Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) has conducted an annual survey of its members for more than 20 years. The purpose of the survey is to provide a means of communicating the Governors’ concerns to the College leadership. The 2016 ACS Governors Survey, conducted in August 2016, had an 84 percent (230/274) response rate.
The following article focuses on the emerging discipline of acute care surgery, and the Governors’ responses to questions about its impact on patient care and general surgery practice. Additional articles on the survey’s findings will be published subsequently.
A new subspecialty of general surgery is emerging: acute care surgery, which encompasses trauma, critical care, and emergency care, with general surgery at its core. Because acute care surgery has gained such prominence, in 2016 we surveyed the 274 members of the B/G on the potential impact of this growing specialty on patients and health care providers.
Acute care surgery timeline
In 2003, the ACS Committee on Trauma (ACS COT), the American Association for the Surgery of Trauma (AAST), the Eastern Association for the Surgery of Trauma, and the Western Trauma Association established the Committee to Develop the Reorganized Specialty of Trauma. This collaborative effort led the AAST to create the Acute Care Surgery Committee in 2005, which established the training and practice parameters for the new specialty. Since then, acute care surgery has grown as a specialty and now has a major presence throughout the U.S.* Jerry Jurkovich, MD, FACS, past-president of the AAST, in a 2007 column wrote that the acute care surgeon should “be responsible for managing acute general surgical problems, covering emergency general surgical and specialty services, providing surgical critical care, and managing acute trauma.”†
Respondents’ general perceptions
U.S. surgeons accounted for 81 percent of the respondents to the 2016 ACS Governors Survey, Canadian surgeons accounted for 5 percent, and international surgeons for 14 percent. Specialists made up 50 percent of survey respondents, 14 percent were general surgeons, and 36 percent identified as both (see Figure 1).
Figure 1. Summary of survey respondents by career category
With respect to practice type, 49 percent of the respondents were in full academic practice, 23 percent in private practice, and 15 percent were hospital employed; the rest were employed at government agencies or other institutions. Most ACS Governors (84 percent) work in academic institutions or community hospitals with more than 250 beds. In all, 68 percent of the respondents indicated that they work in hospitals that have an acute care surgery service (see Figure 2).
Figure 2. Respondents who work at a facility with acute care surgery service
Of the respondents who work at a hospital that has an acute care surgery program, 79 percent indicated that the acute care surgery program had been in place for at least five years. However, only 26 percent of the surgeons who participated in an acute care surgery program were full-time acute care surgeons (see Figure 3).
Figure 3. Surgeon mix within acute care surgery services
Of the surgeons who served on an acute care surgery service, most had little or no formal training (23 percent and 46 percent, respectively) in acute care surgery.
Effects of acute care surgery
The Governors also sought to evaluate specific acute care-related issues, such as the efficiency of care delivery, emergency room (ER) coverage, and costs since the development of an acute care surgery program. Table 1 shows the overall responses to the effect of these programs on health care delivery, and Table 2 identifies the responses to the same questions from acute care general surgeons as compared with all other surgeons. For most of these issues, the percentage of positive answers was higher among the acute care general surgeons than among all other surgeons.
