Surgery News - January 2008 - (Page 5) J A N U A RY 2 0 0 8 • SURGERY NEWS THE THE E Acute Care Surgery Programs Emerging B Y J E F F E VA N S 20/20 / 0/20 V SION O SIO SION IO Else vier Global Medical Ne ws T he experiences of surgeons and fellows involved in existing or soon-tobe-established acute care surgery training programs are valuable for individuals who want to open similar programs or pursue such training. These programs are serving as models for the future of the new surgical subspecialty, according to surgeons in trauma and surgical critical care who are paving the way at their own centers. Leaders of acute care surgery training programs at different institutions and at different stages of development shared some insights that may be useful to those who are interested in acute care surgery training. tablishing an acute care surgery training program, said Dr. Diaz. Once the program is on its feet, it is important to allow the service “to be utilized appropriately,” he said. After that, usually it takes on a life of its own, to the point where “sometimes you don’t necessarily need to advertise that you’re developing such a service.” Teaming Up to Create a Fellowship Texas Acute Care Surgery is a full acute care surgery training fellowship being formed through collaboration between The Methodist Hospital (TMH) and the University of Texas Health Science Center, both in Houston. The TMH model developed by Dr. Frederick Moore is a group hospital–based practice with five surgical intensivists who can provide 24/7 coverage for surgical Providing Acute Care in a emergencies and lead a mulUniversity Setting The five surgical The 2-year acute care surgery intensivists provide tidisciplinary surgical ICU fellowship at Vanderbilt Uni- 24/7 coverage and team. Its purpose is to enhance access to high-quality versity in Nashville, Tenn., lead a emergency surgical and critione of the first such promultidisciplinary cal care as well as to create a grams in the country, is apICU team. new practice paradigm that plying for approval from the DR. MOORE appeals to younger physicians American Association for the Surgery of Trauma (AAST) as a training in training. Currently, residents who are finishing site, according to Dr. Jose J. Diaz Jr., an ACS Fellow and director of Vanderbilt a surgical critical care fellowship may go Medical Center’s emergency general on to complete the acute care surgery training program. Because of the agreesurgery service. The trauma service is the only level I ment with the University of Texas, feltrauma center for all of middle Ten- lows will rotate through TMH and may nessee and parts of surrounding states, opt to stay a second year for training in and has about 3,500 admissions per year. acute care surgery. “We plan on having fellows rotate onto The emergency general surgery service different services” with faculty who are serves about 2,200 patients per year. The program has four positions for fel- both trauma surgeons and surgical sublows to fill in each year of the program. specialists, said Dr. Moore, an ACS Fellow The first year is focused on obtaining who heads the division of surgical criticritical care experience in an Accredita- cal care and acute care surgery at TMH. In the initial period of putting togethtion Council for Graduate Medical Education–approved surgical critical care fel- er acute care surgery fellowships, it is not lowship (including surgical, trauma, feasible for most programs to have the burn, and neurologic critical care). Acute same features because they depend on care surgery fellowships that seek ap- local resources and competition with proval from the AAST must have an general surgery residents, Dr. Moore exACGME-approved surgical critical care plained. But currently, surgery residents are not participating in many of the opresidency program. Second-year fellows function as in- erations performed at Texas Medical structors in surgery and obtain clinical Center institutions (which include the experience in trauma and emergency University of Texas and TMH), “so general surgery (Surgery 2007;141:310- there’s the potential that those acute 6). They rotate on the trauma service care surgery fellows can go out and do and take call, but are always supervised some of those cases,” he said. For attending surgeons, the prospect of by a faculty member. Of the three different attending surgeons on the trauma working with acute care surgery fellows service, one or two may be a fellow and who would be board certified in surgical at least one will be a faculty member. critical care and in their seventh postThe emergency general surgery service graduate year would be more attractive usually has one faculty member and a fel- than working with general surgery resilow. Both the director of the trauma dents, he noted. The number of operations at TMH service and Dr. Diaz serve as primary without surgical resident participation mentors for fellows. Setting equitable boundaries between should help to alleviate the concern that