The Acute Care Surgery Committee met in April 2010 and reviewed the original curriculum and made changes.  The article below gives the history of the Acute Care Surgery Fellowship Program, but does not include the most up-to-date information for curriculum requirements.  Please download the PDF version of the curriculum to find out the latest requirements. 

The Committee on Acute Care Surgery, American Association for the Surgery of Trauma

The American Association for the Surgery of Trauma (AAST) has worked on developing a training paradigm and a career practice model that serves the needs of patients and will be an attractive, viable and sustainable career pathway for current and future trauma surgeons. Following an August 2003 summit meeting of the leadership of the AAST, the American College of Surgeons Committee on Trauma (COT), the Western Trauma Association (WTA) and the Eastern Association for the Surgery of Trauma (EAST), the AAST established the ad hoc Committee to Develop the Reorganized Specialty of Trauma, Surgical Critical Care, and Emergency Surgery. The initial deliberations of the problems facing the specialty of trauma surgery were published in the Journal of Trauma in 2005. ¹This ad hoc committee was subsequently renamed in 2005 as the Acute Care Surgery Committee, and is now a standing committee of the AAST. The continued efforts of this committee have produced a survey of the membership of these organizations regarding the options available ², meeting with the leadership of other surgical specialty societies ³, broadening the membership of the committee, and spurred a large number of related publications and editorials. ^4-21

Coincident with this interest has been the release of a long-anticipated analysis from the Institute of Medicine on the growing problem of emergency medical care. ²² Furthermore, in May 2006 the Health Resources and Services Administration (HRSA) released to Congress its report titled “The Critical Care Workforce: A Study on the Supply and Demand for Critical Care Physicians”, confirming the current shortage of physicians trained to treat critically ill patients that is expected to increase due to the aging population and the increasing utilization of intensivists. ²³

While a variety of options were considered and debated, the consensus conclusion was the approval of a working plan to create a new specialist who has broad training in elective and emergency general surgery, trauma surgery, and surgical critical care. A graduate of this training would have special expertise in managing acute surgical problems, providing surgical critical care and managing acute trauma.

The usual domain of elective general surgery would be retained. The term “surgical hospitalist” has been applied to this training paradigm, but it does not fully convey the breadth or depth of this training and intended practice opportunities.¹³, ²⁴ In addition to doing what is conventionally considered “general surgery” and “general trauma” (neck, thoracic and abdominal injuries), the new Acute Care Surgeon specialist would also be adept at common emergent and urgent thoracic, vascular and abdominal operations. Early in the process of defining this specialty training there was consideration given to training for selected and limited neurosurgical and orthopedic procedures. This option has not been supported by these respective national surgical societies. ¹⁷, ²⁵ and hence local practice patterns will likely define the extent to which acute care surgeons help provide orthopedic and neurosurgical emergency care. ²⁶

This publication further outlines the details of this training fellowship. The training of this specialist would require core general surgery training, which at the current time consists of five years of an ACGME-RRC-approved general surgery training. However, the option of re-defining core general surgery training to three or four years of training, followed by early specialization in a number of fields continues to be considered by the American Board of Surgery, and was the recommendation of a minority report of the American Surgical Association taskforce on the future of surgical training. ^27-29 The proposed curriculum outlined here could be adapted to early specialization in acute care surgery following a core four years of training in general surgery. Additionally, this training model is designed such that the advanced training and experience of these surgeons is substantial, so as to not just allow, but to encourage the development of a diverse elective surgical practice as local practice patterns permit.

Table I outlines the suggested curriculum, including the mandatory and elective rotations for this 24-month fellowship. Essential to the completion of this fellowship is the fulfillment of the requirements of an RRC-approved Surgical Critical Care residency. Currently this entails twelve months of continuous surgical critical care training of which 2 months may be elective rotations and residents may devote up to 25% of their time to direct operative care of critically ill patients. Alternatives to the structure of how this knowledge is gained are being explored. There are some key notes to Table I:

• Trainees should participate in Acute Care Surgery call for no less than 12 months.
• Flexibility in the timing of these rotations, and the structure of the 24-month training should be utilized to optimize the fellow’s training.
• The rationale for out of system rotations for key portions of the training must be based on educational value to the fellow.
• Acute Care Surgery fellowship sites must have ACGME-RRC-approval for Surgical Critical Care residency training.
• Participation in elective surgery both to supplement General Surgery training and experience, and to serve in a supervisory role to residents, is an essential component of this fellowship training.
• An academic environment is mandatory and fellows should be trained to teach others and conduct research in Acute Care Surgery.

Table II outlines the operative cases required and encouraged for satisfactory development of competency in Acute Care Surgery. It is recognized that competency in some of these procedures may have been achieved during prior training. The Acute Care Committee’s ongoing deliberations will address the formulation of tools for measuring competency, the required case volumes, and the use of simulator training such as the Advanced Trauma Life Support (ATLS) course, the Advanced Trauma Operative Management (ATOM) or Definitive Surgical Trauma Care (DSTC) training modules. There are some key notations to Table II:

• Required experience should consider the feasibility and practicality of maintaining operative proficiency in a given area.
• Required experience should be sufficiently broad as to allow a wide range of practice patterns in a variety of communities.
• In consideration of local program constraints, there may be a need for flexibility with respect to strict required minimums number of cases for some procedures.
• The requirements for proficiency in certain operative procedures should reflect good clinical care executed in a timely manner, rather than being bound by strict or traditional disciplinary boundaries. (i.e. this is not “trespassing on turf”)
• Requirements should consider the difference between high-risk, volume-sensitive cases and lower risk cases where outcome is not influenced by volume.
• It is assumed that the fellow is capable of performing all essential procedures in the acute setting.
• Procedures listed in the “Desirable” category, as well as elective surgical experiences, provide valuable training in operative exposure and related surgical techniques of Acute Care Surgery. It also emphasizes that an elective general surgical practice is a foundation of this discipline.

