vice Chair The vice chair for Clinical Operations, Malcolm K. Robinson, MD, leads and enables innovative and efficient approaches to patient care. He is responsible for optimizing patient access, ambulatory care, ambulatory documentation and charge capture, as well as operating room access for the Department of Surgery. His accomplishments include: • Established multidisciplinary surgical clinical operations team to address operational, quality and safety issues throughout the hospital, as they relate to the Department of Surgery. • Piloted and improved patient discharge time from the general Malcolm K. Robinson, MD surgery inpatient surgical unit. • Improved patient discharge time from the Extended Recovery Unit. • Established administrative structure and oversight of the department’s physician assistant workforce. • Part of a multidisciplinary team which improved operations in the Sterile Processing Department. Advance Practice Providers The Department of Surgery has more than 110 full-time physician assistants (PAs) working in 10 of its 11 divisions. The role of the PA has grown and evolved rapidly in the last few years — from the integration of the PA model into the DOS, to the creation of new leadership roles like that of Jennifer Beatty, PA-C, who has been serving as director of Clinical Operations and Surgical Physician Assistants since March of 2019. Beatty’s unique role at the Brigham entails operations, PA leadership, and quality and safety responsibilities. Since Beatty started in her role, the PA group has grown by 25%. This growth speaks to the expert, consistent and valuable care that PAs provide for patients in all areas of care. As director of the surgical PAs, Beatty is responsible for the well-being of the PA workforce. She develops the comprehensive plan for recruitment, retention, training and education of this critical workforce, while also serving on several departmental leadership committees to represent the physician assistants. She oversees eight chief PAs in the divisions of: • Breast Surgery • Trauma, Burn and Surgical Critical Care • Cardiac Surgery • Thoracic Surgery • General and Gastrointestinal Surgery • Vascular and Endovascular Surgery • Plastic and Reconstructive Surgery • Urology Beatty is a key member of the DOS Operations team, working closely with Suzanna Clark, senior director of Operations, and Malcolm K. Robinson, MD, vice chair for Operations, to improve patient access and flow through the surgical inpatient and perioperative spaces. Beatty also helps manage bed flow with 22

Admitting and works on improving workflows for the extended recovery room and inpatient floor discharges as a member of the surgical operations team. The PAs are integrated into patient care within the ambulatory, inpatient and perioperative settings, including the operating room. Our PAs work closely alongside the faculty and residents to ensure patients receive excellent care. The PAs provide continuity of care for patient care teams when surgical residents (due to their educational training) change rotations and responsibilities. The physician assistants also provide important training for new residents, and the support of the PAs allows them to focus on their training. The success of the PA model has resulted in a surge in growth of the PA workforce, which is expected to continue. Hospital Huddles As part of the hospital’s focus on care redesign, hospital leadership implemented “Daily Safety Huddles” in 2018 to support our clinical teams. These huddles bring staff and senior leaders together every weekday for a brief, focused meeting to identify and manage barriers to safe and timely patient care. The goal is to create a system to empower front line leaders to identify and escalate concerns, which helps to eliminate organizational silos, increase accountability, and enhance a shared focus on providing safe and exceptional care. The Department of Surgery Clinical Operations Team is an integral member of these huddles and works to address any surgery-specific issues that may impact patient care. In addition to the Daily Safety Huddles, the DOS Clinical Operations Team is intimately involved with the Daily Peri-Operative Huddle. The purpose of this meeting is to review hospital occupancy, OR caseload, and to bring forward any potential progression issues or concerns for OR holds and ICU beds. This is also a forum to review any additional patient safety and staffing issues. Future Goals Patient capacity is a major issue for the Brigham family and the larger Mass General Brigham enterprise. This is of particular concern in the operating room, where patient case volume has significantly increased, leading to OR delays and last-minute cancellations of “elective” surgical procedures. The increased surgical volume also contributes to inpatient capacity challenges for the Brigham. A major focus of the clinical operations and peri-operative service teams will be to improve OR efficiency and smooth the peaks and valleys of the OR schedule so that both OR and inpatient capacity issues are ameliorated across the Brigham. We will also work with our Mass General Brigham colleagues to identify methods for improving OR operations. The Clinical Operations Team will also focus on increasing the PA workforce across the department to help with management of the inpatient and OR patient volumes. This will involve intensifying PA recruitment efforts, ensuring PA well-being to improve PA retention, and reinvigorating education and training to ensure our PA workforce is practicing at the top of their licenses. 23

Overall, the goal of these initiatives is to improve care of our patients. But it is also anticipated that improved operational efficiency will allow us to devote more time to educational activities, a major mission of the Department of Surgery. Surgical Critical Care: Report from the Vice Chair Surgical Critical Care is an integral part of the Brigham’s Trauma Center and specialized Burn Center. Our physicians and surgeons provide 24-hour, state-of-the-art emergency medical and surgical care for the most critically ill and injured patients. Ali Salim, MD, serves as vice chair of Surgical Critical Care in the Department of Surgery. In this role, Dr. Salim is accountable for the 24-hour operational management, implementation and evaluation of staff and patients on the Surgical directed Intensive Care Units (S- Ali Salim, MD ICU), including general surgery, trauma/burn, thoracic and cardiac surgery. He collaborates with the medical directors and chiefs of the divisions of Trauma, Burn, Surgical Critical Care and Emergency General Surgery, Thoracic and Cardiac Surgery. He also works with the chair for the DOS in the development of S-ICU service programs and processes. As vice chair of the surgical ICUs, Dr. Salim has created a collaborative environment for the division chiefs, ICU medical directors, nursing leadership and hospital leadership. Together, they have worked to ensure standardization of care, decreased variability and enhanced integration across all surgical ICUs. Dr. Salim has established a core leadership team to develop evidence-based protocols that have applicability across all ICU patient populations. His accomplishments include: • Implemented a safe ICU overflow plan. • Implemented a universal ICU checklist. • Successfully aligned the surgical ICUs’ outcomes and metrics utilizing their unit-based teams. • Successfully created a cardiac ICU overnight attending coverage model, including securing call payment funding from hospital leadership. As described previously, the “Daily Safety Huddles” include an ICU huddle to review ICU capacity, expected admissions from the OR and transfer requests. The focus of this meeting is to determine how best to accommodate bed needs, prioritize callouts on the floor and review patient safety issues. Dr. Salim’s leadership team are key participants in these meetings. Future Goals Dr. Salim is actively working with a core group of ICU leaders to develop and implement the first mixed medical and surgical ICU at Brigham and Women’s Hospital. This will be a 10-bed unit, staffed with 24

