Trauma surgery: why so unpopular?

[Misterioso]

I was looking up some info and found that trauma surgery is one of the least popular career choices for general surgeons to pursue after residency, even though there are plenty of attending positions available. I also read that it allows for working in shifts like ER physicians work. Which I would say is a positive thing. The cons I've heard against it are that it is becoming more non-operative and the patients are more likely to be difficult.

Are there other things that make it such an unpopular career choice?

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[FACS]

I was looking up some info and found that trauma surgery is one of the least popular career choices for general surgeons to pursue after residency, even though there are plenty of attending positions available. I also read that it allows for working in shifts like ER physicians work. Which I would say is a positive thing. The cons I've heard against it are that it is becoming more non-operative and the patients are more likely to be difficult.

Are there other things that make it such an unpopular career choice?

Nope. You pretty much summed it up.

 

[Pir8DeacDoc]

does the search function work??

 

[RichL025]

Definitely use the search function - this topic has been discussed ad nauseum (in just the short time _I've_ been a member here).

Another problem with the field has been reimbursement.

Read any of the issues of the journal Trauma over the last summer to see a wide-ranging discussion on the current status and suggested future directions for the field.

 

[Pilot Doc]

1. Largely Non-operative
2. Very diffifuclt patient population
(These bear repeating because they are huge issues)
3. Reimbursement varies inversely with operative load (because stabbing/shooting victims are rarely insured; car wrecks pay better)
4. High incidence of bloodborne disease in trauma pts
5. Very high malpractice exposure
6. Lack of respect from other surgeons (jack of all trades, master of none syndrome - much like ED)
7. Often combined with an urgent/unreferred general surgery service, in which case you are the dumping ground for patients no one else wants
8. Frequently the trauma service babysits patients with primarily or solely orthopedic/neurosugrical/etc. issues and left to handle all the unpleasant social/discharge scutwork

Do you need more?

 

[oldman]

lots of trauma docs end up as critical care.

 

[Misterioso]

lots of trauma docs end up as critical care.

Isn't trauma surgery just another term for surgical critical care?

As I understand it there are two fellowship options for surgeons interested in trauma. One is a trauma surgery fellowship and the other is a surgical critical care fellowship. Both fellowships are the same length (1-2 years) and encompass roughly the same thing, except that you're eligible for the critical care boards if you do the surgical critical care fellowship. Is this correct?

 

[fourthyear]

I don't know how many times this point can be re-iterated too, but again it's very important, so I'll say it again:

Don't do surgery if you think you want to do shift work.

There is some discussion about making trauma-critical care coverage more of a shift work schedule, but this hasn't really completely happened everywhere yet. Even at the places I've heard of this happening, it's still a much more demanding and time-consuming schedule than your average 15 shifts a month of an ER doc.

Not only that, but you still have 80 hours/week through 5 years residency plus a 1-2 year fellowship which will most likely NOT be "shift-work"(haven't heard of any fellowship that's transitioned to that yet). You may say "oh, that's just temporary, I can get thru that"...but it's still 5-7 YEARS of your young life you are working all the time.

There may be more of a transition to more lifestyle-friendly schedules for trauma attendings in the future, but you still have to go through a lot of years of bad lifestyle to get there and I really just don't think a trauma/critical care surgeons' schedule will ever get to the flexibility of, say, an anesthesiologist or a ER doc in terms of really truly being able to walk out the door at shift change or even in terms of number of shifts/total hours worked.

The leaders in trauma surgery are making attempts to make the trauma lifestyle more attractive to young surgeons so we don't have a major shortage of coverage on our hands. But I still feel I have to warn you that you have to be prepared to give up some personal life for a life in surgery. I don't see it ever really being like ER.

 

[FACS]

But I still feel I have to warn you that you have to be prepared to give up some personal life for a life in surgery. I don't see it ever really being like ER.

I think a lot of the people going into surgery right now are in fact expecting it to be lifestyle friendly because of the 80 hour week. I wouldn't be surprized if the attrition rate starts climbing rapidly over the next few years as these folks realize and surgery isn't going to be an easy life.

