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Trauma Centers and Trauma Surgeons: Have We Become Too Specialized?

2000; Lippincott Williams & Wilkins; Volume: 48; Issue: 1 Linguagem: Inglês

10.1097/00005373-200001000-00001

1529-8809

J. David Richardson,

Pelvic and Acetabular Injuries

As this century winds down, there are many reasons to be extremely satisfied and gratified with the status of the American Association for Surgery of Trauma and with trauma care in this country. From an organizational perspective, I believe the American Association for Surgery of Trauma is extremely vibrant and has reason for great optimism. Our membership is enthusiastic about the organization, meeting attendance is excellent, we have great international fellows, the scientific sessions at our annual meetings are outstanding, The Journal of Trauma is a high-quality publication, which is increasingly being cited, and our society is on firm financial ground. As for trauma care itself, we likewise have many reasons to be proud. Trauma care is clearly a primary component of general surgery as promulgated by the American Board of Surgery; the Surgery Residency Review Committee requires every surgical trainee to have trauma experience during residency, and virtually every academic department in the country is represented by at least one surgeon committed to trauma. The efforts of the Committee on Trauma have been exemplary in forging a trauma care agenda for America’s hospitals. If a hospital is to receive the imprimatur of the Committee on Trauma, there must be clearly demonstrated commitment to the care of the injured. That commitment is now seen regularly on television programs, and increasingly the lay public is fascinated by what trauma surgeons do. The term Level I trauma center is now part of the vernacular even if people do not know exactly what it means. So, as I stand here as the last president in the old millennium, I am personally very proud of my commitment to trauma care. I am proud of the University of Louisville’s role in caring for the injured, which has spanned nearly the entire century. I feel I have been blessed to know the members of this organization and to have been fortunate enough to call you colleagues and friends. I am proud of you who have labored in the often thankless task of caring for patients who were injured and had no where else to turn. I have been honored to have been a part of the American Association for Surgery of Trauma, which I believe has contributed so much to better care for the injured. FIGUREFigure: J. David Richardson, MD President, American Association for the Surgery of TraumaI wanted to say a lot of very positive things about trauma care before I embarked on the remainder of my remarks because some might take offense at them, and I am confident many will not agree with all the precepts I might espouse. For the next few minutes, I will share some of the facets of trauma care that I find troublesome and that I believe will be a problem for care of the injured in the next decade. Quite simply, I fear that trauma care has become too specialized, or perhaps our trauma center and trauma surgeons have been so successful at attracting patients that trauma care is moving farther and farther away from its general surgery roots. Clearly, there is great institutional variability in the way trauma care is practiced, but I see in our very success (which I so lauded a moment ago) some trends and I want to use this opportunity to share those worries with you. I will try to make the case that trauma care needs to remain a part of general surgery and that general surgeons need to continue to provide trauma care. General surgeons and trauma care need to be linked in reality and not merely with platitudinous lip service, but in actual practice in our hospitals and in our surgery departments. In medicine, as in other phases of life, we must continue to adapt and acquire new knowledge. Yet, as we specialize and concentrate more and more knowledge and experience in the hands of fewer and fewer practitioners, there will be a flip side of the coin that may not always be in the best interest of providing good trauma care. So, in part, I will be a contrarian and examine the opposite side of the coin in some of the issues facing present day trauma surgeons. The second philosophical item I would like to mention concerns the broad topic of specialization, not just in trauma but in surgery as a whole. As I have observed general surgery training as an academic educator and a member of the American Board of Surgery, I have some concerns about general surgery training in this country. I believe that we differentiate training along specialty lines far too commonly and that practitioners often differentiate into narrow practice areas far too early in their careers. The use of rotations such as trauma services may be convenient and an admirable way to provide care. However, if only trauma patients are included on a service, then the environment may be so artificial that it applies only to trauma centers. If that is the case, then it sends a message that the activities carried out in caring for the injured are not transferable to the non–trauma-center environment. We have developed a plethora of specialists in this country within general surgery, i.e., oncologists, colorectal, hepatobiliary, laparoscopists, hernia surgeons, endocrine surgeons, vascular surgeons, trauma surgeons, surgical intensivists, etc., etc. I feel many young surgeons become too specialized too early in their careers. Although the pursuit of advanced training is laudatory and acquisition of new knowledge is mandatory, the goals for specialization are often not so worthy: competitive advantage, economic betterment or simply choosing to focus one’s interests because it is easier to know more and more about less and less than it is to stay committed to a command of the breadth and depth of general surgery. Narrow, focused specialty practice may work well for metropolitan areas