Fellowship Training in Trauma/Critical Care Surgery

As published in the American Journal of Surgery (February 2010, Volume 199, Number 2). Re-published at OnSurg by permission of our collaborative partners at the Association for Women Surgeons.

Authored by M Margaret Knudsen MD FACS

[Please note a separate article describing Training in Surgical Critical Care (without the dedicated trauma experience available at some programs).]

Abstract: The specialty of trauma/critical care is relatively new and is currently in a state of evolution as we now face not only a shortage of surgeons but also an alarmingly increasing number of well trained surgeons who are unwilling to provide emergency care. Regionalization of both trauma and emergency surgical care nationwide is on the horizon and will require major changes in our surgical training programs. However, careers in trauma/critical care and emergency surgery can offer a controlled life-style, challenging cases that cross over many disciplines, and a rich field for scientific investigation.

Historical Perspectives

For many years, advances in the care of the injured patient were tightly linked to military conflicts. Indeed, the current military actions in Iraq and Afghanistan have resulted in a number of important changes in how trauma patients are managed.⁽¹⁾ For the most part, however, injuries resulting from trauma were considered “accidental” and therefore not a “disease” per se. Even today, most people do not realize that injury is the number one public health problem in our country, with a price tag of over $260 billion annually.⁽²⁾ Fortunately, civilian trauma care in the United States changed dramatically in 1973 with the passage of the Emergency Medical Services Systems Act which provided guidelines and financial assistance for developing EMS systems.⁽³⁾These new emergency systems delivered the critically ill and injured patients to large hospitals with the equipment and services needed to care for them. Inner-city public and academic institutions (for example, Cook County Hospital in Chicago, Grady Memorial Hospital in Atlanta, Bellevue Hospital in New York, and San Francisco General Hospital) became de facto “trauma centers”. Parallel to these developments, the American College of Surgeons published standards for the “Resources for Optimal Care of the Injured Patient,” which greatly facilitated the verification and designation of trauma centers in many locations.⁽⁴⁾ A recent study by MacKenzie and others demonstrated conclusively that that the mortality rate for patients treated in a trauma center are significantly lower than those at non-trauma centers.⁽⁵⁾ While these results should prompt continued development of a nation-wide system of trauma and emergency care assuring that everyone has access to the level of treatment based on their need, the 2007 Institute of Medicine Report suggests that hospital-based emergency care in our country is at the breaking point.⁽⁶⁾ Our field, and particularly our patients, are in need of energetic young surgeons with the proper training to care for emergency general surgical conditions, traumatic injuries, and surgical critical care, and who are committed to being available 24/7 during their scheduled coverage days, and who have an interest in advancing the science of injury/emergency surgical care and prevention.

Training Requirements

Residency

Completion of a general surgery residency is the minimal requirement for working as a trauma surgeon. However, both academic and non-academic trauma surgeons are now opting for at least one year of post-graduate training, primarily in critical care. When choosing a general surgery residency, a student interested in trauma should select a program that includes a broad exposure to organized trauma care, including emergency department training, trauma surgical training, rotations in orthopedic, neurologic and urologic surgery as well as surgical critical care.

Fellowship Training

Because trauma surgeons must be competent in surgical critical care, a year of critical care fellowship is essential. Critical care boards cannot be obtained without at least one year of critical care training, and there are restrictions on the number of hours spent during that year that can be used for trauma surgical call (3 months on the trauma service). At the end of a one-year critical care fellowship, and provided that the candidate has already passed general surgical boards, the fellow can sit for the Special Competency exam for Surgical Critical Care through the American Board of surgery. The listing of approved trauma/critical care fellowships can be found on the Website of the American Association for the Surgery of Trauma (www.aast.org).

Trauma Fellowship

Many programs offer a two-year fellowship, one to fulfill the critical care training, and the second for added experience in trauma surgery. (Note: There is currently no separate board for trauma surgery itself). Trauma fellowships are designed to allow the trainee to learn about the various components of running an organized trauma service (i.e. trauma registry, trauma performance improvement) and to spend time as a junior attending under the guidance of an experienced trauma surgeon. A complete list of RRC Approved Critical Care fellowships can be obtained at the Website of the American Association for the Surgery of Trauma (AAST).⁽¹⁾ Trauma fellowship and trauma research opportunities are also listed on that Website.

Acute Care Surgery

A new paradigm for surgical training is emerging even as this paper is being written. The concept was designed to assure that, as general surgery has become increasingly specialized and fragmented, the acute care surgical fellowship will provide broadly training for surgeon in surgical emergencies, trauma care, and critical care. The curriculum has been finalized and one institution to date has undergone a successful site visit. An example of such a curriculum can be viewed in the newly published book:Acute Care Surgery: Principles and Practice. (Britt, Editor in Chief).⁽⁷⁾ Once again, there has been no decision to date on whether or not this new curriculum will be “certified” by the American Board of Surgery.

Board Certification

As mentioned above, there are no specific boards for trauma surgery itself. After completion of general surgical boards, a critical care fellowship is recommended so that specialty boards in surgical critical care can be obtained.

