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To Be or Not To Be a Fellow


 

In the past decade numerous trends and influences have caused organized trauma surgery to re-examine our role in the care of all acutely ill surgical patients and the training of future general surgeons who will care for these patients.1 In this article we’ll briefly review the influences that brought us to this point, the issues we feel need to be addressed, and the solution that trauma surgery has proposed. In many ways, we believe these trends parallel the influences that led to the development of the hospitalists and, thus, call for a surgical equivalent.

Surgical Trends

The development of laparoscopic surgery has had profound influence on surgical practice. Cholecystectomies and appendectomies are generally 23-hour admissions. Even bariatric surgery is now little more than outpatient surgery, with the average length of stay at two days. Along with laparoscopy, breast surgery is now one of the fastest growing surgical subspecialties.

Many surgeons have tailored their practices to a largely outpatient base. There has been an explosion of free-standing surgery centers with a large shift of this low acuity patient population away from hospitals. This follows an overall shift in medicine to ambulatory practice, which is now projected to increase by 24% over the next five to 10 years. Thus, fewer and fewer surgeons have large inpatient practices. There is growing concern about the reluctance of many surgeons to deal with complex, high acuity patients. The obvious exceptions are transplant and trauma surgeons.

A consensus has been reached: Evolve trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.”

In the past decade profound changes in trauma care have also affected the practices of surgeons and the career choices of surgical residents.2 Following the peak of gun-related violence in the early 1990s, there has been a steady and significant decline in penetrating trauma with a concomitant decrease in operations. Slow but steady improvement in motor vehicle passive safety devices has also decreased the incidence of serious injury to the torso following car crashes.

When a solid organ (liver, spleen, kidney) injury does occur after car crash, fall, or assault, the management has largely shifted away from exploratory laparotomy to non-operative management. This has been made possible by improved imaging techniques, careful monitoring in the ICU and judicious use of interventional radiologic techniques of embolization and percutaneous drainage. Currently, some 60% to 80% of liver and spleen injuries are treated with observation or interventional techniques. Although most surgical residents enjoy the challenges of both trauma surgery and critical care, the decline in operative opportunities has limited the appeal of trauma/critical care as a career choice.2

Many trauma surgeons feel there is a convergence of these two issues—a group of patients that may be underserved and an opportunity to enhance the training and desirability of caring for acutely ill surgical patients.3-5 Either through years of experience or formal training, the vast majority of trauma surgeons are highly experienced in evaluating, operating upon, and providing post-operative care for critically ill and injured patients. In fact, the majority of surgical critical care fellowships are based at level 1 trauma centers and are run primarily by trauma surgeons. Thus, trauma surgeons are ideally situated to address these issues.

[A fellowship] all starts with a core group of people dedicated to hospital medicine. You need a group of people who see the future of hospital medicine and what it can be and who want to dive into different aspects of it. This is the minimum criteria for a successful hospitalist fellowship program.

—Rohit Uppal, MD, MBA

A New Specialty

In 2001 Ron V. Maier, MD, then president of the American Association for the Surgery of Trauma (AAST), commissioned a committee to address these issues and develop an action plan. With broad representation from numerous surgical societies, the committee met several times to consider various training and practice models as potential solutions. After much discussion, the group proposed a model based upon trauma surgery, emergency general surgery, and critical care. This process is outlined in a white paper authored by the committee in 2005.

Basically, the committee recommends the evolution of trauma surgery into a new specialty based on broad training in elective and emergency general surgery, trauma, and critical care surgery. Specific steps to accomplish this goal were outlined by the committee and considerable progress has already been made. After much debate regarding the name, including the consideration of “surgical hospitalists,” the AAST elected to support the name “acute care surgeon.” In fact, this model is how many of us trauma surgeons practice; we take trauma and emergency general surgery call and provide critical care services for these patients.

What was missing from the paradigm was a formal incorporation of emergency general surgery into the training of trauma/surgical critical care fellows and analysis of the benefits of such programs. While this practice paradigm has long been the model at many urban safety net hospitals in cities such as Atlanta, Dallas, Denver, Los Angeles, and Seattle, the practice of many trauma surgeons is often restrained at university hospitals and most level II trauma centers.

Most hospital medicine fellowship directors seem to agree that such a program is of limited value to physicians who just want to be practicing clinical hospitalists and who have no interest in teaching, research, or leadership roles. The clinical experience they are likely to gain in a fellowship probably won’t add greatly to the training they currently have.

Strong Results

The trauma program at University of Pennsylvania, Pittsburgh, under the leadership of C. William Schwab, MD, the current president of the AAST, has taken the lead in documenting the value of incorporating emergency surgery into trauma/surgical critical care training. The addition of emergency general surgery into a trauma/surgical critical care fellowship increases operative experience and fellow satisfaction.3-6 Emergency general surgery now accounts for 57% of operations performed by their faculty. This helps maintain their operative experience despite a decline in operative trauma volume. Finally, with a careful analysis of performance improvement data, there is no compromise in trauma patient outcomes despite the increased patient load.4-5 This experience has been replicated at other trauma centers and strongly suggests that incorporating emergency general surgery into trauma training increases attractiveness to trainees and maintains high standards of patient care. The question is whether it meets an unfilled need.

