Acute Care Surgery and Rural Surgery Similarities and Differences 4th Rural Surgery Symposium

Acute Care Surgery and Rural Acute Care Surgery and Rural SurgerySurgery

Similarities and DifferencesSimilarities and Differences4th Rural Surgery Symposium 4th Rural Surgery Symposium

David Borgstrom, MD, FACSDavid Borgstrom, MD, FACSMary Imogene Bassett HospitalMary Imogene Bassett Hospital

Cooperstown, New YorkCooperstown, New York

May 18, 2009May 18, 2009

ObjectivesObjectives

What is rural?What is rural? What is a rural practice?What is a rural practice? What is an acute care surgery What is an acute care surgery

practice?practice? Who is the rural surgeon?Who is the rural surgeon? Who is the acute care surgeon?Who is the acute care surgeon?

Defining RuralDefining Rural

50 - 60 million50 - 60 million 90% of landmass90% of landmass

Population Density 2000 Census

Rural AmericaRural America

like being rurallike being rural do not like the big citydo not like the big city recognize a potential compromiserecognize a potential compromise

– and that’s OKand that’s OK geographygeography weatherweather

Rural Surgery PracticeRural Surgery Practice

EndoscopyEndoscopy 28%28% GynecologyGynecology 21%21% BiliaryBiliary 8%8% BreastBreast 5%5% OrthoOrtho 5%5% ENTENT 2%2%

HerniaHernia10%10%

ColorectalColorectal 8%8% C-SectionC-Section 5%5% Carpal TunnelCarpal Tunnel 3%3% VenousVenous 2%2%

Landercasper, et al., Archives of Surgery, May, 1997

Rural Surgery PracticeRural Surgery Practice

531 Cases - 279 endoscopy531 Cases - 279 endoscopy– 43 Cholecystectomy43 Cholecystectomy– 11 Hernia11 Hernia– 8 Appendectomy8 Appendectomy– 187 everything else187 everything else

Tyler Hughes MD, FACS ACS 2006

McPherson, KS 13,000

Rural Surgery PracticeRural Surgery Practice

Primary endoscopist for rural Primary endoscopist for rural AmericaAmerica

Gynecology/C-sectionsGynecology/C-sections Carpal tunnel release/ basic handCarpal tunnel release/ basic hand Basic ENTBasic ENT UrologyUrology keep comfort level in the communitykeep comfort level in the community

Rural Surgery PracticeRural Surgery Practice

Geography/ weatherGeography/ weather resource limitationsresource limitations house calls/ EMS callshouse calls/ EMS calls Primary carePrimary care DiagnosticianDiagnostician

– expertexpert

Rural Surgery PracticeRural Surgery Practice

Patients keep coming backPatients keep coming back– long term problemslong term problems

Broad medical backgroundBroad medical background limited volume - always on the limited volume - always on the

hookhook– AAA - dry run/ practiceAAA - dry run/ practice

ownershipownership

Acute Care SurgeryAcute Care Surgery

Metropolitan/ SuburbanMetropolitan/ Suburban Service/ Shift workService/ Shift work AnonymityAnonymity TechnicianTechnician

Acute Care SurgeonAcute Care Surgeon

Fellowship TrainingFellowship Training– 24 month curriculum24 month curriculum

Trauma/Critical CareTrauma/Critical Care 6 months6 months Critical Care electivesCritical Care electives 3 months3 months Emergency and Elective Surgery 15 monthsEmergency and Elective Surgery 15 months

– Acute Care SurgeryAcute Care Surgery– ThoracicThoracic– NeurosurgeryNeurosurgery– BurnsBurns– EndoscopyEndoscopy

Acute Care SurgeonAcute Care Surgeon

Four AAST accredited fellowshipsFour AAST accredited fellowships– 30 page PIF30 page PIF– more to comemore to come

General, Trauma, Burns, Surgical General, Trauma, Burns, Surgical Critical Care, Acute Care SurgeryCritical Care, Acute Care Surgery

Transplant, Hepatobiliary, IR, Vascular, Transplant, Hepatobiliary, IR, Vascular, Thoracic, Peds, Neuro, Ortho Plastics, Urology, Thoracic, Peds, Neuro, Ortho Plastics, Urology, ENT, Anesthesia, Pulmonary, Cardiology, ENT, Anesthesia, Pulmonary, Cardiology, Emergency Medicine, GastroenterologyEmergency Medicine, Gastroenterology

Acute Care SurgeonAcute Care Surgeon

Fellowship trainedFellowship trained YoungerYounger Trauma and Critical CareTrauma and Critical Care

Acute Care SurgeonAcute Care Surgeon

Diversity of casesDiversity of cases system/ patient benefitsystem/ patient benefit protected environmentprotected environment local expertiselocal expertise distribution of responsibilitydistribution of responsibility

– ownershipownership

Acute Care SurgeonAcute Care Surgeon

Blessing to SpecialistsBlessing to Specialists

Acute Care SurgeryAcute Care Surgery

Trauma Center/ Acute Care Surgery Trauma Center/ Acute Care Surgery CenterCenter– Fixed costs/ volume basedFixed costs/ volume based– Income generation for facilityIncome generation for facility