services may be the starting point for es- acute care surgery fellows will take away low rate of insurance and who may or may not have Medicare or Medicaid. The lifestyle factors that residents tend to weigh as they choose surgical speForming a Team at a Private Hospital cialties also may be derived from the exAt Dallas Methodist Hospital, a private periences of trauma surgeons. “Most community hospital with a level II trau- residents look at trauma surgery and see ma center, Dr. Alicia Mangram and two that trauma surgeons are working hard, other trauma surgeons set out to form an and they do not see trauma as being a acute care surgery team when they had lifestyle specialty,” she said. But “the a hard time getting the hospital’s core mere formation of acute care surgery as a specialty likely will lead to an imgeneral surgeons to take trauma call. To do so, they first had to persuade provement in lifestyle.” There are many anecdotal reports in hospital administrators to support the the surgical community of addition of three new surpeople whose lifestyles have geons to their surgery team, improved as a result of tranDr. Mangram said. Then they sitioning to an acute care searched for nearly 2 years surgery model wherein before finding a trauma surthey’re handling all of the geon to join the team. emergency department call There is a scarcity of “peowith their partners and covple who are willing to do ering different times of the trauma call and take care of day, according to Dr. Stauacute general surgery issues,” said Dr. Mangram, assistant There’s a scarcity denmayer. The fact that traudirector of the general of people willing to ma care has become increassurgery residency program at do trauma call and ingly nonoperative in the past the hospital. take care of acute couple decades has led some residents to believe that trau“Early on [in the search], general surgery ma surgery is a nonoperative we were trying to find only issues. specialty. Because those resipeople who were boarded in DR. MANGRAM dents went into surgery to general surgery and critical care, and there’s so few people [who operate, they find this trend to be a dismeet those criteria] that you’ll spend 2 incentive. But adding general surgery years trying to find that one person. If emergency cases to the mix of cases there’s a surgeon who is boarded in gen- probably means that acute care surgeons eral surgery who wants to take trauma will find themselves in the OR more ofcall and do acute care surgery, there’s no ten than will trauma surgeons, she said. At San Francisco General Hospital, reason that they can’t do that. People may have to expand their pool of which does not have large surgical subprospective candidates [beyond those] specialty departments, Dr. Staudenmayer performs emergency general surgery trained in trauma critical care.” Trauma surgeons at Dallas Methodist and trauma surgery. And with only one perform all trauma procedures except for cardiothoracic surgeon and no vascular orthopedic and neurosurgical trauma surgeon on staff, the acute care surgery cases or major vascular cases such as aor- team operates on thoracic and vascular tic tears. At least one trauma surgeon is trauma cases. The hospital’s affiliation always at the hospital, which does not yet with the University of California at San have surgical critical care or acute care Francisco provides resources for those cases that demand subspecialist skills. surgery fellowships. The local environment of trauma Attracting Residents to the Specialty surgery and acute care surgery has a Medical school debt steadily increased by “big impact” on how the two specialties about 60% from 1985 to 1995 and is still are practiced. Trauma and acute care surincreasing. General surgery residents geons in centers with many surgical subhave to defer their loans for 5 years. specialists will probably have a smaller Then they face an average debt of near- scope of practice than will those who practice in rural communities and have ly $200,000 at the end of residency. Poor reimbursement could impact the less subspecialty support, she said. “From the perspective of training peorecruitment of residents into acute care surgery programs, said Dr. Kristan Stau- ple to do acute care surgery, I think most denmayer, a fellow in the trauma/surgi- people would be interested in having cal critical care program at San Francis- somewhat of a protected scope of pracco General Hospital, which has a level I tice so that they would be able to do interesting and diverse cases and maintain trauma center. But it’s difficult to determine what their skills sets in various parts of the level of reimbursement prospective body, regardless of their practice enviacute care surgeons might expect to re- ronment,” Dr. Staudenmayer said. Regardless of where a resident trains ceive, because of the great variability in insurance and reimbursement rates. For for acute care surgery, exposure to all example, Dr. Staudenm
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