medicine, surgery, emergency medicine and anesthesia faculty and an Advance Practice Providers (APP) coverage model. The main goal is to provide an increase in ICU beds to accommodate more complex patients and alleviate capacity issues at the hospital level. In addition to these clinical goals, Dr. Salim hopes to continue expanding the research program within the surgical ICUs. With the help of his team, he will continue resident and fellow research activities, with a goal of developing an ICU research project pipeline to further expand the research footprint in the department. Digital Health Systems: Report from the Vice Chair Louis L. Nguyen, MD, MPH, MBA, serves as vice chair for Digital Health Systems in the Department of Surgery. In this role, Dr. Nguyen is accountable for the design and implementation of the electronic health record and other information systems across the department. He both leads and enables digital practice innovation with the goals of increasing practice efficiency and safety, fostering practice growth through novel patient management interactions and optimizing the EMR for DOS providers. Dr. Nguyen also advises various Brigham IT committees and works Louis L. Nguyen, MD, MPH, MBA with DOS faculty members and leadership to continually evolve our information systems. His accomplishments include: • Implemented virtual care in the Department of Surgery during the COVID-19 pandemic, which allowed the continuation of safe care. • Implemented ambulatory scheduling features such as Direct Scheduling and Fast Pass to improve timeliness of patient appointments. • Designed and implemented a system to allow surgeons to prioritize their operative cases and for OR schedulers to use that information to schedule during a period of restricted OR case volume. • Implemented the Case Request system to improve accuracy and efficiency of scheduling OR cases. • Served as an easily accessible EHR and technology resource for busy clinicians and administrators. Future Goals Digital health is increasingly being recognized as an important aspect of health care. The application of information, technology and communication tools will transform health care delivery, population management and patient interactions with the health care system. Dr. Nguyen’s future goals include further integration of digital tools and systems to improve patient care and provider well-being. The overarching objective is to also maximize usability of technology for providers, staff and patients. 25

Examples of potential future technologies include: • mobile apps for real-time communication • wearables for remote monitoring • artificial intelligence for better decision-making • expansion of telemedicine for great outreach and patient convenience • analysis of large data from EHR encounters The implementation of technology must be balanced by regulatory requirements, patient privacy concerns and the increasing overload of stimuli from technology. Through thoughtful strategy and utilizing input from patients, providers and staff, we can be leaders in the future of digital health. C. CLINICAL VOLUME Over the past five years, the Department of Surgery has grown by 60% in ambulatory visit volume and 9% in OR case volume. All 11 divisions continue to grow and expand access, on the main campus and in the community. As shown in the following data tables, one major change over the past five years was the creation of the Division of Breast Surgery, previously part of the Division of Surgical Oncology. This separation of specialties allows for a more focused approach to the clinical care within the groups. We have seen significant growth in our divisions of General and GI Surgery, Plastic and Reconstructive Surgery and Urology – all of which have recently recruited for additional faculty to meet the continued increase in demand. 26

Exhibit 4: DOS Ambulatory Visit Volume As expected, FY20 was a challenging year due to the initial (and following) surges of the ongoing pandemic. While it did cause limitations for our in-person ambulatory volume and OR volume, the Department of Surgery increased virtual visit volume significantly – from 1,379 in FY 19 to over 44,000 in FY 21. We have continued to see many patients with virtual visits, which currently account for 20% of the overall visit volume. In addition to ambulatory volume, we continue to see an increase in OR volume. 27

Exhibit 5: DOS Case Volume OR Case Volume Division FY 2017 FY 2018 FY 2019 FY 2020 FY 2021 Grand Total Day Surgery 15,816 14,769 Breast 15,566 17,321 2,410 18,276 81,748 Cardiac Surgery 37 37 General & GI 3,189 2,379 2,629 3,344 8,133 Otolaryngology 1,213 864 Plastics 2,916 16 25 2,185 8 123 Surgical Oncology 2,706 1,037 Thoracic 1,427 2,991 3,164 1,453 3,087 15,060 Transplant 127 Trauma Burn 199 1,266 1,462 596 1,102 5,907 Urology 560 2,696 Vascular 2,903 2,809 2,762 735 2,959 13,631 Inpatient 666 13,644 Breast 14,533 2,575 1,100 427 1,128 8,546 Cardiac Surgery 1,359 General & GI 1,360 1,483 1,650 2,234 1,662 7,675 Otolaryngology 2,530 518 Plastics 176 170 1,095 122 794 Surgical Oncology 549 718 Thoracic 1,369 527 731 2,644 585 2,999 Transplant 1,198 150 Trauma Burn 2,621 3,089 2,922 1,821 3,361 14,971 Urology 1,309 Vascular 206 634 956 1,369 918 3,909 Grand Total 1,705 28,413 1,556 13,436 15,969 14,945 72,527 1,439 30,349 596 253 1,276 1,141 1,678 1,553 7,091 2,294 2,432 2,423 11,913 577 534 612 2,790 1,313 1,471 1,057 6,305 1,087 801 828 4,632 2,497 2,902 3,190 13,854 181 156 172 865 1,610 2,207 1,976 9,319 1,462 1,605 1,320 7,252 1,274 1,587 1,561 7,230 29,002 33,290 33,221 154,275 D. RELATIONSHIP TO HOSPITAL GOALS AND INITIATIVES At the beginning of each fiscal year the hospital sets institutional goals, many of which have a direct link to DOS operations. The DOS also collaborates with the hospital in setting department-specific goals, to which the chair is held responsible and measured against. The department will then pass applicable goals along to the division chiefs, who will then often assign to their faculty. We find that the alignment of goals from chair, to chief, to faculty member is an effective way of ensuring goals are met annually. The chart below lists the current goals of the hospital. 28

