The Shape of Things to Come: Results From a National Survey of Trauma Surgeons on Issues Concerning their Future

Orthopaedic faculty trauma call policies: a survey of accredited orthopaedic residency programs

The purpose of the study was to determine the practices and policies for trauma call for orthopaedic faculty at residency training programs. A 2-page survey was mailed to the chairs of 141 nonmilitary, accredited residency programs. Responses were received from 106 (75% response rate). Of the responders, 97 (91.5%) of the programs were associated with a Level 1 trauma center. All faculty took trauma call in 44% of programs. The chair took trauma call in 60% of the programs. In 35% of programs, full-time faculty earned additional compensation for taking call. The source of this compensation for full-time faculty was the hospital alone in 72%. In 32 programs, a per-diem stipend (mean $696, range $100-1,500) was provided. In 59% of programs, there was a specific orthopaedic "trauma team" that took over patient care from other faculty members after call. Thirty-three percent of programs had a policy concerning age when a full-time faculty member went off trauma call. Of these, faculty came off call at age 50 years in 11% of programs; at age 55 years in 29%; at age 60 years in 40%; at age 65 years in 9%; and "other" in 11%. Twenty percent of chairs responded that trauma call adversely affected the chair's ability to recruit new faculty. There was a wide variety of policies concerning orthopaedic faculty trauma call. Additional studies on faculty trauma call are warranted.

Surgical critical care and private practice surgeons: a different world out there!

BACKGROUND

Few graduating residents seek surgical critical care (SCC) fellowships; fewer than half of positions fill. We hypothesized substantial differences exist in practice patterns and attitudes between SCC surgeons in academic practice (ACs) and in private practice (PVTs).

STUDY DESIGN

A survey instrument was sent to 1,544 board-certified SCC intensivists in North America.

RESULTS

Of those invited, 489 responded (32% response rate). Respondents were mostly men (88%) and Caucasian (86%), with a mean age of 48 years; 60% were ACs, 28% were PVTs, and 12% reported "other;" 94% currently practiced SCC. PVTs (50%) were more likely than ACs (18%) to provide SCC for only their own patients, less likely (24% versus 74%) to function as an "ICU attending," and less likely to work with residents (36% versus 91%) and fellows (4% versus 60%; all p < 0.001). PVTs (48%) spent more time performing elective operations than ACs (27%; p < 0.001). They were more likely than ACs to relinquish management of SCC patients to medical consultants: infectious disease (34% versus 12%), cardiology (31% versus 12%), and pulmonary (23% versus 3%; all p < 0.001). Conflicts with medical specialists were a bigger problem for PVTs (43%) than for ACs (17%; p < 0.001).

CONCLUSIONS

Private practice surgical intensivists are more likely than academic intensivists to provide critical care for only their own patients and to use consultants to avoid conflicts.

A county hospital surgical practice: a model for acute care surgery

BACKGROUND

Trauma surgery has changed significantly over the past decade. Nonoperative evidence-based algorithms have become common and surgical trauma volume has become increasingly difficult to maintain. The acute care surgery (ACS) model, which integrates trauma, critical care, and emergency surgery, has been proposed as a future model of trauma practice.

METHODS

Database information from an academic, county-based, trauma center was reviewed. A performance improvement surgical procedure database and level I trauma registry from 2005 were used to evaluate one center's ACS practice.

RESULTS

There were 2,276 cases performed by 7 full-time and 5 part-time surgeons. Elective cases accounted for 64% (1,480) of caseload, emergency/urgent general surgery accounted for 32% (719) of cases, and emergency trauma surgeries accounted for 4% (96 procedures in 77 patients). In all, 23% were performed after hours. The ACS model supported controllable hours, adequate surgical volume, excellent patient care, and an appealing clinical practice.

CONCLUSION

Surgical practice in a county-run trauma hospital can be similar to the ACS model, with positive results in terms of clinical volume and physician satisfaction. As clinical practices shift to the ACS model, there are lessons to be learned from currently existing, thriving, long-standing similar prototypes.

Socioeconomic factors, medicolegal issues, and trauma patient transfer trends: Is there a connection?

