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Sun Dec 30 01:13:55 GMT 2007

Dear Caesar,

Happy New Year.....

Your message has resonance all around the world. You would be familiar with
the issues in Australia and NZ and I don't think there are "one size fits
all" solution. Suggestions include

Having a champion who is Head of Dept. If progression in a subspecialty of
general surgery is dependent on an appropriate commitment to trauma care,
then that may help (the stick)

Centralisation of care. In big countries with widely dispersed populations
this is problematic but as you have outlined, in many areas volumes are low
and every sub or superspecialty has problems in this situation. Everything
should be done within reason to reduce the number of hospitals that have to
suffer this problem while at the same time increasing the satisfaction and
quality of care at those fewer number of hospitals that manage more trauma.
(neither stick nor carrot)

$s help. While they probably can never be enough, getting practically 0$ for
the added grief of trauma call will undoubtedly curb enthusiasm. If the
money is realistic that that certainly helps (the carrot).

I will be interested to see how this thread develops but I can absolutely
relate to the tone of your message. I have heard exactly the same thing
numerous times and I can understand it. Doing it as "service" just doesn't
cut it with the I-generation so whatever the issues are now, they will
probably get worse in the future.

Best wishes for the coming year to you and your family.

Ian Civil
Director of Trauma Services
Auckland City Hospital

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of caesar ursic
Sent: Sunday, December 30, 2007 5:41 AM
To: Trauma &amp, Critical Care mailing list
Subject: The Carrot or the Stick?

I hope that the following leads to some healthy discussions, useful
suggestions and even novel philosophical treatises, rather than dogmatic
posturing... so here goes.....

How does one motivate general surgeons to participate in trauma care?  I'm
referring to mature (in a career sense, not necessarily chronologically
old),  board-certified general surgeons who are already established in their
own various practice patterns within a hospital infrastructure, said
hospital being a level II or III trauma center.  I am not referring to
general surgery residents considering a 'career' in trauma/emergency
surgery.

Some background.  I am often asked by various hospitals in and around New
Mexico who are either newly-designated or considering designation as level
III trauma centers to 'advise' them in matters pertaining to trauma service
function, maintenance, upgrades, lubrication and trouble-shooting.  And one
of the most common problems I see is a lack of 'buy-in' or commitment form
the general surgeons who form the core of the trauma program.  Overall these
are very well qualified doctors; they have a good understanding of the
technical and cognitive approach to trauma care; they have trained in busy
trauma centers as residents or fellows, and know the concepts; they are
ATLS-certified; they know their way around the retroperitoneum, understand
damage control, and can open the chest if need be and address the bleeding
heart or lung.

But they just don't give a damn.  They are committed to their own practices
in general/vascular/GI/endocrine surgery, and taking trauma call is a major
hassle to them.  They won't attend trauma committee meetings because they
are operating that morning or they are making rounds or seeing their
patients.  They participate reluctantly or not at all in the Quality
Assurance/Improvement process;  they do not acquire trauma-related CME
education; they try their best to shunt initial ER care to the Emergency
Medicine physicians, who by necessity have become the primary caregivers and
decision makers during the 'golden hour' in most cases of seriously-injured
patients.  In short, the General Surgeons would just rather Not Be Bothered.

Eliminating them from the trauma call roster is not an option.  These trauma
centers are not large, university-affiliated hospitals with scores of young
consulting/attending surgeons yearning to climb the ladder of promotion and
willing to do whatever it takes to get there.  These surgeons are well
established in the community.  There are not a lot of them.  If one or more
of the surgeons are removed from trauma call, the system will collapse,
because the remaining few would simply be overwhelmed.  Financial incentives
are useless.  Paying extra $$ for full participation in trauma is
meaningless to surgeons who are already doing well financially and for whom
trauma call represents potential misses in general surgery-related payments,
which will always exceed the few hundred $$ to be made for a trauma call
shift.  No hospital will be willing to pay them what the surgeons truly
believe their time on call is worth (more than 1 to 2 thousand dollars, I
can assure you).

Making trauma 'fun' and 'interesting' by implementing well-catered
educational sessions/grand rounds/case studies that involve the surgeons
motivate no one.  Their life is already too busy taking care of their own
patients, attending their tumor board meetings and other various functions.
"If I wanted to be a trauma surgeon, I'd be working over at the University
Hospital right now, pal..."

The hospital administration won't threaten them.  Threaten them with what?
The hospital desperately needs them to take care of a large general surgery
patient population.  After all, the facts are the facts - only a minute
percentage of surgical emergencies presenting to the ER are trauma-related.
Can't argue with those statistics, can you?  The State verifying agencies
are only able/willing to issues vague statements like "we would like to see
greater participation of your surgeons in the various components of your
trauma system ...blah, blah, blah...."

So basically, what I often see is a group of surgeons who do not like to
care for the injured although they know how to do it.  And since they don't
want to, they cut corners, they avoid going the extra mile, they don't
invest themselves to the fullest, and care can and does suffer in subtle but
real ways.  ER times are too long.  Operations are delayed.  Unnecessary
scans are ordered.  Surgical care is deferred to internists.  Participation
in Process Improvement is nil or minimal. Not really what the Green Book
describes as 'Optimal Care,' is it?

And neither carrots nor sticks seem to help.

Happy New Year.

CM Ursic, MD
Trauma Medical Director
St Vincent Regional Medical Center
Santa FE, NM
USA

are just a handfuAnd
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The Carrot or the Stick?