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Emergency Traumatologists as Partners in Trauma Care
LETTERS
Emergency Traumatologists as Partners in Trauma Care
their hospitals that certification in critical care is necessary in order to “round” in the ICU. At most (but not all) hospitals, board certification or eligibility is a requirement to obtain staff privileges in the area requested. I would propose that there is not a lack of interest in trauma surgery and critical care, but rather a lack of access to board certification in these areas. In the same way, many general surgeons and cardiothoracic surgeons perform an extensive amount of vascular operations in their practices, but are not and cannot become board-certified in vascular surgery without completing a formal fellowship. In the Discussion, Grossman and colleagues state that “. . . the American Board of Surgery has supported efforts on behalf of the American Association for the Surgery of Trauma to establish a curriculum in acute care surgery . . . [to] attract more residents to the specialty.” We already have a “curriculum” for acute care surgery: It is called general surgery residency. The last time I was on call at my hospital, I performed a femoral embolectomy for a cold leg and an esophago gastroduodenoscopy for an upper gastrointestinal bleed. That is acute care surgery. That is general surgery. I did not call the vascular surgeon on call for the embolectomy and I would never call a gastroenterologist for gastrointestinal bleeding. That is how to grow an acute care service: take care of everything that is acute. It is not performing craniotomies and femoral nailing! A ruptured abdominal aortic aneurysm is a surgical emergency. Will the acute care surgeon perform that, or will he call a vascular surgeon? I would argue that this is where our focus should be: training our residents to handle emergencies already within their scope of practice and not encroaching into “ortho-world” or “Craniville.” An acute care fellowship that included ruptured abdominal aortic aneurysms and vascular trauma; endoscopy for gastrointestinal bleeding and acute conditions; thoracic trauma, including decortications and video-assisted thoracic surgery for spontaneous pneumothoraces; and all urgent general surgery would attract a considerable amount of interest! Wouldn’t a vascular surgeon interested in trauma be a godsend? Or a cardiothoracic surgeon who wanted to round in the ICU? Why hinder that desire? We should promote it and allow access to board certification in it! Because no one is going to go through a thoracic fellowship, and then a vascular fellowship, and critical care, and then say, “Great! Now I can be an acute care surgeon!” The acute care service needs to have competent surgeons that can cover all surgical emergencies and train their fellows to do the same. It is important to remember that many surgeons gain experience and skills in areas of surgery long
John Alfred Carr, MD, FCCP, FACS Flint, MI I found the article by Grossman and colleagues to be a very sad example of today’s surgical climate.1 Although I congratulate the authors on writing an excellent article and finding a very innovative way of dealing with the staffing issues at their trauma center, I have an opposing perspective of the perceived staff shortage in surgical care in the United States. I am sure that I will be one of many writing about this controversial article, but please allow me to present my point of view. The article by Grossman and colleagues hinges on the false assumption that there are too few surgeons interested in the area of trauma surgery. The Methods section of this article did not mention if or for how long they had attempted to recruit a trauma surgeon unsuccessfully before hiring an emergency physician to “fill in.” As is well-known, many graduating general surgery residents accept a job in general surgery and end up performing primarily breast, vascular, or even colorectal operations, depending on what the geographic area dictates. In addition, few graduating residents want to spend a nonoperative critical care year at a time when they are all worried about how their hands will function out in practice. My first job in private practice required extensive endoscopy, and I performed 163 colonoscopies my first year! But I am not a fellowship-trained colorectal surgeon. There are many general surgeons who take “trauma call” for their hospitals, but are not “critical care” trained or certified. In addition, I would argue that there are even more who are interested in the field of trauma and critical care, but have not been able to sit for their critical care boards because of the lack of a formal fellowship. Interest in trauma and critical care is out there but, for financial or personal reasons, many surgeons cannot take a year away from their practice to complete a fellowship. This very issue of the Journal of the American College of Surgeons has two advertisements for trauma surgeons in the classified section. Both say “board certification in general surgery with added qualifications in surgical critical care.” How many more applicants would apply if the advertisement read “board certification in general surgery and interest or experience in critical care”? It is probably a requirement at
© 2009 by the American College of Surgeons Published by Elsevier Inc.
415
ISSN 1072-7515/09/$36.00 doi:10.1016/j.jamcollsurg.2009.05.013
416
Letters
after they finish formal training; but in terms of board certification, no one acknowledges this fact. It is high time to reconsider applicants for board certification based upon experience, current practice, and knowledge. Isn’t that why we have written and oral examinations, in order to determine who is qualified? Personally, I attempted to petition the American Board of Surgery to sit for the critical care boards based upon experience, but this is no longer possible as of June 1, 1993 (personal communication from the American Board of Surgery). A completed fellowship is mandatory. My extensive experience in ICU care, completion of two fellowships heavily weighted in ICU management (cardiothoracic surgery and cardiopulmonary transplantation), and knowledge in the field does not matter if I do not complete a 1-year fellowship in critical care. Instead, we will have emergency physicians acting as trauma surgeons.