Exhibit 6: FY 22 Goals for Brigham and Women’s Hospital Department of Surgery Response to Hospital Goals Capacity: “Increase absolute capacity to optimize performance across our mission”, which also ties into a Mass General Brigham goal to establish enterprise asset management and active asset management at each of the system hospitals. The Department of Surgery is achieving this goal by: • Increasing OR staffed times at the Brigham • Increasing OR utilization at Foxborough (GGI, Plastics and Urology) • Leveraging Mass Eye and Ear-Longwood space (Otolaryngology) Service Lines: “Provide high-value, world-class care to more lives,” which also ties into the Mass General Brigham goals to define programs, implement governance and management structures, and achieve appropriate organizational realignment and resourcing. The DOS is achieving this goal by: • Making progress toward the MGB Cardiac Surgery Service Line goals of increased volume; reduced total medical expenditures; maintained/improved quality; and improved patient access and/or experience • Maintaining and expanding the number of Brigham hepatology patients on liver transplant list United Against Racism (UAR): “Advance critical system integration priorities through participation and leadership” in the implementation of Mass General Brigham UAR plans to increase leader diversity by 10% over the baseline. The Department of Surgery is achieving this goal by: • Continuing to apply the standard DOS faculty search process with a 100% adherence rate (hospital goal is 90% but DOS already at 100%) • As an institutional leader in diverse and equitable faculty recruitment, supporting the implementation of the enhanced search process in other departments 29

People: “Improve our people experience by ensuring they feel valued, supported in their well-being, engaged and able to reach their full potential; and making certain our organizational make-up reflects the diversity richness of our community and society.” This ties into the Mass General Brigham goal to improve employee engagement and retention. The DOS is achieving this goal by: • Continuing our Office of Professional Development work on behalf of our faculty members • Creating systems for effective recruitment and retention of staff by heightening awareness of existing employee benefits and supporting Brigham pay equity implementation, and ensuring it is rolled out through our divisions Value Based Care & Capacity: “Increase access and throughput to meet patient demand.” This ties into the Mass General Brigham goals to develop a detailed plan shift volume from the AMCs to lower acuity sites and/or retain patients at lower acuity sites. The Department of Surgery is achieving this goal by: • Increasing clinic capacity at Foxborough and Pembroke by two sessions • Expanding services at 51 Performance Drive—Weymouth to include Oral Medicine • Initiating clinical network activity at Milford Regional Medical Center (Urology) and Southcoast Health (Thoracic Surgery) MGB Integrated Care: Current goal is to staff surgical specialty needs at Mass General Brigham Integrated Care (iCare) sites. This goal is shared with the MGH Department of Surgery. The Brigham DOS is achieving this goal by: • Working with iCare and MGH Surgery leadership to appropriately expand services to iCare sites in Westborough, Westwood, Woburn and any additional future sites Department of Surgery Goals In addition to the above system goals, the DOS has set the following goals for itself, which are actively being worked on by each division. 1. Virtual Care: Maintain 20% department utilization of virtual visits. 2. Open Radiology Orders: Reduce open radiology orders and create a system to enable completion in a timely manner (achieving less than 1% delinquent after 30 days). 3. National Research Corporation (NRC) Patient Experience Data: Create a departmental system for analyzing, understanding and disseminating NRC patient experience data. 4. Scheduling Optimization: Complete scheduling optimization in FY22 across all divisions. 5. Research Space Density: Maintain research space density with a particular focus on “dry” space. 6. Financial Strength: Sustain financial strength by meeting hospital target financial margin of $270 million. 30

E. RELATIONSHIP TO ACTIVITIES/NEEDS OF OTHER DEPARTMENTS Consultation Services As a robust surgical service at a major academic medical center, the department provides essential consultation services to the emergency department and to other physicians on a variety of inpatient services. Resident Rotations Our surgical training programs play an important role in responding to the needs of other departments, whose patients may require surgical intervention. The surgical residents rotate through several hospitals, including Brigham and Women’s Hospital, two community hospitals (Brigham and Women’s Faulkner Hospital and South Shore Hospital) and a VA hospital (West Roxbury VA Medical Center). Participation in Interdisciplinary Programs Brigham patients often have access to both the expertise of surgeons and other providers in the management of their disease. Many of our clinical faculty members have deep connections to other departments, centers or programs. This reflects the nature of Brigham’s approach to collaborative care. Faculty and trainees in the DOS also work closely with other departments through multidisciplinary care programs and service lines. We embed surgical trainees and our medical students in multidisciplinary teams, so they learn how to practice medicine with other physicians, physician assistants, nursing staff, physical therapists, speech therapists and all the affiliated disciplines. The following interdisciplinary programs, service lines and centers at the Brigham rely heavily on Department of Surgery divisional expertise. • Dana-Farber Brigham Cancer Center • Lung Center • Heart and Vascular Center • Transplantation Services • Center for Weight Management and Wellness • Brigham Center for Transgender Health • Breast Cancer Personalized Risk Assessment, Education and Prevention Program (B-PREP) • Center for Geriatric Surgery • Nutrition Support Service • Brigham Burn Center 31

