Graduate of the first acute care surgery fellowship program reflects on the experience

In recent decades, one of the overwhelming issues in hospital care has been overcrowding in emergency departments (ED). The general public’s increasing use of the ED, paired with inadequate staffing and resources to meet this demand, has resulted in long wait times for patients in need, ambulance diversions to other centers, and compromises in overall patient safety and care. As a result, patients are being forced to delay care and are expressing a general sense of dissatisfaction. The backlog of patients creates a barrier to the throughput in and out of the ED. This unfortunate reality has led the Institute of Medicine to suggest that emergency medicine has reached its breaking point, particularly in rural hospitals.1 Urgent care centers and retail clinics provide some relief from ED congestion by providing care to patients who are experiencing easy-to-manage illnesses and injuries. As a result, the most common reasons for presentation to the ED are major injuries and abdominal pain, which create a pressing need for general and trauma surgeons who are able to evaluate these patients in a timely way.2,3

This article addresses how acute care surgeons can help alleviate some of these concerns, describes the development and establishment of the first acute care surgery fellowship, and outlines the important role acute care surgeons can play in the changing health care delivery system.

General surgery workforce issues

According to Solucient—an analytical tool providing evidence-based performance improvement suggestions for health care professionals—the recommendation for general surgery coverage is six general surgeons per 100,000 people.4 The Association of American Medical Colleges estimates that the U.S. is experiencing an overall deficit of 13,700 physicians.5 Recent projections suggest that by 2025, the physician shortage may rise to more than 90,000, including a shortage of 31,000 surgeons.6 Even if the Accreditation Council for Graduate Medical Education (ACGME) approved 10,000 additional resident positions, a large gap in the supply and demand of physicians would remain.7

In addition to physician shortage concerns, a shift toward specialization is becoming more prevalent, with an increase in the number of specialist surgeons and a decline in the number of general surgeons, especially those exclusively performing general surgery. The nationwide trend toward use of minimally invasive techniques and the growing restrictions on duty hours limit the operative experience available to surgical residents in training. Furthermore, priorities are changing in the younger generations of physicians. Considerations collectively described as “lifestyle,” which include scheduling, workload, and family life, have risen as driving factors in determining the field of medicine that residents pursue. Moreover, increasing numbers of trainees are choosing fellowships in more specialized fields.

The discipline of surgery has become increasingly specialized for multiple reasons, including rapid expansion of medical knowledge, advances in techniques and technologies, and a rise in patient demands stemming from the proliferation of health care information on the Internet. This rapid expansion of the subspecialties has resulted in the creation of more centers of excellence and centralization of care, which has the unintended effect of further limiting patients’ access to optimal care.

Another consequence of this shift toward specialization is that specialty surgeons often are reluctant to take emergency general surgery call for the following reasons:

  • It shifts the focus of their practice away from their specialty.
  • They prefer to avoid getting involved with problems outside their area of expertise.
  • General surgery call would increase their exposure to liability.

Finally, whereas surgeons historically took general surgery call to build their client base or to maintain hospital admitting privileges, some specialty surgeons are now shifting the focus of their practices away from the hospital setting or to institutions without an ED.

Establishing an acute care specialty

These changes in the specialists’ preferences, coupled with the overcrowding of EDs, necessitate specific remedial changes that will ensure that patients have access to 24/7 emergency care provided by surgeons who have broad-based surgical and critical care skills and training. In response to this need, the American Association for the Surgery of Trauma (AAST) set out to create the specialty of acute care surgery. Jerry Jurkovich, MD, FACS, past-president of the AAST, in a column he wrote in 2007, said that the acute care surgeon should “be responsible for managing acute general surgical problems, covering general surgical and specialty services, providing surgical critical care, and managing acute trauma.”8 Dr. Jurkovich went on to assert that the acute care surgeon would require training in core general surgery, “as well as in thoracic, vascular, and gastrointestinal surgery, so as to not just allow but to encourage the development of a diverse elective surgical practice.”8

In 2003, the Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery was formed through a joint meeting of the American College of Surgeons Committee on Trauma, the AAST, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association. In 2005, the AAST created the Acute Care Surgery Committee to establish the parameters for the new specialty’s training and practice. The committee determined that this new discipline would require broad-based surgical training, including elective and emergency general surgery; it would have a strong emphasis on trauma; and it would have, at its core, a surgical critical care residency approved by the ACGME. Since its inception, the Acute Care Surgery Committee has established acute care surgery as a singular specialty, with its own curriculum, site-verified program requirements, and a certificate of completion. In that time, acute care surgery has grown as a specialty and now has a major presence at many national surgical conferences.

