Wednesday, January 25, 2006

Trauma Surgery: A Victim of Its Own Success

Trauma Team to the Emergency Room!

Attempting to predict the future of medicine using current trend lines is a lot like evaluating a trauma patient. When evaluating a severely injured patient with multiple gun-shot wounds(GSW) in the Trauma Room you are faced with a large, continuous flow of data, of which, only a fraction will be of any use for determining how things will turn out. If you choose correctly the patient lives and you're a hero and if you choose incorrectly, well it doesn't go that way. The process is all about training, experience and pattern recognition. We were drawn into the discipline of Surgery because we enjoy "thinking on our feet" and using our hands to solve problems. When it goes well it is a tremendous rush and when it doesn't life sucks. The thrill of extracting the necessary details from a huge data stream, recognizing a pattern, making a decision and acting on that decision is what keeps us coming back to trauma. For better or worse it is also this skill set which got me to begin looking at patterns I see happening in medicine. As of yet I have avoiding looking at the field of Trauma Surgery and making any bold predictions. It is tempting to take a pass and say I don't have enough information to make any predictions yet, but then again if I did that I wouldn't be a Trauma Surgeon.

I Promise Only One Anecdote

Several years ago I was on call as an attending at a teaching hospital when I was asked to consult on a "sick" patient by one of the ED attendings. As I entered the ED we were alerted to the arrival of a trauma patient. I decided to check out the trauma patient first and walked up to the ambulance entrance with an intern and medical student. We were about thirty feet away from the back of the ambulance as we watched the EMT's unload the patient. I turned to the intern and said, "I want you to check this patient out, I'm going to go look at the 'sick' patient we were called about originally." As I walked away he said, "Are you sure?" I turned back and said, "Don't worry he's ok.", and kept walking. As it turned out he was ok and the "sick" patient was "sick" and needed an operation. Later that evening I was eating dinner with the Trauma Team and the Medical Student turned to me and asked me, "How did you do that? How could you look at someone from thirty feet away for a few seconds and know he was not seriously hurt?" It was a good question because up until then I just did it. I didn't bother to analyze that kind of thing. "Paralysis by analysis" as they say. The student was persistent and when I did reflect on it the answered surprised me as well as the student. What I noticed from that far away was that, despite full spinal precautions, the patient had his legs crossed at the ankles, knees slightly bent and hands clasped and resting on his abdomen. Commonly referred to as "positions of comfort". I also noticed how slowly the EMT's were moving and that all of them, patient included, were smiling and joking. Trauma by mechanism. He still needs to be assessed but does not fall into the category of a "sick" patient. All those years of Medical School, Surgical Residency, Trauma/Critical Care Fellowhip and sitting for the boards and here I am teaching common sense, that and the basics of pattern recognition.

Time to Reflect

Recently I've taken a sabbatical from my career as a Trauma Surgeon and have had some time to reflect on the field of Trauma Surgery. My first impression is similar to that when I see a "sick" patient. Somethings wrong only this time it is with the field of Trauma Surgery as it is currently practiced in much of the United States. It clearly has signs of life but is struggling. As I've mentioned in previous posts I believe this is happening across all of the disciplines in medicine. Some disciplines seem to have it worse than others. While I believe it is the same issue affecting all of us some disciplines also appear to be more vulnerable. For today I will limit my comments to Trauma, not only because it is the field I love the most, but also because I am concerned its status is approaching critical. Trauma Surgeons are becoming fewer and fewer. I used to consider that a sign of job security but not anymore. Trauma Surgeons are quitting trauma, retiring or dying. Many of the few braves souls left in the field tend to be bitter, disillusioned, older men, much like myself. Change the word "older" to "middle-age" and that pretty much describes me. So how does that happen? How do honest, well-trained, compassionate, hard-working professionals reach this point in their careers? I believe it is because we are victims; victims of our own success.