 

[Pilot Doc]

I think a lot of the people going into surgery right now are in fact expecting it to be lifestyle friendly because of the 80 hour week. I wouldn't be surprized if the attrition rate starts climbing rapidly over the next few years as these folks realize and surgery isn't going to be an easy life.

I'll argue the other side. I think we've traditionally lost MANY applicants and residents because surgery was, for lack of a better word, lifestyle-incompatible. Typically this is someone who really likes surgery but already has kids. For many of them, the traditional training was simply unsustainable for 5 years.

I think we're picking up a lot of those people now. They don't expect surgery to be like ER or anesthesia - they just want it to be survivable for 5 years, after which they have control over their practice setting.

At my own institution (which is actually 80 hours compliant), we've had 0% attrition of post-80 hours housestaff, compared to 10-20% beforehand.

 

[Misterioso]

fourthyear,

As long as you're in a surgery residency that is 80 hour compliant then wouldn't you be working just as much as residents in other specialties (except for the ones in the more lifestyle residencies--like derm and rads)?

And once you get out of the 80 hour residency you can tailor how you practice so you're not working many hours, like as was mentioned with shiftwork on the weekends.

 

[FACS]

I'll argue the other side. I think we've traditionally lost MANY applicants and residents because surgery was, for lack of a better word, lifestyle-incompatible. Typically this is someone who really likes surgery but already has kids. For many of them, the traditional training was simply unsustainable for 5 years.

I think we're picking up a lot of those people now. They don't expect surgery to be like ER or anesthesia - they just want it to be survivable for 5 years, after which they have control over their practice setting.

At my own institution (which is actually 80 hours compliant), we've had 0% attrition of post-80 hours housestaff, compared to 10-20% beforehand.

Yeah, that may be true but I can tell you from my experience on the trail there's quite a bunch of puny deluded lifestylers heading your way. I think the pendulum's gonna swing the other way a bit. I bet lots of these folks will be jumping ship when the going gets tough.


BTW, what program is that you speak of?

 

[Pilot Doc]

As long as you're in a surgery residency that is 80 hour compliant then wouldn't you be working just as much as residents in other specialties

The 80 hours assumption you make is a big one. I don't think it's possible for applicants to reliably determine which programs are truly compliant.

Even if you luck into an 80 hour program, you will very likely work 78 hours/wk almost every week of your residency. Surgery doesn't have non-call months like medicine. No clinic rotations with nights & weekends off. You will have zero elective time - no allergy consult month. Nothing but Nsurg, Ortho and ENT will rival Gsurg for unremitting time in the hospital.

 

[avgjoe]

At the ACS this year there was a presentation on the Acute Care Surgery proposal (basically combining trauma, emergency surgery with a little bit of ortho and neurosurg thrown in) and they were mentioning a planned salary of $800-900k. I bet that will help a lot of people get on board!

 

[DO_Surgeon]

At the ACS this year there was a presentation on the Acute Care Surgery proposal (basically combining trauma, emergency surgery with a little bit of ortho and neurosurg thrown in) and they were mentioning a planned salary of $800-900k. I bet that will help a lot of people get on board!

$800-900k are you serious? That seems like an amazingly high figure to me.

 

[avgjoe]

$800-900k are you serious? That seems like an amazingly high figure to me.

I know! It seemed amazingly high to me too.. the speaker however explained it by saying that they are currently having to pay extraordinary amounts to neurosurgeons and ortho guys to make them take call, and that in this scenario, the trauma attending would be qualified to cover those specialties too. So that's how they would then be paid that much and it would still be more cost effective overall.

 

[RichL025]

Hmm, not that I have any direct experience, but...

This jives with something I read over the summer in (I think) Trauma - that the majority of emergent ortho & neuro procedures were not that difficult, and there was thought that it could eventually be rolled into the scope of practice for a fellowship-trained trauma surgeon.

If hospitals could save big bucks by having a less stringent ortho / neuro call schedule, the trauma surgeons could justify billing more for their presence.

Just food for though

 

[FliteSurgn]

Interesting idea. I did several craniotomies for subdural evacuations during my surgery residency (with the neurosurgeon looking over my shoulder). I'd feel completely comfrotable doing that...I can't say the same for trying to clip off an intracranial aneurysm...I guess that patient would be screwed if they came in when I was on "neuro" surgery call.

