Will acute care surgery and surgicalists help to avert an emergency care crisis?

Health care policymakers have expressed growing concern in recent years regarding an imminent emergency care crisis in the U.S. In May 2013, the department of surgery at Emory University, Atlanta, GA, hosted an inaugural Acute Care Surgery Conference under the direction of one of the authors, A.L. Jackson Slappy, MD, FACS, and the chair of Emory’s department of surgery, John Sweeney (see photo). This conference was designed to examine the role of acute care surgery in addressing the emergency care crisis.

More than 70 attendees heard presentations from Emory faculty regarding current issues in health care policy, efforts to standardize care, and the effects of implementation of an acute care surgery program on patient safety, quality, and outcomes. The conference explored acute care surgical practice models, fellowship training, future trends, and quality and administrative issues related to implementation of a dedicated emergency surgery program.

This article provides an overview of the meeting, discusses its relevance in the context of the emergency care workforce shortage, and makes recommendations on future directions for trauma and acute care surgery.

The featured speakers at the conference are listed in the sidebar.

Conference highlights

ACS Past-President L.D. Britt, MD, MPH, DSc(Hon)FACS, FCCM, FRCS(Eng)(Hon), FRCS(Ed)(Hon), FWACS(Hon), FRCS(I)(Hon), FCS(SA)(Hon), Brickhouse Professor and Chairman, department of surgery, Eastern Virginia Medical School, Norfolk, VA, discussed the renaissance of trauma surgery in the 21st century and the future of acute care surgery. Over the last decade, the field of trauma surgery has been reinvigorated by the emergence of the acute care surgeon, who shares with the surgical hospitalist the core concept of serving as a dedicated emergency surgeon. The continued evolution of these disciplines may inspire medical students and residents to focus their future careers on the timely and high-quality delivery of care to the emergency surgical patient, and resolve the emergency surgical care crisis in America.¹ Dr. Britt discussed the training and practice patterns that surgeons should have to be classified as acute care surgeons. He said acute care surgeons must have trauma fellowship training and be in an active practice that includes the provision of critical care and emergency general surgery services. Dr. Britt noted that 16 acute care surgery fellowships nationwide have now graduated 40 surgeons since he first proposed the American training paradigm for the acute care surgeon in 2007.²

John Nelson, MD, FACP, past-president and founder of the Society of Hospital Medicine, shared insights into acute care surgical practice, models, and quality and administrative issues involved in implementation. Dr. Nelson described the initial challenges that the hospitalist movement faced and noted parallels in the evolution of the dedicated emergency surgeon. Identifying an adequate number of surgeons to staff an acute care surgery program, negotiating appropriate strategic support, demonstrating an improvement in quality of care, and documenting a return on investment for the institution are essential to the continued success and viability of the program, he said.

In addition, Dr. Nelson noted that to assist in coordinating the expansion of the field, the Society of Hospital Medicine launched a dedicated website focused on acute care surgery and the surgical hospitalist movement. To track the growth in this field, existing programs are invited to register for collaboration and further research.

John O’Shea, MD, MPA, Senior Health Policy Advisor to the U.S. House Energy and Commerce Committee and co-author of this article, shared his insights on the Affordable Care Act (ACA), the congressional process, and the implications for the future of surgery. Dr. O’Shea reviewed the recent history of health policy issues that affect surgeons, such as medical liability; the Emergency Medicine, Trauma, and Active Labor Act; and Medicare physician payment reform.

Dr. O’Shea focused on the key provisions that will affect surgical practice, including Medicaid expansion, the introduction of the insurance exchanges, the medical device tax, and the Independent Payment Advisory Board. He concluded by sharing some valuable lessons that he has learned as a congressional committee advisor, stressing the importance of clinician leadership in health reform and suggesting future strategies for surgeons to enlighten the health reform debate by working collaboratively with members of Congress and their staffs.

Finally, conference attendees discussed the ongoing debate over how to properly categorize full-time, hospital-based surgeons, including those who provide acute care services. Conference participants were polled regarding their preference for the term “surgical hospitalist” or “surgicalist.” Surgicalist was clearly the preferred title, and it was noted that some nurse practitioners and physician assistants have chosen to use the term “surgical hospitalist” to describe their practice.

The authors believe a potential solution to this nomenclature issue is for emergency surgery programs that include board-certified trauma and critical care surgeons to use the name “acute care surgery,” and for programs that involve general surgeons without trauma and critical care fellowship training to use “surgicalist” in their title. Nationwide, there are approximately 200 Level 1 trauma facilities. The general surgeons practicing at other U.S. hospitals where these physicians provide trauma care services would, under the proposed nomenclature change, be called “surgicalists.”

Solving the emergency care crisis

The conference took place at a time when many public officials are seeking to address the shortage of emergency health care professionals, particularly in rural areas. Various government entities have been working to resolve the emergency care crisis. The U.S. Department of Health and Human Services (HHS) has proposed the creation of a General Surgery National Health Service Corps to deploy board-certified surgeons for several-month rotations across rural America.³ This concept was first advanced by former Emory University chancellor Michael Johns, MD, FACS, in a 1993 Journal of the American Medical Association article.⁴ For this concept to work, it is essential to identify where to recruit physicians who are willing to relocate temporarily.