Grant Funding, Research Fellowships, Travel Fellowships

Medical Students

Unfortunately, there is little trauma care education for medical students. The basic principles of trauma care for medical students can be assessed via the TEAM course, offered by the American College of Surgeons Committee on Trauma. Some students are exposed to trauma on rotations in busy trauma hospitals with a trauma surgeon as a preceptor. Fourth year medical students interested in trauma will often seek out these positions by rotating to another program. Trauma research positions do exist for premedical students at various academic institutions, but there is no central repository containing this information. Even more tragic, medical students are taught almost nothing about injury prevention and control, although there is a move to change the curriculum to accommodate this deficiency. The AAST encourages medical students to attend their annual scientific meeting and selected students will have their expenses covered. Another interesting development is the recent interest displayed by medical student in Global Health.(8) As injury represents a major heath care burden in developing countries, many more medical students have taken an interest in the field of trauma.

Residents

Residents who wish to pursue careers in trauma surgery should seek out research positions from one of the 10 NIH centers who have trauma training grants. These grants are designed for residents who plan an academic trauma career and are usually for 2 years during mid-residency. Both basic and clinical research are included at most centers. The NIH-Trauma Training Centers are listed on the AAST Website (www.aast.org).

Faculty

Funds for research at the faculty level in trauma are very limited. The American Association for the Surgery of Trauma funds several trauma research fellows per year, at the junior faculty level. NIH funds some basic laboratory work of interest to trauma/critical care surgeons but very little in the area of clinical work. However, the Center for Disease Control for Research and Prevention funds 11 Centers of Excellence in Trauma Care and Injury Prevention. Additional funds for injury and violence prevention projects for individuals are also available from the www.CDC.gov

Membership in Societies

The American College of Surgeons Committee on Trauma (ASCOT)

Members and Associate members of the American College of Surgeons (FACS) can join their local Chapter’s Committee on Trauma. By working with the National COT, the Committees on Trauma assist with designation of trauma centers, organizing trauma systems, education of trauma professionals (including sponsoring the Advanced Trauma Life Support Course), advocating for trauma legislation, and injury prevention activities.(www.facs.org; trauma)

The American Association for the Surgery of Trauma (AAST)

This is the largest academic association of trauma surgeons. Their goal is to promote trauma research and dissemination of research findings to the trauma surgical community. Membership requires that the surgeon be a fellow of the ACS and usually has established him/herself in a community as a trauma surgeon for at least 1-2 years after completion of residency/fellowship. (www.aast.org)

The Eastern Association for the Surgery of Trauma

This is another large group of both academic and community surgeons that holds annual meetings with formal paper presentations. Additionally, they have developed some very active subcommittees that focus on practice guidelines and trauma literature reviews. Their prevention committee has also been very active. The membership tends to be younger than that of the AAST and it is a good place for a junior attending to present her first national scientific paper. (www.east.org)

VIDEO: EAST members discuss careers in acute care surgery

The Western Trauma Association

The WTA is the only trauma group with wide-spread representation from trauma sub-specialists (i.e. orthopedic surgeons, ENT, emergency medicine, neurosurgery, thoracic surgery). The scientific presentations are of high quality and most papers are found acceptable for publication in the Journal of Trauma and Critical Care. The subspecialty involvement is critical in trauma care, and the WTA will only allow 40% of its 125 members to be from any one field of trauma. This is a great meeting for residents, fellows, and junior faculty to attend, but one must be invited by a member. The multi-center study group from WTA has published over 20 papers and they are heavily cited in the trauma literature. (www.westerntraumaassociation.org)

References

1. Moore EE, Knudson MM, Schwab CW et al: Military-civilian collaboration in trauma care and the senior visiting surgeon program. New Engl Journal of Medicine 2007;357:2723.
2. Bonnie RJ, Fulco CE, Liverman CT: Magnitude and costs: reducing the burden of injury, advancing prevention and treatment. Washington DC, National Academy Press, 1999, Chapter 2, pp. 41-59.
3. Emergency Medical Services Systems Act of 1973, Public Law 93-154. Washington D.C. 1973.
4. American College of Surgeons Committee on Trauma: Resources for optimal care of the injured patient 2006. American College of Surgeons, Chicago, 2006.
5. Mackenzie EJ, Rivara RF, Jurkovich GJ et al: A national evaluation of the effect of trauma-center care on mortality. New England Journal of Medicine 2006;354:366.
6. Institute of Medicine: Future of emergency care; hospital-based emergency care at the breaking point. 2007, National Academies Press, Washington D.C.
7. Acute Care Surgery: Principles and Practice. L.D.Britt, D.D. Trunkey, D.V. Feliciano (eds). 2007, Springer, New York.
8. Panosian C, Coates TJ: The new medical “missionaries”-grooming the next generation of global health workers. New Engl Journal of Medicine. 2006;354:1771.

Link to OnSurg Directory of Trauma/Critical Care Fellowships
VIDEO: EAST members discuss careers in acute care surgery

Link to descriptions of other gen surg subspeciaties: