Thursday, May 05, 2005

The Future of Surgery XI ........
Maria, of intueri, left a comment on this post concerning trauma surgery:
"Trauma surgery is one of the neatest fields in medicine. It's sickly fascinating."
Or as Dr Yang in Gray's Anatomy puts it:""It's like candy! Only with blood, which is so much better!"
But less and less seem to want to eat the blood candy. In an address to the 2004 meeting of the American Association for the Surgery of Trauma Dr. Steven Shackford, AAST president, gave a talk entitled:The Future of Trauma Surgery-A Perspective, published in the April edition on The Journal of Trauma. Dr. Shackford puts forth many of the challenges facing trauma and general surgery in the future:
The following observations made by Miller and Richardson regarding resident perceptions of trauma care have become icons with regard to perceptions about a career in trauma and critical care: (1) trauma care is increasingly non-operative, (2) trauma surgeons prepare patients for surgical procedures performed by other specialists, (3) trauma care has lower professional reimbursement than many other specialties, (4) trauma care increases the incidence of malpractice suits and increases the size of financial settlements of malpractice suits, and (5) trauma care increases the risk of AIDS and hepatitis C. In planning for the future, it is important to examine each of these perceptions to determine whether there are data to support them.

Trauma care is increasingly non-operative. As Fakhry and colleagues pointed out in a survey of the membership of the Eastern Association for the Surgery of Trauma, the average resident experience per year on a trauma service is approximately 15 laparotomies, 6 diagnostic peritoneal lavages and 45 focused abdominal ultrasound exams. The operative experience of attending surgeons is also decreased. As pointed out by Wayne Meredith in his presentation to the Halstead Society, only 20% of trauma directors at Level I hospitals perform more than 100 trauma operations per year.

The perception that trauma surgeons prepare patients for operations by other surgical specialists has supporting data. Rogers and colleagues showed that there was a large disparity between work effort and financial reward among professionals. They demonstrated that trauma attendings provided about 70% of the work effort on trauma patients, but only billed about 25% of the professional fees. The majority of the fees were generated by the orthopedic surgeons and radiologists.

The perception that trauma care has lower professional reimbursement is difficult to validate. However, Esposito and colleagues in their study of trauma care in Washington State suggested that there be reasonable reimbursement for treating injured patients, but this depends on billing practices, documentation, and payer mix. Recent data suggests that any disparity in professional reimbursement between general surgeons and trauma surgeons is slight.

The data are sparse with regard to trauma care increasing the risk of malpractice suits with resulting increased financial settlement. However, in a Pennsylvania study cited by Esposito and coworkers comparing the malpractice claims of general surgeons to those of trauma surgeons, claims were more frequent against general surgeons than they were against trauma surgeons. When there was a finding for the plaintiff, trauma cases were settled for $25,000 less than general surgeons.

Finally, with respect to the perception that trauma increases the risk of AIDS and hepatitis, there are absolutely no supporting data.
In the study by Rogers cited above (abstract here) the billing of the radiologsts were higher than the trauma surgeons. As the authors themselves note:
This is especially striking considering the attending radiologists were not in-house at night, and many times read the films, which generated their professional charges, after the film had been read and acted on by the TS (trauma surgeon) the night before.

The surgical generation gap:
The perceptions of trainees are shaped not only by their professional experiences, but also by their culture. Most trauma care of today is provided by baby boomers and the trauma care of the future will be provided by Generation X, Generation Y and, the not-as-yet-born Generation Z. It is important in viewing the proposed changes in the specialty to examine the differences in the cultural background of the baby boomer and the cultural background of Generation X. For the most part, the parents of the baby boomers grew up during the depression. At that time, the most important aspect of one's life was having a job and holding on to that job. In effect, you were the job. Baby boomer physicians linked their altruism and their job and were zealously willing to make the necessary sacrifices, not only for their patients, but also for their job. This, you are the job mentality of the baby boomers created a rather narrow view of people who desired a more balanced lifestyle. As a result, baby boomers have been skeptical and critical about the commitment of Generation X to patient care.

