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

Abstract

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 care center for a as the by planners because all of have part of their in the and the to the Morehead is located in a narrow between the of the I in Kentucky and for Kentucky a to We had no in the of those found in areas a public and what then a However, there were other i.e., a of great with and The of the county and the excellent where one a of as well as and and good I had a family on both with Kentucky even there were many who were and those who were some and many but all to to and and to the of an to me when I young and an important part of my the beginning of this Morehead far from an The which in as a for the had grown to nearly people early in this century. of and and some were the primary of Kentucky, like many had been by the of the and often by that a reality even in the when I a In the my who the county of where Morehead is from and a a of that to a of and a that for Although the and more the in Morehead much had more and more In it the in this country and not the of the last century when were into Morehead to the as far away as and those to the as the were about the from and a very of our of the country not As a of the of the town and areas a of people to the with an interest to better the Although many to better to Kentucky were much good from the that more more and better and better health care. In and health care have been a positive on the entire When I a Morehead to have more than town in and many were by people from the who with a to this in the of a of which in the and in of the of the it a natural in the of some for the of a to the environment. the a that is now Morehead care much as I will mention The family to in the early part of the century from in family had been in before the of the century. my and who were were as to a into a in many much than the we now a part of our we in those for things to early and were as a of Although we as and the of in a reality in our and work, and work were were a part of life, and during my and of the things that me to trauma care an of the of the way commitment less from an interest in on the injured than to a of that trauma patients better care than I often patients who are issues with of over their trauma that of is often and are at the of the their and the the of As I in Morehead, we were at the of for we had no hospital and no system of trauma care a If you were injured, an would like over the to and you you In when I a in a hospital and on our The University of Kentucky to use the in Morehead as a were in the hospital and practitioners were all and surgical specialists have now been to a hospital that has grown to general surgeons practice and all are well the of surgery at in and a to the by his of the country. services have been and patients from to the hospital for their care. The hospital and its are excellent, and many of my have been fortunate to have their care at this The of a hospital that can provide care has been a to the and to my I have had injured by and being by a Trauma people and often Our family has had have been by of their as well as and who have in Morehead or to a A of at the hospital a of services in the a is now in a new and center has is a is and a of services are that the health care in my hometown and the the only where there is a of is in trauma care. In the few has become more or even is not done by surgeons the is clearly so are for As we have Level I trauma hospitals their as being who the injured for an or If that patients can to a trauma center by some then I believe it is If that patients and of and only for then I believe we to provide it in my part of the country. all hospitals in our now to patients but all trauma patients to or Louisville within the or to or Huntington, West if are on the I from my to many of the country that this out in many and not just in has this The on the trauma center side is that patients are for financial reasons or there is of commitment on the hospital and physician Although financial consideration all care, it clearly is not the in my hometown hospital for patients from the so I have no reason to believe trauma patients on economic I do not of commitment as an The Morehead hospital now for and vascular in the of the which has been a in the few I know surgeons and believe are excellent, committed In Kentucky, much of the to the of a trauma care We have Level I at and a of other hospitals the who care for the injured and the remainder have no role other than to I have to over surgeons in and in Kentucky, and about the of trauma care. as many as are do not have to be in trauma care are not the remainder a of for their role in trauma care. If I some of the The at trauma are so that virtually with of be to a trauma so we not only those but who be If the of care patients to a trauma it is to caring for Trauma care to be more of a specialty and less a part of general surgery. The of providing services such as care has general surgeons in centers. as one surgeon trauma make feel even if we do a The has surgeons and hospitals about caring for trauma In there is the problem of specialists It is that injured patients need to be in a trauma center and in no way do I to the role that we need to in trauma centers. the other I am by the that the in care in my hometown in the if you are of being now as well as when I a the injured are often and can an or to So, as we consider access for trauma we need to think areas that may be well by trauma to like my trauma care in areas simply must the general surgeon and the opportunity for of some The second issue I would like to discuss is the effect of our system of trauma care on trauma i.e., from the hospital is no or between hospitals and trauma In many in this country it might be that our trauma have been so successful at attracting patients that it an in of other patients that care. I will only about my concerns the University of Louisville I there is some to my and I have to and all patients that are to we have to provide high-quality care and good to and that So, in that we for From to the of trauma patients has increased from to over The has not the more injured but in the patients who were in hospitals less than patients were and from the patients who are not injured being I am In many of patients not but it is to a from the who in by In we patients from other hospitals by prehospital and We are to be to provide services to patients and it as to our the on the is at many trauma the I know our is not and I am of many trauma that have even more such a of is from a hospital on the or whether there is a for care. In our the for trauma is as good or better than the for our hospital and for the of by trauma patients has our hospital in some it has had in the the other the simply of injured patients has it for our hospital to its other at care have been at a for when patients are to be from the care there are no other The of patients on in or in for or often is a problem that has me with I trying to to a must the on a hard in the department their family has no to no and not the best care. I this is a system but I can you in our trauma center it has not been simply because there are so many From the of a general surgery