Acute%20Care%20Surgery%20and%20Rural%20Surgery%20Similarities%20and%20Differences%204th%20Rural%20Surgery%20Symposium

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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

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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?

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Defining Rural

• 50 - 60 million
• 90 of landmass

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Population Density 2000 Census
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Rural America

• like being rural
• do not like the big city
• recognize a potential compromise
• and thats OK
• geography
• weather

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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

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

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Rural Surgery Practice

• Geography/ weather
• resource limitations
• house calls/ EMS calls
• Primary care
• Diagnostician
• expert

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Rural Surgery Practice

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

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Acute Care Surgery

• Metropolitan/ Suburban
• Service/ Shift work
• Anonymity
• Technician

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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

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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

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Acute Care Surgeon

• Fellowship trained
• Younger
• Trauma and Critical Care

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Acute Care Surgeon

• Diversity of cases
• system/ patient benefit
• protected environment
• local expertise
• distribution of responsibility
• ownership

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Acute Care Surgeon

• Blessing to Specialists

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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
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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
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Acute Care Surgery

• pancreas-biliary - 41
• appendectomy - 26
• soft tissue infection - 15
• bowel resection or repair - 8
• anorectal surgery - 5
• other - 5

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Acute Care Surgery Center

• What about the patient?

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Acute Care Surgery Center

• What about the patient?
• Transportation?

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Acute Care Surgery Center

• What about the patient?
• Transportation?
• Long term effects on Community Hospital?

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Acute Care Surgery

• ? New income streams in a non-operative
  specialty?

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Acute Care Surgery

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

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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?

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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?

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Rural Surgery Practice

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

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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

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Similarities

• Quality
• Breadth of experience
• Critical Care
• Trauma

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Partnership

• Surgical Care Delivery System
• Resources
• Innovation
• Experience

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Partnership

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

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Partnership

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

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Partnership

• Surgical Care Delivery System
• Resources
• Innovation
• Experience
• Australia model

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

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Brisbane 1.6 m
Alice Springs 25 K
Sydney 4.3 m
Adelaide 1.2 m
Perth 1.4 m
Melbourne 3.7 m
Whyalla 24 K
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• 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
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