 

[Pilot Doc]

At the ACS this year there was a presentation on the Acute Care Surgery proposal (basically combining trauma, emergency surgery with a little bit of ortho and neurosurg thrown in) and they were mentioning a planned salary of $800-900k. I bet that will help a lot of people get on board!

Dream on.

The reason hospitals have to pay neuro/ortho guys so much to take call is that it takes them away from very high paying jobs. The opportunity cost for a GS to take call is nowhere near as high.

Any GS resident could learn this material in a correctly structured 5 year residency. Any current GS attending could learn it, easily, in a 1 year fellowship. Start paying people 800K for that job and there would be a stampede. Long-term salaries would be nowhere near 7 figures - they'd probably end up not substantially different from where GS is now.

 

[fourthyear]

fourthyear,

As long as you're in a surgery residency that is 80 hour compliant then wouldn't you be working just as much as residents in other specialties (except for the ones in the more lifestyle residencies--like derm and rads)?

NO. Pilot doc basically answered this. SOME weeks in other common specialties - internal med, peds, ect, will be a max of 80 hours...but usually after intern year it gets significantly less demanding in terms of call schedule, with many months of no call/most weekend off if you're not on an inpatient service that month. Even when you do take call its less frequent - once to twice a week vs. 2-3x/wk for surgery. Or the upper-level residents have this "short call" thing in other specialties where they take "call" till 10 pm or midnight or something, then get to sleep - no such thing in surgery residency.

Surgery residents will be pushing the max of 80 hours/barely leaving on time post-call/getting only the required one day off per week avg for every single week of the whole 5 years. This is pretty standard for all programs, even the most compliant ones. Most programs probably are pretty compliant, but it still feels a lot different to work 80 hour every week for 5 years straight vs. maybe just a few months of the "senior resident" years in about any other specialty. Surgery residency is now more do-able for more people than it used to be, but it is still the hardest residency compared to all others.

 

[Pilot Doc]

it is still the hardest residency compared to all others.

Agreed except for neurosurgery

 

[toxic-megacolon]

At the ACS this year there was a presentation on the Acute Care Surgery proposal (basically combining trauma, emergency surgery with a little bit of ortho and neurosurg thrown in) and they were mentioning a planned salary of $800-900k. I bet that will help a lot of people get on board!

This will never happen... Currently the standard of care is to have a neurosurgeon drill a hole in your head. Having a non-neurosurgeon do the same would be an (ever-so-slight) departure from this standard of care. Lawyers would have a field day with that.

 

[avgjoe]

NO. Pilot doc basically answered this. SOME weeks in other common specialties - internal med, peds, ect, will be a max of 80 hours...but usually after intern year it gets significantly less demanding in terms of call schedule, with many months of no call/most weekend off if you're not on an inpatient service that month. Even when you do take call its less frequent - once to twice a week vs. 2-3x/wk for surgery. Or the upper-level residents have this "short call" thing in other specialties where they take "call" till 10 pm or midnight or something, then get to sleep - no such thing in surgery residency.

Surgery residents will be pushing the max of 80 hours/barely leaving on time post-call/getting only the required one day off per week avg for every single week of the whole 5 years. This is pretty standard for all programs, even the most compliant ones. Most programs probably are pretty compliant, but it still feels a lot different to work 80 hour every week for 5 years straight vs. maybe just a few months of the "senior resident" years in about any other specialty. Surgery residency is now more do-able for more people than it used to be, but it is still the hardest residency compared to all others.

Plus from the interview circuit it seems as though many programs are using the 'home call' loophole to get close to an 80 hour workweek. That essentially means that you could be getting calls all night but will still have to be in-house all day post-call, with no more sleep than had you been in-house for the call night. I don't think other specialties do this as often (or if they do, they probably don't get called as frequently).

 

[toxic-megacolon]

Plus from the interview circuit it seems as though many programs are using the 'home call' loophole to get close to an 80 hour workweek. That essentially means that you could be getting calls all night but will still have to be in-house all day post-call, with no more sleep than had you been in-house for the call night. I don't think other specialties do this as often (or if they do, they probably don't get called as frequently).