REFERENCE 1. Grossman MD, Portner M, Hoey BA, et al. Emergency traumatologists as partners in trauma care: the future is now. J Am Coll Surg 2009;208:503–509.
Reply Michael D Grossman, MD William Schwab, MD, FACS Bethlehem, PA We appreciate the response to our article by Dr Carr and his continuing interest in trauma care and acute care surgery. However, we do not think Dr Carr’s letter focused on the article’s hypothesis, ie, that graduates of emergency medicine residencies, with appropriate training in trauma care, can and should participate in the care of trauma patients beyond episodic involvement in the resuscitative phase. It might be argued, as Dr Carr suggests, that there is no shortage of surgeons participating in trauma call, but this ar-
J Am Coll Surg
gument runs counter to published data. We did not hire an emergency medicine physician to “fill in,” as Dr Carr suggests. Rather, we invested in the training of these physicians through a formal fellowship and developed a model that we believe can improve patient care in a variety of settings. Beyond “trauma call,” the well-trained traumatologist manages complex trauma patients through the ICU phase of care. Although much more difficult to assess objectively, it seems intuitive that this phase of care has important implications for patient outcomes. Our own experience with well-trained and well-intentioned community surgeons covering call in our trauma center is that they are less comfortable with this important aspect of care. The model described in our article has an equal, if not greater, focus on critical care, although we did not report specific critical care metrics. We would respond to Dr Carr by acknowledging that many surgeons might practice critical care, but we would also suggest that some do so less well than others. Dr Carr makes several important points germane to training of any type; that a considerable portion of practice experience and expertise is gained after formal training has been completed. Highly motivated individuals can pursue and maintain expertise in a wide variety of technical and cognitive skills. Having acknowledged this, our article was not intended to address the concept of specialization and subspecialization and issues of access to practice. These are issues of importance, but do not impact on the study in question. What might be inferred from our study is that we do believe surgeons should not abdicate the care of trauma patients to other specialties simply because those specialties believe that participation of surgeons is superfluous. Rather, we should encourage educated involvement with appropriate training and mentorship. This rationale holds equally true for the community surgeon and emergency physician. Willingness, desire, and availability remain at a premium in medicine and surgery; and when combined with expertise and effective mentoring, the best clinical outcomes can be obtained.
Emergency Traumatologists as Partners in Trauma Care
their hospitals that certification in critical care is necessary in order to “round” in the ICU. At most (but not all) hospitals, board certification or eligibility is a requirement to obtain staff privileges in the area requested. I would propose that there is not a lack of interest in trauma surgery and critical care, but rather a lack of access to board certification in these areas. In the same way, many general surgeons and cardiothoracic surgeons perform an extensive amount of vascular operations in their practices, but are not and cannot become board-certified in vascular surgery without completing a formal fellowship. In the Discussion, Grossman and colleagues state that “. . . the American Board of Surgery has supported efforts on behalf of the American Association for the Surgery of Trauma to establish a curriculum in acute care surgery . . . [to] attract more residents to the specialty.” We already have a “curriculum” for acute care surgery: It is called general surgery residency. The last time I was on call at my hospital, I performed a femoral embolectomy for a cold leg and an esophago gastroduodenoscopy for an upper gastrointestinal bleed. That is acute care surgery. That is general surgery. I did not call the vascular surgeon on call for the embolectomy and I would never call a gastroenterologist for gastrointestinal bleeding. That is how to grow an acute care service: take care of everything that is acute. It is not performing craniotomies and femoral nailing! A ruptured abdominal aortic aneurysm is a surgical emergency. Will the acute care surgeon perform that, or will he call a vascular surgeon? I would argue that this is where our focus should be: training our residents to handle emergencies already within their scope of practice and not encroaching into “ortho-world” or “Craniville.” An acute care fellowship that included ruptured abdominal aortic aneurysms and vascular trauma; endoscopy for gastrointestinal bleeding and acute conditions; thoracic trauma, including decortications and video-assisted thoracic surgery for spontaneous pneumothoraces; and all urgent general surgery would attract a considerable amount of interest! Wouldn’t a vascular surgeon interested in trauma be a godsend? Or a cardiothoracic surgeon who wanted to round in the ICU? Why hinder that desire? We should promote it and allow access to board certification in it! Because no one is going to go through a thoracic fellowship, and then a vascular fellowship, and critical care, and then say, “Great! Now I can be an acute care surgeon!” The acute care service needs to have competent surgeons that can cover all surgical emergencies and train their fellows to do the same. It is important to remember that many surgeons gain experience and skills in areas of surgery long