Dana-Farber Brigham Cancer Center Dana-Farber Brigham Cancer Center is a premier cancer center, offering treatments and expertise not available anywhere else in New England. Dana-Farber Brigham Cancer Center brings together specialists from two world-class medical centers. Our team has deep experience in treating various cancers and includes experts from a wide span of disciplines, such as medical and radiation oncologists, cancer surgeons and many others. We offer access to the latest treatments, many of which were pioneered here, along with clinical trials of promising new therapies. The Department of Surgery is directly involved in many of the specialized centers at the Dana-Farber Brigham Cancer Center, including: • Breast Oncology Program • Gastrointestinal Cancer Treatment Center • Genitourinary Cancer Treatment Center • Head and Neck Cancer Treatment Center • Sarcoma and Bone Treatment Center • Thoracic (Lung) Cancer Treatment Center • Cutaneous Cancer Treatment Center • Melanoma Treatment Center Multidisciplinary Oncology: Report from the Vice Chair Tari A. King, MD, serves as vice chair for Multidisciplinary Oncology in the Department of Surgery, where she leads and enables innovative and efficient approaches to oncology patient care at the Dana-Farber Brigham Cancer Center. Dr. King is responsible for optimizing oncology care provided by DOS practitioners in areas such as patient access, ambulatory care and care coordination. Her accomplishments include: • Increased presence and engagement of surgical representation on Dana-Farber Cancer Institute (DFCI) operations and leadership Tari A. King, MD committees. • Increased focus on the value of multidisciplinary care as evidenced by DFCI commitment to accommodate new multi-specialty care groups at the new Chestnut Hill ambulatory location. • Increased recognition and utilization of ancillary services for cancer patients at BWFH, particularly those receiving outpatient care at Chestnut Hill. 32

• Created a multidisciplinary data dashboard with shared (the Brigham and DFCI) data to allow ongoing assessment and evaluation of metrics for delivering patient-centered multidisciplinary care. • Created new agreements for contracting of clinical services between the Brigham and DFCI, that place emphasis and value on multidisciplinary care. Future Goals With new contracting agreements (which provide incentives for both the Brigham and DFCI to provide multidisciplinary care) and the opening of new multidisciplinary clinics at Chestnut Hill, both institutions should be positioned to improve access, timeliness and quality of care for cancer patients across all solid tumor disease centers. Further, the availability of the dashboard will allow for all disciplines to be more engaged with metrics around delivery of care and the downstream impacts. At the highest level, the goals of this engagement include assessing how providing multidisciplinary care translates into increased patient retention and patient satisfaction. Detailed data for each disease center can be used to assess patterns of care delivery. For example, tracking the proportion of patients scheduled with multiple specialty providers on the same day versus multiple visit days, sequencing of care provider visits and documenting time to initiation of first line of therapy. Dr. King’s goal is to ensure that all surgical division leaders participating in multidisciplinary care are able to take advantage of this resource through monthly or quarterly reports (as dictated by volume of care). Surgical and medical oncology teams will use the data to improve quality of care in their disease centers. F. QUALITY AND SAFETY The Department of Surgery is committed to providing high quality surgical outcomes and the best patient experience possible. Our goal is to continuously exceed national and internal quality benchmarks for standards of care, while addressing the growing urgency to improve affordability. Quality and Patient Safety: Report from the Vice Chair The Quality Improvement Committee focuses on improving project design, and implementing and disseminating results of this work through publications, presentations and participation in health care education forums. The committee collaborates with an outstanding group of experienced faculty, residents and nurses in the Department of Surgery to share insights, perspectives and ultimately set the standard for surgical quality improvement. The mission of the committee is: • To improve the quality of surgical care at Brigham and Women’s Hospital • To continue to be recognized as international leaders in surgical quality improvement • To have every surgeon in our department working on a quality improvement project 33

Ronald Bleday, MD, serves as vice chair for Quality and Patient Safety in the Department of Surgery. Dr. Bleday leads quality projects and enables safe and efficient approaches to optimize the quality and safety of care provided at Brigham and Women’s Hospital and at Brigham and Women’s-Faulkner Hospital. Dr. Bleday has implemented more than 10 enhanced recovery after surgery (ERAS) pathways in surgery. The pathways have led to a decrease in length of stay and complications, without an increase in readmissions. Ronald Bleday, MD Additional accomplishments include: • Standardized all antibiotic and mechanical bowel preparations at Brigham and Woman’s Hospital and throughout the Mass General Brigham system, in collaboration with colleagues. The improvements and standardization led to an 80% reduction in colorectal superficial surgical site infections throughout all MGB hospitals. • Implemented a standard discharge prophylactic lovenox regimen for high-risk surgical patients at the Brigham. The protocol has reduced post discharge DVTs in most GI, surgical oncology, urology and gynecological oncology patients from 2% to nearly zero. • Started a multidisciplinary Grand Rounds series for Anesthesia, Nursing, surgical techs and surgeons. These sessions occur four times per year and can be used for credit with CRICO for “team-based training.” The sessions help create a dynamic team with shared goals in the operating room. • Created an elective surgery restart team during COVID-19 – Surgery, Anesthesia, Nursing, Pathology/Lab and Infectious Disease worked together to develop protocols for the safe resumption of elective surgery in the spring of 2020. The rationale and science behind the effort were published in the Annals of Surgery in 2020. The practices adopted are still in place. Clinical Pathways Program The Clinical Pathways Program within the Department of Quality and Safety was developed in January of 2017, with the vision of expanding upon the existing Enhanced Recovery After Surgery (ERAS) pilot. The goal is to create standardized pathways for clinical care for surgical and medical patients. The DOS Clinical Operations Team is closely involved with the Clinical Pathways Program. They worked to develop ERAS, which is a set of perioperative guidelines based on best practices that optimize patient recovery after surgery. ERAS ensures we give every patient the benefit of every known best-practice for every surgical procedure by: • Standardizing care to eliminate unintentional variation, improve quality and reduce costs • Engaging patients and their families to be active participants in their care • Helping patients recover faster from surgery 34