One potential target group is the new generation of acute care surgeons and surgicalists, who are mastering the delivery of emergency care. Another possibility is to harness the altruism of surgeons who seek to address global disparities in health care, and persuade them to travel to rural U.S. hospitals instead.

Another possible strategy is to focus on funding programs that are designed to strengthen emergency care. The ACA authorized $224 million to support existing systems of trauma care and to stimulate research into new models of innovation for regionalization and emergency care coordination. The American College of Surgeons (ACS) has called upon HHS Secretary Kathleen Sebelius to implement this provision, but the President’s budget proposals for fiscal years 2010 to 2013 have excluded a specific request for the appropriation of the necessary funds.⁵

This omission is somewhat surprising as a trauma and emergency care bill, S.B. 1873, introduced by then-Sen. Barack Obama (D-IL) in the 110th Congress in 2007, would have allocated $12 million for fiscal years 2008 through 2013 for the design and implementation of regionalized systems of emergency care (see figure). Although the bill did not pass the Senate Committee on Health, Education, Labor and Pensions, portions of it were used to craft the ACA. The crisis in emergency care has only intensified since 2007, and surgeons should call upon their members of Congress to fund the trauma sections of the ACA.

Success in mass-casualty care

As Kate Heilpern, MD, chair of the department of emergency medicine at Emory, noted at the conference, the emergency department is often a mirror for society’s problems, including the misuse of guns, the underuse of seatbelts, and the hazards of drinking and driving. The tragedies at Sandy Hook Elementary School in Newtown, CT, the Boston Marathon, and the Navy Yard in Washington, DC, further underscore the need for federal and state legislation to address the epidemic of gun violence, which is consistent with the ACS Statement on Firearm Injuries,⁶ and the need for dedicated acute care health care professionals.

The heroism and lifesaving care offered by the first responders, paramedics, law enforcement, and surgical and emergency medicine providers on April 15, 2013, at the Boston, MA, Marathon bombing were highlighted in an essay by Atul Gawande, MD, FACS, in the New Yorker.⁷ In it, he describes firsthand his experience at the Brigham and Women’s Hospital and provides accounts from other health care professionals involved in caring for the wounded. All of the patients transported from Copley Square to Boston hospitals survived, and the three fatalities were all pronounced at the scene. Dr. Gawande explains why the outcome was so favorable, in the following excerpt:⁷

What prepared us? Ten years of war have brought details of attacks like these to our towns through news, images, and the soldiers who saw and encountered them. Almost every hospital has a surgeon or nurse or medic with battlefield experience, sometimes several. Many also had trauma personnel who deployed to Haiti after the earthquake, Banda Aceh after the tsunami, and elsewhere. Disaster response has become an area of wide interest and study. Cities and towns have conducted disaster drills, including one in Boston I was involved in that played out the scenario of a dirty-bomb explosion at Logan Airport on an airliner from France.

His reflections highlight the need for continued research in emergency and trauma care.

Bright future of emergency surgery

The battle on Capitol Hill over health care reform has continued since the enactment of the ACA, culminating in a federal government shutdown last fall. As lawmakers seek to pass additional reforms, the authors believe these efforts should be aimed at inspiring and incentivizing a new generation of physicians to dedicate their careers to acute care emergency surgery. We encourage physicians to share stories from the clinical front lines to attract the media and move Capitol Hill to enact new laws ensuring all Americans receive safe, efficient, and high-quality care.

The mass-casualty events that have occurred in recent years and the inaugural Acute Care Surgery Conference at Emory provide a window of opportunity to remind Congress and the President of the importance of continued research in trauma and emergency care coordination, regionalization, and mass-casualty preparedness. It also is a good time to ask our elected officials to appropriate the $224 million to fund the trauma and emergency medical services programs authorized in the Public Health Service Act provisions in the ACA.

As an outgrowth of the Acute Care Surgery Conference in Atlanta, a Capitol Hill briefing on the topic is being planned in an effort to share the key findings of the meeting with legislators. At press time, a date had not yet been set for the meeting, but we believe there is a special opportunity to transform emergency surgical care and solve the larger challenges facing emergency rooms throughout the national and worldwide.

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References

1. Maa J. Solving the emergency care crisis in America: The power of the law and storytelling. Perm J. 2012;16(3):71-74.
2. Britt LD. Acute care surgery: A proposed training curriculum. Surgery. 2007;141(3):304-306.
3. Maa J. Solving the emergency surgical care crisis in America. ACEP Now. June 20, 2012. Available at: www.acepnow.com/article/solving-emergency-surgical-care-crisis/. Accessed January 14, 2014.
4. Johns MM. Mandatory national health service: An idea whose time has come. JAMA. 1993;269(24):3156-3157.
5. American College of Surgeons. Advocacy and health policy. Federal legislation. Trauma and EMS. Available at: www.facs.org/ahp/trauma/index.html. Accessed December 12, 2013.
6. American College of Surgeons. Statement on Firearms Injuries. Available at: www.facs.org/fellows_info/statements/st-12.html. Accessed December 12, 2013.
7. Gawande A. Why Boston’s hospitals were ready. New Yorker. April 17, 2013. Available at: www.newyorker.com/online/blogs/newsdesk/2013/04/why-bostons-hospitals-were-ready.html. Accessed December 4, 2013.