Sunday, November 23, 2008

Trauma center with time on its hands

This article from the American College of Surgeons' monthly newsmagazine Surgery News pricked my interest. Dr Ernest Block, director of the trauma program at Orlando Regional Medical Center, tries to make a case for the "regionalization" of acute care surgery. In English, this means he wants to justify life-flighting acute appendicitis and hot gallbladders out of surrounding community hospital ER's and depositing them at the doorstep of the glorious Orlando Level I Trauma Center. Dr. Block rationalizes this proposed plundering with an economic argument. If community hospitals can ship all their after hours emergency surgical cases to referral centers, they will consequently save themselves the "readiness costs" of maintaining the infrastructure needed to deliver such care themselves. At least that's the theory. Meanwhile, the plan is certainly profitable from the perspective of the large level I trauma center, generating an extra $1.5 million for the Orlando center in this case.

There has a been a push lately from the trauma community to redefine themselves as "emergency care surgeons". They want to be able to scavenge all the midnight appendectomies and free air cases because, well, otherwise they wouldn't ever operate. Trauma has become so non-operative that these guys are just starving for cases. So now we see these pseudo-scientific articles in journals supporting what they want. It's politics cloaked in science. The argument goes like this: the trauma surgeon is in house, might as well let him/her have the case because it can be done right away. I can understand the angst. I couldn't stand being strictly a "trauma surgeon" and going weeks without doing a legitimate operation. However, if trauma as a subspecialty is non-operative and unappealing to its practitioners then perhaps we need to re-evaluate the viability of trauma as a legitimate stand-alone subspecialty. Stealing non-trauma emergency cases from outside communities is clearly not a just solution to the problem of trauma ennui.

The reality is that such a policy would destroy community hospitals. Surgeons are the big money makers at hospitals in the community setting, let's be honest. And emergency surgery is actually a big part of a typical community general surgeon's practice. The gallbladders that come in overnight. The incarcerated hernias. The GI bleeds that end up being secondary to a colon cancer. Even the laparoscopic appendectomies on the uninsured can lead to long term benefit. That kid whose appendix you took out remembers you and is appreciative (even though maybe you dont get paid). And then someday when he's older and has a job and is properly insured, he comes back to you for his thyroid surgery or hernia repair or whatever. Or maybe he mentions to his brother-in-law that he ought to see Dr. Buckeye down the road for his inguinal hernia because he did such a great job on my appendix. General surgeons, over the course of a career, develop a relationship with the community in which they practice. Transferring out all the patients that need emergent or semi-emergent surgery would only serve to sabotage that relationship over the long haul...


Anonymous said...

And what about all those community hospitals that have trouble getting surgical coverage? That's what the gist of that article was about. Isn't there a trend towards "breast surgeons" and "colorectal surgeons" and "endocrine surgeons" muttering that they don't feel confident taking general surgery call.

Ortho? Plastics? Hand? I bet you half of those community hospitals already have to ship those cases out...

Anonymous said...

Sorry, meant to add to the above, I'm a resident who will probably just become a plain ole general surgeon... but statistics show that I make up only 33% of the graduating surgical workforce, with 50-55% getting ready to retire in the next 10 years.

It would be nice if everyone could get emergent surgical care at their local hospitals... but that's gonna require a heckuva lot more "general surgeons" that we are making right now.


Anonymous said...

As a second year medical student, I'm the walking embodiment of naivete, but I think this kind of critical care surgery could be the solution to a lot of the problems facing general surgery. I'm not referring to the idea of flying people to large centers for run of the mill surgical problems. I'm proposing that surgery attempt to do what medicine did with "hospitalists".

Basically if you could have a specialty in general surgery that handled the emergent stuff and the trauma/ SICU, and paid for shift work, you could attract a ton more applicants into general surgery. Most medical students with a passing interest in surgery drool at the thought of surgical shift work. Heaven. Not to mention the decreasing work load and elective schedule disruption for the 66% of general surgeons who are trying to build specialized practices.

Until I read your post, I had thought most gen surgeons are not well reimbursed and generally grumpy about appy's in the middle of the night when they have a days work ahead of them.