This program continues to grow at the Brigham, as it has been shown to reduce length of stay and surgical complications. This is a great example of how the Department of Surgery partnered with other groups within the hospital to serve our patients in a meaningful way. Future Goals The goals over the next few years are to continue the work listed above and then to expand quality and safety efforts in several areas. One important effort is the development of geriatric surgery pathways. The implementation of geriatric “pathways” was first adopted in our trauma service with Zara Cooper, MD, and her colleagues. A couple of surgical specialties have adopted these pathways as well. With the assistance of the geriatric medicine services, our goal is to systematically expand the number of surgical services that use these pathways. Professional assessment is an important program for the Department of Surgery; is a surgeon safe, competent and professional? In the past, we relied on subjective measurements for these evaluations. The department has recently created a more objective way to assess surgeons through the use of individual surgeon “dashboards.” Under the direction of the vice chair for Quality and Patient Safety, and in collaboration with IT colleagues and division chiefs, we have reported current high value metrics for each surgeon with assessments of professionalism, teaching and non-technical skills. The first version of the dashboard is good, and it will improve over time with additional input from divisions chiefs and surgeons. This process is mundane but critically important for a department of surgery to ensure high functioning and quality providers to our patients. Other quality and safety projects to be continued or initiated include: • a preoperative anemia clinic to restore normal red cell volume to patients prior to elective surgery • continued work on reducing vulnerabilities that lead to lost surgical specimens, particularly in the pre-analytic phase or during hand-offs • simplification of operating room kits so as to decrease the workload and risk of too much instrumentation • improving the “culture” between all health care professionals within the surgical services so that there is a shared mission of safety and quality improvement for our patients G. NETWORK AFFILIATIONS AND PROGRAMS The Department of Surgery is committed to developing strategic relationships and programs with health care systems, hospitals and provider groups outside of the Mass General Brigham system. These programs enable the DOS to better serve patients in their communities and advance common goals. 35

• Goals for Patients: Ensure that patients receive the best possible care in a health network that emphasizes service, convenience, value and clinical excellence. • Goals for Affiliated Hospitals and Systems: Help affiliated hospitals strengthen the clinical capabilities at their organizations and purposefully move health care services to these lower- cost, local settings when possible. • Goals for Physicians: Provide value to referring physicians though streamlined referral processes, provision of high-quality care, and timely communication supported by integrated EMR/IT platforms and telehealth. • Goals for the Brigham Department of Surgery: Build a strong alignment with network partners to facilitate advanced local care delivery and provide appropriate, seamless referrals of complex patients who need advanced clinical services, innovative care approaches and expertise. The department has established network partnerships across southern Massachusetts and Rhode Island, which allows faculty to care for patients closer to home. 36

Department of Surgery Network Programs South Shore Health DOS Programs at SSH South Shore Health (SSH) is an independent health system based in • ACS Trauma Surgery Weymouth, MA. SSH includes South Shore Hospital, a 393-bed acute • Breast Surgery care facility providing primary and specialty care and home health, • Critical Care amongst other services. The DOS and SSH began collaborating in the • General Surgery – including: early 2000s, and over 20 years of collaboration have delivered exceptional surgical care to the patients of the South Shore, while – Bariatric Surgery developing, growing and sustaining critical services and programs at – Colorectal Surgery SSH. For example, DOS faculty partnered with SSH to develop and • Thoracic Surgery enhance programs in trauma and acute care surgery. This partnership • Vascular Surgery enabled SSH to receive and maintain Level II trauma designation, filling • Urology (Call Coverage) a critical need for the South Shore and southeastern Massachusetts • Surgical specialties at Dana- more broadly. Farber/Brigham and Women’s Cancer Center in Clinical Affiliation with South Shore Hospital Seven Department of Surgery faculty members currently serve in leadership roles at SSH. South Shore Hospital is also an important site for the Brigham General Surgery Residency Program. Additionally, DOS faculty members play a key role in the provision of surgical care at Dana-Farber/Brigham and Women’s Cancer Center at South Shore Hospital, a collaborative, multidisciplinary center. DOS Programs at CNE Care New England • Cardiac Surgery, offering a valve clinic Care New England (CNE) Health System is an independent health system in Rhode Island that includes Kent Hospital, a in collaboration with BWPO 395-bed acute care hospital in Warwick, RI; Women & Infants Cardiology Hospital, a specialty hospital for women and newborns; Butler • General Surgery – including: Hospital, a free-standing psychiatric hospital; and the Integra Community Care Network. – Colorectal Surgery • Plastic Surgery • Thoracic Surgery • Vascular Surgery The DOS and CNE have collaborated to advance surgical care at Kent Hospital. This is part of a broader clinical affiliation between the BWPO and CNE, which also includes collaboration with BWPO cardiologists and pulmonologists practicing at Kent Hospital and within the CNE system. Two Department of Surgery faculty members serve in critical leadership roles at CNE and Kent Hospital — specifically the executive chief of surgery for CNE and the chief of thoracic surgery at Kent Hospital. Milford Regional Medical Center Milford Regional Medical Center (MRMC) is a health care system based in Milford, MA, which includes a 149-bed acute care facility and a physician group. The DOS and MRMC have collaborated on thoracic surgery since 2002. This partnership has enabled MRMC and the DOS to jointly advance local thoracic care delivery, while also developing key services such as a lung cancer screening program. A DOS faculty 37

