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.
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