- Email: [email protected]
Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery
The American Journal of Surgery 190 (2005) 212–217
Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery David A. Spain, M.D.a,*, Frank B. Miller, M.D.b a
Department of Trauma/Critical Care Surgery, Stanford University, 300 Pasteur Dr. H3680, Stanford, CA 94305-5655, USA b Department of Surgery, University of Louisville, Louisville, KY, USA Manuscript received April 13, 2005; accepted manuscript April 15, 2005
Abstract Background: Trauma surgery as a specialty in the United States is at a crossroads. Currently, less than 100 residents per year pursue additional specialty training in trauma and surgical critical care. Many forces have converged to place serious challenges and obstacles to the training of future trauma surgeons. In order for the field to flourish, the training of future trauma surgeons must be modified to compensate for these changes. Data Sources: Recent medical literature regarding the training of trauma surgeons and report of the Future of Trauma Surgery/Trauma Specialization Committee of the American Association for the Surgery of Trauma. Conclusions: The new post-graduate trauma training fellowship of the future should be built on a foundation of general surgery. The goal of this program will be to train a surgeon with broad expertise in trauma, critical care, and emergency general surgery. This new emphasis on non-trauma emergency surgery required an image change and thus a new name; Acute Care Surgery: Trauma, Critical Care, and Emergency Surgery. © 2005 Excerpta Medica Inc. All rights reserved. Keywords: Emergency surgery; Trauma fellowship training; Trauma centers
Under the leadership of Hiram C. Polk Jr, M.D., and J. David Richardson, M.D., trauma care has been showcased at the University of Louisville. The trauma program has a long and rich history of training residents to care for the injured patient, contributing new knowledge to trauma care, and being thoughtful regarding the future of general and trauma surgery [1– 8]. For decades, Dr. Polk has led Trauma/intensive care unit (ICU) walk rounds every Monday morning at 7:00 AM (Fig. 1). This commitment from the top sends an important message to the residents regarding the importance of trauma care. Many current and former trainees and faculty members have assumed national leadership roles in trauma care including the presidency of the American Association for the Surgery of Trauma (AAST: Lewis M. Flint, J. David Richardson, and H. Gil Cryer). Numerous other training programs across the country also have displayed a similar commitment to trauma care. However, * Corresponding author. Tel.: ⫹1-650-723-0173; fax: ⫹1-650-7250791. E-mail address: [email protected]
trauma care at many institutions has been relegated to second-class citizen status and interest in trauma as a career choice has been discouraged. Trauma surgery as a specialty in the United States is at a cross-roads. Currently, only about 60 to 80 residents per year pursue additional specialty training in trauma and surgical critical care. Many forces have converged to place serious challenges and obstacles to the training of future trauma surgeons. First and foremost of these challenges is the evolving management of trauma patients with increased emphasis on nonsurgical management of most solid-organ injuries. Although this clearly has been an advance for our patients, it has eroded interest in trauma care among general surgeons. The ongoing fragmentation of general surgery itself, the heart of trauma surgery, has been detrimental to trauma training and care. Despite warning signs, the trauma community has been slow to respond. We review recent events and trends that have affected the practice of trauma surgery in the United States, what is ongoing currently in many training programs, and plans for the training of future trauma surgeons.
0002-9610/05/$ – see front matter © 2005 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2005.05.014
D.A. Spain and F.B. Miller / The American Journal of Surgery 190 (2005) 212–217
Fig. 1. Bedside trauma/surgical ICU rounds being led by Dr. Polk, circa 1990. Courtesy of University of Louisville Healthcare.
Recent History The warning bell was sounded clearly in 1992 when Richardson and Miller [1] published a landmark report. They reported the views of senior surgical residents toward their trauma training and their level of interest in providing trauma care after residency. A total of 1,795 questionnaires were distributed to postgraduate year 3, 4, and 5 general surgeon residents. The purpose of the questionnaire was to determine (1) the resident experience in trauma care, (2) their comfort level in caring for trauma patients, (3) their interest in providing trauma care in practice, and (4) both positive and negative factors of trauma care for the practicing surgeon. Responses were obtained from 49% of residents, representing 76% of the training programs from 30 states. Respondents were split about evenly between the various levels of training. Most residents (86%) had either a formal trauma rotation or significant exposure during training. Almost all residents (93%) felt they would be prepared to care for trauma patients independently after training. Many residents (nearly two-thirds) thought that trauma in general was attractive and more than 80% had some interest in trauma. More than 70% characterized trauma as exciting and challenging. Despite this generally favorable attitude toward their training, only 18% of residents thought that trauma would be part of their practice and only 8% were interested in trauma as a career. Much of this was owing to other specialty interests (77%), however, many residents cited the heavy work load and decreasing surgical cases (81%), night work (40%), and unsavory patients (36%) as negative factors influencing their interest in trauma [1]. Most disappointing were the write-in comments that also cited many trauma surgeons as poor role models. This commonly was associated with the view of the trauma surgeon as a nonsurgical surgeon more interested in the ICU. In somewhat of a contradiction though, 55% of residents felt that a formal link between trauma and critical care would make the field more attractive. Richardson and Miller [1] raised concerns “about who will care for the injured in the next generation.” They suggested that “improvement in trauma training
213
should focus on making it an enjoyable educational opportunity that will appeal to surgeons for a lifetime.” This observation was confirmed by Scalea et al [9]. When they formally linked trauma and critical care services they noticed an increase in the number of residents pursuing trauma fellowships from 7% to approximately 30%. Many “described the link between trauma care and critical care with a designated ICU service as strong positive influences. The understanding of resuscitation physiology gained in the ICU, including nonsurgical therapy, was felt to enhance trauma care, making it more attractive” [9]. The addition of critical care also may make trauma a more financially viable career choice. An analysis of surgeon charges at one trauma center showed that “surgical critical care provides valid additional earning capacity to surgical practitioners. Reimbursement is at least as good as for traditional surgical care, and fees generated actually can exceed revenue from surgical care. With impending decreases in global reimbursement, and attempts to unbundle surgical fees, this additional capability becomes an important consideration in potential career choice, as well as a major component in the fiscal stability of trauma programs” [10]. Essentially, over the past 10 to 15 years, that is what has happened: roughly 75% to 80% of surgical critical care fellowships are based at level I trauma centers and they draw most of their patient experience from trauma patients. Despite the apparent attractiveness of combining trauma and surgical critical care, Flint [11] rightly pointed out that “surgical critical care is vulnerable as well because of negative and intolerant attitudes. . .and imprudent pronouncements by the Residency Review Committee for Surgery including preposterous declarations that surgical critical care fellowships should be exclusively nonoperative.” In truth, this artificial separation of surgical care from surgical critical care has hurt the field. This, coupled with the increased use of nonsurgical trauma management, only has served to reinforce the negative connotation of trauma surgeons as nonsurgical intensivists. The trauma community also has been slow to respond to the changing nature of trauma over the past 20 years. Two major trends have had an enormous impact on trauma care:
Fig. 2. DPL and abdominal CT use for the academic years 1993–1994 through 1997–1998. , DPL; □, CT scan. Reprinted with permission from Spain et al [5].