The UNSOM experience

A total of 19 fellowship programs have been certified by the AAST as training facilities for the specialty of acute care surgery. The first of these was at the University of Nevada School of Medicine (UNSOM) in Las Vegas. As part of the first graduating class of acute care surgery fellows at UNSOM, I had the honor of being part of the development, training, and the completion of this new specialty. In my mind, acute care surgery encompasses a combination of trauma surgery and critical care surrounding a core of elective and emergency surgery. However, there are many types of surgical emergencies: orthopaedic, neurosurgical, and those that fall under the rubric of general surgery subspecialties including vascular, thoracic, and biliary. An acute care surgeon should be familiar with each of these disciplines.

UNSOMPerhaps one of the purest examples of an acute care surgeon is the general surgeon who practices in a rural environment with little specialty support. This surgeon must be a “Renaissance person” capable of taking care of anything that may come through the hospital door. This is the surgeon that one would hope to have in the hospital when a surgical emergency enters the building. This surgeon would be able to take care of some of the most critical patients during the worst possible times.

I wanted to be the surgeon who everyone could depend on when they needed me most. I was told that UNSOM was planning to become a training facility for acute care surgeons, and I jumped at the opportunity to become a part of this process. Although I was aware that the program did not exist when I applied for fellowship, I knew my training would likely be modeled on the acute care surgery curriculum, and I anticipated that I would need a second year of fellowship training to obtain additional skills in trauma. However, three months into my fellowship, my program director at UNSOM, John Fildes, MD, FACS, told me that the curriculum for the acute care surgery fellowship had been established and that the committee was ready to review applications to approve training programs in acute care surgery. Over the course of the next month, we furiously developed goals and objectives for all of the ACGME core competencies for each rotation that the acute care surgical fellow would be expected to complete. In addition to the predetermined rotations in emergency, neurological, orthopaedic, thoracic, trauma, and vascular surgery, we created curricula for interventional radiology, burn surgery, rural surgery, and colorectal surgery, among others. Most of these curricula had never been created, but we derived the information from programs that offered complete training fellowships in these specialties, and modified them for a surgical fellow.

After submitting the application for an acute care surgery fellowship, UNSOM became the first training institution to undergo a site visit for such a program in December 2007. An esteemed panel toured each of the UNSOM facilities and probed the faculty, fellows, and residents with questions about the desire, feasibility, and impact of having an acute care surgery fellowship at UNSOM. Our specific center, the University Medical Center of Southern Nevada, Las Vegas, was in the unique situation of having no orthopaedic or neurological surgery residency programs and no fellows in vascular, thoracic, pediatric, or colorectal surgery. Thus, the faculty, caseload, and desire were abundant for training acute care surgeons in each of these disciplines without negatively affecting the training of other fellows. In the last few hours of their inspection, the ACGME representatives spoke to my co-fellow, Scott Cinelli, DO, and me, stating, “We’ll be keeping a close eye on your careers.” At that point I knew that we had passed the inspection and were on our way to becoming the first training program for acute care surgeons.

Personal impressions

The new curriculum for acute care surgery was innovative and unique. The rotations I completed provided experience in many different disciplines, and not simply at the level of a medical student or intern. In most respects, Dr. Cinelli and I were trained like specialty fellows. I gained knowledge in many domains, performed diverse surgeries and procedures, and earned a level of respect among the specialists for the ultimate care of our patients.

One of the most valuable rotations that I experienced was in trauma systems. This rotation was designed to familiarize us with the requirements of caring for trauma cases beyond the walls of the hospital. We attended meetings with the Southern Nevada Health District, spent time with the coroner witnessing autopsies, rode along with emergency medical services personnel when they responded to a call, and observed incident command tactics. This gave us additional experience and insight into what it takes for a trauma system to run smoothly—from the level of government offices down to each individual within the hospital.

