• ACS Highlight: Acute Care Surgery: An Origin Story

    Dr. Patrick Murphy

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    Acute Care Surgery: An Origin Story

    Depending on your perspective, Acute Care Surgery is either the oldest surgical specialty or the youngest. Before the current sub-specialization of surgeons was the era of the Generalist: the true general surgeon. A surgeon who cared for patients in independent practice and referred only the most fringe cases. This era, in the early to mid-1900s, is over, and by all measures represents an improvement of patient care, particularly for patients requiring complex elective surgery. 

    In the post-Halstedian era, broad subspecialties of surgery were cleaved off General Surgery, including Neurosurgery, Plastic Surgery, Urology, Orthopaedic Surgery, and Vascular Surgery. Whether sub-specialization was driven by increased knowledge or increased knowledge drove specialization is hotly debated. General Surgery remained resistant, however, it too faltered. Additional training via fellowship (1 or 2 years) was soon recommended/required for operations once thought to be in the domain of the Generalist: Hepatobiliary Surgery, Colorectal Surgery, Minimally Invasive Surgery, Breast Surgery, and Complex Surgical Oncology. A strong argument can be made for the centralization of more complex general surgery, and general surgery has become more complex. It is near impossible for a general surgeon to stay current in the management nuances of complex breast cancer, rectal cancer, Crohn’s disease, trauma, and liver malignancies. Further, improved outcomes with respect to volume and experience, particularly from a systems level, are increasingly observed. Arguably, complex operations should be centralized and performed at high-volume centers/surgeons with systems of care in place to monitor the quality of care and outcomes. However, in the era of sub-specialization, there was a patient population left behind and lead to a burning, unanswered question in the early 2000s. What about general surgery emergencies?

    General surgery emergencies span all subspecialties of general surgery, from acute cholecystitis, haemorrhaging liver cysts, obstructing colon cancer, breast abscesses, and internal hernias after bariatric surgery. It is untenable to have every different subspecialty surgeon on-call every night. Only a minority of hospitals have direct, easy access to many of the general surgery subspecialties. Most hospitals were challenged to find any surgeon to care for patients in the emergency room. The Institute of Medicine in their 2006 report on the Future of Emergency Care in the United States Health System highlighted the ongoing crisis:

               “Many specialists find the demands of providing on-call services too disruptive to their privacy practices and their family life. After being in surgery all day, they have little desire to be called back into the hospital in the middle of the night, often without

    the assurance of payment for their services” – IOM 2006 Report

    The unmet need of emergency general surgery patients collided, timely, with a specialty in crisis: Trauma Surgery. The transition from the 20th to 21st Century brought an abrupt end to mandated surgery for traumatic injury. The pendulum swung from operative to non-operative due to a perfect storm of increased access/fidelity of CT and the demonstrated safety of non-operative management for common injuries. Drastic reductions in gun violence also reduced exposure to the classic operative penetrating trauma patient who would be whisked off to the OR, leading to another life saved. The fallout in trauma surgery was palpable: fewer surgical trainees were interested in a non-operative specialty, the satisfaction of existing trauma surgeons decreased and the “Golden Age” of trauma surgery was over. Trauma surgeons in the early 2000s had a choice – remain within ‘trauma’, mirror a more European model, and learn to operate on fractures and perform craniotomies or be innovative, both options with the goal to most importantly help patients