214
D.A. Spain and F.B. Miller / The American Journal of Surgery 190 (2005) 212–217
Fig. 4. Percentage of liver injuries, spleen injuries, or both, managed surgically. Reprinted with permission from Spain et al [5].
Fig. 3. J. David Richardson, M.D.
the increased use of nonsurgical management and the significant decrease in penetrating trauma volume. The introduction of computed tomography (CT), and subsequently surgeon-performed ultrasound, virtually has eliminated diagnostic peritoneal lavage (DPL) (Fig. 2). The decreased reliance on DPL virtually has eliminated nontherapeutic laparotomy [7]. The increased use of CT scans has facilitated nonsurgical management of most solid-organ injuries. In a review spanning a 25-year period, Richardson et al [8] noted that the percent of liver injuries managed surgically decreased from 100% to approximately 20% to 25% most recently. During that same time period, liverrelated mortality was decreased dramatically from 12% to 5% for penetrating injuries and from 8% to 2% for blunt trauma [8]. Although nonsurgical management of solid-organ injuries clearly has been beneficial to patients, it often is cited as a detriment to a career in trauma. Most training programs have seen a steady decrease in the number of major surgical repairs for splenic or hepatic injuries [7,12,13]. Fakhry et al [12] surveyed 82 trauma centers at general surgery training programs. Assuming on-call duties occurred every fourth night and a patient mix of more than 80 blunt traumas, they calculated the average resident would have the potential to participate in only 15 trauma laparotomies and would have to care for an average of 500 blunt trauma patients to perform 1 splenectomy or liver repair [12]. Clearly, this is a poor return on investment and will not entice residents to a career in trauma. In addition, nonsurgical management is reimbursed poorly relative to effort [14]. By using the management of splenic injuries as a model, it was estimated that nonsurgical management only reimbursed approximately 20% to 25% of payments for a splenectomy. The volume of penetrating traumas peaked in the early 1980s. Many trauma centers were overrun with so much
penetrating trauma that many trauma surgeons were forced to forego elective surgery. For many during this time, the laparoscopy and endoscopy boom passed by without some trauma surgeons obtaining these skill sets. Then the market boom of the early 1990s started and the penetrating trauma volume began to decrease. Statistics from the Bureau of Justice and the Centers for Disease Control document a 30% to 35% reduction in penetrating trauma after peaking in 1993. This trend was highlighted in a report from the trauma center at the University of California San Diego [15]. In the early 1980s, penetrating trauma accounted for approximately 20% of admissions to the trauma center. After peaking at one third of admissions in 1993, penetrating trauma represented less than 10% of patients in 1999. Many other trauma centers have reported a similar 30% to 40% decrease in penetrating trauma volume [16 –18]. The net effect of these 2 trends—increased nonsurgical management of blunt trauma and decreasing incidence of penetrating trauma—significantly reduced surgical cases at many trauma centers. This clearly has been the major detriment to residents pursuing a career in trauma surgery. Although the warning signs have been present for some time, the trauma community only recently has begun to respond. Once again, Richardson [4] (Fig. 3) led the charge in his presidential address to the AAST in 1999, wondering if we have become too specialized and urged us to return to our general surgery roots. Richardson [4] warned that “a career in trauma divorced from general surgery is not going to be rewarding in the long run.” At that same meeting, we reviewed our experience with an integrated general surgery service that included trauma, emergency, and elective surgery [5]. Despite a decrease in surgical management of solid-organ injuries (Fig. 4), we have been able to maintain our surgical volumes through elective surgery and other urgent cases (Fig. 5). We suggested this helps offset “many of the subtle ‘second-class’ citizen connotations associated with trauma care. Although this is a description of a successful model in one institution, we believe it has worked well and may be more widely applicable to other trauma centers” [5]. In truth, the model has been used for a long time at many prominent trauma centers such as Parkland
D.A. Spain and F.B. Miller / The American Journal of Surgery 190 (2005) 212–217
Fig. 5. Two years of surgical experience for the 5 core trauma surgeons. Urgent cases are both trauma and emergency general surgery. Each type of shading refers to a single surgeon. Reprinted with permission from Spain et al [5].