Recent experience at Vanderbilt Medical Center suggests that the formal incorporation of emergency general surgery into a service has benefits for patients and the hospital.6 The service brings in more referrals from the surrounding community and increases trauma surgeon operative cases. The elective general surgeons also experience an increase in operations and admissions after removing the disruption of emergency admissions. The hospital benefits by the addition of new patients that frequently require operations and intensive care.

In a recent supplement to the The Hospitalist Larry Wellikson, MD, notes that hospitalists add value by (among other things):

  • Providing measurable quality improvement;
  • Creating seamless continuity from inpatient to outpatient care, from emergency department to floor, and from ICU to floor;
  • Doing things other physicians had given up, such as indigent care and hospital committee functions;
  • Creating healthcare teams to improve the working environment; and
  • Taking care of acutely ill, complex hospitalized patients.7

We believe that trauma surgeons, or acute care surgeons, exemplify these values. We have provided these services to surgical patients for the past 25 years. Trauma surgeons have been leaders in quality improvement, as demonstrated by the American College of Surgeons Committee on Trauma verification program.

We take care of whoever comes through the door, regardless of acuity, time of day (or night), or payer status. We have always provided comprehensive care for our patients—from involvement in prehospital care and planning, through the emergency department, operating room, ICU, and even post-discharge rehabilitation. This requires an effective healthcare team and a truly multidisciplinary approach with other physicians (orthopedics, neurosurgery, anesthesia), nurses, and others, including respiratory, occupational, and physical therapy.

Conclusion

We see a synergy between hospitalist and acute-care surgeons. Both groups have stepped forward to fill a void in patient care. The redefining of trauma surgery as acute care surgery and the development of dedicated training programs will no doubt benefit current and future surgeons, but our patients will benefit the most. TH

Dr. Spain is professor of surgery and chief of Trauma, Emergency and Critical Care Surgery, Stanford University (California). He is also chairman of the Critical Care Committee, American Association for the Surgery of Trauma. Dr. Jurkovich is professor of surgery at the University of Washington, chief of Trauma and Emergency Surgical Services at Harborview Medical Center, and chairman of the Acute Care Surgeon Committee, American Association for the Surgery of Trauma.

References

  1. Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma. 2005;58:614-616.
  2. Spain DA, Miller FB. Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg. 2005;190:212-217.
  3. 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 Sep;57(3):467-471.
  4. 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 Oct;238(4):596-603.
  5. 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 Jul;199(1):96-101.
  6. 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 May;58(5):906-910.
  7. Wellikson L. Hospitals recognize and reward value. The Hospitalist. 2005;9:3-5.

Unlikely Fellows

Dan Goldblatt, MD, a hospitalist in Minneapolis, was an atypical fellow. A family practice physician for about 17 years, he was burned out on clinic work and was attracted by the prospect of caring for sicker, more complex hospital patients. However, he knew that he would need more specific clinical training to be successful in this role.

“Most hospitals around here wouldn’t hire a family medicine physician as a hospitalist,” says Dr. Goldblatt. “The fellowship was a way to get into this growing field without going through an internal medicine residency. A lot of that training would be redundant anyway. I just wanted to focus on specific areas.

“Someone fresh out of an internal medicine program probably wouldn’t need this,” he adds. “But I needed to refresh my skills and gain more hospital experience. It’s like skiing. If you don’t do it for a while and then you go out on the slopes, it’s a little uncomfortable because you aren’t used to it.”

The hospital medicine fellowship was a rewarding and eye-opening experience for Dr. Goldblatt. “It was very helpful to get in there and get caught up,” he recalls. “Things have changed a great deal since I did my original training years ago.”

All of the skills and experience he gained also increased Dr. Goldblatt’s confidence that he would be effective working with acutely ill, complex patients.

He admits that the fellowship route isn’t necessary for everyone. In fact, he said that he knows of at least one family physician who was able to become a hospitalist without this extra training. However, he notes, “This was the right course for me. It was hard to take a big salary cut, but it was well worth it. I definitely think that it will increase my employment opportunities.”

Padma Pavuluri, DO, a pediatric hospital medicine fellow at Baylor College of Medicine (Section of Emergency Medicine) Houston, explains her reasons for choosing such a program: “As the hospitalist field matures, there are a lot of questions we are asking ourselves. A fellowship gives us the opportunity to answer questions with research projects.”

She also lauds the value of her ability to learn from her mentors and teachers. “I have 100 combined years of pediatric experience working with me,” she says. “As long as I do well in this program, I have a good shot at getting the job I want later.”—JK

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