    The joint meeting of the American College of Surgeons (ACS), The American Association for the Surgery of Trauma (AAST), Eastern Association for the Surgery of Trauma (EAST), and The Western Trauma Association (WTA) met in 2003 to address the unmet need of emergency surgical patients and the future of trauma surgery. What came next was a re-birth of the general surgeon of an era passed. The idea of trauma surgeons expanding his or her practice to include emergency general surgery was not necessarily new. Trauma surgeons at numerous centers across North America were already taking care of the often septic emergency general surgery patients, and there was already significant overlap with surgical critical care. Trauma surgeons are adept at caring for sick patients after all. Re-imaging the generalist from the days before subspecialization to a rebranded ‘Acute Care Surgeon’ was not without challenges. Trauma surgeons were traditionally MIS surgeons with a capital M for maximally. Minimally invasive surgery was taking off and trauma surgeons would be challenged to adapt. Unlike trauma surgery systems, there was no corollary to take care of emergency general surgeons. The regionalization of emergency general surgery is debated at conferences to this day. At one extreme, uncomplicated appendicitis in a young person probably should not be transferred out of local hospitals. At the other end of the spectrum is complex emergency general surgery or emergency general surgery in the complex patient, both of which may require care at a high acuity centres. To this day, systems of care for emergency general surgery patients are in their infancy. Unlike mature trauma systems, there are few local registries and no national quality improvement programs such as the Trauma Quality Improvement Program (TQIP). This lack of robust systems for Acute Care Surgery makes it difficult to define high-quality care and reduce variations in care or develop benchmarking for emergency general surgery patients.

    Perhaps more inconsistent is the scope of practice for Acute Care Surgery. While the three pillars of Acute Care Surgery are Emergency General Surgery, Trauma Surgery, and Surgical Critical Care, the scope of the latter two is established. The practice variation is broad both at the individual and hospital level and often will depend on agreements with subspecialty surgeons based on local culture at each hospital. Much of the criticism from naysayers is: “Isn’t Acute Care Surgery just General Surgery?” These critics are both right and wrong. At an individual surgeon level, Acute Care Surgery is truly General Surgery: caring for whoever comes through the emergency room. Acute Care Surgery as a specialty is more, however, and exactly how much more is what is being witnessed today as the specialty continues to develop. Guidelines to standardize care are beginning to be published. Consistent disease severity scores are being established. More importantly, dedicated systems and models of care have been developed to focus solely on the optimal care of a vulnerable and forgotten patient population. 

    Moving forward, the specialty of Acute Care Surgery faces several challenges. First, despite nearly 20 years since the branding of Acute Care Surgery, the nomenclature is unclear. Is it Acute Care Surgery or Emergency General Surgery? Only recently do new graduates consider themselves acute care Surgeons as opposed to trauma surgeons. Our surgeon colleagues are only recently learning what an acute care surgeon is and how capable we are. The expansion of the 2-year AAST fellowship has greatly contributed. Second, the variation in practice expectations and scope of practice is inconsistent. Acute care surgeons must avoid learned helplessness. Like trauma surgeons who may be uncomfortable with vascular surgery, some acute care surgeons may be uncomfortable with emergency colorectal surgery. The solution is the same. Resuscitate, get the patient to the operating room and do the case with a senior partner or a colorectal surgeon. Postoperatively, keep the patient on the Acute Care Surgery service and let them benefit from the developing systems of care designed for patients with surgical emergencies. Third, the best model of care for patients and the best model of care for surgeons has yet to be established, and may at times be conflicting. A battle is ongoing between the 12-hr shift model and the service of the week model. Both have potential benefits to patients (continuity) and surgeons (fewer 24-36 hour call shifts). Fourth, and finally, is remuneration. Just like in trauma surgery, acute care surgeons have no control over who is injured, who will have appendicitis, or who will require a ventilator. Financial compensation in a purely RVU model understanding these truths seems short-sighted but quite common.

    Expectations are high for current and graduating acute care surgeons. New graduates must find a place in a specialty that is simultaneously very old and very young. Current Acute Care Surgeons must apply what was learned from the evolution of trauma systems and apply it to an ever-growing acute surgical population. We are not alone. Multiple organizations such as the AAST have made it their mission to support and foster research for patients with acute surgical conditions. There is no doubt this challenge will be met. I, for one, am proud to be an acute care surgeon. 

    I would like to thank Dr. Jurkovich and Dr. Spain for their correspondence, which greatly influenced this article and much of the perspective on the evolution of acute care surgery. 