Table 1. Effects of acute care surgery programs on health care delivery (all specialties)
| Issue | Yes | No | Don’t know |
| ER patients that need a general surgery consult are seen more quickly |
59% |
17% |
24% |
| Inpatients that need a general surgery consult are seen more quickly |
56 |
23 |
21 |
| It has been easier for our hospital to provide ER general surgery coverage |
57 |
27 |
16 |
| Patients with nontraumatic general surgical emergencies get to the operating room (OR) more quickly |
48 |
27 |
25 |
| The length of stay for patients with nontraumatic surgical emergencies has decreased |
32 |
27 |
41 |
| Care of patients with nontraumatic surgical emergencies has improved |
55 |
21 |
24 |
| Care of patients in the surgical intensive care unit (ICU) has improved |
43 |
25 |
32 |
| The cost of care for emergency surgical patients has decreased |
14 |
23 |
63 |
| General surgeons are happy that they no longer have to take ER general surgery call |
48 |
24 |
28 |
| Surgical specialists are happy that they no longer have to take ER general surgery call |
44 |
28 |
28 |
| General surgeons now have a more predictable lifestyle with less interruption of scheduled surgery days and office days |
58 |
19 |
23 |
| Surgical specialists now have a more predictable lifestyle with less interruption of scheduled surgery days and office days |
49 |
28 |
23 |
| Patients prefer the acute care surgery model over the traditional model |
18 |
17 |
65 |
| The nursing staff prefers the acute care surgery model over the traditional model |
29 |
10 |
61 |
Table 2. Effects of acute care surgery programs on health care (acute care surgeons vs. other surgical specialists)
| Acute care surgery | All other specialists | |||||
|
Issue |
Yes |
No |
Don’t know |
Yes |
No |
Don’t know |
| ER patients that need a general surgery consult are seen more quickly |
64% |
22% |
14% |
57% |
15% |
28% |
| Inpatients that need a general surgery consult are seen more quickly |
62 |
27 |
11 |
54 |
22 |
24 |
| It has been easier for our hospital to provide ER general surgery coverage |
65 |
27 |
8 |
54 |
27 |
19 |
| Patients with nontraumatic surgical emergencies get to the OR more quickly |
59 |
19 |
22 |
44 |
30 |
26 |
| The length of stay for patients with nontraumatic surgical emergencies has decreased |
39 |
28 |
33 |
29 |
27 |
44 |
| Care of patients with nontraumatic surgical emergencies has improved |
69 |
17 |
14 |
51 |
22 |
27 |
| Care of patients in the surgical ICU has improved |
44 |
31 |
25 |
42 |
24 |
34 |
| The cost of care for emergency surgical patients has decreased |
19 |
33 |
48 |
13 |
19 |
68 |
| General surgeons are happy that they no longer have to take ER general surgery call |
53 |
19 |
28 |
47 |
25 |
28 |
| Surgical specialists are happy that they no longer have to take ER general surgery call |
44 |
28 |
28 |
44 |
28 |
28 |
| General surgeons now have a more predictable lifestyle with less interruption of scheduled surgery days and office days |
61 |
17 |
22 |
57 |
20 |
23 |
| Surgical specialists now have a more predictable lifestyle with less interruption of scheduled surgery days and office days |
51 |
26 |
23 |
49 |
28 |
23 |
| Patients prefer the acute care surgery model over the traditional model |
14 |
20 |
66 |
19 |
17 |
64 |
| The nursing staff prefers the acute care surgery model over the traditional model |
40 |
11 |
49 |
25 |
9 |
66 |
The Governors also wanted to determine the positive effects of an acute care surgery service on patient and provider well-being based on responses from acute care surgeons as compared with all other surgeons (see Table 3). Again, for most of these issues, acute care surgeons were more likely than other surgeons to answer in the affirmative.
Table 3. Positive effects of an acute care surgery service on patient and provider well-being
| Acute care surgery |
All other specialists |
|||||
|
Issue |
Yes |
No |
Don’t Know |
Yes |
No |
Don’t Know |
| Care of patients with nontraumatic surgical emergencies has improved |
69% |
17% |
14% |
51% |
22% |
27% |
| ER patients that need a general surgery consult are seen more quickly |
64 |
22 |
14 |
57 |
15 |
28 |
| It has been easier for our hospital to provide ER general surgery coverage |
65 |
27 |
8 |
54 |
27 |
19 |
| Inpatients that need a general surgery consult are seen more quickly |
62 |
27 |
11 |
54 |
22 |
24 |
| General surgeons now have a more predictable lifestyle with less interruption of scheduled surgery days and office days |
61 |
17 |
22 |
57 |
20 |
23 |
| Patients with nontraumatic surgical emergencies get to the OR more quickly |
59 |
19 |
22 |
44 |
30 |
26 |
| General surgeons are happy that they no longer have to take ER general surgery call |
53 |
19 |
28 |
47 |
25 |
28 |
| Surgical specialists now have a more predictable lifestyle with less interruption of scheduled surgery days and office days |
51 |
26 |
23 |
49 |
28 |
23 |
The survey also sought to determine perceptions of the intermediate or negative effects of an acute care surgery service from the acute care surgeon perspective versus all other surgeons (see Table 4).
