Acute Care Surgery

Gregory J. Jurkovich

The training and scope of practice of today’s trauma surgeon has evolved into a burgeoning field known as acute care surgery. Acute care surgery both defines an advanced surgical training paradigm and describes a type of surgical practice. The history of this evolution is short, and somewhat cyclic. In 1922 Charles L. Scudder, a general surgeon from Boston who had a strong academic interest in fracture management, established the Committee on Fractures within the American College of Surgeons. This early forerunner of today’s Committee on Trauma was composed of 22 fellows of the College, and the work of this committee encouraged the specialization of trauma surgeons and laid the foundation for the modern concept of quality improvement. As the results of physical force injury from wars, motor vehicle crashes, and interpersonal violence fostered the training of “trauma care” during the mid-20th century, the scope of the trauma surgeon encompassed more than fracture management. In 1950 the Regents of the College authorized the current title—the Committee on Trauma—to emphasize this expanding scope of practice.¹

Further advancement of a surgical discipline uniquely dedicated to the care of the injured patient in the United States occurred in the 1960s with the establishment of civilian trauma centers. These early trauma centers were almost exclusively within the domain of city–county hospitals in urban areas such as Chicago, Dallas, and San Francisco, but their impact and influence was rapidly spread by devotees of the charismatic leaders of these centers.² During the ensuing two decades, trauma surgery became an attractive career based largely on the mentorship of trauma surgeons in urban city–county hospitals who epitomized the master technician, and who developed an academically productive career based on the physiology of the injured patient and lessons learned from the Vietnam War. These trauma surgeons operated confidently and effectively in all body cavities, and perhaps were the last of the “master surgeons” that once were the hallmark of general surgery. Operating primarily in large-volume public, “safety net” hospitals, these surgeons were also typically referred the most challenging surgical problems from the surrounding city or region, particularly if there was a financial disincentive to providing care in a private for-profit hospital. As a result, the city–county or “safety net” hospital trauma surgeons developed an active elective and emergency surgical practice while providing trauma coverage and care to the most critically ill and injured surgical patients.³

The academic success of these leading trauma surgeons (Blaisdell, Carrico, Davis, Freeark, Lucas, Ledgerwood, Mattox, Moore, Shires, Feliciano) fostered their incorporation into university hospitals, and the economic viability of civilian blunt trauma care, particularly in no-fault auto insurance states, led to an expansion of trauma programs out of the safety net hospitals and into private hospitals. The American College of Surgeons contributed to the widespread adoption of trauma programs by the remarkably successful and innovated activities of the Committee on Trauma, including hospital verification, the ATLS course, and the National Trauma Data Bank (NTDB). The federal government fostered the “inclusive trauma system” concept and encouraged the widespread development of trauma centers, in large part by reports of high preventable death rates in nontrauma hospitals, and by publications from the prestigious and influential National Research Council that characterized trauma as “the neglected disease” of modern society.⁴ The result is that today there are over 1,600 trauma centers in the United States, including 203 Level I centers, 271 Level II centers, 392 Level III centers, and 43 pediatric-specific trauma centers,^5,6 with 84% of the population within 1 hour of a Level I or II trauma center.⁷ This remarkable adaptation of regionalized medical care is nearly unique to trauma, and has been fostered by the recognition of the specialty of its care model and the evidence of its survival benefit.⁸

Yet the attractiveness of this career, and indeed this type of practice, has been challenged and changed by a number of forces. As trauma surgery became more specialized and expanded out of the domain of the urban safety net hospital, the trauma surgeon no longer remained the “renaissance surgeon” of the urban/county hospitals of the 1970s. This success may in and of itself have paradoxically led to a declining interest and commitment to the practice of trauma surgery. The requirement of a surgical presence for the resuscitation and early decision making was interpreted by many hospitals (and surgeons) as a preclusion to developing a competitive elective practice, thereby discouraging technically proficient and talented clinicians from accepting such positions. Yet perhaps most importantly, as pointed out in an essay by Gene Moore and his “senior active trauma surgeon colleagues,” a declining interest in trauma surgery as a career was influenced by the loss of operative practice due to a number of factors: the nonoperative management of solid organ injuries, effective injury prevention strategies, the emergence of surgical specialties diverting thoracic and vascular injuries away from trauma surgeons, the explosion of technical capabilities of interventional radiology, and the emergence of surgical critical care as a part and parcel of trauma care.⁹ These forces challenged the viability of a career in trauma surgery, noted by a lack of interest in a trauma by residents and students toward the end of the 20th century. A number of articles have focused on the perceived lack of interest in any on-call practice, the aging of the trauma surgeon workforce, the focus on “lifestyle” residencies that result in highly remunerative and restricted practices, and concern that trauma surgery was primarily a nonoperative field.^10–13

