1. Acute Care Surgery and Rural Surgery Similarities and Differences 4th Rural Surgery Symposium David Borgstrom, MD, FACS Mary Imogene Bassett Hospital Cooperstown, New York May 18, 2009

2. Objectives n What is rural? n What is a rural practice? n What is an acute care surgery practice? n Who is the rural surgeon? n Who is the acute care surgeon?

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

4. Population Density 2000 Census

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

6. Rural Surgery Practice n Endoscopy28% n Gynecology21% n Biliary8% n Breast5% n Ortho5% n ENT2% n Hernia10% n Colorectal8% n C-Section5% n Carpal Tunnel3% n Venous2% Landercasper, et al., Archives of Surgery, May, 1997

7. Rural Surgery Practice n 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 n Primary endoscopist for rural America n Gynecology/C-sections n Carpal tunnel release/ basic hand n Basic ENT n Urology n keep comfort level in the community

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

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

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

12. Acute Care Surgeon n Fellowship Training –24 month curriculum n Trauma/Critical Care6 months n Critical Care electives3 months n Emergency and Elective Surgery 15 months –Acute Care Surgery –Thoracic –Neurosurgery –Burns –Endoscopy

13. Acute Care Surgeon n Four AAST accredited fellowships –30 page PIF –more to come n General, Trauma, Burns, Surgical Critical Care, Acute Care Surgery n Transplant, Hepatobiliary, IR, Vascular, Thoracic, Peds, Neuro, Ortho Plastics, Urology, ENT, Anesthesia, Pulmonary, Cardiology, Emergency Medicine, Gastroenterology

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

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

16. Acute Care Surgeon n Blessing to Specialists

17. Acute Care Surgery n Trauma Center/ Acute Care Surgery Center –Fixed costs/ volume based –Income generation for facility n $150K for physician - $1.5m hospital n savings $100K for community hospital –pancreas-biliary, appendectomy, soft tissue infection –25% no insurance Block, AAST 2008

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

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

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

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

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

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

25. Acute Care Surgery n ? New income streams in a non- operative specialty? n ? Is this a further narrowing of the once broad scope of general surgery? n ? Is this the same thought process that promoted the specialist in Surgical Critical Care?

26. Acute Care Surgery n ? New income streams in a non- operative specialty? n ? Is this a further narrowing of the once broad scope of general surgery? n ? Is this the same thought process that promoted the specialist in Surgical Critical Care? n ? Is this a good thing?

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

28. 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

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

30. Partnership n Surgical Care Delivery System –Resources –Innovation –Experience

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

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

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

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

35. Brisbane 1.6 m Sydney 4.3 m Melbourne 3.7 m Adelaide 1.2 mPerth 1.4 m Alice Springs 25 K Whyalla 24 K

36. “Shortage of General Surgeons Endangers Rural Americans” Washington Post, January 1, 2009 Wall Street Journal, January 13, 2009 “Surgeon Shortage Pushes Hospitals to Hire Temps”