but is not the best model for much of the American population. So let me be clear, especially to the surgeons in training and young surgeons in this audience, that I think you can be proficient in broad areas of surgery; it is hard work, but it can be fun and I think you can provide first rate trauma care and do other things in surgery as well. Therefore, I would submit that we be cautious in trying to drive the specialty of trauma care, for in trying to specialize more we may be retreating from our roots in general surgery and stand to lose some of our great natural strengths. In considering whether or not we are becoming too specialized in trauma care as the title of this address suggests, I would like to consider three areas of concern. The first is the issue of access to trauma care. The second involves the consideration of what specialization in trauma care is doing to our trauma center hospitals. The third consideration is what effect increased specialization is doing to surgeons, both in training and those already in practice. When I hear physician health planners or politicians discuss access to care I find access to be a sterile word. Access may be a great word to describe a door to a building or the on-ramp of a freeway but not something associated with health care. Because health care is ultimately personal, I believe it is important to “personalize” the situation, i.e., what would I want done for me and my family; how would I want to be treated? In truth, I am positioned well enough in Louisville that receiving elective care is not an issue; likewise, Louisville has excellent trauma care beginning with a good prehospital system and a Level I trauma center at the university hospital where I work. A test I have always found more valid when discussing availability of health care is to look at my hometown of Morehead, Kentucky, where my parents and younger brother and his family live, as well as a passel of aunts, uncles, and cousins. Morehead, Kentucky, is located in Northeastern Kentucky roughly equidistant between Lexington, Kentucky, and Huntington, West Virginia. Morehead is a town of approximately 15,000 in a county that has now grown to over 30,000. It serves as the primary cultural, educational, and medical care center for a five-county area known as the Gateway area by state planners because all of these counties have part of their eastern borders in the Daniel Boone National Forest and are, hence, the gateway to the Appalachian Mountains. Morehead is located in a narrow valley between the foothills of the Appalachian Mountains chain. I was born in eastern Kentucky and for me, eastern Kentucky was a wonderful place to grow up. We had no cultural advantages in the sense of those found in most urban areas except a small public library and what was then a struggling state college. However, there were numerous other advantages, i.e., a land of great physical beauty with deep forests, gorges, and streams. The eastern end of the county was mountainous and wooded, whereas the western end provided excellent farm land where one could raise a variety of crops as well as strong horses and mules and good cattle. I had a large family on both sides filled with tough, self-reliant people. Like Kentucky families even today, there were many who were educated and those who were not; some acquired worldly goods and many did not, but all seemed bound to each other, to neighbors and family, and to the land. This sense of belonging was an enormous asset to me when I was young and remains an important part of my life today. At the beginning of this century, Morehead was far from an idyllic place. The town, which was founded in 1855 as a coaling station for the railroad, had grown to nearly 2,000 people early in this century. Mining of clay and brick processing, lumber, and some farming were the primary occupations. This area of Kentucky, like many others, had been divided by the politics of the civil war and political factionalism often marred by violence that was a reality even in the 1950s when I was a child. In the late 1800s, my wife Suzanne’s great-great grandfather, who was the county judge of Rowan County where Morehead is located, was shot from horseback and killed after a bitter election. This killing initiated a series of factional disputes that eventually lead to a group of families banding together and fighting a bloody feud that lasted for several decades. Although the Hatfield and McCoy feud was more famous, the Tolliver-Martin feud in Morehead was much larger, had more violence and more deaths. In fact, it was the largest feud ever fought in this country and did not end until near the end of the last century when federal troops were sent into Morehead to quell the violence. This was reported as far away as New York and those newspapers referred to the conflict as the Rowan County War. There were discussions about withdrawing the official “county status” from Rowan County, and a very negative image of our portion of the country developed, not inappropriately. As a result of the tremendous amount of adverse attention, the town and surrounding areas received, a number of dedicated people came to the area with an interest to better the conditions there. Although many attempts to bring better conditions to eastern Kentucky were misguided, much good came from the outside influences that brought more religion, more and better education, and better health care. In fact, religion, education, and health care have been a remarkably positive influence on the entire area. When I was a child, Morehead seemed to have more churches per capita than almost any town in America, and many were initially founded by people from outside the region who brought with them a missionary zeal to tame this violent land. Education came in the form of a series of moonlight schools, which began in the 1900s and brought remarkable changes in adult literacy. Some of the negative attention of the Rowan County War made it a natural spot in the minds of some for the funding