member serves as the chief of thoracic surgery at MRMC. DOS thoracic surgeons also practice at the Dana-Farber/Brigham and Women’s Cancer Center at Milford Regional Medical Center. Additionally, the DOS and MRMC are developing collaborations in urology, including the local provision of robotic urology care. Boston Medical Center Boston Medical Center (BMC) is a 514-bed academic medical center located in the South End neighborhood of Boston. BMC is the largest safety net hospital in the region and a critical resource for the local community. DOS faculty members play a critical role in the BMC Kidney Transplant Program. This collaboration began with the provision of call coverage at BMC by DOS faculty and deepened to include a DOS faculty member serving as the director of transplant surgery at BMC from 2019 to 2021. Additionally, DOS faculty members provide call coverage in cardiac surgery at BMC. The Division of Transplant Surgery also plays a key role in kidney transplant programs within the city of Boston. In addition to the collaboration with Boston Medical Center, DOS transplant surgeons also provide call coverage at Tufts Medical Center, a 286-bed hospital located in the Chinatown neighborhood of Boston. DOS transplant surgeons are trusted partners for colleagues at academic medical centers across the city, which helps to maintain access to transplantation services for patients in these smaller systems. Cape Cod Healthcare Cape Cod Healthcare (CCHC) is a health system providing services to the residents and visitors of Cape Cod. CCHC includes two acute care hospitals—Cape Cod Hospital, a 269-bed hospital in Hyannis, MA, and Falmouth Hospital, a 103-bed hospital in Falmouth, MA—which also provide homecare and hospice services, as well as skilled nursing and rehabilitation services. DOS and CCHC began collaborating in 2001 and created a cardiac surgery program through which Brigham cardiac surgeons, perfusionists and cardiac anesthesiologists work with CCHC colleagues to enable cardiac surgery procedures to be performed locally at Cape Cod Hospital. Throughout this collaboration, a DOS faculty member has served as the chief of Cardiac Surgery for CCHC. In addition to the aforementioned programs, network programs play a critical role in numerous divisions within the Department of Surgery. Thoracic Surgery The Division of Thoracic and Cardiac Surgery is a leader in the development of several community thoracic surgery programs. DOS faculty members run thoracic surgery services and serve in leadership roles at the following institutions: • Boston VA Healthcare System (Boston, MA) • Milford Regional Medical Center (Milford, MA) 38

• Care New England, Kent Hospital (Warwick, RI) • Steward HealthCare, Good Samaritan Medical Center (Brockton, MA) • Southcoast Health, Charlton Hospital (Fall River, MA) and St. Luke’s Hospital (New Bedford, MA) • South Shore Health, South Shore Hospital (Weymouth, MA) The Division of Thoracic and Cardiac Surgery shares best practices across these network programs, working to advance the delivery of thoracic surgery across southern Massachusetts and Rhode Island. H. CONSTRAINTS AND CHALLENGES TO SUCCESS Space Clinical space to practice in ambulatory, inpatient and operating room settings have each absorbed increased volume but are now reaching the point of inefficient function due to excess capacity. This problem has been exacerbated by the pandemic, and its effects on inpatient census, staffing shortages and competing care demands. However, the limitations were present prior to 2020 and persist outside of COVID-19 surges. Academic office space is at the limit now for most divisions, with doubling up of faculty members becoming routine where the physical design permits. Inpatient working space is a significant issue for house staff; it is difficult to accomplish clinical duties and thus affects the house staff learning environment and the working environment for the PA staff. Transition Work in Mass General Brigham Integration Our health care system is undertaking a significant reorganization of clinical planning, decision-rights, funds flow and governance. In the medium- to long-term, this will be beneficial in diminishing the significant energy that has gone into internal competition, particularly between the Brigham and Mass General, and should redirect that work to the benefit of our faculty, staff and patients. In the short- term, there is a tremendous effort necessary to design and execute the reorganization, which necessarily distracts from the primary missions of the DOS, as leadership across the department is involved to support this work. Aging Infrastructure Though the Brigham has added new buildings over the last decade (the Shapiro building housing mainly cardiovascular services, including some new operating rooms, and the Hale building housing mainly neurosciences and musculoskeletal services), the core of the hospital is the Braunwald Tower, an aging facility. This imposes mainly clinical space inconveniences, with mostly semiprivate patient rooms, smaller operating rooms with intermittent infrastructure challenges, and workspaces designed for a different era. This places some limits on the work that can be done and the options for DOS growth on the Longwood campus. 39

Service Dependence on Limited House Staff As clinical services have grown, our house staff has remained relatively fixed and PA staff has grown modestly. In addition, we have had a significant vacancy rate among the PA staff. This combination impacts the training satisfaction of the house staff and the job satisfaction of the PA staff. However, to their credit, neither of these highly motivated, professional groups has allowed this to affect the quality of patient care. But it is reflected in the house staff evaluations of the training programs. Impact of COVID on Work and Learning Environment The COVID-19 pandemic has impacted our work and learning environment in a substantial way. All the necessary adjustments needed to respond to this societal challenge have affected our faculty and trainees. While we have worked to protect the trainees from the disruptions – for example, by redeploying PAs from their primary services to COVID-19 support care, and maintaining the resident staff on their primary duties – there have been inevitable effects on their training experience. 40

Division Reports Clinical Division Page Breast Surgery 42 Thoracic and Cardiac Surgery (Cardiac Surgery) 49 General and Gastrointestinal Surgery 57 Oral Medicine 67 Otolaryngology—Head and Neck Surgery 72 Plastic and Reconstructive Surgery 79 Surgical Oncology 84 Thoracic and Cardiac Surgery (Thoracic Surgery) 93 Transplant Surgery 100 Trauma, Burn and Surgical Critical Care 106 Urology 115 Vascular and Endovascular Surgery 124 41