Hospital at the University Texas Southwestern, Denver General Hospital at the University of Colorado, and Grady Hospital at Emory University, to name only a few.
Current Changes Richardson [4] urged training programs to be “inventive in finding ways to make trauma care fun for ourselves and our trainees. If you do not have an integrated emergency general surgery service, then I believe that is a good place to start.” Over the next several years, many training programs began to report their experiences with an integrated trauma and emergency general surgery service. In a series of thoughtful articles, the trauma group at the University of Pennsylvania with the leadership of C. William Schwab, M.D., presented their experience with inventive improvements made in their training program [19 –21]. These included new responsibilities for the fellow and integrating emergency general surgery into their program. The program at the University of Pennsylvania allows theirs fellows in the latter half of their second year to function as the attending surgeon [19]. Through the performance improvement process they were able to document no affect on outcomes. The fellows rated this transition period of increased independence as a very valuable experience and strongly felt it enhanced their training and the desirability of the fellowship. However, a fair number (31%) did cite the low surgical volume during this time as a negative factor [19]. The program took the next logical step and redefined their service as a comprehensive trauma and emergency general surgery service [20]. The program was able to offset the decrease in surgical trauma cases by integrating emergency general surgery. Most importantly, there was improved satisfaction of the trauma surgeons. Finally, they were able to document that the addition of emergency general surgery did not impact trauma care [21]. Despite a significant increase in nontrauma admission and surgeries, there was no change in mortality or provider-specific errors for the trauma patients. This suggests that the addition of
215
emergency general surgery may be a method to “increase operative experience without compromising care of the injured patient” [21]. Several other programs including the University of California Davis, University of Colorado, and Vanderbilt University have reported encouraging results [22–24]. However, all has not been perfect. A fair percentage of the cases brought in by emergency general surgery are not particularly glamorous. In the series from the University of Pennsylvania, appendectomies (17%), soft-tissue debridement (14%), and incision and drainage (13%) accounted for almost half the cases performed [20]. After the inception of this program at Yale, surgical cases did increase (by ⬎100%) and operating room billings increased by 45% [25]. This did occur at the expense of increased attending work hours and more postcall surgeries. But there is no free lunch. Clearly there will be growing pains for new emergency general surgery services. The hope has been that once these services are established they could be staffed adequately and eventually would lead to new and hopefully more complex referrals. This appears to be what happened at Vanderbilt University [24]. After the establishment of an emergency general surgery service, there was a 38% increase in emergency general surgery cases. Many of these were referrals from the community for major postoperative complications, abdominal catastrophes, and major soft-issue infections. Almost all of these patients required surgeries and intensive care and most were insured. As an added benefit, elective surgery admissions also increased by 30%. The emergency general surgery service seemed to be a win-win solution; more surgical cases for the trauma surgeons and increased volume for the elective surgeons.
Future Directions At the 61st annual meeting of the AAST in 2002, President Ron V. Maier formed an ad hoc committee and charged them with assessing the future of trauma surgery (Table 1). The following year, President David B. Hoyt also challenged the committee to define a clear vision for trauma surgery and to develop a training paradigm to achieve this goal [26]. This experienced group of surgeons held 5 meetings over a 14-month span. There was broad representation from major organizations influencing the training and practice of trauma surgery. The group gathered data from many sources regarding the following: challenges facing trauma surgery, population demographics and predictions, resident and student perspectives, finances, and American Board of Surgery and Accreditation Council for Graduate Medical Education requirements and plans. The goal of this group was to develop a specialty that would best serve the needs of our patients; offer an attractive, viable, and sustainable career and lifestyle; and be
216
D.A. Spain and F.B. Miller / The American Journal of Surgery 190 (2005) 212–217 Table 3 Implementation steps for acute care surgery training
Table 1 Future of trauma surgery/trauma specialization committee Jerry Jurkovich, Chair Peter Angood William G. Cioffi H. Gill Cryer Tom Esposito Dave Feliciano David B. Hoyt Ronald V. Maier William J. Mileski E. Eugene Moore Robert Mackersie Lena Napolitano Mike Rotondo Thomas M. Scalea David A. Spain Steve Shackford Donald D. Trunkey Wayne Meredith
The AAST must take the lead in developing and implementing this fellowship Write a competency-based curriculum, implement site visits, verification standards, and a match program Seek and obtain advisory council status for this specialty on the ABS Identify programs that could and will adopt this fellowship Encourage and support participation in the current critical care match Seek recognition for this specialty within the ACS advisory council structure Work with the ABS in discussions of new paradigms for the core training in general surgery ABS ⫽ American Board of Surgery; ACS ⫽ American College of Surgeons.
recognized by the public and profession as a valuable specialty. The group felt strongly that the fundamental requirements were to better define what we mean by a trauma surgeon and to enhance the surgical experience of current trauma surgeons. The committee considered several different training paradigms and philosophies [3,11,27]. After much discussion and deliberation the committee decided to define, develop, and promote a new postgraduate training fellowship that built on a foundation of general surgery. The goal of this program will be to train a surgeon with expertise in trauma, critical care, and emergency general surgery. In truth, this reflects the actual practice of many trauma surgeons who take both trauma and general surgery calls together and provide critical care for their patients. However, we felt that this new emphasis on nontrauma emergency surgery required an image change and thus a new name: Acute Care Surgery: Trauma, Critical Care, and Emergency Surgery The outline of this training program is shown in Table 2. The goal of this program is to train a broad-based, general Table 2 Acute care surgery fellowship training: draft plan Rotation Surgical critical care (minimum 6 months trauma critical care) Thoracic surgery Vascular surgery Hepatobiliary or transplant surgery Orthopedic surgery (trauma) Neurosurgery (trauma) Otolarygnology Electives or expand rotations listed previously Total
Duration 9 mo 2–3 mo 2–3 mo 2–3 mo 1–2 mo 1–2 mo 1–2 mo 0–6 mo 24 mo
NOTE. Trauma and emergency surgery call during fellowship: 12 months minimum.
surgeon who is capable of handling cervical, thoracic, abdominal, and vascular emergency procedures in critically ill and injured patients and who is able to provide ICU care for these patients. This will be a go-to surgeon as described by Hoyt [26], who could do almost anything. This should achieve the first of our 3 goals: to best serve the needs of our patients. By increasing surgical experience, this will make acute care surgery more attractive as a career choice. By developing these services within hospitals, this should allow for a viable and sustainable career and lifestyle. Finally, the major hurdle will be to have this recognized by the public and profession as a valuable specialty. The committee outlined the next steps required to move this idea forward (Table 3). One key caveat along the way is that we must remain nimble and responsive to variable needs and not try to make this a one-size-fits-all solution. Although these new training programs may face challenges along the way, we cannot afford to stand by and watch if we truly believe what we do is important. The key to “any model of improved trauma training is an unwavering commitment to its inherent value” [2]. We believe we have created a specialty that is attractive, viable, sustainable, and, most importantly, in the best interests of our patients.
References [1] Richardson JD, Miller FB. Will future surgeons be interested in trauma care? Results of a resident survey. J Trauma 1992;32:229 –33. [2] Richardson JD, Miller FB, Polk HC Jr. Can we improve the surgical manpower for providing trauma care? A model for success. J Trauma 1993;34:773– 4. [3] Richardson JD, Miller FB. Is there an ideal model for training the trauma surgeons of the future? J Trauma 2003;54:795–7. [4] Richardson JD. Trauma centers and trauma surgeons: have we become too specialized? J Trauma 2000;48:1–7. [5] Spain DA, Richardson JD, Carrillo EH, et al. Should trauma surgeons do general surgery? J Trauma 2000;48:433–7. [6] Cheadle WG, Franklin GA, Richardson JD, et al. Broad-based general surgery training is a model of continued utility for the future. Ann Surg 2004;239:627–32. [7] Lukan JK, Carrillo EH, Franklin GA, et al. Impact of recent trends of noninvasive trauma evaluation and nonoperative management in surgical resident education. J Trauma 2001;50:1015–9.
D.A. Spain and F.B. Miller / The American Journal of Surgery 190 (2005) 212–217 [8] Richardson JD, Franklin GA, Lukan JK, et al. Evolution in the management of hepatic trauma: a 25-year perspective. Ann Surg 2000;232:324 –30. [9] Scalea TM, Trooskin SZ, Wait RB. Critical care training makes trauma care more attractive as a career. J Trauma 1994;36:548 –53. [10] Schinco MA, Tepas JJ 3rd, Johnson K, et al. Two careers in one: an analysis of the earning power of certification in surgical critical care. Trauma 2002;52:1087–90. [11] Flint L. Achievements, present-day problems, and some solutions for trauma care, surgical critical care, and surgical education. Am J Surg 1991;161:207–12. [12] Fakhry SM, Watts DD, Michetti C, et al. The resident experience on trauma: declining surgical opportunities and career incentives? Analysis of data from a large multi-institutional study. J Trauma 2003;54: 1–7. [13] Bulinski P, Bachulis B, Naylor DF Jr, et al. The changing face of trauma management and its impact on surgical resident training. J Trauma 2003;54:161–3. [14] Sutyak JP, D’Amelio LF, Chiu WC, et al. Cognitive trauma care is undervalued: adult splenic injury as a paradigm. Am Surg 1997;63: 752–7. [15] Engelhardt S, Hoyt D, Coimbra R, et al. The 15-year evolution of an urban trauma center: what does the future hold for the trauma surgeon? J Trauma 2001;51:633–7. [16] Patton JH Jr, Woodward AM. Urban trauma centers: not quite dead yet. Am Surg 2002;68:319 –22. [17] Ovadia P, Szewczyk D, Walker K, et al. Admission patterns of an urban level I trauma center. Am J Med Qual 2000;15:9 –15.
217
[18] Demetriades D, Murray J, Sinz B, et al. Epidemiology of major trauma and trauma deaths in Los Angeles county. J Am Coll Surg 1998;187:373– 83. [19] Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg 2003;238:596 – 603. [20] Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg 2004;199:96 –101. [21] Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma 2004;57:467–71. [22] Scherer LA, Battistella FD. Trauma and emergency surgery: an evolutionary direction for trauma surgeons. J Trauma 2004;56:7– 12. [23] Ciesla DJ, Moore EE, Cothern CC, et al. The academic trauma center is the model for training in emergency surgery. J Trauma 2004;57: 442. [24] Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma 2005;58:906 – 10. [25] Kaplan LJ, Frankel H, Hojman H, et al. What price for general surgery? J Trauma 2004;57:456. [26] Hoyt DB. Rock on—staying focused on our way to greatness. J Trauma 2004;56:1– 6. [27] Trunkey DD. In search of solutions. J Trauma 2002;53:1189 –91.
Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery David A. Spain, M.D.a,*, Frank B. Miller, M.D.b a
Department of Trauma/Critical Care Surgery, Stanford University, 300 Pasteur Dr. H3680, Stanford, CA 94305-5655, USA b Department of Surgery, University of Louisville, Louisville, KY, USA Manuscript received April 13, 2005; accepted manuscript April 15, 2005
Abstract Background: Trauma surgery as a specialty in the United States is at a crossroads. Currently, less than 100 residents per year pursue additional specialty training in trauma and surgical critical care. Many forces have converged to place serious challenges and obstacles to the training of future trauma surgeons. In order for the field to flourish, the training of future trauma surgeons must be modified to compensate for these changes. Data Sources: Recent medical literature regarding the training of trauma surgeons and report of the Future of Trauma Surgery/Trauma Specialization Committee of the American Association for the Surgery of Trauma. Conclusions: The new post-graduate trauma training fellowship of the future should be built on a foundation of general surgery. The goal of this program will be to train a surgeon with broad expertise in trauma, critical care, and emergency general surgery. This new emphasis on non-trauma emergency surgery required an image change and thus a new name; Acute Care Surgery: Trauma, Critical Care, and Emergency Surgery. © 2005 Excerpta Medica Inc. All rights reserved. Keywords: Emergency surgery; Trauma fellowship training; Trauma centers
Under the leadership of Hiram C. Polk Jr, M.D., and J. David Richardson, M.D., trauma care has been showcased at the University of Louisville. The trauma program has a long and rich history of training residents to care for the injured patient, contributing new knowledge to trauma care, and being thoughtful regarding the future of general and trauma surgery [1– 8]. For decades, Dr. Polk has led Trauma/intensive care unit (ICU) walk rounds every Monday morning at 7:00 AM (Fig. 1). This commitment from the top sends an important message to the residents regarding the importance of trauma care. Many current and former trainees and faculty members have assumed national leadership roles in trauma care including the presidency of the American Association for the Surgery of Trauma (AAST: Lewis M. Flint, J. David Richardson, and H. Gil Cryer). Numerous other training programs across the country also have displayed a similar commitment to trauma care. However, * Corresponding author. Tel.: ⫹1-650-723-0173; fax: ⫹1-650-7250791. E-mail address: [email protected]
trauma care at many institutions has been relegated to second-class citizen status and interest in trauma as a career choice has been discouraged. Trauma surgery as a specialty in the United States is at a cross-roads. Currently, only about 60 to 80 residents per year pursue additional specialty training in trauma and surgical critical care. Many forces have converged to place serious challenges and obstacles to the training of future trauma surgeons. First and foremost of these challenges is the evolving management of trauma patients with increased emphasis on nonsurgical management of most solid-organ injuries. Although this clearly has been an advance for our patients, it has eroded interest in trauma care among general surgeons. The ongoing fragmentation of general surgery itself, the heart of trauma surgery, has been detrimental to trauma training and care. Despite warning signs, the trauma community has been slow to respond. We review recent events and trends that have affected the practice of trauma surgery in the United States, what is ongoing currently in many training programs, and plans for the training of future trauma surgeons.
0002-9610/05/$ – see front matter © 2005 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2005.05.014
D.A. Spain and F.B. Miller / The American Journal of Surgery 190 (2005) 212–217
Fig. 1. Bedside trauma/surgical ICU rounds being led by Dr. Polk, circa 1990. Courtesy of University of Louisville Healthcare.
Recent History The warning bell was sounded clearly in 1992 when Richardson and Miller [1] published a landmark report. They reported the views of senior surgical residents toward their trauma training and their level of interest in providing trauma care after residency. A total of 1,795 questionnaires were distributed to postgraduate year 3, 4, and 5 general surgeon residents. The purpose of the questionnaire was to determine (1) the resident experience in trauma care, (2) their comfort level in caring for trauma patients, (3) their interest in providing trauma care in practice, and (4) both positive and negative factors of trauma care for the practicing surgeon. Responses were obtained from 49% of residents, representing 76% of the training programs from 30 states. Respondents were split about evenly between the various levels of training. Most residents (86%) had either a formal trauma rotation or significant exposure during training. Almost all residents (93%) felt they would be prepared to care for trauma patients independently after training. Many residents (nearly two-thirds) thought that trauma in general was attractive and more than 80% had some interest in trauma. More than 70% characterized trauma as exciting and challenging. Despite this generally favorable attitude toward their training, only 18% of residents thought that trauma would be part of their practice and only 8% were interested in trauma as a career. Much of this was owing to other specialty interests (77%), however, many residents cited the heavy work load and decreasing surgical cases (81%), night work (40%), and unsavory patients (36%) as negative factors influencing their interest in trauma [1]. Most disappointing were the write-in comments that also cited many trauma surgeons as poor role models. This commonly was associated with the view of the trauma surgeon as a nonsurgical surgeon more interested in the ICU. In somewhat of a contradiction though, 55% of residents felt that a formal link between trauma and critical care would make the field more attractive. Richardson and Miller [1] raised concerns “about who will care for the injured in the next generation.” They suggested that “improvement in trauma training
213
should focus on making it an enjoyable educational opportunity that will appeal to surgeons for a lifetime.” This observation was confirmed by Scalea et al [9]. When they formally linked trauma and critical care services they noticed an increase in the number of residents pursuing trauma fellowships from 7% to approximately 30%. Many “described the link between trauma care and critical care with a designated ICU service as strong positive influences. The understanding of resuscitation physiology gained in the ICU, including nonsurgical therapy, was felt to enhance trauma care, making it more attractive” [9]. The addition of critical care also may make trauma a more financially viable career choice. An analysis of surgeon charges at one trauma center showed that “surgical critical care provides valid additional earning capacity to surgical practitioners. Reimbursement is at least as good as for traditional surgical care, and fees generated actually can exceed revenue from surgical care. With impending decreases in global reimbursement, and attempts to unbundle surgical fees, this additional capability becomes an important consideration in potential career choice, as well as a major component in the fiscal stability of trauma programs” [10]. Essentially, over the past 10 to 15 years, that is what has happened: roughly 75% to 80% of surgical critical care fellowships are based at level I trauma centers and they draw most of their patient experience from trauma patients. Despite the apparent attractiveness of combining trauma and surgical critical care, Flint [11] rightly pointed out that “surgical critical care is vulnerable as well because of negative and intolerant attitudes. . .and imprudent pronouncements by the Residency Review Committee for Surgery including preposterous declarations that surgical critical care fellowships should be exclusively nonoperative.” In truth, this artificial separation of surgical care from surgical critical care has hurt the field. This, coupled with the increased use of nonsurgical trauma management, only has served to reinforce the negative connotation of trauma surgeons as nonsurgical intensivists. The trauma community also has been slow to respond to the changing nature of trauma over the past 20 years. Two major trends have had an enormous impact on trauma care:
Fig. 2. DPL and abdominal CT use for the academic years 1993–1994 through 1997–1998. , DPL; □, CT scan. Reprinted with permission from Spain et al [5].