of a college to improve the higher educational environment. Eventually the college became a state institution that is now Morehead State University. Health care came much later as I will mention later. The Richardson family came to Rowan County in the early part of the century from Powell County, also in eastern Kentucky. My mother’s family had been in Rowan County since before the turn of the century. Thus, my wife and I, who were high school sweethearts, were born as World War II came to a close, into a world in many ways much different than the world we now face. Fatalism was certainly a part of our upbringing; we expected in those days for things to go wrong. Illness, early death, and injury were regarded as a necessary matter of course. Although we grew up as happy children, injury and the threat of injury in particular was a constant reality in our daily lives. Farming and livestock work, logging, and mill work were dangerous. Clay mining was perilous; auto crashes were a constant part of life, and numerous friends died during my teenage and college years. One of the things that drew me to trauma care was an acute awareness of the awfulness of the way injury affected ordinary people. My commitment was engendered less from an inherent interest in operating on the injured than to a deep sense of duty that trauma patients deserved better care than I often saw provided them. All patients who are ill face issues with loss of control over their outcome. With trauma patients, that loss of control is often complete and they are completely at the mercy of the forces surrounding their injury and the local resources available near the area of injury. As I was growing up in Morehead, we were totally at the mercy of external forces for we had no hospital and no system of trauma care (even a primitive one). If you were injured, an ambulance would travel like hell over the roads to Lexington and you prayed you arrived safely. In 1963 when I was a senior in high school, a hospital was built, and again fate smiled on our town. The newly formed University of Kentucky Medical School decided to use the St. Claire Hospital in Morehead as a teaching outpost. Thus, residents were soon stationed in the small hospital and outstanding practitioners were recruited. Virtually all medical and surgical specialists have now been attracted to a hospital that has grown to 125 beds. Five general surgeons practice there, and all are well trained; the chief of surgery trained at Barnes Hospital in St. Louis and was a Kentuckian attracted back to the mountains by his love of the country. Prehospital services have been developed, and patients from several surrounding counties come to the local hospital for their care. The hospital and its medical staff are excellent, and many of my relatives have been fortunate to have received their care locally at this hospital. The advent of a local hospital that can provide medical care has been a tremendous boon to the community and to my family. I have had relatives injured by gunshot wounds, auto crashes, logging misadventures, and farm accidents (including being gored by a bull). Trauma affects real people - suddenly and often uncontrollably. Our family has had relatives whose lives have been saved by prompt, local treatment of their injuries as well as relatives and friends who have died either in Morehead or en route to a larger hospital. A survey of resources available at the local hospital presently indicates a tremendous growth of services in the past decade: a cardiac catheterization unit is now in place; a new chemotherapy and radiation therapy center has opened; dialysis is done; a neonatal unit is present; and a host of sophisticated local services are provided that enhances the health care in my hometown and the surrounding area. Perhaps the only service where there is a retrenchment of local service provided is in trauma care. In the past few years since helicopter transfer has become more common, pretransfer evaluation or even hemorrhage control is usually not done by surgeons unless the patient is clearly so unstable they are deemed unsuitable for transport. As we have stoked up Level I trauma centers, local hospitals view their mission as primarily being processing centers who package up the injured for an ambulance or helicopter ride. If “access” means that patients can get to a trauma center by some means, then I believe it is readily available. If “access” means that patients get evaluation and treatment of most injuries locally, and transported only for serious injuries, then I believe we usually fail to provide it in my part of the country. Virtually all smaller hospitals in our area now fight to keep most nontrauma patients locally but ship almost all trauma patients to either Lexington or Louisville within the state or to Vanderbilt, Cincinnati, Knoxville, or Huntington, West Virginia if they are on the periphery. I suspect from my travels to many parts of the country that this scenario plays out in many states and not just in Kentucky. Why has this phenomenon occurred? The stock answer on the trauma center side is that patients are dumped for financial reasons or there is lack of commitment on the referring hospital and physician side. Although financial consideration impacts all medical care, it clearly is not the total answer in my opinion. My hometown hospital cares for countless indigent patients from around the region so I have no reason to believe they discriminate solely against trauma patients on economic grounds. I also do not buy lack of commitment as an answer. The Morehead hospital now cares for ruptured aneurysms and vascular emergencies in the middle of the night, which has been a responsibility added in the past few years. I know these surgeons and believe they are excellent, committed physicians. In Kentucky, much of the answer relates to the complete lack of a trauma care system. We have two Level I centers at two universities and a couple of other hospitals spread throughout the state who care for