Many community hospitals employ hospitalists, which are the medical equivalent to what I'm proposing. If it were economically feasible to employ surgical hospitalists, your internist would be more comfortable telling Mrs. Surgical Abdomen Jones to head on over to the community hospital because he knows there are people in house who can operate. She won't be doubled over in an ER gurney while she waits for the surgeon on call to come in.

The patients win because they have less down time, sitting in pain/ acting as a human culture medium for anaerobes while you drive to the hospital. The private practice surgeons are relieved of call. The specialty at large wins because there would be a massive boost in interest if people could start equating general surgery with predictable lifestyles. The quality and number of applicants would shoot through the roof. More general surgeons, more quality people, more innovation and more access to health care.

That's my vision.

/I predict grumbling about continuity of care
//also reminiscences about the days of the iron men and women who grit their teeth and loved it

Anonymous said...

Man, I remember my first really big case on call as an anesthesia resident..Dead Bowel came in at 5:30am, in an 114 year the patient to sleep, running 3 different pressors, hangin blood, finally get caught up, and start fillin out the paperwork, and watta ya know, 7 am came, and I got to go home, was ordered to go home actually, had to get my Anesthesis Beauty Sleep.

Jeffrey Parks MD FACS said...

It's one thing to advocate for some sort of surgical hospitalist model for the covergae of community/rural hospitals that lack gen surgeons willing to take ER call. It's quite another to whisk appies out of community hospitals because trauma attendings at tertiary referral centers are bored out of their minds...

Anonymous said...

"I couldn't stand being strictly a "trauma surgeon" and going weeks without doing a legitimate operation."

Not that I've experienced trauma surgery in any more than two hospitals, only one of which had dedicated trauma surgeons, but this was hardly my experience. Our trauma service had a steady flow of very-much-operable gunshot wounds, stab wounds, ejected-from-then-rolled-over-by-SUV wounds, etc. Sure, lots of things get medically managed, but a ruptured diaphragm still only has one solution. Our service mostly had the opposite problem from what you're describing - we got lots of things from community hospitals that they "weren't comfortable with" that were hardly more than scratches and scrapes.

Tyro said...

I think Buckeye has nailed the worrisome undertone of this article and I'll go him one more as a probable community ED doc. General surgeons are vital to a local community hospital for all the reasons he says. The add on is to note how terrible an idea it is to transport someone who you can handle in-house. EMS is frought with risks and transport is currently already growing more than it should--witness the explosion of air transport companies and the attendant helicopter accidents.

Appys and hernias and gall bladders should damn well be handled by local centers. The public, of course, will love going to the big fancy hospital not realizing that they will be getting some second-year surgical res doing their op rather than a seasoned community doc. Granted good medicine happens at the trauma centers but more for huge resource drains like sick MBT patients and aortic dissections and, medically, septic chemo patients or the like. To essentially gut the community hospital system for the big dogs is a bad idea.

ER's Mom said...

The other thing that the original article is missing is the thought of other services.

As an OB, we NEED the OR team to be on-call for us for c-sections. We have 24 hour in-house anesthesia (we have enough deliveries to justify it), so that cost will be present no matter what. But I can't do a section without a skilled assist easily (although in a true emergency I have done it - but it sucks, is more difficult, and is fraught with more complications).

MiamiMed said...

It's very simple. I am entering surgical residency next year, and I am strongly considering staying in general surgery. Yes, lifestyle considerations matter at times, but there are two real reasons that G-surg is on the decline:

1. Reimbursement. I'm not even sure that this is truly as much of a problem as we are lead to believe, but the university system would love you to think that you'll be eating canned dog food forever if you don't subspecialize. There is clearly a pay differential. It's very simple, if you reimbursed general surgeons in small town some extra money for seeing midnight cases, there would be no shortage of them. Everything has a price, and I suspect that the price that would woo a general surgeon in at midnight to do a gallbladder is a heck of a lot cheaper than a chopper flight across the state.

2. They steal all of your cases. The article in question is simply another example of academic hotshots with 10 extra years in fellowship training trying to steal every remotely interesting case from the community. When we first started talking about Acute Care Surgery, it really had me asking, "Isn't this just general surgery?" I had to ask why I needed a two year fellowship to be able to practice general surgery.

