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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