BACKGROUND

A number of forces have come together to effect a perceived change in the volume and nature of transfers to Level I trauma centers recently. These may have little to do with the actual clinical need. This study seeks to verify whether a change in the profile of trauma transfers has occurred and to characterize the nature of any changes.

METHODS

Retrospective review of state trauma registry data from 1999 through 2003 including day and time of transfer, Injury Severity Score (ISS), primary ICD-9, payor status, and mortality. The transfer group (TTP) was compared with the general population of trauma patients (ATP) and variables trended. Analysis employed descriptive statistics and logistic regression. Average malpractice insurance premium charges and measures of subspecialty surgeon participation in trauma care were also trended.

RESULTS

During the study period ATP increased by 6% and TTP by 34%. The majority of transfers were from Level II to Level I trauma centers. Mean ISS increased from 9.1 to 10.0 (1.2%) in ATP and from 11.3 to 12.8 (2%) in TTP. The mortality rate over time was essentially unchanged for both groups; 4% ATP versus 5% TTP. Proportion of self-pay patients in each group remained relatively static between 20% to 25%. The number of patients with head injury (HI) increased by 14%, their transfer rate increased by 44%. Orthopedic injury (OI) prevalence increased 25% whereas transfers increased by 48%. Mean ISS increased from 13.7 to 14.8 and 11.1 to 12.9, respectively. The variables most significant for predicting transfer were arrival at initial emergency department between 3:00 pm and 7:00 am and OI or HI. Concomitantly, the mean malpractice insurance premium paid by general, orthopedic, and neurosurgeons each rose by approximately 90% during the study period. Waivers of regulatory compliance were requested by 28% of trauma centers (72% Level II) with 39% of requests related to lack of neurosurgery services.

CONCLUSION

During the study period, a disproportionate increase in TTP occurred in comparison to ATP. This finding is more pronounced in patients with HI and OI. Findings do not appear attributable to changes in severity or proportion of self payors. The ISS of TTP is below 16. Concomitantly, there was a precipitous rise in malpractice premiums and a functional decrease in neurosurgeons. This suggests a multifactorial reluctance or inability of initial hospitals to care for patients they are theoretically capable of treating, placing undo burden on Level I centers.

Do we need neurosurgical coverage in the trauma center?

The undersupply and maldistribution of neurosurgeons coupled with the apparent abandonment of trauma care by a significant number of rank and file neurosurgeons, and perhaps an over demand for their services, has created a crisis in access to neurotrauma care across the country. There is evidence to support that the immediate availability of a neurosurgeon to participate in the care of all trauma patients, including those who have documented head injury, may not be essential to providing optimal care, calling the American College of Surgeons' mandated criterion for trauma center verification into question. Given the volume, nature, and timeliness of head injury and its care, it seems this crisis can be resolved to a great extent by having trauma surgeons or other properly trained, credentialed, and monitored providers assume nonoperative, in-patient neurotrauma care when hospital admission is actually indicated. Although part of the solution lies in increased supply of neurotrauma services regardless of provider type, a second component rests in decreasing demand for these services in cases of mild and extremely severe head injury. Such a solution seems feasible and advantageous in several respects and should be seriously considered by healthcare policy makers, trauma system planners, and the leaders of the neurosurgical and trauma surgery disciplines. What is truly needed in hospitals treating trauma patients (ie, trauma centers) is a philosophy centered on patient services rather than the specific provider. What is needed is a provider who is committed, capable, and competent, who recognizes and meets the patients' needs and provides the appropriate services. These providers, regardless of pedigree, must be supported and valued by the healthcare system and society. In the future this may require regionalization of services. In some hospitals and systems the primary person responsible for providing these services will be a neurosurgeon. In others, it may not and perhaps need not be.

Should the trauma surgeon do the emergency surgery?