Time to Rock the Boat

We love to operate and we love to take care of sick and seriously injured patients. That is why we became Trauma Surgeons. Over the years we focused our efforts in Trauma Centers and that was good for the patients. The economics of assessing and treating victims of trauma were a disincentive for the non-trauma center hospitals which encouraged them to divert all victims of trauma , regardless of injury severity, to the Trauma Centers. Our Intensive Care Units and wards were overflowing and our Trauma Services were filling up fast. In that time operative rates plummeted, especially for those in an exclusive trauma practice. Prior to my sabbatical my most recent operative rate was 5.5%. When I excluded soft tissue cases it dropped to 3.8%. That means I was not performing major operations on 25/26 trauma patients I assessed. That may sound great for the patient but for an individual who loves to operate that is awful and not the best use of years of training to be a Surgeon. Now I would hope these kinds of numbers are not representative of the nation as a whole but I don't think they are that much different. Our patient distribution matched up closely to the numbers from the most recent National Trauma Data Bank (NTDB). Like the distribution in the NTDB most of our "Level 1" trauma patients had minor injury severity scores. Efforts to convince my colleagues that we need to address "overtriage" fell on deaf ears. As someone reminded me, "Terry, we're making a lot of money and you're making a lot of money, why do you want to rock this boat?" Oh, I don't know, maybe because this is wrong and not the best way to "run a railroad". Well, like I said I was getting bitter and decided to take some time off, to write and to reflect.

"It is difficult to get a man to understand something when his job depends on not understanding it."
Upton Sinclair (1878-1968)

We call trauma a "surgical disease" but I think that has done the field of Trauma Surgery a disservice. We have convinced everyone that we are the only ones who can take care of these patients. It is simply not true. Even in my fellowship we had many non-surgeons providing excellent care for trauma patients. We have created a system that has served the needs of our patients well. I am not convinced that we have done as good a job for ourselves. In our efforts to be everything to everyone we discourage those who would follow in our footsteps. Attrition has hurt the ranks of those in Trauma Surgery and has decimated the ranks of those who could be joining Trauma Surgery. They are voting with their feet long before we had a chance to hear their footsteps. The reasons are numerous and go beyond a low operative rate and managing (babysitting) a service of patients treated by other surgical specialties (Primarily Orthopedic Surgery, Neurosurgery and Plastic Surgery).

The Signs of Things to Come

So what patterns exist that may shed some light on all of this. As I have mentioned in previous posts I believe that the many changes in medicine we are experiencing are the effects produced by an emerging paradigm for healthcare delivery. The established paradigm for delivering healthcare services, including how we deliver trauma services, is undergoing a transformation. It is being driven by the Digital Revolution and the Information Age. The goal is to create a radically different but markedly better Healthcare System. In the process it is transforming the providers of the established paradigm into providers who will be better adapted to the emerging paradigm. I know what you're thinking, "Terry, you have had way to much time off. Get a job!" Well that much is true but I can't help recognizing and commenting on the patterns that I'm seeing.

Such As?

There are trends that I am sure we have all noticed in the recruitment of physicians. They tend to make the same set of promises. The Locum Tenens offers are some of the most revealing. They typically use the term "flexible" which is code for "life style". The phrase older physicians tend to loathe. They offer part-time and even shift work for surgeons. They offer "travel and adventure". In order to do this they facilitate portability. That is another way of saying that they take care of credentialing and licensing. They take care of liability insurance, travel and lodging expenses. Payment for services is usually within weeks of the service provided. They offer greater choice in practice options and the list goes on. I don't think Locum Tenens is necessarily the future for all providers but I believe they are offering the conditions that will be necessary for future providers practicing in the emerging paradigm. Think of the buzz words and phrases being floated around in these ads and withhold judgment because I think they are really trying to tell us what the future of medicine is going to look like. Flexible. Portable. Freedom of choice. Predictable scheduling. Team work. Shift work. Adjustable practice style. Variable assignments. No overhead or administrative concerns. Medical liability covered. Remain independent. Entrepreneurial. Adventurous. Likes to travel. Comfortable meeting new people. Detail oriented. Adaptable. Competent. Skillfull. Full and timely payment for services rendered. Focus on patient care. Time with family. Healthy lifestyle. Too good to be true? I think the ads are but you have to admit they are definitely shaping the minds of those who will be a part of the future of medicine.

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