$150K for physician - $1.5m hospital$150K for physician - $1.5m hospital savings $100K for community hospitalsavings $100K for community hospital

– pancreas-biliary, appendectomy, soft pancreas-biliary, appendectomy, soft tissue infectiontissue infection

– 25% no insurance25% no insuranceBlock, AAST 2008

Acute Care SurgeryAcute Care Surgery

ConclusionsConclusions– reduced readiness costsreduced readiness costs– minimal increase in Trauma Center OR minimal increase in Trauma Center OR

volumevolume– $100,000 savings in call pay and other $100,000 savings in call pay and other

variable costsvariable costs

Block, AAST 2008

Acute Care SurgeryAcute Care Surgery

pancreas-biliary - 41%pancreas-biliary - 41% appendectomy - 26%appendectomy - 26% soft tissue infection - 15%soft tissue infection - 15% bowel resection or repair - 8%bowel resection or repair - 8% anorectal surgery - 5%anorectal surgery - 5% other - 5%other - 5%

Acute Care Surgery CenterAcute Care Surgery Center

What about the patient?What about the patient?

Acute Care Surgery CenterAcute Care Surgery Center

What about the patient?What about the patient? Transportation?Transportation?

Acute Care Surgery CenterAcute Care Surgery Center

What about the patient?What about the patient? Transportation?Transportation? Long term effects on Community Long term effects on Community

Hospital?Hospital?

Acute Care SurgeryAcute Care Surgery

? New income streams in a non-? New income streams in a non-operative specialty?operative specialty?

Acute Care SurgeryAcute Care Surgery

? New income streams in a non-? New income streams in a non-operative specialty?operative specialty?

? Is this a further narrowing of the ? Is this a further narrowing of the once broad scope of general once broad scope of general surgery?surgery?

Acute Care SurgeryAcute Care Surgery

? New income streams in a non-? New income streams in a non-operative specialty?operative specialty?

? Is this a further narrowing of the ? Is this a further narrowing of the once broad scope of general once broad scope of general surgery?surgery?

? Is this the same thought process ? Is this the same thought process that promoted the specialist in that promoted the specialist in Surgical Critical Care?Surgical Critical Care?

Acute Care SurgeryAcute Care Surgery

? New income streams in a non-? New income streams in a non-operative specialty?operative specialty?

? Is this a further narrowing of the ? Is this a further narrowing of the once broad scope of general surgery?once broad scope of general surgery?

? Is this the same thought process ? Is this the same thought process that promoted the specialist in that promoted the specialist in Surgical Critical Care?Surgical Critical Care?

? Is this a good thing?? Is this a good thing?

Rural Surgery PracticeRural Surgery Practice

Big Fish - small pondBig Fish - small pond know your neighborsknow your neighbors must plan aheadmust plan ahead

– contingency v. improvisation or luckcontingency v. improvisation or luck educator - community/ EMSeducator - community/ EMS flat learning curveflat learning curve

DifferencesDifferences

Rural SurgeonRural Surgeon– CommunityCommunity– 24/724/7– limited resourceslimited resources– flat learning curveflat learning curve– manpowermanpower– skilled, well skilled, well

trainedtrained

Acute Care SurgeonAcute Care Surgeon– SystemSystem– Shift workShift work– many resourcesmany resources– accelerated learning accelerated learning

curvecurve– manpowermanpower– skilled, well trainedskilled, well trained

SimilaritiesSimilarities

QualityQuality Breadth of experienceBreadth of experience Critical CareCritical Care TraumaTrauma

PartnershipPartnership

Surgical Care Delivery SystemSurgical Care Delivery System– ResourcesResources– InnovationInnovation– ExperienceExperience

PartnershipPartnership

Surgical Care Delivery SystemSurgical Care Delivery System– ResourcesResources– InnovationInnovation– ExperienceExperience

Leave the Bread and ButterLeave the Bread and Butter

PartnershipPartnership

Surgical Care Delivery SystemSurgical Care Delivery System– ResourcesResources– InnovationInnovation– ExperienceExperience

Leave the Bread and ButterLeave the Bread and Butter Let the patients stay in their Let the patients stay in their

communitycommunity

PartnershipPartnership

Surgical Care Delivery SystemSurgical Care Delivery System– ResourcesResources– InnovationInnovation– ExperienceExperience– Australia modelAustralia model

USA 300 millionUSA 300 million Australia 20 Australia 20

millionmillion New York 20 New York 20

millionmillion

Brisbane 1.6 m

Sydney 4.3 m

Melbourne 3.7 m

Adelaide 1.2 m

Perth 1.4 m

Alice Springs 25 K

Whyalla 24 K

““Shortage of General Surgeons Shortage of General Surgeons Endangers Rural Americans”Endangers Rural Americans”

Washington Post, January 1, 2009Washington Post, January 1, 2009

Wall Street Journal, January 13, 2009

““Surgeon Shortage Pushes Surgeon Shortage Pushes Hospitals to Hire Temps”Hospitals to Hire Temps”