Trauma/concept
Trauma Surgery: Discipline in Crisis

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Throughout the past quarter century, there have been slow but dramatic changes in the nature and practice of trauma surgery, and this field increasingly faces potent economic, logistic, political, and workforce challenges. Patients and emergency physicians have much to lose by this budding crisis in our partner discipline. This article reviews the specific issues confronting trauma surgery, their historical context, and the potential directions available to this discipline. Implications of these issues for emergency physicians and for trauma care overall are discussed.

Introduction

As articulated by a recent president of the American Association for the Surgery of Trauma: “The specialty of trauma surgery is in trouble!”1 Potent economic, logistic, political, and workforce challenges increasingly confront this discipline. Trauma surgeons have characterized their field as “in the throes of an identity crisis that threatens its future”2, 3 and that the status quo is “untenable.”4 They have stated that “the discipline must change to remain viable and attractive to future candidates.”5 Trauma surgeons are “clearly an endangered species,”6 “gasping for air,”7 and “in danger of becoming extinct.”3, 7, 8 One contends that “the contemporary model of trauma care where dedicated trauma/critical care surgeons exclusively manage trauma patients has become progressively unsustainable.”9

These adverse conditions in the field of trauma surgery have developed and progressively worsened during the past quarter century; however, the rate of change has been slow enough that few emergency physicians have taken notice or considered the potential ultimate effect. Patients and emergency physicians have much to lose by this budding crisis in our partner discipline. In this article, I review the challenges facing the field of trauma surgery, their historical context, current workforce issues, and the potential directions available to this discipline. I discuss the implications of these issues for emergency physicians and for trauma care overall.

Section snippets

The “Golden Age” of Trauma Surgery

One quarter century ago was the “golden age of trauma surgery.”3, 6, 10 General surgery was a hotly competitive and prestigious specialty choice, and many of the best and brightest surgeons gravitated to careers in trauma care. The practice of trauma surgery was founded on aggressive, lifesaving operations. “The trauma surgeon was regarded as the ‘master surgeon'3, 6 who operated effectively on the neck, chest, abdomen, and any injured blood vessel.”6

The life of a trauma surgeon was regarded as

The Surgical Paradigm of Trauma

Surgeons were justifiably alarmed at the uneven trauma expertise of physicians staffing emergency departments (EDs) in the late 1970s—primarily internists, family physicians, and residency dropouts—and understandably acted to fill this void. The founding tenets of their trauma care philosophy were the concept of golden hour11, 12 and the possessive declaration that “trauma is a surgical disease.”11

Accordingly, the American College of Surgeons–developed paradigm for trauma care was wholly

The Shift to Nonoperative Management

A quarter century of progress has fundamentally altered the premises underlying the surgical paradigm of trauma. Dramatic advances in the speed and resolution of computed tomography have largely replaced “exploratory” surgery; indeed, even in the setting of radiographically documented intra-abdominal injury, most patients can now be safely treated nonoperatively.4, 9, 16, 17, 18, 19, 20 The practice of trauma surgery has transitioned from the invigoration of frequent “emergency” laparotomies to

Threats to the Field of Trauma Surgery

Potent economic, logistic, political, and workforce challenges increasingly confront trauma surgery and are summarized as follows.

The Shortage of Trauma Surgeons and Its Implications

For reasons already discussed, fewer medical students are becoming surgeons, and fewer surgeons are becoming trauma surgeons. Many existing trauma surgeons are scaling back or abandoning their trauma practice in favor of traditional general surgery.1, 2, 3, 5, 79 As stated by the American College of Surgeons, “surgeons who remain in the emergency care system are experiencing professional and personal burdens that are simply unsustainable.”50

Despite this shortage of trauma surgeons, to maintain

How Are Trauma Surgeons Responding to These Threats?

Some trauma surgeons propose to reinvigorate their field by redefining it as “Acute Care Surgery.”10 Specifically, this makeover would expand their operative scope to include selected neurosurgical and orthopedic trauma procedures and would expand their nontrauma scope to include critical care and emergency surgeries. The premise is that adding more actual surgery will make the practice more interesting and attractive and that a switch to shift work will permit a more controllable lifestyle.

The

What Else Can be Done?

Patients and emergency physicians have much to lose by this crisis in our partner discipline. The shortage of career trauma surgeons is serious and a grave threat to the quality of trauma care. Substituting moonlighting struggling surgeons in their place can only diminish the overall quality of trauma care. It is conceivable that inaction will lead to a true crisis in the loss of trauma surgeon coverage for those uncommon patients who truly require emergency operations.

Conclusion

The discipline of trauma surgery is in crisis, partly from external economic and political forces and partly from their own dated paradigm of trauma care. Emergency physicians must understand these threats and do what they can to help preserve the career trauma surgeon for the benefit of our patients.

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    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

    Supervising editors: Judd E. Hollander, MD; Michael L. Callaham, MD

    Drs. Hollander and Callaham were the supervising editors on this article. Dr. Green did not participate in the editorial review or decision to publish this article.

    Reprints not available from the author.

    Publication dates: Available online September 11, 2008.

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