Equally pressing has been the continued and unabated emphasis on specialty training beyond core general surgery training. This is a universal trend in medicine as evidenced by the 145 subspecialty certificates awarded by the 24 member boards of the American Board of Medical Specialties (ABMS).¹⁴ The exodus of general surgery trainees into surgical subspecialties has created a void of general surgeons with broad-based training who are capable of providing the expertise needed to continue the type of practice once common in city–county hospitals as well as in many rural communities. Many general surgeons, particularly those in group practices, will “subspecialize” within their group by virtue of additional training. Increasingly, surgical subspecialists exhibit less interest in providing emergency and trauma on-call coverage, often concluding that they “aren’t comfortable” or “don’t feel qualified” to do so. Lifestyle interests and an elective practice volume that does not require taking emergency room call to enhance billing often fuel this attitude. This is a reflection of both a demand in surgical manpower that has not yet been addressed and a tendency of hospitals and surgical departments to acquiesce to this demand in order to attract and retain these lucrative and desirable elective clinical practices.

Stitzenberg and Sheldon report that 70% of trainees who complete general surgery residencies pursue further training.¹⁵ The greatest interest has been in newer subspecialties, particularly surgical oncology (including breast surgery), endocrine surgery, and “minimally invasive surgery,” which usually includes gastrointestinal and bariatric diseases. In contrast, cardiothoracic surgery and vascular surgery have experienced a decline in interest as evidenced by the marked reduction of applicants to fellowships in these areas and a number of vacant positions in the match. Each of these specialties has had a decline in traditional open operative caseload primarily because of technological advances. Vascular surgeons have responded to this challenge by adding required training in endovascular techniques to their fellowship programs, and have been rewarded by a renewed interest in resident applicant. Cardiothoracic surgery has chosen to increase its focus on thoracic surgical procedures. There is a common thread here. Specialties that have declining operative caseloads are not as attractive to those interested in a career in surgery.¹⁶

In response to these changing social, economic, and demographic forces, a joint meeting of the leadership of the American College of Surgeons, the Association for the Surgery of Trauma (AAST), Eastern Association for the Surgery of Trauma (EAST), and Western Trauma Association (WTA) was held in August 2003, with the AAST taking the lead in considering how to restructure the training and practice of trauma surgery to make it a viable, attractive, and sustainable career, in the best interest of patient care, and, importantly, to keep trauma a surgical care disease. The result was the formation of a working group within the AAST to develop a surgical training curriculum that would be attractive to new trainees, and provide the training for a practice that would be viable, sustainable, and, importantly, in the best interest of the patients.¹⁷

Surveys of membership of the major trauma societies of the United States were undertaken to document the factors influencing the thinking of current trauma surgeons in both academic and nonacademic settings.¹⁸ The average workweek was 80 hours, with one half reporting mandatory in-house night call. Two thirds (67%) of the respondents care for trauma, surgical critical care, and emergency general surgery while on call. Widely valued and enjoyed by these surgeons were the intellectual challenges and the diverse aspect of a trauma career, but the major disincentives to participating in trauma care were the disproportionately poor income, irregular-hour time demands, and an inadequate trauma operative practice spurred by a preponderance of blunt trauma and interference or prohibition from developing an elective general surgical practice. These practicing trauma surgeons largely felt the best current model of trauma care was a training and practice paradigm that included trauma, surgical critical care, and emergency general surgery, and also allowed the option of an elective surgical practice if desired. They generally endorsed an option to include limited orthopedic and neurosurgical skills such as external fixation of uncomplicated long-bone fractures and ICP monitoring, but only if such specialty coverage was unavailable. They envision the ideal practice model as one involving a group practice at a designated trauma center, supported financially by the hospital and regionalized care. They would not mind mandatory in-house night call if such call was necessary for good care, limited in its frequency, predictable, compensated, and earns the next day off.

These results, along with a careful consideration of the needs of society and access to emergency surgical care, result in the development of a recommendation for a new advanced training fellowship to provide the expert surgical workforce to manage trauma and surgical emergencies. The AAST Committee on Acute Care Surgery developed and has promulgated a training curriculum for a specialist that has broad training in elective and emergency general surgery, trauma surgery, and surgical critical care.¹⁷ As reflected by the name of this committee, this new

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