SPECIAL REPORT

Refining the operative curriculum of the acute care surgery fellowship Kimberly A. Davis, MD, MBA, Christopher J. Dente, MD, Clay Cothren Burlew, MD, Gregory J. Jurkovich, MD, Patrick M. Reilly, MD, Eric A. Toschlog, MD, and William G. Cioffi, MD

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uring the last decade, it has been increasingly recognized that the insufficient number of participants in emergency call panels has reached crisis proportions.1 According to the National Center for Health Statistics, from 1993 to 2003, there has been a 26% increase in the number of patients receiving care in emergency departments across the country.2 In contrast, during the same period, the total number of hospitals decreased by 703, the number of hospital beds decreased by 198,000, and there are 425 fewer emergency departments.3 In 2005, nearly half of all hospital emergency departments reported that they were routinely at or beyond capacity resulting in ambulance diversion.4 This problem is more severe for major teaching institutions, with 79% of their emergency departments at capacity or overcapacity.5 The Institute of Medicine highlighted this crisis in access to emergency care on the future of emergency care in the US health system in a report entitled Hospital-Based Emergency Care: At the Breaking Point. Central among the issues discussed in the Institute of Medicine report included the boarding of nonfunded and underfunded patients in the nation’s shrinking number of emergency departments as well as the problem of minimal surge capacity.3 Although workforce shortages exist across a range of medical disciplines, they are generally more significant for surgical disciplines. While the workforce in nonsurgical specialties has grown steadily over time, the number of surgeons trained in our nation’s graduate medical education system has remained stable for more than 20 years (Fig. 1). The rate of growth of the US population has outpaced the supply of general surgeons. During the 25-year period between 1981 and 2006, the US population grew by 31%, while the number of general surgeons grew by 4%.6 The American Association of Medical Colleges estimates that a 35% increase in the number of surgeons will be necessary to meet clinical demands by 2025 (Fig. 2). An aging surgical workforce and increasing surgical subspecialization driven in part by technological advances are compounded these shortages.1 As of 2012, 43% of general surgeons were 55 years or older, compared with only 36% of internal medicine From the Departments of Surgery, Yale School of Medicine (K.A.D.), New Haven, Connecticut; Emory School of Medicine (C.J.D.), Atlanta, Georgia; Denver Health Medical Center (C.C.B., G.J.J.), Denver, Colorado; University of Pennsylvania School of Medicine (P.M.R.), Philadelphia, Pennsylvania; East Carolina University School of Medicine (E.A.T.), Greenville, North Carolina; Alpert Medical School of Brown University (W.G.C.), Providence, Rhode Island. Corresponding author: Kimberly A. Davis MD, MBA, Yale School of Medicine, 330 Cedar Street, BB 310, P.O. Box 208062, New Haven, CT, 06520; email: [email protected]. DOI: 10.1097/TA.0000000000000477

physicians.7 In addition, almost 80% of general surgery residents finishing from Accreditation Council for Graduate Medical Education (ACGME)Yapproved programs pursue fellowships and become specialists.8 As a result, there are fewer general surgeons available to take emergency department call to care for patients with time-sensitive general surgical conditions. A survey conducted by the American College of Emergency Physicians in 2005 demonstrated that nearly 75% of emergency department medical directors believed that they had inadequate on-call surgical specialist coverage, up from 66% in 2004.9 At the center of these issues, described as ‘‘the perfect storm,’’ is the patient.10 As the needs of the injured patient drove the development of the field of trauma surgery, so must the needs of the emergency general surgery patient drive the development of a systematic approach to care.10 In response to this crisis in access to emergency surgical care, the leadership of the American Association for the Surgery of Trauma (AAST) developed the specialty of acute care surgery (ACS), a fellowship training model to produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and timesensitive general surgery. Unlike most specialty training, this paradigm strives to create a broad-based surgical specialist, specifically trained in the treatment of acute surgical disease across as a wide array of anatomic regions.

ACS FELLOWSHIPS: THE BIRTH OF A TRAINING PARADIGM The ACS fellowship was designed to follow the completion of the ACGME general surgery residency program and is in alignment with the core competencies set forth by the ACGME. The initial 2-year curriculum contained mandatory components of the fellowship but allowed a certain amount of latitude and creativity in rotation design. This freedom allowed programs to capitalize on their individual strengths and to ensure the training met the individual needs of the fellow. Rotations in thoracic surgery, transplant/hepatobiliary/ pancreatic, and vascular (including vascular interventional) were encouraged but not required.11 The goal of the 2-year fellowship was to ensure training in an ACGME-approved surgical critical care fellowship and participation in complex operative procedures to expand the technical skills obtained in a general surgery residency. The original fellowship program was approved in 2007, and since that time, 17 programs have been approved by the AAST. As of 2014, 59 fellows have J Trauma Acute Care Surg Volume 78, Number 1