214
D.A. Spain and F.B. Miller / The American Journal of Surgery 190 (2005) 212–217
Fig. 4. Percentage of liver injuries, spleen injuries, or both, managed surgically. Reprinted with permission from Spain et al [5].
Fig. 3. J. David Richardson, M.D.
the increased use of nonsurgical management and the significant decrease in penetrating trauma volume. The introduction of computed tomography (CT), and subsequently surgeon-performed ultrasound, virtually has eliminated diagnostic peritoneal lavage (DPL) (Fig. 2). The decreased reliance on DPL virtually has eliminated nontherapeutic laparotomy [7]. The increased use of CT scans has facilitated nonsurgical management of most solid-organ injuries. In a review spanning a 25-year period, Richardson et al [8] noted that the percent of liver injuries managed surgically decreased from 100% to approximately 20% to 25% most recently. During that same time period, liverrelated mortality was decreased dramatically from 12% to 5% for penetrating injuries and from 8% to 2% for blunt trauma [8]. Although nonsurgical management of solid-organ injuries clearly has been beneficial to patients, it often is cited as a detriment to a career in trauma. Most training programs have seen a steady decrease in the number of major surgical repairs for splenic or hepatic injuries [7,12,13]. Fakhry et al [12] surveyed 82 trauma centers at general surgery training programs. Assuming on-call duties occurred every fourth night and a patient mix of more than 80 blunt traumas, they calculated the average resident would have the potential to participate in only 15 trauma laparotomies and would have to care for an average of 500 blunt trauma patients to perform 1 splenectomy or liver repair [12]. Clearly, this is a poor return on investment and will not entice residents to a career in trauma. In addition, nonsurgical management is reimbursed poorly relative to effort [14]. By using the management of splenic injuries as a model, it was estimated that nonsurgical management only reimbursed approximately 20% to 25% of payments for a splenectomy. The volume of penetrating traumas peaked in the early 1980s. Many trauma centers were overrun with so much
penetrating trauma that many trauma surgeons were forced to forego elective surgery. For many during this time, the laparoscopy and endoscopy boom passed by without some trauma surgeons obtaining these skill sets. Then the market boom of the early 1990s started and the penetrating trauma volume began to decrease. Statistics from the Bureau of Justice and the Centers for Disease Control document a 30% to 35% reduction in penetrating trauma after peaking in 1993. This trend was highlighted in a report from the trauma center at the University of California San Diego [15]. In the early 1980s, penetrating trauma accounted for approximately 20% of admissions to the trauma center. After peaking at one third of admissions in 1993, penetrating trauma represented less than 10% of patients in 1999. Many other trauma centers have reported a similar 30% to 40% decrease in penetrating trauma volume [16 –18]. The net effect of these 2 trends—increased nonsurgical management of blunt trauma and decreasing incidence of penetrating trauma—significantly reduced surgical cases at many trauma centers. This clearly has been the major detriment to residents pursuing a career in trauma surgery. Although the warning signs have been present for some time, the trauma community only recently has begun to respond. Once again, Richardson [4] (Fig. 3) led the charge in his presidential address to the AAST in 1999, wondering if we have become too specialized and urged us to return to our general surgery roots. Richardson [4] warned that “a career in trauma divorced from general surgery is not going to be rewarding in the long run.” At that same meeting, we reviewed our experience with an integrated general surgery service that included trauma, emergency, and elective surgery [5]. Despite a decrease in surgical management of solid-organ injuries (Fig. 4), we have been able to maintain our surgical volumes through elective surgery and other urgent cases (Fig. 5). We suggested this helps offset “many of the subtle ‘second-class’ citizen connotations associated with trauma care. Although this is a description of a successful model in one institution, we believe it has worked well and may be more widely applicable to other trauma centers” [5]. In truth, the model has been used for a long time at many prominent trauma centers such as Parkland
D.A. Spain and F.B. Miller / The American Journal of Surgery 190 (2005) 212–217
Fig. 5. Two years of surgical experience for the 5 core trauma surgeons. Urgent cases are both trauma and emergency general surgery. Each type of shading refers to a single surgeon. Reprinted with permission from Spain et al [5].