Membership, Committee on Acute Care Surgery, 2005-2006

• Gregory J. Jurkovich, MD, Chair
• Kim Anderson, Ph D, Consultant
• L.D. Britt, MD, MPH
• Christopher T. Born, MD
• William G. Cioffi, MD
• Thomas J. Esposito, MD
• David B. Hoyt, MD
• Robert C. Mackersie, MD
• Mark A. Malangoni, MD
• Ronald V. Maier, MD
• J. Wayne Meredith, MD
• Ernest E. Moore, MD
• Lena M. Napolitano, MD
• Michael F. Rotondo, MD, Vice Chair
• Grace S. Rozycki, MD
• David A. Spain, MD
• Alex B. Valadka, MD

References

1. Acute care surgery: trauma, critical care, and emergency surgery. J Trauma 2005; 58(3):614-6.
2. Esposito T, Leon L, Jurkovich G. The shape of things to come: results from a national survey of trauma surgeons on issues concerning their future. J Trauma 2006; 60(1):8-16
3. Division of Advocacy and Health Policy. A growing crisis in patient access to emergency surgical care. Bull Am Coll Surg 2006; 91(8):8-20.
4. Schwab CW, Pryor JP, Earley AS, et al. An acute care surgery model improves outcomes in patients with appendicitis. Ann Surg 2006; in press.
5. Moore EE, Maier RV, Hoyt DB, et al. Acute care surgery: Eraritjaritjaka. J Am Coll Surg 2006; 202(4):698-701.
6. Moore EE. Acute Care Surgery: The safety-net hospital model. Surgery 2006.
7. Malangoni M. Acute Care Surgery: The challenges ahead. Surgery 2006.
8. Esposito TJ, Rotondo M, Barie PS, et al. Making the case for a paradigm shift in trauma surgery. J Am Coll Surg 2006; 202(4):655-67.
9. Esposito TJ. Rank and file weighs in on trauma and general surgery issues: Results from a survey of ACS fellows. Bull Am Coll Surg 2006; 91(9):13-20.
10. Cherr GS. Acute care surgery: Enhancing outcomes or fragmenting care? Bulletin of the American College of Surgeons 2006; 91(7):40-43.
11. Trunkey DD. Trauma in modem society: major challenges and solutions. Surgeon 2005; 3(3):165-70.
12. 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(2):212-7.
13. Shackford S. The future of trauma surgery - a perspective. J Trauma 2005; 58(4):663-7.
14. Rotondo MF, Esposito TJ, Reilly PM, et al. The position of the Eastern Association for the Surgery of Trauma on the future of trauma surgery. J Trauma 2005; 59(1):77-9.
15. Cryer HM, III. The future of trauma care: At the crossroads. J Trauma 2005; 58:425-436.
16. Ciesla DJ, Moore EE, Moore JB, et al. The academic trauma center is a model for the future trauma and acute care surgeon. J Trauma 2005; 58(4):657-61; discussion 661-2.
17. Bosse MJ, Tornetta P, Sanders R, et al. Letter to the editor re: Acute care surgery. J Trauma 2005; 59(4):1035-6.
18. 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; 58(5):906-10.
19. Jurkovich GJ. Training in trauma and emergency surgery. Am Surgeon 2006; submitted.
20. Jurkovich GJ. Acute care surgery: the surgeon's perspective. Surgery 2006; submitted.
21. Velmahos G, Jurkovich GJ. The concept of acute care surgery: A vision for the not-so-far future. Surgery 2006; submitted.
22. Institute of Medicine National Academy of Sciences. The Future of Emergency Care: Key Findings and Recommendations Fact Sheet. Future of Emergency Care Report 2006:available on line at: http//:www.iom.edu.
23. The Critical Care Workforce: A Study on the Supply and Demand for Critical Care Physicians. http://bhpr.hrsa.gov/healthworkforce/reports/criticalcare/cc1.htm, accessed October 1, 2006. , May 2006.
24. Spain D, Jurkovich GJ. The acute care surgeon. Journal of Hospital Medicine 2006; 10(5):24-33.
25. Valadka A. The acute care surgery curriculum. Neurotrauma and Critical Care News; Fall, 2006:3-4.
26. Bosse M, Henley B, Bray T, Vrahas M. An AOA critical issue access to emergent musculoskeletal care: resuscitating orthopaedic emergency-department coverage. JB&JS 2006; 88:1385-1394.
27. Bass BL. Matching training to practice: the next step. Ann Surg 2006; 243(4):436-8.
28. Brennan MF, Debas HT. Surgical education in the United States: portents for change. Ann Surg 2004; 240(4):565-72.
29. Pellegrini CA, Warshaw AL, Debas HT. Residency training in surgery in the 21st century: a new paradigm. Surgery 2004; 136(5):953-65.

Table I. Acute Care Surgery Fellowship Training Curriculum Rotations

Suggested rotations during Emergency and Elective Surgical experience.

Table II. Operative Management Principles and Technical Procedure Requirements of Acute Care Surgery Fellowship.