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TABLE 1. Revised ACS Curriculum ExpectationsVHead and Neck Exposures/incisionsVessential Neck exploration

Organ managementVessential Brain Nose Trachea

n=5

Collar incision Sternocleidomastoid incision Thoracic extension May include exposures for vascular, thyroid, and parathyroid cases

Intracranial pressure monitor Nasal packing for hemorrhage Tracheostomy Cricothyroidotomy

n = 19 n n n n

=5 =2 = 10 =2

Organ managementVdesired

Figure 1. Projections of physicians by specialty group. Source: AAMC The Complexities of Physician Supply and Demand: Projections Through 2025. * 2008 Association of American Medical Colleges. Accessed July 30, 2014. Reproduced with permission of the Association of American Medical Colleges.

graduated from AAST-approved fellowships. In addition, to quantify the trainees’ operative experiences, a case log system was created (Infotech, San Diego, CA), and data were collected from the last three academic years (academic years 2012Y2014). Case log data were analyzed to determine whether the training programs were providing the expected operative experience. Dente et al.12 demonstrated that ACS fellows had substantial operative experience, averaging more than 200 cases. However, they demonstrated a high variability in the case mix of the fellows, with approximately 50% of the fellows’ operative case volumes not meeting the goals set forth by the AAST in their initial curriculum expectations. Duane et al.13 confirmed these findings in an analysis of 2 years of case log data. Based in large part on the observations mentioned earlier, the AAST Acute Care Surgery Committee and

Figure 2. Cumulative percent growth in demand by specialty group. Source: AAMC The Complexities of Physician Supply and ` Demand: Projections Through 2025. * 2008 Association of American Medical Colleges. Accessed July 30, 2014. Reproduced with permission of the Association of American Medical Colleges.

Brain Eye Trachea Esophagus Endocrine

Burr hole Craniotomy/craniectomy Canthotomy Resection/repair Resection/repair Thyroidectomy Parathyroidectomy

Cervical lymphadenectomy Alternate modalities Simulation, ATOM, or ASSET courses may fulfill one requirement for each of the following: neck dissection, or cricothyroidotomy. ATOM, Advanced Trauma Operative Management; ASSET, Advanced Surgical Skills for Exposure in Trauma.

the Board of Managers revised the operative curriculum for the ACS fellowship in 2014.

THE ACS FELLOWSHIP: THE NEXT ITERATION In revising the curriculum for the ACS fellowship, several key points were considered. The first observation, derived from the case log review, was that the original essential and desired case list as initially constructed only captured a portion of the operative experience of ACS fellows and may have been too granular. In addition, it was clear that operative trauma volumes were not providing adequate exposure to some of the more complex cases. It was felt that the surgical approach or exposure to anatomic regions obtained during elective and urgent cases would provide valuable experience to the fellow, rather than focusing on specific operations. The type of incision used to gain exposure was deemed as important as the type of case the fellow was performing. The goal of the fellowship remains the development of a surgeon who has working technical and procedural knowledge and experience in many anatomic domains. This totality of extra training remains the unique feature of our specialty. The revised curriculum is broken up into anatomic subsections, including head and neck, thoracic, abdominal, vascular, and ultrasound. With the exception of the ultrasound component, each section lists specific case volumes of surgical

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TABLE 2. Revised ACS Curriculum ExpectationsVThoracic

TABLE 3. Revised ACS Curriculum ExpectationsVAbdominal

Exposures/incisionsVessential

Exposures/incisionsVessential Thoracotomy Thoracoscopy Sternotomy Pericardiotomy (includes subxiphoid, transdiaphragmatic, and transthoracic approaches)

n = 10 n = 10 n = 10 n=5

Endoscopy Enteral access Laparotomy Diagnostic laparoscopy Hepatic mobilization Damage-control techniques Complex laparoscopy (includes colectomy, lysis of adhesions, common bile duct exploration, Graham patch, hernia repair, enteral access)

Organ managementVessential Lung

Diaphragm Cardiac

Esophagus Intrathoracic great vessel injury

n = 35 Operative evacuation of the pleural space (n = 5) Parenchymal procedures (n = 10) Bronchoscopy (n = 20) May include thoracoabdominal exposures for spine surgery Includes emergent or elective cases requiring cardiac suture or repair Includes elective resection Includes endovascular stenting of aortic and subclavian injuries