You can top that with surgery is psychologically tougher too. Often sicker patients, and very impatient/condescendnig/stressfull attendings. Getting yelled at several times a week despite doing your best is something that surgery also does well....

 

[droliver]

$800-900k are you serious? That seems like an amazingly high figure to me.

That's a ridiculous number. There is no way health care systems can (or will) subsidize salaries like that. This is an era of budget tightening, reimbursement slashing, larger uninsured populations, and shrinking margins. States, employers, & the feds are being bankrupted by progressive health care burdens. That someone suggested that figure suggests they're out of touch with health-care finances.

 

[RichL025]

Dr Oliver,

Would not the higher salary be justified (and supported by the payers) if one doc is doing the work of two, and there is STILL a net savings?

I have zero idea how reimbursement & mandatory staffing works. But if the extra training in ortho & neuro were worked into the trauma surgeon's training, and that (regulatory & litigation issues aside) allowed trauma centers to save money on their ortho / neuro call schedule, wouldn't it then be realistic?

 

[Pilot Doc]

Dr Oliver,

Would not the higher salary be justified (and supported by the payers) if one doc is doing the work of two, and there is STILL a net savings?

I have zero idea how reimbursement & mandatory staffing works. But if the extra training in ortho & neuro were worked into the trauma surgeon's training, and that (regulatory & litigation issues aside) allowed trauma centers to save money on their ortho / neuro call schedule, wouldn't it then be realistic?

There are two separate questions here:

1) Would 1 physician replacing on call GS/ortho/nsurg potentially be "worth" 800K. Answer: maybe

2) Will the market support that salary. ABSOLUTELY NOT. Even if hospitals are willing to pay it (which I and Dr. Oliver very much doubt) that salary would draw enormous numbers of people into the market. Somebody would be willing to do it for $700K, somebody else would be willing to do it for $600K, etc. The salary would fall until supply and demand curves crossed just like they taught you in Econ 101. $800,000/yr for trauma surgery is utter fantasy.

 

[RichL025]

Somebody would be willing to do it for $700K, somebody else would be willing to do it for $600K, etc. The salary would fall until supply and demand curves crossed just like they taught you in Econ 101. $800,000/yr for trauma surgery is utter fantasy.

Never took Econ 101, but an excellent point nonetheless....

 

[Misterioso]

1) Would 1 physician replacing on call GS/ortho/nsurg potentially be "worth" 800K. Answer: maybe

Realistically speaking how can a general surgeon replace an orthopod and neurosurgeon? Each of them is a different residency and scope of practice. Sure a trauma surgeon can be trained to handle the most basic procedures in ortho and neurosurgery, but beyond that there needs to be a fully trained orthopod or neurosurgeon.

 

[Celiac Plexus]

2) Will the market support that salary. ABSOLUTELY NOT. Even if hospitals are willing to pay it (which I and Dr. Oliver very much doubt) that salary would draw enormous numbers of people into the market. Somebody would be willing to do it for $700K, somebody else would be willing to do it for $600K, etc. The salary would fall until supply and demand curves crossed just like they taught you in Econ 101. $800,000/yr for trauma surgery is utter fantasy.

Though I too agree that 800k/yr it unrealistic, consider that ortho spine, and neurosurgeons make 800k/yr. Is that high salary drawing "enormous numbers of people" into the otho spine, and neurosurgery market and applying negative price pressure? No. I think that the key to supporting a very high salary for a new "super trauma" specialty is control the number of trainees the same way that neurosurgery, and orthopedics do. If the number of general surgery training positions per year was cut down to around 110 (roughly the number of neurosurgical training spots per year), general surgeons would be making much more. Physician salaries are affected by a number of factors, but supply and demand is the most important force.

If you tightly control the number of individuals who could be trained, and certified for these new trauma positions, then high salaries would be realistic. But otherwise, I don't see how the system could support paying someone 800k/yr to cover ER call.