The specialty of trauma surgery is evolving. The continued decline in general surgery operative interventions in trauma patients has led to an exodus of promising young surgeons away from the field. A concurrent decline in the number of burn surgeons, as well as orthopedists and neurosurgeons interested in providing emergency care, led to a pressing need for surgeons able to perform emergency surgical care. In addition, the general surgery workforce has followed a trend of increased specialization, with young surgeons gravitating toward specialties that are perceived to have a more forgiving lifestyle. This development has led to troublesome gaps in the emergency surgery call schedule at many institutions. Several intrepid centers already have begun assimilating acute care surgery into their departments with impressive results for their patients. Increased operative volume, increased reimbursements, and a palatable lifestyle add to the allure of treating these complex and interesting patients. Training future surgeons to staff the ranks of acute care surgery is an important and exciting challenge. It may be that "Should the trauma surgeon do the emergency surgery?" is the wrong question. A better question may be "How best can we train surgeons for this new specialty"?

Has the trauma surgeon become house staff for the surgical subspecialist?

BACKGROUND

The role of the trauma surgeon is perceived to be mostly supportive of other procedure-oriented specialties. We designed this study to characterize the surgical and nonsurgical responsibilities of the contemporary trauma surgeon.

METHODS

Trauma patients admitted to an urban academic level I trauma center were studied using trauma registry data for 2004.

RESULTS

The large majority of patients admitted to trauma service has mild single-system injuries to 1 or 2 anatomic regions. Most (57%) did not have injuries to the neck, chest, or abdomen. Head and extremity injuries were present in 45% and 46% of patients, respectively. Surgeries were performed by orthopedists in 28%, trauma surgeons in 11%, and neurosurgeons in 6% of patients.

CONCLUSIONS

The contemporary trauma surgeon has little surgical opportunity and provides a disproportionate amount of nonsurgical care in support of consultant specialists. This is a major deterrent to general surgeon interest in trauma care and must be addressed as the acute-care surgeon evolves.

An acute care surgery model improves outcomes in patients with appendicitis

OBJECTIVE

To compare outcomes of appendectomy in an Acute Care Surgery (ACS) model to that of a traditional home-call attending surgeon model.

SUMMARY BACKGROUND DATA

Acute care surgery (ACS, a combination of trauma surgery, emergency surgery, and surgical critical care) has been proposed as a practice model for the future of general surgery. To date, there are few data regarding outcomes of surgical emergencies in the ACS model.

METHODS

Between September 1999 and August 2002, surgical emergencies were staffed at the faculty level by either an in-house trauma/emergency surgeon (ACS model) or a non-trauma general surgeon taking home call (traditional [TRAD] model). Coverage alternated monthly. Other aspects of hospital care, including resident complement, remained unchanged. We retrospectively reviewed key time intervals (emergency department [ED] presentation to surgical consultation; surgical consultation to operation [OR]; and ED presentation to OR) and outcomes (rupture rate, negative appendectomy rate, complication rate, and hospital length of stay [LOS]) for patients treated in the ACS and TRAD models. Questions of interest were examined using chi tests for discrete variables and independent sample t test for comparison of means.

RESULTS

During the study period, 294 appendectomies were performed. In-house ACS surgeons performed 167 procedures, and the home-call TRAD surgeons performed 127 procedures. No difference was found in the time from ED presentation to surgical consultation; however, the time interval from consultation to OR was significantly decreased in the ACS model (TRAD 7.6 hours vs. ACS 3.5 hours, P < 0.05). As a result, the total time from ED presentation to OR was significantly shorter in the ACS model (TRAD 14.0 hours vs. ACS 10.1 hour, P < 0.05). Rupture rates were decreased in the ACS model (TRAD 23.3% vs. ACS 12.3%, P < 0.05); negative appendectomy rates were similar. The complication rate in the ACS model was decreased (TRAD 17.4% vs. ACS 7.7%, P < 0.05), as was the hospital LOS (TRAD 3.5 days vs. ACS 2.3 days, P < 0.001).

CONCLUSIONS

In patients with acute appendicitis, the presence of an in-house acute care surgeon significantly decreased the time to operation, rupture rate, complication rate, and hospital length of stay. The ACS model appears to improve outcomes of acute appendicitis compared with a TRAD home-call model. This study supports the efficacy and efficiency of the ACS model in the management of surgical emergencies.