= 20 = 10 = 10 =5 =2 = 10 = 10

Organ managementVessential Liver

n=5

n=2 n=3

n=5 Management of hemorrhage (n = 3) Reexploration of hepatic wound Hepatotomy Donor hepatectomy Transplantation Partial hepatectomy

n=5

Spleen

n=2 Splenectomy Splenorrhaphy

Kidney

Organ managementVdesired

Alternate modalities Simulation, ATOM, or ASSET courses may fulfill one requirement for each of the following: thoracotomy, sternotomy, diaphragm repair, cardiac repair, esophageal repair, or thoracic vascular repair. Similarly, organ harvest may fulfill one requirement for sternotomy.

n=3 Exploration Nephrectomy Partial nephrectomy Donor/recipient nephrectomy Renal repair Renal transplantation

Elective or emergent tracheal or bronchial procedures (not tracheostomy) Management of chest wall injuries (includes rib plating) Operative management intrathoracic great vessel injury Extracorporeal vascular support (includes ECMO, partial left heart bypass) Pancreas

n=5 Drainage Resection Repair Donor pancreatectomy Pancreatic transplantation

ATOM, Advanced Trauma Operative Management; ASSET, Advanced Surgical Skills for Exposure in Trauma; ECMO, extracorporeal membrane oxygenation.

Stomach

approaches or exposures and also addresses organ-based management. With the use of the thoracic subsection as an example, the desired approaches include thoracotomy, thoracoscopy, sternotomy, and pericardotomy, followed by organ management pertaining to the lung, diaphragm, heart, esophagus, and great vessels. In each anatomic subsection, simulation including but not limited to the Advanced Trauma Operative Management course and the Advanced Surgical Skills for Exposure in Trauma course, both products of the American College of Surgeons, can be used to satisfy one case. Organ harvest exposures may also be used for less common surgical exposures. It is anticipated that the fellow would choose both the exposure and the organ-based procedure performed for each case in their case log. Tables 1 to 5 detail the operative curriculum. Curricular changes included the identification of a minimum number of operative cases needed in specific body regions, in a manner similar to defined case volumes in general surgery as defined by the ACGME. The thought 194

n n n n n n n

n=5 Gastrectomy Management gastric injury Management gastric ulcer

Duodenum

n=2 Management duodenal injury Management duodenal ulcer

Small intestine

n = 10 Enterectomy Repair of injury Lysis of adhesions Management of volvulus/ intussusception/ internal hernia

Colon/rectum

n = 10 Colectomy Colostomy reversal Management rectal injury (continued on next page)

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TABLE 3. (Continued)

TABLE 4. Revised ACS Curriculum ExpectationsVVascular

Organ managementVessential

Exposures/incisionsVessential

Appendix

n = 15

Sternocleidomastoid incision Left medial visceral rotation Right medial visceral rotation Infrarenal aortopelvic exposure Brachial exposure Femoral Popliteal Retrograde balloon occlusion of aorta (may be obtained at the time of endovascular stenting for other disease)

Appendectomy Anus

n=5 Incision and drainage perirectal abscess Exam under anesthesia Fistula management

Biliary system Cholecystectomy with or without cholangiography Common bile duct exploration Hepaticoenterostomy

n = 3 exclusive of cholecystectomy

Bladder

=3 =2 =5 =3 =3 =5 =2 =5

Exposures/incisionsVdesired n=3

Trap door incision Cervical extension from sternotomy Supraclavicular incision Infraclavicular incision

Repair Cystectomy Ureter

n n n n n n n n

n=1 Repair/stent

Organ managementVessential

Alternate modalities Simulation, ATOM, or ASSET courses may fulfill one requirement for the following: bladder repair, or ureter repair.

Management of arterial disease for injury or occlusion

ATOM, Advanced Trauma Operative Management; ASSET, Advanced Surgical Skills for Exposure in Trauma.

process behind the creation of desired case volumes was twofold: first, to provide guidance to the fellows as to the types of cases they should seek, and second, to provide guidance to program directors and subspecialty colleagues as to the types of cases deemed important for fellowship training. Through a revision in the case log system, expected to go live in the winter of 2015, these data will be captured and reviewed. An end-of-fellowship examination has undergone several iterations and is currently administered to all graduating fellows. Although the fellow is not currently required to achieve a certain percentage score, as ongoing psychometrics is performed and the examination is refined, it is expected that successful completion of the examination will be required for certification in the future. Competencies are assured through the ACGME core competencies methodology, with plans to develop milestones for the entire 2-year fellowship in the near future.

