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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
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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?
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Defining RuralDefining Rural
50 - 60 million50 - 60 million 90% of landmass90% of landmass
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Population Density 2000 Census
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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
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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
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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
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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
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Rural Surgery PracticeRural Surgery Practice
Geography/ weatherGeography/ weather resource limitationsresource limitations house calls/ EMS callshouse calls/ EMS calls Primary carePrimary care DiagnosticianDiagnostician
– expertexpert
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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
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Acute Care SurgeryAcute Care Surgery
Metropolitan/ SuburbanMetropolitan/ Suburban Service/ Shift workService/ Shift work AnonymityAnonymity TechnicianTechnician
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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
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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
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Acute Care SurgeonAcute Care Surgeon
Fellowship trainedFellowship trained YoungerYounger Trauma and Critical CareTrauma and Critical Care
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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
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Acute Care SurgeonAcute Care Surgeon
Blessing to SpecialistsBlessing to Specialists
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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
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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
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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%
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Acute Care Surgery CenterAcute Care Surgery Center
What about the patient?What about the patient?
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Acute Care Surgery CenterAcute Care Surgery Center
What about the patient?What about the patient? Transportation?Transportation?
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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?
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Acute Care SurgeryAcute Care Surgery
? New income streams in a non-? New income streams in a non-operative specialty?operative specialty?
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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?
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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?
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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?
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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
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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
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SimilaritiesSimilarities
QualityQuality Breadth of experienceBreadth of experience Critical CareCritical Care TraumaTrauma
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PartnershipPartnership
Surgical Care Delivery SystemSurgical Care Delivery System– ResourcesResources– InnovationInnovation– ExperienceExperience
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PartnershipPartnership
Surgical Care Delivery SystemSurgical Care Delivery System– ResourcesResources– InnovationInnovation– ExperienceExperience
Leave the Bread and ButterLeave the Bread and Butter
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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
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PartnershipPartnership
Surgical Care Delivery SystemSurgical Care Delivery System– ResourcesResources– InnovationInnovation– ExperienceExperience– Australia modelAustralia model
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USA 300 millionUSA 300 million Australia 20 Australia 20
millionmillion New York 20 New York 20
millionmillion
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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
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““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”
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