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

1. 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

2. 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?

3. Defining Rural • 50 - 60 million • 90% of landmass

4. Population Density 2000 Census

5. Rural America • like being rural • do not like the big city • recognize a potential compromise • and that’s OK • geography • weather

6. 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

7. 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

8. 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

9. Rural Surgery Practice • Geography/ weather • resource limitations • house calls/ EMS calls • Primary care • Diagnostician • expert

10. Rural Surgery Practice • Patients keep coming back • long term problems • Broad medical background • limited volume - always on the hook • AAA - dry run/ practice • ownership

11. Acute Care Surgery • Metropolitan/ Suburban • Service/ Shift work • Anonymity • Technician

12. 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

13. 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

14. Acute Care Surgeon • Fellowship trained • Younger • Trauma and Critical Care

15. Acute Care Surgeon • Diversity of cases • system/ patient benefit • protected environment • local expertise • distribution of responsibility • ownership

16. Acute Care Surgeon • Blessing to Specialists

17. 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

18. 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

19. Acute Care Surgery • pancreas-biliary - 41% • appendectomy - 26% • soft tissue infection - 15% • bowel resection or repair - 8% • anorectal surgery - 5% • other - 5%

20. Acute Care Surgery Center • What about the patient?

21. Acute Care Surgery Center • What about the patient? • Transportation?

22. Acute Care Surgery Center • What about the patient? • Transportation? • Long term effects on Community Hospital?

23. Acute Care Surgery • ? New income streams in a non-operative specialty?

24. Acute Care Surgery • ? New income streams in a non-operative specialty? • ? Is this a further narrowing of the once broad scope of general surgery?

25. 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?

26. 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?

27. Rural Surgery Practice • Big Fish - small pond • know your neighbors • must plan ahead • contingency v. improvisation or luck • educator - community/ EMS • flat learning curve

28. 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

29. Similarities • Quality • Breadth of experience • Critical Care • Trauma

30. Partnership • Surgical Care Delivery System • Resources • Innovation • Experience

31. Partnership • Surgical Care Delivery System • Resources • Innovation • Experience • Leave the Bread and Butter

32. Partnership • Surgical Care Delivery System • Resources • Innovation • Experience • Leave the Bread and Butter • Let the patients stay in their community

33. Partnership • Surgical Care Delivery System • Resources • Innovation • Experience • Australia model

34. USA 300 million • Australia 20 million • New York 20 million

35. 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

36. “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