CONCLUSION In times of challenge, creative solutions are often required. In response to the need for better emergency general surgery access and other pressing issues such as the surgeon workforce shortage and the consequences of the duty hour restrictions, the specialty of ACS was created, with the intent of providing a network of broad-based surgical specialists, trained to care for patients with emergent general surgical conditions including trauma and surgical critical care. The AAST has expended effort to assure adequate resources and infrastructure to oversee the ACS fellowship program. The AAST has established standards for training that are common for all ACS

n = 10 Open arterial bypass graft On-table angiography Thromboembolectomy Repair of arteriotomy or venous injury

Amputation of extremity Fasciotomy

n=3 n=5

Organ managementVdesired Placement of inferior vena caval filter Alternate modalities Simulation, ATOM, or ASSET courses may fulfill one requirement for the following: left medial visceral rotation, right medial visceral rotation, infrarenal aortopelvic exposure, or retrograde balloon occlusion of aorta. ATOM, Advanced Trauma Operative Management; ASSET, Advanced Surgical Skills for Exposure in Trauma.

TABLE 5. Revised ACS Curriculum ExpectationsVUltrasound Exposures/incisionsVessential None Organ managementVessential FAST and/or E-FAST Thoracic ultrasound to assess cardiac function Thoracic ultrasound-guided drainage Ultrasound-guided central line insertion

n n n n

= 25 = 15 =5 =5

Organ managementVdesired Transesophageal echocardiography Percutaneous cholecystostomy Ultrasound guided pericardiocentesis Ultrasound-guided IVC filter placement (IVUS or transabdominal) E-FAST, extended Focused Assessment with Sonography for Trauma; FAST, Focused Assessment with Sonography for Trauma; IVC, inferior vena cava; IVUS, intravascular ultrasound.

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fellowships, including the development of milestones of progress and the pragmatic use of objective testing of knowledge and independent experience of the fellows. As this training paradigm continues to mature, ongoing reevaluation of the program will continue, as we strive to augment the standard of emergency care for surgical patients in the United States. REFERENCES 1. Division of Advocacy and Health Policy. A growing crisis in patient access to emergency surgical care. Bull Am Coll Surg. 2006;91:8Y19. 2. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary. National Center for Health Statistics, Centers for Disease control and Prevention. Department of Health and Human Services. Available at: http://www.cdc.gov/nchs/ data/ad/ad358.pdf. Accessed December 11, 2009. 3. Institute of Medicine, Committee on the Future of Emergency Care in the U.S. Health System. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academy Press; 2006. 4. Kellermann A. Crisis in the emergency department. N Engl J Med. 2006; 355:1300Y1303. 5. American Hospital Association. Hospital Statistics 2006. Chicago, IL: Health Forum LLC; 2006. 6. Poley S, Belsky D, Gaul K, Ricketts T, Fraher E, Sheldon G. Longitudinal Trends in the U.S. Surgical Workforce, 1981Y2006. Chapel Hill, NC: American College of Surgeons Health Policy Research Institute; 2009.

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7. AAMC Center for Workforce Studies. 2012 Physician Specialty Data Book, https://members.aamc.org/eweb/upload/12-039%20Specialty%20Databook_ final2.pdf. Accessed September 30, 2014. 8. Borman KR, Vick LR, Biester TW, Mitchell ME. Changing demographics of residents choosing fellowships: long-term data from the American Board of Surgery. J Am Coll Surg. 2008;206:782Y788. 9. On-call specialist coverage in U.S. emergency departments, American College of Emergency Physicians Survey of Emergency Department Directors. April 2006. Available at: http://www.acep.org/NR/rdonlyres/ DF81A858-FD39-46F6-B46A-15DF99A45806/6/RWJ_oncallReport2006.pdf Accessed: September 30, 2014. 10. Rotondo MF. At the center of the ‘‘perfect storm’’: the patient. Surgery. 2007;141:291Y292. 11. Davis KA, Rozycki GS. Acute care surgery in evolution. Crit Care Med. 2010;38(Suppl):S405YS410. 12. Dente CJ, Duane TM, Jurkovich GJ, Britt LD, Meredith JW, Fildes JJ. How much and what type: analysis of the first year of the acute care surgery operative case log. J Trauma Acute Care Surg. 2014;76: 329Y339. 13. Duane TM, Dente CJ, Fildes JJ, Davis KA, Jurkovich GJ, Britt LD. Defining the acute care surgery curriculum. Paper #15 presented at the 73rd Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery. Available at: http:// www.aast.org/Assets/9e224825-382a-4e99-8a5f-ec8fd499ca76/635439546 750700000/oral-presentations-2014-8-18-14-pdf. Accessed October 6, 2014.

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Refining the operative curriculum of the acute care surgery fellowship.

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