Benefits to the community

How does acute care surgery benefit the hospital and community? In the eyes of the hospital, the acute care surgeon can fill many roles: as a trauma surgeon who can meet the day-to-day requirements of managing severely injured patients, as an intensivist who manages the critically ill and injured patients, and as a general surgeon who can ameliorate the paucity of general surgeons taking emergency call. All of these roles are fully integrated into the specialty of acute care surgery. Those surgeons who enter this specialty are fully aware of the requirements and expectations of taking in-house trauma and emergency general surgery call. For hospitals in small communities or in rural environments, the acute care surgeon has the expertise to stabilize critical patients so that they can be transported to more definitive specialty care. Those surgeons will likely become indispensable to these smaller centers, which often lack many specialists.

The crucial question for larger communities is whether acute care surgery only benefits suburban and rural communities and smaller hospitals. In fact, acute care surgeons and the acute care surgery model of staffing emergency rooms can improve patient access to on-call emergency surgeons. A recent study in the Annals of Surgery indicates that the acute care surgeon model improves care in acute appendicitis.9 In a large academic center, the ED was staffed by either a model analogous to acute care surgery (staffed by trauma/emergency surgeons) or a traditional general surgery model. Between September 1999 and August 2002, a total of 294 appendectomies were performed at this center—167 by in-house acute care surgeons and 127 by traditional house-call surgeons.8 The study’s researchers found no statistical difference in the time these individuals needed to complete the consultation, but the acute care surgery model resulted in significant decreases in time from consultation to operating room, and in complication rates, rupture rates, as well as overall length of stay.

The effect of acute care surgeons on other general surgeons also is positive; they complement each other. As previously stated, practice models are changing, and current graduating physicians place more emphasis on workload and lifestyle. To satisfy their desire for work-life balance, an increasing number of general surgery graduates continue their training to obtain subspecialty fellowships, which creates a potential shortage of practicing general surgeons. The availability of acute care surgeons to care for many of the emergency surgery patients will encourage more trainees to enter the field of general surgery because they will be able to maintain an elective practice with more consistent office hours and surgery schedules that are not disrupted by emergency consultations and add-on operations. In return, as an acute care surgeon, I experience the satisfaction of helping patients in their time of need, dealing with the diagnostic dilemmas of the presentation to the emergency room, and performing various complex procedures—all before I go home when my shift is done.

Acknowledgments

The author would like to acknowledge the guidance and mentorship of Frederick B. Rogers, MD, MS, FACS, trauma program medical director, Lancaster General Health, PA, and John Fildes, MD, FACS, foundation professor; acting chair, surgery; chief, division of acute care surgery; and program director, acute care surgery fellowship, University of Nevada School of Medicine, Las Vegas.


References

  1. Committee on the Future of Emergency Care in the United States Health System. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2006.
  2. Wynne SP, Carr K. Lancaster General Health urgent care and express care. J Lanc Gen Hosp. 2010;5(3):69-71.
  3. Committee on the Future of Emergency Care in the United States Health System. Emergency Medical Services: At the Crossroads. (Future of Emergency Care.) Washington, DC: National Academies Press; 2006.
  4. ACS Health Policy Research Institute, Association of American Medical Colleges. The Surgical Workforce in the United States: Profile and Recent Trends. Chapel Hill, NC: American College of Surgeons Health Policy Research Institute; April 2010.
  5. Cheney C. HealthLeadersMedia.com. Physician shortage to quadruple within decade, AAMC says. Available at: http://healthleadersmedia.com/page-1/PHY-258409/Physician-Shortage-to-Quadruple-Within-Decade-AAMC-Says. Accessed September 11, 2015.
  6. Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections from 2013 to 2015. 2013. Available at: www.aamc.org/download/426242/data/ihsreportdownload.pdf. Accessed August 10, 2015.
  7. Sheldon GF. The surgeon shortage: Constructive participation during health reform. J Am Coll Surg. 2010;210(6):887-894.
  8. Jurkovich GJ. Acute care surgery: A trauma surgeon’s perspective. Surg. 2007;141(3):293-296.
  9. Earley AS, Pryor JP, Kim PK, et al. An acute care surgery model improves outcomes in patients with appendicitis. Ann Surg. 2006;244(4):498-504.

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