New fields in general surgery and the rise of the surgical hospitalist

As medicine adapts to the 21st century, new specialties arise.

General surgery is seeing two new fields emerge. One is “Acute Care Surgery,” which encompasses three facets of general surgery — emergency surgery, critical care and trauma care. The other is the concept of a surgical hospitalist. That is, a surgeon works only in a hospital and has no office or private practice. The idea is similar to the medical hospitalist movement, which has existed for several years now.

The changes in surgery are in response to a number of forces. General surgeons are becoming increasingly more focused, especially in areas such as advanced laparoscopic surgery, bariatric (obesity) surgery, endovascular surgery and breast surgery. With these areas of concentration comes decreasing interest in taking emergency call, which interferes with elective cases and office practice. In addition, a concentration on something like breast surgery leads to diminished experience and skills in treating gunshot wound and bowel obstructions.

Acute Care Surgery arose in response to the need for emergency call coverage as well as the desire of trauma surgeons to increase their operative case load as trauma care itself becomes less involved with operative procedures. In many trauma centers, the percentage of blunt trauma cases is well over 90% and a large majority of these patients are treated without surgery. Many academic medical centers have established acute care surgery services which are staffed mostly by trauma/critical care surgeons.

A surgical hospitalist usually does acute care surgery but does not see outpatients unless they have emergencies. I have been working as a surgical hospitalist for the past two years. I am on duty for two five-day weekends per month. During that time I cover for the general surgeons in the area, make rounds on their inpatients, handle phone calls from their private practice patients, see consults from the emergency department and inpatient medical services and perform any emergency procedures that are needed. At the end of my tour of duty, I sign out my patients to one of the general surgeons. The positive features of my job are as follows: there is no office practice or overhead; it’s a salaried position; I have 20 days/month off; when I am not on duty, I am completely without responsibilities. The downsides include loss of continuity, having to pick up many patients often with complex problems all at once and occasionally having to leave a very sick patient for someone else to take care of. I am the sole surgical hospitalist at my institution, but there can also be groups which can cover inpatients and emergencies.

The surgical hospitalist model is a far cry from anything I would have dreamed of when I started in surgery years ago. But it is the wave of the future. Other specialties such as orthopedic surgery are getting on the bandwagon. The field will see much growth in the next few years as graduating residents, who are used to shift work, will see a surgical hospitalist career as a logical extension of their experience as residents.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • solo fp

    I think gen surgeons are tires of doing the free appendectomies and other 24 hour free ER surgical care. Elective surgeries usually are insured patients. A lot of the ER care is free self pays or Medicaid patients. I feel for the surgeon repairing a knife wound or taking out an appendix at 3 am for free.

  • md

    Kind of an alarming trend with many doctors giving up traditional parts of their practice. Internal medicine doctors are now relying on hospitalists to take care of inpatients. Surgeons relying on hospitalists to take care of sick inpatients, ER care, etc. Soon we will have residencies dedicated to surgeons who only want to do elective breast surgeries and those for surgeons who want to do more critical care. Seems like a waste of training and tax dollars if surgeons are going to spend their career doing only breast surgery.

  • JF Sucher, MD FACS

    I applaud the fact that you have separated and defined the differences between the “Acute Care Surgeon” and the “Surgical Hospitalist”. The fact is that most people don’t understand what the heck an Acute Care Surgeon is, while at the same time they do understand what a hospitalist is… therefore, what I find is that most people simply think that we are all Surgical Hospitalists.

    Nonetheless. I do not agree with the concept of a surgical hospitalist. Additionally, I am not sure that I can continue to fully endorse the idea of an Acute Care Surgeon outside the scope of a trauma surgeon.

    First, in my humble opinion (as it relates to the idea of surgical hospitalists), most people are likely to do a better job when they have ultimate responsibility for the outcome of what they do. The mercenary approach to surgical intervention, while practical financially, potentially has a downside for the care of complex surgical conditions. Additionally, the skillset of a surgical hospitalist will quickly become limited due to the scope of problems that need acute management. This is not good for the surgeon or the patient.

    Second, as it relates to acute care surgery: Acute care surgeons within the context of a trauma center, is a necessary and good thing. As the complex care is managed by the trauma surgeon throughout the entirety of the hospitalization (ER -> OR -> ICU -> Floor -> Outpatient). However, the “acute care surgeon” outside the trauma center has a completely different function. Outside a trauma center, you are more likely to care for patients of surgeons outside your own practice (in the ICU). You therefore, have only that limited snapshot of that patient’s care. Additionally, the time in the ICU is less efficient on an RVU basis and therefore reimbursement basis. This is not necessarily good for the hospital that employs or contracts such a service.

    In summary, I am very concerned over the idea of a surgical hospitalist. Surgeons should maintain a full relationship with their patients from start to finish. In regards to the acute care surgeon – their home is in a trauma center. Outside of a trauma center, their benefit will depend upon many factors, and I suspect that they may do well in some hospitals, while in others they may not.

  • Skeptical Scalpel

    @solo fp, @md, @jfsucher

    Interesting comments all. As I said in the post, this is not something I would have ever thought I would be doing. A few years ago, the idea of a medical hospitalist was equally scorned. Now 95% of IM inpatients where I work are strictly cared for by medical hospitalists. Don’t forget to factor in the new wave of graduating residents who will be quite used to “shift work.”

  • dragonfly

    @md: In Australia the figure is 1/8-1/11 women get breast cancer. I hardly think that being a breast surgeon is a waste.

  • solo fp

    I’ve noticed a lot of the 60 y.o and older gen. surgeons in town have gotten permsion to remove themselves from ER call. Many of them have switched to elective surgeries, such as breast biopsies, lumpectomies, and skin cysts for fast money for the retirement with reasonably low risk.

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