There is an incredible interest in my incoming residency group in Peds Surgery. If you speak to most of them, it's because Peds surgeons still function a lot like general surgeons. It's not so much the money with this group as the lack of variety in the urban zones due to hyperspecialization.

I really do have to wonder why I need to become a trauma surgeon to do a gallbladder at midnight, but I can do one at 7:00 am as a general surgeon. The argument sounds a lot like the radiologists who are arguing that foreign docs are qualified to read films only outside of normal business hours. I think that an ACS model works well at a specific center. In other words, the in house trauma covers emergent cases that come from the ER in the hospital with the trauma center. This works well at my home program. It makes no sense to send over everyone else's cases as well.

By the way Buckeye, I love the blog. I'm a long time lurker. I would love to have a similar practice one day.

Joseph Sucher, MD FACS said...


You have valid points encased in inflamatory talk. It makes for excellent reading (that's why I am stuck here still looking through your archives) but in this case your synopsis and subsequent analysis is misleading and superficial. Please don't get bored with my diatribe to follow, I promise that you will actually like some of my remarks.

Point: Flying acute appendicitis and cholecystitis out of community hospitals to the "big house" sounds to be overkill. But what is the rest of their story? Is the morbidity for these issues high in that community? Is the ER wait in that community significantly longer than it should be? I don't know.

Nonetheless, acute care surgery (ACS) isn't about soaking up every little emergency case because its nighttime. Its about the fact that our ERs are overcrowded, and the hospital is full. This is real data. Throughput is the issue at hand, and ACS is a tool to address optimizing this problem by having surgeons readily available to care for these patients. Therefore ACS can be implemented to reduce the ER overcrowding as well as the inpatient census by providing timely and efficient care.

Point: Trauma surgeons are operating less and that is why ACS was created. This is rooted in pseudo-truth. But not the whole story. ACS is a specialty (The college and board have already began processes towards the approval of this designation) with fellowship training directed at developing surgeons that can perform emergent care across a wide range of surgical specialties including neuro, ortho, urology, ENT, vascular and GYN. This may be the rebirth of the old general surgeon, and a process to address training a surgeon that will practice in a rural location. This is one point that I think you would actually appreciate.

Additionally, ACS came from trauma surgeons because of their surgical critical care background, thus giving them the specialty training of caring for the catastrophically ill patient. Sure, this isn't necessary for your run of the mill surgical emergency, but it means the difference between life and death on that 80 year old patient with CHF and COPD in septic shock from perforated diverticulitis. Not a fun thing to handle if you are a solo practicing general surgeon.

ACS has significant benefits to offer, just like any specialty. It can be set up well, or poorly. There is one truth that I live. ACS is a model that can provide a very high level of surgical care for patients with emergent issues who otherwise would face a higher risk of delayed care, and higher risk of morbidity and mortality than with some of the care provided by our unsustainable current surgical models.

Jeffrey Parks MD FACS said...

Dr Sucher-
Thanks for stopping, your comments are appreciated. My question is: if the ER's are full and patients are waiting too long to have their appendectomy/cholecystectomy, why wouldn't the answer be to increase the number of community general surgeons rather than creating an entirely new subspecialty of surgery based on trauma practitioners at major centers? It doesn't make sense. A general surgeon in the community needs to be doing these cases. But the problem is lack of availability. It's the same issue as primary care; not enough family practice docs/internists to take care of people in rural areas/small towns. And why are there not enough surgeons available? Diminishing compensations, lack of long term support from community hospitals. Simply shipping patients to the tertiary referral center is just slapping a bandaid on a fundamental problem. And it's unnecessarily expensive.

No one wants to be a general surgeon anymore. That's the issue that needs to be addressed. We need to change that mindset before we rush off and "solve" the situation by referring all late night cases to bored trauma attendings in urban centers.

I think your model works better (paradoxically) in the academic setting where you have endocrine surgeons and colorectal guys who dont want to take ER call and have to fit appies and hot gallbladders into their schedule. I think residents would certainly benefit from a ACS rotation.

I also like the idea of revamping surgical training for young surgeons interested in "rural surgery". Instruction on OB/Gyn, basic ortho stuff and vascular cases would be included....