01 December 2008

Inexorable Trend

Buckeye Surgeon has an interesting post about an academic surgical/trauma program which, it seems, is trying to poach the good cases redefine trauma surgery as "Acute Care Surgery." In short, the Orlando program is making a (rather lame) argument that they should do not just all trauma, but all the acute surgical cases in the region, as "specialists" in acute care surgery.

I can't add much to Buckeye's commentary -- it's dead-on. This is a play for dollars and training cases, and completely unjustified from an economic, efficiency, and quality of care perspective. But there's another, tangentially related point here. Buckeye asks whether trauma surgery, as a specialty, is viable. In my humble opinion it is not, at least not on a large scale. As a niche it will persist as long as guns and motor vehicles do. What will happen, I predict, is that "Trauma surgery" ultimately will, in fact, transform itself into (or be replaced by) a new specialty of "Acute Care Surgery," which might be more simply described as "Surgical Hospitalists."

This specialty, rather than sucking cases from community centers to academic, will function somewhat the other way. The surgical hospitalists will metastasize to smaller institutions, instead of centralizing to the academic centers. The market makes a compelling case for surgical hospitalists in community facilities (on an efficiency basis), which will promote community hospitals retaining more surgical cases and transferring fewer cases to the Mecca.

Think of it this way: every ER call, every acute case, every in-hospital consult represents a time burden for the on-call surgeon. At academic hospitals, this burden is typically borne by the in-house residents, 24/7, so there is no real cost (other than to the limited sleep of the intern). If you are a community surgeon, trying to see patients in clinic, or operate on your scheduled cases, or get some sleep before a full day of clinic, this burden is rather more onerous. Cases get canceled, clinics get backed up, and you are tired and overwhelmed. Call is not easy for community-based surgeons, and the cost to their paying, elective cases, is significant. There is a compelling need for these doctors to want to end the "on-call" system.

Surgical hospitalists are the answer to their prayers. They handle the bogus (and unprofitable) trauma cases. They handle the ER and the consults. They free you up to focus on your own patients. And it's not a bad lifestyle either, for the hospitalsts. They work shifts, have a predictable schedule, get to operate a lot and generally get to do the "fun" surgical stuff. This is often most appealing to newer graduates, who are closer to their training and perhaps more comfortable with hospital-based medicince, complex cases, and

The economics of the case are the most challenging. A hospital would need a certain volume of acute cases to support a surgical hospitalist program. I've not done any research on the matter, but my back-of-the-envelope guess would be a 200-bed hospital with a 40,000-visit ER would be the smallest facility that could keep their surgeons busy. And who pays? As with internist hospitalists, they may not generate enough pro-fee revenue to cover a competive salary. Perhaps the facility itself might subsidize them, to keep the call schedule filled and to keep the community surgeons happy. Perhaps the community surgeons would see enough value in the efficiency to hire their own hospitalists. Or maybe each surgeon would take their turn in the barrel. There are a variety of models that could work for this program.

I should point out, in fairness, that our facility has had such a program in operation for a few years now -- maybe as many as four. I am not quite sure. It's been a huge success for all of us -- the ER, the internists, the clinic surgeons, and the surgical hospitalists (I mean, the acute care surgeons). If I need a surgical consult, they can be there right away, even at three AM. They come to see patients more, rather than just asking for a CT scan and a call-back. They are willing to admit more cases which could have been challenging dispositions, and they have service agreements with the internal medicine hospitalists for the overlapping cases (SBOs, gallstone pancreatitis, etc), so "dumping" on internal medicine never happens any more.

Better yet, it's vastly improved the relationship of our two departments. The in-house surgeons are in the ER enough that it's just part of their routine and they don't resent the calls, because they bring an attitude of "this is what I'm here for." The community surgeons still occasionally get calls from us, but more often during working hours and less often at 3AM, and thus they view us as less of a burden and more as valued colleagues.

I don't know for certain whether this model will catch on in the larger sense. Maybe surgical care is too fragmented into small competing practices. Maybe you need a really busy facility to support them. I think it's the future, though, and I know it's been an amazingly positive experiment for us.


  1. One of the things that I criticized about the original paper is that the author never considered the need for OR readiness beyond the ER. OB will always need the OR to be on call, so community hospitals STILL will have to have the team on call.

    But I like the idea of surgical hospitalists. That idea is percolating through OB as well, Weinstein out of Philly calls them "laborists". We're too small to justify it, you need about 2000 deliveries/year to do so and we do about 1200.


  2. You commented, Maybe surgical care is too fragmented into small competing practices.

    The surgical hospitalists at our shop drew together despite the competing fragmentation. The community surgeons apparently see more value in cooperating than in redundant call schedules.

  3. Another real positive effect of this is better health. I've been working straight nights in our ED for 7+ years and am a certified "sleep health" nut. My sleep health and general health, I believe, is far better than any of the on call specialists that are even occasionally busy. The health toll of "call" is significant and this approach is a step in the right direction.

    Our hospital has 400 beds, 50,000 ED visits, and a large trauma referral area (rural area - North Dakota). The surgeons are in the ER during the middle of the night at least half of the nights during the year and every weekend during the summer months as our trauma tends toward blunt / MVC. It's easy to see how it wears them down, especially as they age.

    Most of us cheat our bodies out of sleep when we're young and "get away with it", although I'm not sure we really do get away clean, given the health and morbidity statistics connected with shift work in the US. Moving toward better sleep health is a positive thing for all concerned, especially the patient.

  4. Dr. Chris Kosakowski, MD, started the first Surgical Hospitalist program in 2001 at Sutter Medical Center of Santa Rosa. Private practice surgeons in the area often boycotted hospitals, services, and payors at their whim, often leaving 10's of thousands of patients without surgical specialists.

    Dr. Kosakowski, by integrating computer systems and billing systems, was able to cover 2 of the 3 hospitals in Santa Rosa (almost 200 beds), 2 ICUs, 2 emergency departments, general, vascular, sometimes specialty surgery (such as urology), and a wound care center. He did this with between 3 and 5 rotating surgeons, drawing on surgeons sometimes from regional hospitals, thereby integrating regional care.

    Dr. Kosakowski's surgical hospitalist program provided care for much of Sonoma County that otherwise would not have had access to surgical care. He was very forward thinking and, like the model for Sutter Santa Rosa, Dr. Albert Schweitzer, a truly caring individual.


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