Hospital at the University Texas Southwestern, Denver General Hospital at the University of Colorado, and Grady Hospital at Emory University, to name only a few.
Current Changes Richardson [4] urged training programs to be “inventive in finding ways to make trauma care fun for ourselves and our trainees. If you do not have an integrated emergency general surgery service, then I believe that is a good place to start.” Over the next several years, many training programs began to report their experiences with an integrated trauma and emergency general surgery service. In a series of thoughtful articles, the trauma group at the University of Pennsylvania with the leadership of C. William Schwab, M.D., presented their experience with inventive improvements made in their training program [19 –21]. These included new responsibilities for the fellow and integrating emergency general surgery into their program. The program at the University of Pennsylvania allows theirs fellows in the latter half of their second year to function as the attending surgeon [19]. Through the performance improvement process they were able to document no affect on outcomes. The fellows rated this transition period of increased independence as a very valuable experience and strongly felt it enhanced their training and the desirability of the fellowship. However, a fair number (31%) did cite the low surgical volume during this time as a negative factor [19]. The program took the next logical step and redefined their service as a comprehensive trauma and emergency general surgery service [20]. The program was able to offset the decrease in surgical trauma cases by integrating emergency general surgery. Most importantly, there was improved satisfaction of the trauma surgeons. Finally, they were able to document that the addition of emergency general surgery did not impact trauma care [21]. Despite a significant increase in nontrauma admission and surgeries, there was no change in mortality or provider-specific errors for the trauma patients. This suggests that the addition of
215
emergency general surgery may be a method to “increase operative experience without compromising care of the injured patient” [21]. Several other programs including the University of California Davis, University of Colorado, and Vanderbilt University have reported encouraging results [22–24]. However, all has not been perfect. A fair percentage of the cases brought in by emergency general surgery are not particularly glamorous. In the series from the University of Pennsylvania, appendectomies (17%), soft-tissue debridement (14%), and incision and drainage (13%) accounted for almost half the cases performed [20]. After the inception of this program at Yale, surgical cases did increase (by ⬎100%) and operating room billings increased by 45% [25]. This did occur at the expense of increased attending work hours and more postcall surgeries. But there is no free lunch. Clearly there will be growing pains for new emergency general surgery services. The hope has been that once these services are established they could be staffed adequately and eventually would lead to new and hopefully more complex referrals. This appears to be what happened at Vanderbilt University [24]. After the establishment of an emergency general surgery service, there was a 38% increase in emergency general surgery cases. Many of these were referrals from the community for major postoperative complications, abdominal catastrophes, and major soft-issue infections. Almost all of these patients required surgeries and intensive care and most were insured. As an added benefit, elective surgery admissions also increased by 30%. The emergency general surgery service seemed to be a win-win solution; more surgical cases for the trauma surgeons and increased volume for the elective surgeons.
Future Directions At the 61st annual meeting of the AAST in 2002, President Ron V. Maier formed an ad hoc committee and charged them with assessing the future of trauma surgery (Table 1). The following year, President David B. Hoyt also challenged the committee to define a clear vision for trauma surgery and to develop a training paradigm to achieve this goal [26]. This experienced group of surgeons held 5 meetings over a 14-month span. There was broad representation from major organizations influencing the training and practice of trauma surgery. The group gathered data from many sources regarding the following: challenges facing trauma surgery, population demographics and predictions, resident and student perspectives, finances, and American Board of Surgery and Accreditation Council for Graduate Medical Education requirements and plans. The goal of this group was to develop a specialty that would best serve the needs of our patients; offer an attractive, viable, and sustainable career and lifestyle; and be
216
D.A. Spain and F.B. Miller / The American Journal of Surgery 190 (2005) 212–217 Table 3 Implementation steps for acute care surgery training
Table 1 Future of trauma surgery/trauma specialization committee Jerry Jurkovich, Chair Peter Angood William G. Cioffi H. Gill Cryer Tom Esposito Dave Feliciano David B. Hoyt Ronald V. Maier William J. Mileski E. Eugene Moore Robert Mackersie Lena Napolitano Mike Rotondo Thomas M. Scalea David A. Spain Steve Shackford Donald D. Trunkey Wayne Meredith
The AAST must take the lead in developing and implementing this fellowship Write a competency-based curriculum, implement site visits, verification standards, and a match program Seek and obtain advisory council status for this specialty on the ABS Identify programs that could and will adopt this fellowship Encourage and support participation in the current critical care match Seek recognition for this specialty within the ACS advisory council structure Work with the ABS in discussions of new paradigms for the core training in general surgery ABS ⫽ American Board of Surgery; ACS ⫽ American College of Surgeons.
recognized by the public and profession as a valuable specialty. The group felt strongly that the fundamental requirements were to better define what we mean by a trauma surgeon and to enhance the surgical experience of current trauma surgeons. The committee considered several different training paradigms and philosophies [3,11,27]. After much discussion and deliberation the committee decided to define, develop, and promote a new postgraduate training fellowship that built on a foundation of general surgery. The goal of this program will be to train a surgeon with expertise in trauma, critical care, and emergency general surgery. In truth, this reflects the actual practice of many trauma surgeons who take both trauma and general surgery calls together and provide critical care for their patients. However, we felt that this new emphasis on nontrauma emergency surgery required an image change and thus a new name: Acute Care Surgery: Trauma, Critical Care, and Emergency Surgery The outline of this training program is shown in Table 2. The goal of this program is to train a broad-based, general Table 2 Acute care surgery fellowship training: draft plan Rotation Surgical critical care (minimum 6 months trauma critical care) Thoracic surgery Vascular surgery Hepatobiliary or transplant surgery Orthopedic surgery (trauma) Neurosurgery (trauma) Otolarygnology Electives or expand rotations listed previously Total
Duration 9 mo 2–3 mo 2–3 mo 2–3 mo 1–2 mo 1–2 mo 1–2 mo 0–6 mo 24 mo
NOTE. Trauma and emergency surgery call during fellowship: 12 months minimum.
