Acute Surgery - Building a New Specialty
Mike Rotondo
Outline Acute Care Surgery
Building a New
Specialty
Michael F. Rotondo MD FACS
Professor and Chairman
Department of Surgery
Brody School of Medicine
What is acute care surgery?
A response to a need.
Key Problems
* Overcrowding: 40 percent of hospitals report ED overcrowding on a daily basis
* Boarding: patients waiting 48 hours or more for an inpatient bed
* Ambulance Diversion: Half a million ambulance diversions in 2003
* Uncompensated Care: results in financial losses and closures for EDs and
trauma centers
Recommendations
* Hospitals: End boarding and diversion, supported by CMS working group, JCAHO.
* Hospitals: Adopt operations management techniques and IT improvements to
enhance patient flow, supported by training and certification organizations.
* States and Regions: Regionalize on-call specialty services.
* Congress: Establish a commission to evaluate the impact of medical liability
on on-call services
* Congress: Provide $50 million for uncompensated emergency and trauma care.
Trauma Surgery Response
* American Association for the Surgery of Trauma (AAST)
* Committee on Trauma of the ACS, EAST, WTA
* Strategic planning meeting, August, 2002
* AAST to take the lead: ad hoc committee on the Future of Trauma Specialization
Future of Trauma Surgery / Trauma Specialization Committee
* G. Jerry Jurkovich, Chair
* William G. Cioffi David Spain
* Bill Mileski Robert Mackersie
* E. E. Moore Donald Trunkey
* Thomas Scalea Wayne Meredith
* Added members:
* Tom Esposito Steve Shackford
* Lena Napolitano Peter Angood
* Mike Rotondo David Hoyt
* Gil Cryer Ron Maier
* Dave Feliciano L.D. Britt
* Additional contributions from individuals members:
* Rochelle Dicker Kristin Staudemeyer
Deliberations
* Trouble with Trauma
* Population demographics, predictions
* Resident and student perspectives
* Finances
* ABS, ACGME requirements/plans
* Settings of trauma care and practice patterns locally & world-wide
Deliberations (cont.)
* Loss of Professionalism
* Changing Work Ethic
* Turmoil in Medical Finances
* More Women in Surgery
* More Specialty Practices
* Fewer Surgeons Taking "Call
Goals
Develop a specialty that would:
* Best serve the needs of patients
* Offer an attractive, viable and sustainable career and lifestyle
* Be recognized by the public and profession as a valuable specialty
* Better define the "trauma surgeon"
* Provide a solid foundation of operative experience
Four Major Options
* Status quo
* Give up non-operative care to non-surgeons (English model; ER medicine wants
this)
* Develop extensive orthopedic experience (Swiss-Dutch-German model; NS & Ortho
oppose)
* Combine Trauma (GS) + Surgical Critical Care + Emergency Surgery (GS)
Primary Recommendations
* Define, develop and promote a new post-graduate training fellowship
* Build on a foundation of "General Surgery"
* Define and train a surgeon with expertise in trauma, critical care, and
emergency general surgery
* Allow for flexibility in local practice patterns
What is Acute Care Surgery?
A training fellowship.
Fellowship Training
* 2 years in length
* Follows certification in General Surgery
* Includes RRC-approved trauma-based Surgical Critical Care
* Operative skills and clinical training that focuses on advanced and difficult
surgical challenges
* Competency based curriculum
* At least 52 nights of trauma and emergency call
Model Fellowship Design
* 12 months Surgical Critical Care
6-9 months trauma; 3-6 months other, e.g. burns; operative
* 6-9 months advanced general surgery
* 2-3 months vascular
* 2-3 months thoracic
* 2-3 months hepatobiliary/transplant/GI
* 2-4 months specialty surgery
* Orthopedic trauma
* Neurosurgery
* 2-5 months trauma/emergency surgery and electives
Flexibility in Training
* Electives during fellowship
* Endoscopy Burns Radiology
* GYN Pediatrics Administration
* Oto-H&N Urology Research
* Public Health EMS Agency Medical Examiner
* Individualized training programs
* Not all expected to be all
* Academics and investigative efforts encouraged
Flexibility for Local Practice
* Eventual practice not constrained by training
* Expect full elective general surgery privileges
* Excellent training for "rural" surgeon
* Excellent training for military surgeons?
* Likely most applicable to regionalize acute care centers
Acute Care Surgery
Addressing the Criticisms
Isn't This Just General Surgery?
It's what general surgery WAS. Not what it is now.
