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One of the most interesting articles I have ever read from this month's issue of Annals of Emergency Medicine- Volume 53 Number 2 February 2009.
http://linkinghub.elsevier.com/retrieve/pii/S0196-0644(08)00615-X
Some quotes off of MDconsult link:
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
The life of a trauma surgeon was regarded as glamorous because its practitioners regularly whisked injured victims to the operating room to explore abdomens and remove spleens within the so-called golden hour.11,12 This essential heroism captured the imagination of other physicians and of the general public and provided the political clout that led to profound and enduring political achievements.
The practice of trauma surgery has transitioned from the invigoration of frequent "emergency" laparotomies to fairly routine and increasingly protocol-driven ward management.1,16,17,19,21-23 In retrospect, many or most of those "lifesaving" laparotomies from the early days of trauma were unnecessary.
At my busy American College of Surgeons Level I trauma center, the incidence of such intervention is just 3.0% of adult trauma team activations and just 0.35% of pediatric activations,24 numbers comparable to those reported elsewhere.9,25,26 Most of these emergency surgeries are for penetrating trauma. If one considers blunt mechanisms separately, the frequencies decrease to 1.2% of adults and 0.09% of children. For blunt injury at my trauma center, emergency operative intervention by a trauma surgeon averages once every 7 weeks for adults and less than once every 3 years for children.24 Ciesla et al25 report that at their urban Level I trauma center, "a trauma surgeon must evaluate 10 trauma patients, admit 9, and provide up to 65 days worth of inpatient care for every one that needs an acute care operation."
During this same quarter century of profound change within trauma care, the specialty of general surgery has experienced a recruiting crisis. In 1981 general surgery was the first specialty choice for 12.1% of senior medical students; however, in ensuing years it has eroded to less than half of this number (Figure).36-39 Approximately 70% of graduating surgical residents now go on to subspecialties rather than remain
in general surgery.40 The proportion of general surgeons as a fraction of the total physician workforce has decreased by half during the past 30 years (8% to 4%), and Fischer40 has predicted "the impending disappearance of the general surgeon." The reasons for this decline are clear. Graduating medical students increasingly balk at the total dedication of personal life traditionally deemed essential for general surgeons.13,19,38,41 The sacrifices have been likened to being called into the priesthood or a nunnery.42 Dissatisfaction prompts one fourth of surgery residents to resign and move on to other specialties.42 As one surgery resident recalled his training: "_ there must be some alternative to a system that chews up individuals and crushes families with such ruthless efficiency."43
Given this decrease in popularity, surgical residencies cannot be as selective as they once were. Surgeons worry about the quality of their new trainees.7,19,38,39,44-46 At one medical school, the majority of students pursuing careers in general surgery scored below the mean on standardized medical licensure examinations.44 Residencies are receiving fewer applicants from the top 10% of medical school classes and are going deeper into their rank lists to fill.45
The allure of trauma surgery has been particularly hard hit during this downturn in the popularity of general surgery.2,10 Given its rarity of operative intervention, residents and medical students often view trauma surgery rotations as a "baby-sitting service,"19 ie, watching patients while orthopedists, neurosurgeons, and other subspecialists perform nonemergency evaluations and interventions.1,2,10,17,19,21-23 Ciesla et al25 refer
to trauma surgeons as having become "house staff for the surgical subspecialist."
As a new attending, I have experienced a lot of the above first hand. I have never had a general surgeon at the bedside during a trauma in 9 months. If they are sick enough to need a surgeon, it has always been a subspecialty that the trauma surgeon consults when I send the patient to them.
Some new general surgery grads are a little scary as well.
A lot of med students on this forum that are attracted to the previously glorious field of trauma surgery should read this article.
http://linkinghub.elsevier.com/retrieve/pii/S0196-0644(08)00615-X
Some quotes off of MDconsult link:
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
The life of a trauma surgeon was regarded as glamorous because its practitioners regularly whisked injured victims to the operating room to explore abdomens and remove spleens within the so-called golden hour.11,12 This essential heroism captured the imagination of other physicians and of the general public and provided the political clout that led to profound and enduring political achievements.
The practice of trauma surgery has transitioned from the invigoration of frequent "emergency" laparotomies to fairly routine and increasingly protocol-driven ward management.1,16,17,19,21-23 In retrospect, many or most of those "lifesaving" laparotomies from the early days of trauma were unnecessary.
At my busy American College of Surgeons Level I trauma center, the incidence of such intervention is just 3.0% of adult trauma team activations and just 0.35% of pediatric activations,24 numbers comparable to those reported elsewhere.9,25,26 Most of these emergency surgeries are for penetrating trauma. If one considers blunt mechanisms separately, the frequencies decrease to 1.2% of adults and 0.09% of children. For blunt injury at my trauma center, emergency operative intervention by a trauma surgeon averages once every 7 weeks for adults and less than once every 3 years for children.24 Ciesla et al25 report that at their urban Level I trauma center, "a trauma surgeon must evaluate 10 trauma patients, admit 9, and provide up to 65 days worth of inpatient care for every one that needs an acute care operation."
During this same quarter century of profound change within trauma care, the specialty of general surgery has experienced a recruiting crisis. In 1981 general surgery was the first specialty choice for 12.1% of senior medical students; however, in ensuing years it has eroded to less than half of this number (Figure).36-39 Approximately 70% of graduating surgical residents now go on to subspecialties rather than remain
in general surgery.40 The proportion of general surgeons as a fraction of the total physician workforce has decreased by half during the past 30 years (8% to 4%), and Fischer40 has predicted "the impending disappearance of the general surgeon." The reasons for this decline are clear. Graduating medical students increasingly balk at the total dedication of personal life traditionally deemed essential for general surgeons.13,19,38,41 The sacrifices have been likened to being called into the priesthood or a nunnery.42 Dissatisfaction prompts one fourth of surgery residents to resign and move on to other specialties.42 As one surgery resident recalled his training: "_ there must be some alternative to a system that chews up individuals and crushes families with such ruthless efficiency."43
Given this decrease in popularity, surgical residencies cannot be as selective as they once were. Surgeons worry about the quality of their new trainees.7,19,38,39,44-46 At one medical school, the majority of students pursuing careers in general surgery scored below the mean on standardized medical licensure examinations.44 Residencies are receiving fewer applicants from the top 10% of medical school classes and are going deeper into their rank lists to fill.45
The allure of trauma surgery has been particularly hard hit during this downturn in the popularity of general surgery.2,10 Given its rarity of operative intervention, residents and medical students often view trauma surgery rotations as a "baby-sitting service,"19 ie, watching patients while orthopedists, neurosurgeons, and other subspecialists perform nonemergency evaluations and interventions.1,2,10,17,19,21-23 Ciesla et al25 refer
to trauma surgeons as having become "house staff for the surgical subspecialist."
As a new attending, I have experienced a lot of the above first hand. I have never had a general surgeon at the bedside during a trauma in 9 months. If they are sick enough to need a surgeon, it has always been a subspecialty that the trauma surgeon consults when I send the patient to them.
Some new general surgery grads are a little scary as well.
A lot of med students on this forum that are attracted to the previously glorious field of trauma surgery should read this article.