surgeon who is capable of handling cervical, thoracic, abdominal, and vascular emergency procedures in critically ill and injured patients and who is able to provide ICU care for these patients. This will be a go-to surgeon as described by Hoyt [26], who could do almost anything. This should achieve the first of our 3 goals: to best serve the needs of our patients. By increasing surgical experience, this will make acute care surgery more attractive as a career choice. By developing these services within hospitals, this should allow for a viable and sustainable career and lifestyle. Finally, the major hurdle will be to have this recognized by the public and profession as a valuable specialty. The committee outlined the next steps required to move this idea forward (Table 3). One key caveat along the way is that we must remain nimble and responsive to variable needs and not try to make this a one-size-fits-all solution. Although these new training programs may face challenges along the way, we cannot afford to stand by and watch if we truly believe what we do is important. The key to “any model of improved trauma training is an unwavering commitment to its inherent value” [2]. We believe we have created a specialty that is attractive, viable, sustainable, and, most importantly, in the best interests of our patients.
References [1] Richardson JD, Miller FB. Will future surgeons be interested in trauma care? Results of a resident survey. J Trauma 1992;32:229 –33. [2] Richardson JD, Miller FB, Polk HC Jr. Can we improve the surgical manpower for providing trauma care? A model for success. J Trauma 1993;34:773– 4. [3] Richardson JD, Miller FB. Is there an ideal model for training the trauma surgeons of the future? J Trauma 2003;54:795–7. [4] Richardson JD. Trauma centers and trauma surgeons: have we become too specialized? J Trauma 2000;48:1–7. [5] Spain DA, Richardson JD, Carrillo EH, et al. Should trauma surgeons do general surgery? J Trauma 2000;48:433–7. [6] Cheadle WG, Franklin GA, Richardson JD, et al. Broad-based general surgery training is a model of continued utility for the future. Ann Surg 2004;239:627–32. [7] Lukan JK, Carrillo EH, Franklin GA, et al. Impact of recent trends of noninvasive trauma evaluation and nonoperative management in surgical resident education. J Trauma 2001;50:1015–9.
D.A. Spain and F.B. Miller / The American Journal of Surgery 190 (2005) 212–217 [8] Richardson JD, Franklin GA, Lukan JK, et al. Evolution in the management of hepatic trauma: a 25-year perspective. Ann Surg 2000;232:324 –30. [9] Scalea TM, Trooskin SZ, Wait RB. Critical care training makes trauma care more attractive as a career. J Trauma 1994;36:548 –53. [10] Schinco MA, Tepas JJ 3rd, Johnson K, et al. Two careers in one: an analysis of the earning power of certification in surgical critical care. Trauma 2002;52:1087–90. [11] Flint L. Achievements, present-day problems, and some solutions for trauma care, surgical critical care, and surgical education. Am J Surg 1991;161:207–12. [12] Fakhry SM, Watts DD, Michetti C, et al. The resident experience on trauma: declining surgical opportunities and career incentives? Analysis of data from a large multi-institutional study. J Trauma 2003;54: 1–7. [13] Bulinski P, Bachulis B, Naylor DF Jr, et al. The changing face of trauma management and its impact on surgical resident training. J Trauma 2003;54:161–3. [14] Sutyak JP, D’Amelio LF, Chiu WC, et al. Cognitive trauma care is undervalued: adult splenic injury as a paradigm. Am Surg 1997;63: 752–7. [15] Engelhardt S, Hoyt D, Coimbra R, et al. The 15-year evolution of an urban trauma center: what does the future hold for the trauma surgeon? J Trauma 2001;51:633–7. [16] Patton JH Jr, Woodward AM. Urban trauma centers: not quite dead yet. Am Surg 2002;68:319 –22. [17] Ovadia P, Szewczyk D, Walker K, et al. Admission patterns of an urban level I trauma center. Am J Med Qual 2000;15:9 –15.
217
[18] Demetriades D, Murray J, Sinz B, et al. Epidemiology of major trauma and trauma deaths in Los Angeles county. J Am Coll Surg 1998;187:373– 83. [19] Reilly PM, Schwab CW, Haut ER, et al. Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship. Ann Surg 2003;238:596 – 603. [20] Kim PK, Dabrowski GP, Reilly PM, et al. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg 2004;199:96 –101. [21] Pryor JP, Reilly PM, Schwab CW, et al. Integrating emergency general surgery with a trauma service: impact on the care of injured patients. J Trauma 2004;57:467–71. [22] Scherer LA, Battistella FD. Trauma and emergency surgery: an evolutionary direction for trauma surgeons. J Trauma 2004;56:7– 12. [23] Ciesla DJ, Moore EE, Cothern CC, et al. The academic trauma center is the model for training in emergency surgery. J Trauma 2004;57: 442. [24] Austin MT, Diaz JJ Jr, Feurer ID, et al. Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital. J Trauma 2005;58:906 – 10. [25] Kaplan LJ, Frankel H, Hojman H, et al. What price for general surgery? J Trauma 2004;57:456. [26] Hoyt DB. Rock on—staying focused on our way to greatness. J Trauma 2004;56:1– 6. [27] Trunkey DD. In search of solutions. J Trauma 2002;53:1189 –91.