 

[droliver]

Would not the higher salary be justified (and supported by the payers) if one doc is doing the work of two, and there is STILL a net savings?

I have zero idea how reimbursement & mandatory staffing works. But if the extra training in ortho & neuro were worked into the trauma surgeon's training, and that (regulatory & litigation issues aside) allowed trauma centers to save money on their ortho / neuro call schedule, wouldn't it then be realistic?

By this logic, why don't ER physicians make 800K? They too allow other physicians not to be on site and provide a great deal of care.

You have to realize that there's not some $800,000 lump sum that's unrealized currently sitting around. There's no money there at all, especially set aside for indigent and trauma care. Most of the money set aside for that comes from the county in most metro areas & they have little flexibility to fund something like that. There's no incentive for for hospital's to use the trauma service as a loss leader, as the stigma of being a trauma center drives well-insured patients away by and large.

Paying MD's to take call for subspecialties is still rare & very controversial. Opening that door will send costs spiraling which is limiting it. Substituting some Trauma specialist still doesn't change the fact that someone has to subsidize it or collect enough reimbursements to pay for it. Both of those are increasingly dificult propositions.

A more practical & workable solution is some kind of liability waiver for desighnated providers in trauma systems. That removes part of the overhead & risk hurdle, but as far as the salaries go there is NO way that's workable. You're more likely to see more triage/diversions to remote trauma centers especially as hospitals were released from some on-call requirements for specialists

 

[RichL025]

Not to be overly argumentative, but this is a good discussion on medical economics, so I'll continue the ball rolling...

By this logic, why don't ER physicians make 800K? They too allow other physicians not to be on site and provide a great deal of care.

I could argue TWO reasons...

One, there was no net decrease in the number of physicians - ie, a moderate-sized ED that had two or three MDs (who were previously a smattering of GPs, moonlighting residents, FP, etc) were replaced by two or three MDs who were BC in EM. No gain to the hospital by paying fewer people.

Two (OK, maybe related to number one) the move to EM physicians was driven by standard of care issues - hopsitals _had_ to go to them to "keep up with the (legal) Jones's"

And finally, while EM docs don't make 800K a year (maybe some get close, I dunno) they _do_ make significantly more than any other specialty after only three years of GME. And that's _with_ all those lifestyle perks they are always crowing about

 

[njbmd]

Hi there,
To get back to the OPs question as to why Trauma Surgery is fairly unpopular: Most general surgery residents rotate on Trauma Surgery as interns (PGY-1) and as chiefs (PGY-4). The patients can be very difficult to manage in terms of no insurance, multiple substance abusers and on the fringe of society. Another group that is often in the trauma bay are the elderly with multiple medical problems (definitely not the favorite patients to manage by any surgeon).

As a PGY-1 on the Trauma service, I found that my job consisted of finding placement for many of my folks who were injured and needed rehab. This involved many hours of working with social services and other departments. This was not great fun.

As a PGY-4 chief of trauma service, I found that most trauma was blunt and non-operative. There are tons of details to track down and keep up with but not much OR time. I have had plenty of M & M time though.

I just think that many folks have less than a fun experience on Trauma surgery and that colors it as a choice for career. Unlike Trauma Surgery, I found my experience on Burn Surgery totally fun and very rewarding. Of course, I had more operative time on Burn surgery than on Trauma Surgery.

njbmd

 

[Winged Scapula]

njmd hit the nail on the head, as far as I'm concerned.

We spend more time on trauma here than they do (as PGY1s, 2s, 4s and 5s). As the current Chief (PGY5) on ou trauma service, the social issues and babysitting patients for other services really get to you. Let's see...what did I deal with this weekend...

- the call from the nurses, as we're discharging a facial trauma patient home (to come back next week for his ORIF), that his wife "doesn't feel safe going home with him". Hmmm...did anyone pick up on this during the 2 days he was here before d/c? Guess who gets to talk to the wife and document our conversation (thoroughly).

- same patient, call from wife, to MY HOME, at 1030 pm, because she doesn't know what to do about his pain. I explained that he could use some of his own OxyContin that we found in his car when he was brought in. This was the reason we didn't give him any extra narcs. No one explained this to her (and she can't find the discharge summary) and oh, "those are my meds, not his, anyway" (despite the prescription bottle clearly labeled with his name).