Generation X, as compared with baby boomers, are individualists who are techno-competent and more flexible in their outlook. They desire immediate feedback, but do necessarily want definitive control. Most importantly, they desire balance in their life and define themselves by their personal life rather than by their job. Most Generation X students view surgery as a rigid, inflexible discipline with uncontrollable hours. Furthermore, Generation Xers desire personal time over financial reward when selecting a career. In fact, the amount of personal time is the major factor in career selection for Generation X of both genders. Generation X is not necessarily threatened by the hard work and the long hours, but they want defined time certain time off from their job for personal time. This desire has led to the selection of careers with a more controllable lifestyle.
So what to do? Dr. Shackford takes the "emergency surgery" tack that is becoming increasingly popular:
I am of the opinion that all of these forces are creating another centripetal need to care for the whole patient that will be well received, not only by our patients, but also by payers, legislators, the American Board of Medical Specialties (as well as member boards in the surgical fields), and by the next generation of physicians. The centripetal need will necessitate the development of a specialty to care for the whole patient at all times. However, for this change to be embraced by all constituencies (patients, payers, policy makers, etc.) several key factors are essential. First, the change in our specialty should be motivated by altruism (as it was when the AAST was created). That is, this change is not about us but rather about our patients. Second, we must define our scope of practice and define a training paradigm that addresses this scope. The ad hoc committee has proposed a reasonable curricular program Third, the specialty must address the cultural issues and cultural desires of the next generation of surgeons. It may be that the acute care surgeon will be a surgical hospitalist who works 40 hours a week, divided into varying shifts (yes, shifts). Shift physicians of the future will no longer wear the scarlet letter of shift doctors that was once placed upon them by baby boomers. The dangers of shift medicine associated with the handing-off of patients are being reduced because we are developing systems, born by the resident 80-hour workweek that can capably address the problems with hand-offs. These problems are not entirely solved, but they soon will be. Having surgeons in-house 24-hours a day, capable of a wide variety of operations, will decrease length of stay, improve the efficiency of operating rooms, and decrease the cost of care. These changes have already been observed on the medical side of the house with the implementation of the hospitalist practice.31 Finally, the full development of the Acute Care Surgeon will only occur when there is complete collaboration by all of the professional societies that address the care of the injured and critically ill. That means that there must be collaboration among the AAST, the American College of Surgeons Committee on Trauma, the Western Trauma Association, the Eastern Association for the Surgery of Trauma, the American Burn Association, and the Surgical Section of the Society of Critical Care Medicine. There is great power in such collaboration of professional organizations, as was demonstrated by the vascular surgeons. This power will provide at a seat at the table with regard to RVU assignment. It will allow the specialty to speak with one voice regarding legislative action that affects the care of critically ill and injured patients. With collaboration must come compromise with respect to curricular design, oversight of training programs, maintenance of certification, and turf issues.
A tall order indeed. The emergence of a dedicated "emergency surgeon" may serve mainly to throw some, as we say down south, into the briar patch. In a paper, also in the April JOT:The Academic Trauma Center Is a Model for the Future Trauma and Acute Care Surgeon the group from Denver General describes their experience with such a system. The money quote:
A popular trend to increase the operative potential of the trauma service is to add nontrauma emergency surgery responsibilities. Although this appears to improve the trauma surgeon's operative experience and job satisfaction, reports thus far have focused on providing general surgery emergency services with limited coverage of vascular and thoracic nontrauma emergencies. Initial enthusiasm for this solution has the potential to be short lived because the majority of these surgical emergencies consist of draining soft tissue infections and excising necrotic gastrointestinal structures. Indeed, it can be argued that the trauma surgeon coverage of these surgical emergencies has a greater effect on the job satisfaction of the somnolent elective surgeon that is relieved of these responsibilities
A panacea or long term cure? Unless some of the underlying issues are addressed, I fear the former.


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