General Surgery : Salami Slicing
Women in Surgery
General Surgery Certificates Issued 1991-2003: Males
General Surgery Certificates Issued 1991-2003: Females
Acute Care Surgery is harmful to General Surgery
It is the salvation of general surgery.
It has the interests of historical general surgery at heart.
It is attractive to patients, payers and policy makers.
ACS is not a solution to the crisis of emergency care
Agreed. It is not the one and only solution.
It is part of the solution.
You can never train enough people to solve all the problems in emergency care.
Agreed.
But it is a great solution to building regionalized care.
It is the logical answer to man-power needs for urban emergency care.
Total number of residents enrolled in Critical Care fellowship training programs
in the United States by year.
Surgical Critical Care Fellowship- Increasing
* 2005: 68 ACGME accredited programs
* 2006: 87
* 2008: 89
* 2009: 95 programs, 189 positions
* Positions filled 2005: 130 (79%)
* Positions filled in 2009: 159 (84%)
* 2009: 118 registered and 103 participated, 89 matched (81 enrolled programs)
Acute Care Surgery Recruitment
* Will Acute Care Surgery help overcome trauma's challenges with recruitment?
* Will it reach a "tipping point"
Accomplishments to date (May 2010)
* The AAST has taken the lead in developing this fellowship
* A competency-based curriculum has been written
* Advisory Council status has been obtained from the American Board of Surgery
* Identified 25+ programs interested in providing fellowship training
* Establish match program (Surgical Critical Care)
* Program requirements and program application forms available
* Site visit committee established
* MOC and fellowship completion exam written
* 9 sites visited: 6 sites approved, 2 sites pending revision of program, 1
consultation visit.
Next steps
* Continue to work with pediatrics, burns, others to design best fellowship
training
* Encourage residents, promote the fellowship, accept applications
* Develop on-line, secure, AAST-centered case log
* Revise competency and evaluation tools (written test, case log, evaluations,
others?)
* Work with the ABS and ACGME on surgical training issues and role for Acute
Care Surgery ACGME-ABS certificate
American Board of Surgery
* New Advisory Councils (2005)
* Trauma, Burns and Surgical Critical Care
* Breast and Endocrine Surgery
* GI Surgery
* Transplant Surgery
* Pediatric Surgery
* Separate boards
* Surgical Critical Care
* Vascular Surgery
What is Acute Care Surgery?
A training program
A broad umbrella definition of a scope of practice.
You can't possibly do it as well as I can . .
Really?
May be true for 1-5% of the operations.
Wouldn't you rather be called for those rare times?
* 8/2000 - 9/2001
* In-house ACS vs. home-call GS
* N = 298 appendectomhy
* In patients with acute appendicitis, the presence of an in-house ACS
significantly decreased the time to operation, length of stay, complication
rate, and rupture rate, without a difference in the negative appendectomy rate.
Ann Surg 2006, October
Earl, Pryor, Kim, et al
TRAD = Traditional Model
ACS = Acute Care Surgery Model
It's too much. Trauma and emergency general surgery will overwhelm you.
Nope.
Now you are really reaching.
We want to operate.
We just need the right wo-man power.
Acute Care Surgery Operations
* All admissions 7/1/2000 - 6/30/2003
* N = 9405 admissions
* July 2002 EGS separate service
* A decrease in trauma operations was offset by an increased EGS operative
volume
* EGS patients were often sicker with more than 50% requiring ICU admission
Emergent GS - Annual Caseload
* Operations for trauma decreased in 2002 compared with 1999, despite a higher
number of penetrating injuries and total trauma contacts.
* Non-trauma general surgery operations performed by trauma faculty increased.
* 57% of all cases performed by trauma surgeons were emergency general surgery,
which accounted for 32% to 74% of an individual surgeon's caseload.
Potential fields who may perceive turf issues
* General Surgery programs
* Orthopedics
* Neurosurgery
* Vascular surgery
* Thoracic surgery
* Emergency medicine
* Critical care
"They" wont let you do this.
"They" are coming around.
It is the right thing to do.
It is an aid to neurosurgeons and orthopedic surgeons.
It is an attractive practice pattern for general surgery.
It is the way to regionalization of emergency care.
Acute Care Surgery
The need exists.
Not a threat.
A reality.
Acute Care Surgery
A training fellowship.
A broad umbrella definition of a scope of practice.
A functional specialty.
The Future
* The ABS becomes a certifying body for the specialty
* The RRC of the ACGME accredits programs
* The COT of the ACS sets the practice standards, benchmarks outcomes and
verifies centers
Acute Care Surgery
Trauma, Critical Care, and Emergency Surgery
Thank You INJURY 2010
(Hope I got it right this time!)
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Ministry of Health