- elderly lady falls and breaks prox humerus and distal radius. Ortho can't fix radius for 3 days and humerus for 1 week. Patient refuses to go home; she can't take care of elderly husband (who looks fine to me) with "only one arm" and Ortho refuses to take her on their service, "she can go home" (obviously oblivious to the social issues and the fact that the family is livid with them for putting off her ORIF for so long). Takes an attending to attending phone call for the patient to be transferred to Ortho, despite a 24 hour rule that single system trauma cleared by the trauma service goes to the service with the system injured (ie, Ortho in this case), 4 days after admission.

- patient having sexual relations, LOUD sexual relations according to the nurses, with his 16 year old girlfriend in the room. Call the cops say I, she's a minor. But she has a baby so she's an emancipated minor, so I guess its ok. Sure, if you aren't trying to sleep in the next room while 16 yo and her 36 yo BF are going at it. Guess who gets to address issue with patient and "friend"?

- the myriad of patients who treat this as a hotel that they can check in and out at their leisure. Families don't want to take responsibility anymore - its rare that we can discharge someone when we want because no one can ever get a ride home, family "has to work" or "can't come then", or no one will be able to help me (in otherwise perfectly able-bodied patients with minor injuries).

- the endless phone calls for more narcs. We have to have a list of frequent callers who have figured out the cross cover system and will call on different nights at different times hoping to find someone who doesn't know them and will give them more drugs.

- the homeless trauma patients with nowhere to go when ready for discharge; can we really send them to a shelter with visiting nurses to care for their stoma and G tube?

- the ridiculous trauma consults from the ER. Fall from standing (that's a favorite) without any obvious injuries.

- the patients accepted in transfer by a surgical subspecialty who arrive in the ER which then generates a full trauma response, bringing everyone down to see a patient who's already been worked up at an outside facility and determined to have a neurosurg, ortho, etc. injury but we have to repeat all the films (at our expense because the insurance company won't pay for two sets) and ask everyone in house (surgery residents, anesthesia, OR reps, Chaplain, nurses, etc.) to come down to evaluate this patient.

Any of this sounding tiring (or bitter) yet?

 

[Selznick]

Wow, this all sounds very bleak. Is there anything good about trauma??

 

[CellSaver99]

I'll add on:

- Getting to talk to the family at 2AM about their elderly loved one with a severe closed head injury regarding "the plan" because either your neurosurg colleagues (who are your same PGY level) are in the OR, you're on in-house call and they're not, or my favorite "because no one else has talked to them."

- Enjoying a few hours in medical records every few months signing restraint orders, discharge summaries, middle of the night verbal orders, etc from the trauma service... and it's not your intern year

You do learn a lot in the OR and the more advanced critical aspect from trauma; however, it comes at the price of spending a disproportionately high amount of time on the BS work year after year in residency that steers most people away from it by the time they finish.

 

[Winged Scapula]

I'll add on:

- Getting to talk to the family at 2AM about their elderly loved one with a severe closed head injury regarding "the plan" because either your neurosurg colleagues (who are your same PGY level) are in the OR, you're on in-house call and they're not, or my favorite "because no one else has talked to them."

I'll add to that...

AND you're the CROSS-COVER resident who barely knows the patient, but family wants to talk to the DOCTOR right now! Of course, they haven't been seen at the patient's bedside for days, but suddenly want to know "the plan"...at 2 am.

 

[Winged Scapula]

Wow, this all sounds very bleak. Is there anything good about trauma??

Sure, if there wasn't no one would do it.

It can be exciting, especially when its a penetrating trauma.

Lots of unexpected suprises; great for people who want to do something different every day.

Lots of critical care management; good combination of medicine and surgery.

Even if you aren't in the OR much, there can be lots of procedures (bronchs, trachs, PEGs, central lines, etc.) which are billable.

Money-maker if a large proportion of your trauma is blunt (we make money on it here at Hershey).

Little clinic time.

and...

well, I'm sure there are other things to like about Trauma but I find it hard to think of many more!