Table 4. Intermediate or negative impact of an acute care surgery service
| Acute care surgery |
All other specialists |
|||||
|
Issue |
Yes |
No |
Don’t Know |
Yes |
No |
Don’t Know |
| Care of patients in the surgical ICU has improved |
44% |
31% |
25% |
42% |
24% |
34% |
| Surgical specialists are happy that they no longer have to take ER general surgery call |
44 |
28 |
28 |
44 |
28 |
28 |
| The nursing staff prefers the acute care surgery model over the traditional model |
40 |
11 |
49 |
25 |
9 |
66 |
| The length of stay for patients with nontraumatic surgical emergencies has decreased |
39 |
28 |
33 |
29 |
27 |
44 |
| The cost of care for emergency surgical patients has decreased |
19 |
33 |
48 |
13 |
19 |
68 |
| Patients prefer the acute care surgery model over the traditional model |
14 |
20 |
66 |
19 |
17 |
64 |
Since the development of acute care surgery services, 26 percent of the survey respondents reported a decrease in the number of surgical cases done by general surgeons who were not involved in the acute care surgery program (see Figure 4). In addition, 79 percent reported no significant change in income (see Figure 5).
Figure 4. Workload post-implementation of acute care surgery service
Figure 5. Income since the development of an acute care surgery service
Tables 5 and 6 show income variability based on the specialty of the respondent. For all types of surgeons, most noted no significant change in income. More general surgeons (17 percent) noted an increase in their income than a decrease in earnings (9 percent).
Table 5. Income variability for acute care surgeons vs. other specialists
| Effect on income | Acute care surgery | All other specialists |
| Increased |
33% |
7% |
| Decreased |
11 |
7 |
| Not changed significantly |
56 |
86 |
Table 6. Income variability for general surgeons vs. other specialists
| Effect on income | General surgeons | All other specialists |
| Increased |
17% |
12% |
| Decreased |
9 |
8 |
| Not changed significantly |
74 |
80 |
We also asked the Governors to describe any negative developments that have emerged since their hospital developed an acute care surgery service. These responses can be combined into six categories, which are listed below in order of the frequency of the response:
- Fragmented care/poor continuity of care: 10 responses
- Negative effects on the call schedule: seven responses
- Decreased quality of care due to less experienced acute care surgeons: six responses
- OR access issues due to acute care surgery cases needing to be scheduled urgently/emergently: four responses
- Conflicts/controversy between acute care surgeons and community surgeons: four responses
- Devaluation of the general surgeon: Two responses
Although overall, 70 percent of survey respondents could foresee no significant change in their income if their hospital developed an acute care surgery program, 65 percent of the responders would prefer not to develop such a program. When analyzed by type of surgeon, a substantial majority—73 percent of general surgeons and 54 percent of other surgeons—are opposed to the development of an acute care surgery service.
ER call
Among the Governors who participated in the study, 57 percent reported that they take ER call. Of those who take ER call, general surgeons are most likely to do so (76 percent) versus other surgical specialists (31 percent). Furthermore, 100 percent of the general surgery respondents said they feel comfortable taking ER call versus 78 percent of all others. Compensation for ER call is provided to 48 percent of the respondents.
In total, 48 percent of survey participants said they would consider it a negative change if their hospital developed an acute care surgery service and they no longer were able to take ER general surgery call. In fact, the survey participants who indicated such a move would be a negative change were largely general surgeons (52 percent) compared with all other surgeons (33 percent).
Career choices
When asked whether they believe acute care surgery will become a popular career choice for medical students and surgical residents in the future, 52 percent of the respondents answered yes and 18 percent said no. In addition, 42 percent of the respondents said they believe that acute care surgery will be a more attractive career choice for medical students and residents than trauma surgery or critical care surgery. This perceived preference could be related to the need for a better defined work schedule, more predictable work hours, and an expectancy for an improved quality of life.