Breast Surgery A. OVERVIEW Tari King, MD, has led the breast surgical team at Brigham and Women’s Hospital since fall of 2015 and has made significant strides in streamlining and standardizing the group’s clinical care and research activities. Breast surgery officially became its own division in fall of 2018. Over the last six years, the group has grown significantly. Currently, the group consists of 11 breast surgeons (five hired since 2016), nine physician assistants (all hired since 2016) and three nurse practitioners (two hired since October 2016). In an effort to streamline clinical services, the division has consolidated ambulatory clinical activity to four locations: Dana-Farber/Brigham Cancer Center (DF/BCC) at the Brigham main campus, DF/BCC at Chestnut Hill, DF/BCC at South Shore Hospital (SSH) and the Brigham Comprehensive Breast Health Center. This allows for optimal multidisciplinary care for cancer patients at DFCI locations and at the specialized program for risk and prevention at the Brigham. Additionally, inpatient and outpatient surgical activity has been streamlined to three locations — the Brigham, Brigham and Women’s Faulkner Hospital (BWFH) and SSH — to improve efficiency and patient experience, with the majority of surgeries being performed at BWFH. In 2018, Dr. King recruited Elizabeth Mittendorf, MD, PhD, to co-lead the program and direct the research efforts of the division. To further support clinical care and research for our patients at these sites, Laura Dominici, MD, serves as chief of the breast service at BWFH; Suniti Nimbkar, MD, serves as the medical director of the DF/BCC Breast Care Center at SSH; and Anna Weiss, MD, serves as director of research for the Division of Breast Surgery at DF/BCC at SSH. The division’s significant and continued growth has also provided the opportunity to establish a leadership structure for the physician assistant (PA) team. Kathryn Anderson, PA-C, was named chief PA for the division; Katie McLean, PA-C, was named lead PA of Breast Surgery at BWFH; and Lara Novak, PA- C, was named senior PA of Education for the division. The well-coordinated PA team, aligned with the nurse practitioner (NP) support in the division, is critical to maintaining the high level of clinical care we provide. B. CLINICAL SERVICES Our division is a regional and national leader in providing surgical care for patients with breast cancer and non-cancerous breast conditions. Our surgeons have robust clinics, both at the Brigham and Dana- Farber Cancer Institute (DFCI), and they perform over 2,500 surgeries per year. Our key accomplishments over the last five years are outlined below. 42

Clinical Innovations Over the last five years, we have implemented a number of patient-centered clinical initiatives that have represented significant improvements in the quality of surgical services that we provide to our patients with both malignant and benign breast disease. These include: • Establishing a standard practice for margin evaluation for patients undergoing breast conserving surgery that reduced our re-excision rate (need to return to the operating room) by 50% • Transitioning from wire localization to radioactive seed localization (RSL) for the operative management of non-palpable breast lesions. RSL offers many advantages for both patients and surgeons in that the procedure is performed one to five days prior to the day of surgery, minimizing patient anxiety on the day of surgery and eliminating scheduling/timing challenges between the radiology suite and the operating room. RSL also provides greater accuracy and certainty intraoperatively as there is no concern that the seed has migrated after placement • Transitioning to surgeon-directed intraoperative isotope injection for sentinel lymph node biopsy procedures. Intraoperative isotope injection eliminates the need for a separate appointment in nuclear medicine and allows the injection to happen after induction of anesthesia, thereby eliminating patient discomfort • Establishing an enhanced recovery after surgery (ERAS) pathway. ERAS allows for outpatient mastectomy procedures for select patients who can then recover comfortably in their own home. This program also contributes to efforts to maintain hospital bed access for those in the greatest need • Creating an Adolescent Patient Breast Care Pathway (2020) for patients under the age of 18 requiring specialized services not provided at Children’s Hospital During the COVID-19 pandemic, we quickly transitioned to virtual pre-op teaching visits and virtual postop visits to continue to provide a high level of patient care, while minimizing risk to our patients and providers. This effort included the development of patient education videos and modification of our clinic workflows, all of which were accomplished with the leadership and support of our PA/NP teams. We also incorporated virtual visits for risk assessment in the Brigham Comprehensive Breast Health Center B-PREP Program. Clinical Collaborations Focused on Quality and Outcomes The Division of Breast Surgery is committed to building and maintaining collaborative programs with our multidisciplinary colleagues. In 2020, Faina Nakhlis, MD, was named associate director of the DFCI Inflammatory Breast Cancer (IBC) Program and will continue to focus on clinical and research initiatives to optimize loco-regional control in this patient population. Dr. Nakhlis was recently awarded a DFCI Friend’s grant to support her work in IBC. Christina Minami, MD, MS, holds a joint appointment in the Brigham Center for Surgery and Public Health, where she is driving important research focused on improving the quality of care for our geriatric population. Dr. Minami has been awarded several awards for her research (see below). Dr. Dominici has an interest in patient-reported outcomes and has 43

established important collaborations with Ann Partridge, MD, MPH, leader of the Young Women’s Program at DFCI, and Andrea Pusic, MD, chief of the Division of Plastic and Reconstructive Surgery at the Brigham and director of the Patient-Reported Outcomes, Value & Experience (PROVE) Center. This collaboration has led to the recent establishment of a novel app-based platform for real-time collection of patient-reported data for use in both clinical care and research. Multidisciplinary Programs In 2017, the breast surgery team launched the Breast Cancer Personalized Risk Assessment, Education and Prevention (B-PREP) Program. This program, led by Dr. King, provides comprehensive and customized care for women and men looking to gain a better understanding of their breast cancer risk and seeking options for risk reduction, including participation in clinical trials. The B-PREP team includes a patient navigator, medical oncologists, breast surgeons, a PA and an NP. Since initiation of the program, we have identified over 3,100 patients at elevated breast cancer risk, the majority of whom now participate in ongoing follow-ups in our program. Since 2019, we have hosted an annual patient forum. In 2021, the division launched a program focused on ductal carcinoma in situ (DCIS), the earliest form of breast cancer. Under the directorship of Dr. Mittendorf and Dr. King, the program combines clinical care with in-depth research and educational resources to provide patients with the highest quality and compassionate care specific to their individual needs. The DCIS program team consists of a dedicated program coordinator, breast surgeons, radiation oncologists, PAs and an NP. The team provides patient- centered treatment options for DCIS, as well as opportunities to participate in clinical trials. Our newest initiative, led by Dr. Minami, will bring real-time frailty assessment for breast cancer patients over 65 years of age into our clinics to investigate the impact of frailty on shared surgical decision-making. C. RESEARCH ACTIVITIES Under the direction of Dr. King and Dr. Mittendorf, our team is collaborating on research across the continuum of care―from prevention and diagnosis, to treatment and survivorship. We aim to drive clinical innovation focused on four key priorities: Prevention and early disease, patient-centered outcomes, tailored local-regional therapeutic strategies and tumor immunology. These efforts rely on a foundation of quality and value; the importance of training and educating the next generation of breast surgical oncologists; and rigorous stewardship of our comprehensive biospecimen collection. Many of these research efforts are embedded in the clinical programs and collaborations described above. In addition, the team is actively involved in recruiting patients to a wide range of clinical trials. In FY- 2021, our division consented 216 patients to both national cooperative group studies and DF/BCC- specific surgeon-led studies, such as investigating the impact of genetic counseling methods on surgical decisions in patients with newly diagnosed breast cancer (GET FACTS), investigating surgery versus no 44

