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Acute Care Surgery and Rural Surgery Similarities and Differences 4th Rural Surgery Symposium. David Borgstrom, MD, FACS Mary Imogene Bassett Hospital Cooperstown, New York May 18, 2009. Objectives. What is rural? What is a rural practice? What is an acute care surgery practice?

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acute care surgery and rural surgery similarities and differences 4th rural surgery symposium

Acute Care Surgery and Rural SurgerySimilarities and Differences4th Rural Surgery Symposium

David Borgstrom, MD, FACS

Mary Imogene Bassett Hospital

Cooperstown, New York

May 18, 2009

objectives
Objectives
  • What is rural?
  • What is a rural practice?
  • What is an acute care surgery practice?
  • Who is the rural surgeon?
  • Who is the acute care surgeon?
defining rural
Defining Rural
  • 50 - 60 million
  • 90% of landmass
rural america
Rural America
  • like being rural
  • do not like the big city
  • recognize a potential compromise
    • and that’s OK
  • geography
  • weather
rural surgery practice
Endoscopy 28%

Gynecology 21%

Biliary 8%

Breast 5%

Ortho 5%

ENT 2%

Hernia 10%

Colorectal 8%

C-Section 5%

Carpal Tunnel 3%

Venous 2%

Rural Surgery Practice

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

rural surgery practice1
Rural Surgery Practice
  • 531 Cases - 279 endoscopy
    • 43 Cholecystectomy
    • 11 Hernia
    • 8 Appendectomy
    • 187 everything else

Tyler Hughes MD, FACS ACS 2006

McPherson, KS 13,000

rural surgery practice2
Rural Surgery Practice
  • Primary endoscopist for rural America
  • Gynecology/C-sections
  • Carpal tunnel release/ basic hand
  • Basic ENT
  • Urology
  • keep comfort level in the community
rural surgery practice3
Rural Surgery Practice
  • Geography/ weather
  • resource limitations
  • house calls/ EMS calls
  • Primary care
  • Diagnostician
    • expert
rural surgery practice4
Rural Surgery Practice
  • Patients keep coming back
    • long term problems
  • Broad medical background
  • limited volume - always on the hook
    • AAA - dry run/ practice
  • ownership
acute care surgery
Acute Care Surgery
  • Metropolitan/ Suburban
  • Service/ Shift work
  • Anonymity
  • Technician
acute care surgeon
Acute Care Surgeon
  • Fellowship Training
    • 24 month curriculum
      • Trauma/Critical Care 6 months
      • Critical Care electives 3 months
      • Emergency and Elective Surgery 15 months
        • Acute Care Surgery
        • Thoracic
        • Neurosurgery
        • Burns
        • Endoscopy
acute care surgeon1
Acute Care Surgeon
  • Four AAST accredited fellowships
    • 30 page PIF
    • more to come
  • General, Trauma, Burns, Surgical Critical Care, Acute Care Surgery
  • Transplant, Hepatobiliary, IR, Vascular, Thoracic, Peds, Neuro, Ortho Plastics, Urology, ENT, Anesthesia, Pulmonary, Cardiology, Emergency Medicine, Gastroenterology
acute care surgeon2
Acute Care Surgeon
  • Fellowship trained
  • Younger
  • Trauma and Critical Care
acute care surgeon3
Acute Care Surgeon
  • Diversity of cases
  • system/ patient benefit
  • protected environment
  • local expertise
  • distribution of responsibility
    • ownership
acute care surgeon4
Acute Care Surgeon
  • Blessing to Specialists
acute care surgery1
Acute Care Surgery
  • Trauma Center/ Acute Care Surgery Center
    • Fixed costs/ volume based
    • Income generation for facility
      • $150K for physician - $1.5m hospital
      • savings $100K for community hospital
    • pancreas-biliary, appendectomy, soft tissue infection
    • 25% no insurance

Block, AAST 2008

acute care surgery2
Acute Care Surgery
  • Conclusions
    • reduced readiness costs
    • minimal increase in Trauma Center OR volume
    • $100,000 savings in call pay and other variable costs

Block, AAST 2008

acute care surgery3
Acute Care Surgery
  • pancreas-biliary - 41%
  • appendectomy - 26%
  • soft tissue infection - 15%
  • bowel resection or repair - 8%
  • anorectal surgery - 5%
  • other - 5%
acute care surgery center
Acute Care Surgery Center
  • What about the patient?
acute care surgery center1
Acute Care Surgery Center
  • What about the patient?
  • Transportation?
acute care surgery center2
Acute Care Surgery Center
  • What about the patient?
  • Transportation?
  • Long term effects on Community Hospital?
acute care surgery4
Acute Care Surgery
  • ? New income streams in a non-operative specialty?
acute care surgery5
Acute Care Surgery
  • ? New income streams in a non-operative specialty?
  • ? Is this a further narrowing of the once broad scope of general surgery?
acute care surgery6
Acute Care Surgery
  • ? New income streams in a non-operative specialty?
  • ? Is this a further narrowing of the once broad scope of general surgery?
  • ? Is this the same thought process that promoted the specialist in Surgical Critical Care?
acute care surgery7
Acute Care Surgery
  • ? New income streams in a non-operative specialty?
  • ? Is this a further narrowing of the once broad scope of general surgery?
  • ? Is this the same thought process that promoted the specialist in Surgical Critical Care?
  • ? Is this a good thing?
rural surgery practice5
Rural Surgery Practice
  • Big Fish - small pond
  • know your neighbors
  • must plan ahead
    • contingency v. improvisation or luck
  • educator - community/ EMS
  • flat learning curve
differences
Rural Surgeon

Community

24/7

limited resources

flat learning curve

manpower

skilled, well trained

Acute Care Surgeon

System

Shift work

many resources

accelerated learning curve

manpower

skilled, well trained

Differences
similarities
Similarities
  • Quality
  • Breadth of experience
  • Critical Care
  • Trauma
partnership
Partnership
  • Surgical Care Delivery System
    • Resources
    • Innovation
    • Experience
partnership1
Partnership
  • Surgical Care Delivery System
    • Resources
    • Innovation
    • Experience
  • Leave the Bread and Butter
partnership2
Partnership
  • Surgical Care Delivery System
    • Resources
    • Innovation
    • Experience
  • Leave the Bread and Butter
  • Let the patients stay in their community
partnership3
Partnership
  • Surgical Care Delivery System
    • Resources
    • Innovation
    • Experience
    • Australia model
slide34

USA 300 million

  • Australia 20 million
  • New York 20 million
slide35

Brisbane 1.6 m

Alice Springs 25 K

Sydney 4.3 m

Perth 1.4 m

Adelaide 1.2 m

Melbourne 3.7 m

Whyalla 24 K

slide36
“Shortage of General Surgeons Endangers Rural Americans”

Washington Post, January 1, 2009

“Surgeon Shortage Pushes Hospitals to Hire Temps”

  • Wall Street Journal, January 13, 2009