Refining the operative curriculum of the acute care surgery fellowship

D the last decade, it has been increasingly recognized that the insufficient number of participants in emergency call panels has reached crisis proportions. According to the National Center for Health Statistics, from 1993 to 2003, there has been a 26% increase in the number of patients receiving care in emergency departments across the country. In contrast, during the same period, the total number of hospitals decreased by 703, the number of hospital beds decreased by 198,000, and there are 425 fewer emergency departments. In 2005, nearly half of all hospital emergency departments reported that they were routinely at or beyond capacity resulting in ambulance diversion. This problem is more severe for major teaching institutions, with 79% of their emergency departments at capacity or overcapacity. The Institute of Medicine highlighted this crisis in access to emergency care on the future of emergency care in the US health system in a report entitledHospital-Based Emergency Care: At the Breaking Point. Central among the issues discussed in the Institute of Medicine report included the boarding of nonfunded and underfunded patients in the nation’s shrinking number of emergency departments as well as the problem of minimal surge capacity. Although workforce shortages exist across a range of medical disciplines, they are generally more significant for surgical disciplines. While the workforce in nonsurgical specialties has grown steadily over time, the number of surgeons trained in our nation’s graduate medical education system has remained stable for more than 20 years (Fig. 1). The rate of growth of the US population has outpaced the supply of general surgeons. During the 25-year period between 1981 and 2006, the US population grew by 31%, while the number of general surgeons grew by 4%. The American Association of Medical Colleges estimates that a 35% increase in the number of surgeons will be necessary to meet clinical demands by 2025 (Fig. 2). An aging surgical workforce and increasing surgical subspecialization driven in part by technological advances are compounded these shortages. As of 2012, 43% of general surgeons were 55 years or older, compared with only 36% of internal medicine physicians. In addition, almost 80% of general surgery residents finishing from Accreditation Council for Graduate Medical Education (ACGME)Yapproved programs pursue fellowships and become specialists. As a result, there are fewer general surgeons available to take emergency department call to care for patients with time-sensitive general surgical conditions. A survey conducted by the American College of Emergency Physicians in 2005 demonstrated that nearly 75% of emergency department medical directors believed that they had inadequate on-call surgical specialist coverage, up from 66% in 2004. At the center of these issues, described as ‘‘the perfect storm,’’ is the patient. As the needs of the injured patient drove the development of the field of trauma surgery, so must the needs of the emergency general surgery patient drive the development of a systematic approach to care. In response to this crisis in access to emergency surgical care, the leadership of the American Association for the Surgery of Trauma (AAST) developed the specialty of acute care surgery (ACS), a fellowship training model to produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and timesensitive general surgery. Unlike most specialty training, this paradigm strives to create a broad-based surgical specialist, specifically trained in the treatment of acute surgical disease across as a wide array of anatomic regions.