Tuesday, March 24, 2009

Canary, Meet a Possible Coal Mine Air Shaft

GruntDoc recently posted about how he feels the EDs in this country are similar to lobsters, slowly cooking while to death while they think they are doing reasonably OK. The same could be said for a variety of specialties in medicine, where the poisonous trifecta of poor insight of our governing bodies, the insidious nature of reimbursement decreases brought on by the RBRVS system (thanks, AMA!), and government intervention has generated unintended outcomes in patient care and physician behavior. Add to that the cost of "CYA medicine" (yes, Matt, it does happen) generated by the fear of being sued, and you've got a swell recipe for boiled lobster.

But I've posted about this before, and certainly anyone connected with medical care can see that there are big challenges ahead for us. Peruse the most recent National Medical Resident Match Program Data, and compare it with historical data, and you'll get a sense of how few front line physicians there will be available in the future. There are not, however, a whole lotta big solutions on the horizon. Some folks are starting to get innovative in their thinking, however, and are starting to look beyond the knee-jerk response of "hire more physician extenders."

I spend a considerable amount of time in the hospital providing trauma coverage for our ED. This requires me to be physically here for a 24 hour stretch, in addition to my regular work as a general surgeon. It gets, to be honest, old. And I suspect that there will come a time when I will no longer provide trauma care, particularly if my income gets slashed by the socialists in Washington. There are many institutions in larger cities where there are trauma services that provide essentially nothing other than trauma care, because the volume of injured patients requires this. That, for me, would get really old.....and there really isn't an abundance of general surgeons who feel differently. As a result, there is already a shortage of dedicated trauma surgeons, and there will be a gradually growing deficit in the future.

Cue one innovative and interesting solution -- "Emergency Traumatologists as Partners in Trauma Care: The Future is Now." Brought to you courtesy of one of my old senior residents, now part of the Penn system. Here's the abstract:

Background Decreasing manpower available to care for trauma patients both in and out of the ICU has led to a number of proposed solutions, including increasing involvement of emergency medicine-trained physicians in the care of these patients. We performed a descriptive comparative study in an effort to define the role of fellowship-trained emergency medicine physicians as full-time traumatologists.

Study Design We performed a retrospective review of concurrent and prospectively collected data comparing process of care and outcomes for the resuscitative phase of trauma patients cared for by full-time fellowship-trained trauma surgeons (TS), a fellowship-trained emergency medicine physician (ET), and a first-year fellowship-trained trauma surgeon (TS1).

Patient age, Revised Trauma Score, and Injury Severity Score were similar between groups. Process of care, defined by transfusion of uncrossmatched blood, prevalence of hypotension in patients receiving uncrossmatched blood, time spent in the emergency department, frequency of ICU admission, severity of injury for ICU admission, and time between emergency department and operating room for patients requiring surgery, was equivalent between groups. Outcomes evaluated by mortality and length of stay in the hospital and ICU did not differ between groups, and provider group was not predictive of mortality in stepwise logistic regression.

These data suggest that emergency traumatologists can provide trauma care effectively within a defined scope of practice and may provide an effective solution to manpower issues confronting trauma centers.
Interesting. Innovative. But workable?

Let's look at the positives first. Evaluating all the data, the patients cared primarily for by the fellowship trained trauma surgeons and the fellowship trained emergency medicine physician were similar in characteristics, and had similar outcomes. In other words, the patients did as well regardless of which of the three physicians were caring for them.

However, we are talking primarily about patients with blunt trauma --- auto accidents, primarily. Those with penetrating injuries, while they can initially be assessed by a non-surgeon, will require surgical intervention. And the occasional blunt trauma patient also needs a laparotomy. From the article --
Clinical coverage grids were designed using the ET in appropriate areas and in compliance with PTSF/ACS (American College of Surgeons) guidelines for trauma center accreditation. So the ET could not provide independent in-house coverage for trauma unless supported by a surgeon.
Additionally, this retrospective study looked at the involvement of a single fellowship trained emergency medicine physician. It would be very unwise to therefore extrapolate this data to suggest that it is a workable model for most institutions. But it may be an alternative to the approach that has been suggested by the AAST and ABS:
...the American Board of Surgery has supported efforts on behalf of the American Association for the Surgery of Trauma to establish a curriculum in acute care surgery in the hope that redefining the content and spectrum of care provided by trauma surgeons might attract more residents to the specialty. It is too early to judge the effectiveness of these efforts, but as yet only two institutions have applied for accreditation for this fellowship. In addition, it is unclear how much this curriculum differs from the current practice of many trauma surgeons, because the requirement and opportunity to learn and apply operative skill sets derived from orthopaedics and neurosurgery are very limited.
Is the Penn approach a good solution? Perhaps, rather than being a solution for all, it is an indication that there is no single solution that will work for every institution. As the system as a whole struggles in the future with fewer physicians, each hospital is going to have to find a workable solution to fill their needs, whether in trauma surgery, OB, thoracic surgery, or medicine. As I have often said, the future of medicine is paved not with concrete, but quicksand, and knowing how quickly to keep moving in any particular direction is difficult. Finding the missing piece of each puzzle will require innovative thinking. Nice work, Dr. Grossman.