Therefore, it is possible that because the presence of an active acute care surgery service could make the practice lifestyle of a general surgeon (one who is not a member of the acute care surgery service) more predictable, 60 percent of the ACS Governors indicated that more medical students and residents may choose general surgery if they knew they could forgo call responsibility.
Overall, 50 percent of the respondents agree that the development of acute care surgery services should be supported across the U.S. (see Figure 6). However, this sentiment varies depending on whether the respondent’s hospital already has an acute care surgery program and if this individual is a general surgeon or a surgical specialist (see Tables 7 and 8).
Figure 6. Support for development of an acute care surgery service
Table 7. Institutions with acute care surgery program: Should acute care surgery programs be instituted across the U.S.?
| Category | Yes | No | I’m not sure |
| General surgeons |
59% |
15% |
26% |
| Other non-acute care surgeons |
49 |
13 |
38 |
| Acute care surgeons |
84 |
8 |
8 |
Table 8. Institutions without acute care surgery program: Should acute care surgery programs be instituted across the U.S.?
| Category | Yes | No | I’m not sure |
| General surgeons |
29% |
34% |
37% |
| Other non-acute care surgeons |
53 |
18 |
29 |
| Acute care surgeons |
0 |
0 |
100 |
Summary and implications of findings
Acute care surgery is a relatively new field that will continue to evolve. Our 2016 survey of the members of the ACS B/G shows that most hospitals (68 percent) have an acute care surgery program. Of these programs, 79 percent have been in place for at least five years. These programs are usually a mix of full-time acute care surgeons, or both general surgeons and acute care surgeons. However, at most, 31 percent of the surgeons in an acute care service are fellowship trained.
The general surgery respondents who are presently in an acute care surgery program express an overall positive attitude toward their experience. Likewise, respondents indicate that the presence of an acute care surgery service has a positive effect on patient care.
General surgeons and other surgeon specialists have seen 30 percent and 24 percent decreases, respectively, in the number of cases since the development of acute care service programs. However, overall income has not changed significantly for 79 percent of the survey respondents. Interestingly, 17 percent of general surgeons saw an increase in income.
Negative developments that hospitals with acute care surgery services have experienced include fragmentation of care, negative effects on the call schedule, and decreased quality of care due to acute care surgeons with less experience in caring for certain conditions compared with their general surgeon counterparts.
Overall, of respondents who work in hospitals that have yet to develop an acute care surgery program, 65 percent would prefer that their hospital refrain from developing such a service. This sentiment is even more common among general surgeons (73 percent). However, if their institutions did develop an acute care surgery service, 70 percent of the respondents thought their income would remain relatively stable, although general surgeons were most likely to express concern that their income would decline (37 percent versus 17 percent).
In all, 57 percent of ACS Governors take ER general surgery call, and 95 percent feel capable and comfortable doing so. Of those who do take call, 48 percent receive compensation for it. Interestingly, 47 percent of Governors in hospitals that do not have an acute care surgery program had a negative response to the possibility of no longer taking ER call. This reaction was more common among general surgeons (52 percent) than all other surgeons (33 percent). It’s possible that being compensated for taking ER general surgery call might influence whether surgeons would want their hospitals to develop an acute care surgery program.
Most Governors believe that acute care surgery will become a popular career choice for medical students and surgical residents, even more so than trauma surgery and/or critical care. Likewise, it is possible that the appeal of acute care surgery programs may encourage medical students to pursue general surgery as a career since they would not be expected to be on call as frequently.
Despite the limitations of the survey—specifically, the limited response number, as only B/G members were surveyed—these responses suggest that acute care surgery is an important and growing area of concentration, and that the development of programs across the U.S. should be encouraged.
*Wu D. Graduate of the first acute care surgery fellowship program reflects on the experience. Bull Am Coll Surg. 2015;100(10):11-16. Available at: bulletin.facs.org/2015/10/graduate-of-the-first-acute-care-surgery-fellowship-program-reflects-on-the-experience/.
†Jurkovich GJ. Acute care surgery: A trauma surgeon’s perspective. Surg. 2007;141(3):293-296.