John Alfred Carr, MD, FCCP, FACS Flint, MI I found the article by Grossman and colleagues to be a very sad example of today’s surgical climate.1 Although I congratulate the authors on writing an excellent article and finding a very innovative way of dealing with the staffing issues at their trauma center, I have an opposing perspective of the perceived staff shortage in surgical care in the United States. I am sure that I will be one of many writing about this controversial article, but please allow me to present my point of view. The article by Grossman and colleagues hinges on the false assumption that there are too few surgeons interested in the area of trauma surgery. The Methods section of this article did not mention if or for how long they had attempted to recruit a trauma surgeon unsuccessfully before hiring an emergency physician to “fill in.” As is well-known, many graduating general surgery residents accept a job in general surgery and end up performing primarily breast, vascular, or even colorectal operations, depending on what the geographic area dictates. In addition, few graduating residents want to spend a nonoperative critical care year at a time when they are all worried about how their hands will function out in practice. My first job in private practice required extensive endoscopy, and I performed 163 colonoscopies my first year! But I am not a fellowship-trained colorectal surgeon. There are many general surgeons who take “trauma call” for their hospitals, but are not “critical care” trained or certified. In addition, I would argue that there are even more who are interested in the field of trauma and critical care, but have not been able to sit for their critical care boards because of the lack of a formal fellowship. Interest in trauma and critical care is out there but, for financial or personal reasons, many surgeons cannot take a year away from their practice to complete a fellowship. This very issue of the Journal of the American College of Surgeons has two advertisements for trauma surgeons in the classified section. Both say “board certification in general surgery with added qualifications in surgical critical care.” How many more applicants would apply if the advertisement read “board certification in general surgery and interest or experience in critical care”? It is probably a requirement at
© 2009 by the American College of Surgeons Published by Elsevier Inc.
415
ISSN 1072-7515/09/$36.00 doi:10.1016/j.jamcollsurg.2009.05.013
416
Letters
after they finish formal training; but in terms of board certification, no one acknowledges this fact. It is high time to reconsider applicants for board certification based upon experience, current practice, and knowledge. Isn’t that why we have written and oral examinations, in order to determine who is qualified? Personally, I attempted to petition the American Board of Surgery to sit for the critical care boards based upon experience, but this is no longer possible as of June 1, 1993 (personal communication from the American Board of Surgery). A completed fellowship is mandatory. My extensive experience in ICU care, completion of two fellowships heavily weighted in ICU management (cardiothoracic surgery and cardiopulmonary transplantation), and knowledge in the field does not matter if I do not complete a 1-year fellowship in critical care. Instead, we will have emergency physicians acting as trauma surgeons.
REFERENCE 1. Grossman MD, Portner M, Hoey BA, et al. Emergency traumatologists as partners in trauma care: the future is now. J Am Coll Surg 2009;208:503–509.
Reply Michael D Grossman, MD William Schwab, MD, FACS Bethlehem, PA We appreciate the response to our article by Dr Carr and his continuing interest in trauma care and acute care surgery. However, we do not think Dr Carr’s letter focused on the article’s hypothesis, ie, that graduates of emergency medicine residencies, with appropriate training in trauma care, can and should participate in the care of trauma patients beyond episodic involvement in the resuscitative phase. It might be argued, as Dr Carr suggests, that there is no shortage of surgeons participating in trauma call, but this ar-
J Am Coll Surg
gument runs counter to published data. We did not hire an emergency medicine physician to “fill in,” as Dr Carr suggests. Rather, we invested in the training of these physicians through a formal fellowship and developed a model that we believe can improve patient care in a variety of settings. Beyond “trauma call,” the well-trained traumatologist manages complex trauma patients through the ICU phase of care. Although much more difficult to assess objectively, it seems intuitive that this phase of care has important implications for patient outcomes. Our own experience with well-trained and well-intentioned community surgeons covering call in our trauma center is that they are less comfortable with this important aspect of care. The model described in our article has an equal, if not greater, focus on critical care, although we did not report specific critical care metrics. We would respond to Dr Carr by acknowledging that many surgeons might practice critical care, but we would also suggest that some do so less well than others. Dr Carr makes several important points germane to training of any type; that a considerable portion of practice experience and expertise is gained after formal training has been completed. Highly motivated individuals can pursue and maintain expertise in a wide variety of technical and cognitive skills. Having acknowledged this, our article was not intended to address the concept of specialization and subspecialization and issues of access to practice. These are issues of importance, but do not impact on the study in question. What might be inferred from our study is that we do believe surgeons should not abdicate the care of trauma patients to other specialties simply because those specialties believe that participation of surgeons is superfluous. Rather, we should encourage educated involvement with appropriate training and mentorship. This rationale holds equally true for the community surgeon and emergency physician. Willingness, desire, and availability remain at a premium in medicine and surgery; and when combined with expertise and effective mentoring, the best clinical outcomes can be obtained.