    References

    1. Gawande, Atul. “Two Hundred Years of Surgery.” New England Journal of Medicine, vol. 366, no. 18, 2012, pp. 1716–1723., doi:10.1056/nejmra1202392.
    2. “100 Years of Surgical Education: The Past, Present, and Future.” The Bulletin, 6 June 2016, bulletin.facs.org/2013/07/100-years-of-surgical-education/.
    3. Mattar SG, Alseidi AA, Jones DB, Jeyarajah DR, Swanstrom LL, Aye RW, Wexner SD, Martinez JM, Ross SB, Awad MM, Franklin ME, Arregui ME, Schirmer BD, Minter RM. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013 Sep;258(3):440-9. doi: 10.1097/SLA.0b013e3182a191ca. PMID: 24022436.
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    5. Birkmeyer, John D., et al. “Surgeon Volume and Operative Mortality in the United States.” New England Journal of Medicine, vol. 349, no. 22, 2003, pp. 2117–2127., doi:10.1056/nejmsa035205.
    6. Hata, Tatsuo, et al. “Effect of Hospital Volume on Surgical Outcomes After Pancreaticoduodenectomy.” Annals of Surgery, vol. 263, no. 4, 2016, pp. 664–672., doi:10.1097/sla.0000000000001437.
    7. “IOM Report: The Future of Emergency Care in the United States Health System.” Academic Emergency Medicine, vol. 13, no. 10, 2006, pp. 1081–1085., doi:10.1197/j.aem.2006.07.011.
    8. Green SM. Trauma surgery: discipline in crisis. Ann Emerg Med. 2009 Feb;53(2):198-207. doi: 10.1016/j.annemergmed.2008.03.023. Epub 2008 Apr 24. PMID: 18439724.
    9. Cohn, D’Vera, et al. “Gun Homicide Rate Down 49% Since 1993 Peak; Public Unaware.” Pew Research Center's Social &amp; Demographic Trends Project, Pew Research Center, 30 May 2020, www.pewresearch.org/social-trends/2013/05/07/gun-homicide-rate-down-49-since-1993-peak-public-unaware/.
    10. Hadzikadic L, Burke PA, Esposito TJ, Agarwal S. Surgical Resident Perceptions of Trauma Surgery as a Specialty. Arch Surg. 2010;145(5):445–450. doi:10.1001/archsurg.2010.49
    11. “Acute Care Congress on the Future of Emergency Surgical Care in the United States.” Journal of Trauma: Injury, Infection &amp; Critical Care, vol. 67, no. 1, 2009, pp. 1–7., doi:10.1097/ta.0b013e3181abe928.
    12. Spain DA, Richardson JD, Carrillo EH, Miller FB, Wilson MA, Polk HC Jr. Should trauma surgeons do general surgery? J Trauma. 2000 Mar;48(3):433-7; discussion 437-8. doi: 10.1097/00005373-200003000-00010. PMID: 10744280.
    13. Jurkovich GJ. Identity: 2009 AAST presidential address. J Trauma. 2010 Apr;68(4):753-60. doi: 10.1097/TA.0b013e3181d692f5. PMID: 20386270.
    14. Utter GH, Miller PR, Mowery NT, Tominaga GT, Gunter O, Osler TM, Ciesla DJ, Agarwal SK Jr, Inaba K, Aboutanos MB, Brown CV, Ross SE, Crandall ML, Shafi S. ICD-9-CM and ICD-10-CM mapping of the AAST Emergency General Surgery disease severity grading systems: Conceptual approach, limitations, and recommendations for the future. J Trauma Acute Care Surg. 2015 May;78(5):1059-65. doi: 10.1097/TA.0000000000000608. PMID: 25909431.
    15. “Acute Care Surgery.” The American Association for the Surgery of Trauma, 17 Aug. 2020, www.aast.org/acute-care-surgery-overview.

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