surgery for DCIS patients and investigating the role of supine MRI in surgical decision-making. In 2020, our division published a total of 50 articles, 68% of which were original research articles. Of the original articles published in 2020, DF/BCC surgeons led the research (i.e., listed as either first, second or last author) in 44% of the publications and in the last 6 years, the team has led the research in 52% of original published articles. With the support of their mentorship committees, junior faculty members have been successful in obtaining funding for their research initiatives. Ana Weiss, MD, has secured two awards for GET FACTS. Dr. Minami was awarded an American Society of Clinical Oncology Young Investigator Award in Geriatric Oncology, an early career award from the American College of Surgeons, as well as a prestigious GEMSSTAR R03 award from the National Institutes of Health (NIH) for her work with the geriatric population. As noted above, Dr. Nakhlis was awarded funding for her work with IBC, and Thanh Barbie, MD, a mid-career translational investigator, was awarded an R01 grant from the NIH for her laboratory work on triple-negative breast cancer. Dr. Mittendorf also continues to be successful in funding her laboratory-based team and serves as an outstanding role model for our junior investigators. Key Grants Name of study: Combination Sacituzumab Govitecan and Atezolizumab to Prevent Recurrence in Triple- Negative Breast Cancer PI: Elizabeth Mittendorf, MD, PhD Funding source: Stand Up 2 Cancer (SU2C) Funding amount: $3,000,000 Brief description of the study w/goals and objectives: The specific aims of this grant are to 1) conduct a single arm, phase II trial of the antibody-drug conjugate sacituzumab govitecan, in combination with the anti-PD-L1 antibody atezolizumab, enrolling TNBC patients with residual disease and cfDNA following neoadjuvant chemotherapy and 2) perform correlative biomarker studies. Name of study: Optimizing Therapeutic STING Agonism in Triple-Negative Breast Cancer PI: Thanh Barbie, MD Funding source: National Institutes of Health Funding amount: $2,000,000 Brief description of the study w/goals and objectives: The goals of the study are to identify the best clinical context for STING agonist use, amplify its cellular response and retain it in the tumor microenvironment. At the completion of the proposed project, it is anticipated that the findings will result in a presurgical window trial for patients with triple-negative breast cancer, who have had a limited response to neoadjuvant chemotherapy. 45

Name of study: Translational Resource for Immuno-Biology to Understand Therapeutic Efficacy (TRIBUTE) PI: Elizabeth Mittendorf, MD, PhD Funding source: Parker Institute for Cancer Immunotherapy, Breast Cancer Research Foundation and Cancer Research Institute Funding amount: $1,500,000 Brief description of the study w/goals and objectives: The major goal of this project is to collect clinical data and biospecimens to include tissue, blood and stool from patients with metastatic triple-negative breast cancer receiving immunotherapy as part of their standard treatment, to perform correlative studies to identify biomarkers of response to therapy and toxicity. Name of study: Locoregional Treatment Decision-Making in Older Adults with Early-Stage, Hormone Receptor-Positive Breast Cancer PI: Christina Minami, MD, MS Funding source: NIH-National Institute on Aging Funding amount: $100,000 Brief description of the study w/goals and objectives: The major goals of this project are to 1) determine factors associated with physician-level and regional variation in the receipt of de-escalated locoregional treatment of older adults with early-stage HR+ breast cancer using SEER-Medicare data, 2013-2017; and 2) detail how geriatric-specific concerns are currently integrated into treatment conversations, and to create patient-physician interaction typologies by using discourse analysis to analyze audio-recorded clinical encounters between older adults with early-stage HR+ breast cancer and surgical, medical and radiation oncologists. Name of study: Physician-Level Variation in Sentinel Lymph Node Biopsy Use in Older Women with Early-Stage Hormone Receptor-Positive Breast Cancer PI: Christina Minami, MD, MS Funding source: American College of Surgeons Faculty Fellowship Award Funding amount: $80,000 Brief description of the study w/goals and objectives: This project has two aims: 1) to use SEER- Medicare study to evaluate omission of sentinel lymph node biopsy use, and 2) a mixed-methods aim to evaluate practitioner attitudes toward omission of sentinel lymph node biopsy in older adults with early- stage hormone receptor-positive breast cancer. Name of study: Trends in Locoregional Therapy in Older Adults with Early-Stage Hormone Receptor- Positive Breast Cancer by Life Expectancy PI: Christina Minami, MD, MS Funding source: American Society of Clinical Oncology Young Investigator Award in Geriatric Oncology Funding amount: $50,000 Brief description of the study w/goals and objectives: This project aims to define trends in breast conservation, axillary evaluation and radiation use in women 70 years and older with early-stage hormone receptor-positive breast cancer by life expectancy. 46