I about the of general surgical We are fortunate in Louisville because our trauma services are services that provide care to patients other than the injured. Although this the even it provide experience to our and and some to a trauma that has become increasingly a We have elective services at other if we the by the of trauma patients would to our by I this hospital may be very in other areas where there are trauma or in that have trauma that may provide some of and on a In our situation, I believe we now have a Although we care for a of injured we are increasingly being a of patients who do in my need a trauma but simply a a general who will and care for However, in many of our trauma or general surgery have a by the because of issues such as more care that even less of and in some the that trauma surgeons are from doing elective surgery, we simply must have to the need for more and to care for the patients we are in the need for more and on and I am at how many trauma are now with other hospitals to provide trauma care or care care, which needs and I am well of this because I it every day as every or trauma not be into I have for this I do believe that we all our in the trauma care we are providing perhaps with a few is the trauma care my care that be by the care the and training for and and is the of our or by so many The third I would like to discuss is the of trauma and trauma surgeons specialization on both at a and let me make some about the of trauma care on training and how our caring for the injured. there are many of trauma training in this and I am are I would that trauma training is in a good general surgeon and must be and When our discuss their trauma experience with always do so with a of the positive feel that can the of a and do it well. In we the role of the trauma as the i.e., where or are and is this service, may be with their physician to an on a an in an with or a family have that their has in the have with of you can see the in this of to It is what have to and know surgery will be their work. The of and serves surgeons well in The and work to on a trauma to and I am always gratified to see how our and to their best to the that a trauma I to the many experience on our trauma the of and of of our the have a lot of on our are simply too many patients at a the in of trauma patients is there are far too few trauma for the of patients and of all simply is not When I a I not only trauma care fun but I believe of my the I am not the I would you of the and I a few trauma care. from over In the we had only positive and for being this were the trauma simply has a lot of work that is not as and trauma have this of surgical role on the trauma who do not and do not have an elective and Trauma care is not a part of general surgery. We that by there to be a rate of for trauma as a and that see fewer and fewer to practice trauma surgery as a part of a general surgery I have seen in the that me the of those I those young and who are the and trauma care into this new I am proud of you and you to continue commitment to the injured. the other we must not let the care of the injured with trauma If there will simply not be enough We must find a way to trauma care a part of general surgery and must have general surgeons trauma caring for injured In this on and trauma care, I want to mention one on the of trauma care in trauma that I find Although trauma center surgeon at all of care, i.e., in the and care it is to who much of the and care of patients in many trauma centers. The the trauma the more the care is by care of family practice practitioners, physician and trauma case Clearly, are to patients and to the already surgical of our the other we are very of this of in but it in trauma centers. I surgeons are in in trauma but we must be not to be effect trauma specialization have on the positive we have like this and all the many at the of this are patients who are injured and are in all our that are I am simply at what our and can do with patients on a Clearly, this of trauma surgeons and care must be The I fear is the of trauma surgeons away from general surgery. me my that a in trauma surgery that is from general surgery is not to be in the for who would such a will the of being from the that can their injured such as and do trauma surgeons who are focused in the with other surgeons that is so much a part of in we need surgeons to of patients who increasingly do not the use of that be from an economic or surgeons who do trauma only out more I can you that it is for me to the of I am that young surgeons who focus on a trauma from general surgery will one day and find their have and that are not in their I have been at the of academic and trauma who their trauma surgeons away from general surgery by not access to elective and by the of other patients on trauma of message this to about the role of trauma care in the of general I that many will not like what I have and may my remarks as being trauma and what some would like to be the specialty of trauma surgery. I want to that trauma are and trauma specialists are However, the entire not need to and the model I would is that of a general surgeon with a commitment to trauma. or not an be to this address on whether or not you think we have a of what I have may not be the that trauma centers. the access many of the such as Kentucky need a trauma that would the of a I have to of such a system in Kentucky to but system must remain a for areas with that We in trauma must that system may patients and not be so and competitive that we system I am when one of our in Kentucky an Level in our from the That is and we not let institutional better access for From the perspective, if we are general surgeons as well as trauma surgeons, we will have to do. there are important issues we General surgeons be to do trauma care in areas where that is not be as by those of in trauma and there be that a commitment to their The that a general surgeon is not to care for many trauma patients must be this can be I think there are trauma center issues that need to be We need to look at i.e., areas may need than A who be by to a trauma center in Louisville may be than one who is injured Morehead, I believe some of the Committee on Trauma need to be For of the last three in our surgeons have been that we need to narrow our of a for to committed general surgeons, there has been that we annual The to an of surgeon such an has been to is there that trauma services be of institutional I on and on but you my problem with many of the trauma center is that drive If only a few surgeons a trauma service, will become trauma specialists whether want to or not because do not have the to do I the of many of but I believe to often be of you in trauma not be into a where you do general surgery. not take those for what you want and I believe that for hospital Level and academic can do trauma and general surgery well. I do my do and you can and as well. I believe we must be in to make trauma care fun for and our If you do not have an general surgery service, then I believe that is a good to In let me my to this organization for all it has to me during my of For a country from a town in Kentucky, it is a experience to have been honored by to the of this great I am honored and will be in