the injured and the remainder generally have no defined role other than to transport patients. I have talked to over 30 surgeons in small- and medium-sized towns in Kentucky, Ohio, and Indiana about the provision of local trauma care. Perhaps as many as half are relieved they do not have to be involved in trauma care (they are not committed), whereas the remainder offer a number of often-repeated explanations for their diminishing role in trauma care. If I could summarize some of the views stated: (1) The triage criteria at trauma centers are so strict that virtually anyone with any chance of injury should be sent to a trauma center, so we send not only those seriously hurt but almost anyone who could be hurt. (2) If the standard of care says patients should go to a trauma center, it is difficult to justify caring for any patient locally. (3) Trauma care seems to be more of a specialty and less a part of general surgery. The comfort level of providing services such as nonoperative care has decreased among general surgeons in nontrauma centers. Or as one surgeon stated, “you trauma guys make us feel guilty even if we do a life-saving splenectomy.” (4) The medicolegal climate has made surgeons and hospitals wary about caring for trauma patients. In addition, there is the added problem of specialists availability. It is obvious that seriously injured patients need to be in a trauma center and in no way do I intend to denigrate the role that we need to play in trauma centers. On the other hand, I am struck by the irony that despite the tremendous advances in medical care in my hometown in the past 30 years, if you are suspected of being hurt, now as well as when I was a boy, the injured are often crated up and hopefully can sustain an ambulance ride or helicopter flight to Lexington. So, as we consider access for trauma patients, we need to think beyond urban areas that may be well served by trauma centers to places like my hometown. Good trauma care in these areas simply must involve the general surgeon and the opportunity for local treatment of some injuries. The second issue I would like to discuss briefly is the effect of our current system of trauma care on trauma centers, i.e., from the hospital perspective. There is certainly no simple or completely characteristic relationship between hospitals and trauma patients. In many instances in this country it might be that our trauma centers have been so successful at attracting patients that it creates an imbalance in terms of other patients that require care. I will speak only about my concerns regarding the University of Louisville Hospital, although I suspect there is some universality to my observation. My associates and I have certainly tried to treat any and all patients that are presented to us; we have tried to provide high-quality care and give good feedback to referring physicians and emergency departments that send patients. So, in that sense we compete for patients. From 1994 to 1998, the number of trauma patients treated has increased from 1,800 to over 2,200. The big increase has not occurred among the more seriously injured but in the patients who were in hospitals less than 48 hours. Another thousand patients were evaluated and discharged from the emergency department. Those patients who are not badly injured were, heretofore, being treated locally, I am sure. In fact, many of these patients did not require admission, but it is embarrassing to discharge a patient from the emergency room who was flown in by helicopter! In 1998, we received patients transferred from 68 other hospitals by 107 different prehospital providers and seven different flight services. We are pleased to be able to provide services to these patients and view it as vital to our hospital’s mission. Nonetheless, the burden on the institution is quite large at times. Having visited many trauma centers around the country, I know our situation is not unique, and I am aware of many trauma centers that have even more admissions. Whether such a large number of admissions is economically beneficial from a hospital standpoint depends on the payor mix or whether there is a stipend for indigent care. In our hospital, the payor mix for trauma is as good or better than the reimbursement level for nontrauma patients. Additionally, our hospital receives state and local funds for indigent care; therefore, the large number of beds filled by trauma patients has generally served our hospital well, particularly in some troubled times it has had in the past. On the other hand, the simply overwhelming numbers of injured patients has made it difficult for our hospital to achieve its other missions at times. Intensive care unit beds have been at a premium for years. Often when patients are able to be discharged from the intensive care unit, there are no other beds available. The backlog of patients waiting on stretchers in recovery rooms, or worse in emergency departments for hours, or often days, is a problem that has bothered me with each passing year. I get embarrassed trying to explain to a patient why he/she must spend the night on a hard stretcher in the emergency department while their family has no place to wait. No comforts, no privacy, and not really the best care. I understand this is a system problem, but I can tell you in our trauma center it has not been reliably solved simply because there are so many patients. From the perspective of a general surgery division director, I worry about the balance of general surgical training. We are fortunate in Louisville because our trauma services are actually emergency services that provide care to patients other than the injured. Although this increases the workload even further, it does provide operative experience to our residents and faculty and provides some balance to a trauma service that has become increasingly a nonoperative experience. We also have large elective services at other hospitals; if we did not, the imbalance caused by the large number of trauma patients would probably require us to decrease our residency by half. I realize this hospital situation may be very different in other urban areas where there are multiple trauma centers or in states that have true trauma systems that may provide some degree of checks and balances on a single center’s admissions. In our situation, I believe we now have a major overtriage problem. Although we still care for a seemingly unlimited number of critically injured patients, we are increasingly being sent a large number of patients who do not, in my opinion, need a trauma center, but simply a doctor (more specifically a general surgeon) who will evaluate them and care for them locally. However, in fact, many of our trauma divisions or general surgery divisions really have a tiger by the tail. Economically, because of issues such as declining reimbursement, more nonoperative care that produces even less revenue, large numbers of indigent patients, and in some centers the fact that trauma surgeons are barred from doing elective surgery, we simply must have large patient volumes to meet budgetary needs. This produces the need for more attending physicians and fellows to care for the patients we are attracting. This in turn produces the need for more revenue, and on and on. I am amazed at how many trauma units are now contracting with other outside hospitals to provide trauma care or intensive care unit care, which keeps workforce needs spiraling and creates greater budgetary demand. I am well aware of this conundrum, because I face it every day as almost every division director or trauma director does. Do not be misled into thinking I have any solution for this problem. But, I do believe that we should all reexamine our priorities in the trauma care we are providing perhaps with a few simple questions. First, is the trauma care my unit provides really care that cannot be provided by others? Second, does the care enhance the teaching and training mission for residents and students, and third, is the research mission of our unit enhanced or hindered by treating so many patients? The third area I would like to discuss is the impact of trauma centers and trauma surgeons specialization on physicians, both at a resident and attending level. First, let me make some observations about the impact of trauma care on resident training and how our trainees view caring for the injured. Obviously, there are many different models of trauma training in this country, and I am sure most are excellent. I would also categorically state that strong trauma training is imperative in producing a good general surgeon and must be continued and improved. When our residents discuss their trauma experience with me, they almost always do so with a certain degree of ambivalence. On the positive side, most feel enormous pride that they can master the challenges of a busy service and do it well. In Louisville, we stress the role of the trauma service as the crucible, i.e., where high-volume, high-intensity, results matter, life or death decisions are made, and treatment is provided. On this service, residents may be required with their attending physician to perform an emergency tracheostomy on a cyanotic teenager, suture an aortic wound in an obese patient, deal with end-stage cardiac tamponade, or tell a large, hostile family whom they have never met that their son has died in the operating room. Once residents have dealt with these kinds of defining emergencies successfully, you can see the maturation in them immediately. Interestingly, this type of pressure never seems to bother residents. It is what they have chosen to do, and they know high-pressure surgery will likely be their life’s work. The transfer of decision-making skills, quick-thinking, and rapid action certainly serves surgeons well in nontrauma areas. The camaraderie and team work required to function effectively on a trauma service hopefully provides lasting lessons to trainees, and I am always gratified to see how our residents and students rise to their personal best to clear the high bar that a busy trauma service sets. I referred to the ambivalence many residents experience on our trauma service. Despite the pride of accomplishment and sense of camaraderie most of our residents feel, the majority have a lot of negative experiences on our service. There are simply too many patients at times. After a while, the educational value in evaluating hundreds of blunt trauma patients is lost, there are far too few trauma operations for the large number of patients treated, and most damning of all -it simply is not fun!!!!! When I was a resident, I not only thought trauma care was fun but I believe most of my fellow residents thought the same way. I am not sure the average resident today believes that. I would remind you of the resident survey 1 Frank Miller and I completed a few years ago regarding trauma care. Nearly 900 residents responded from over 100 programs. In the open-ended sections we had only 6 positive responses and 440 negative comments. Even after allowing for residents being negative, this difference seems significant! These comments were the ones most frequently mentioned: (1) Blunt trauma simply has a lot of work involved that is not viewed as surgical, and trauma centers have greatly concentrated this type of patient; (2) Poor surgical role models on the trauma service who do not operate and do not have an elective practice; and (3) Trauma care is not a part of general surgery. We concluded that study by saying there seemed to be a high rate of dissatisfaction for trauma as a career and that residents see fewer and fewer opportunities to practice trauma surgery as a part of a general surgery career. I have seen little in the past 5 years that makes me doubt the validity of those observations today. I congratulate those young men and women who are picking up the torch and carrying trauma care into this new millennium. I am proud of you and urge you to continue your commitment to the injured. On the other hand, we must not let the ca