The evidence that the present organizational structure of trauma centers saves lives has most recently been presented by McKenzie et al.,¹ Durham et al. (June Annals of Surgery), and Demetriades et al.² The finding that survival from equivalent injury treated in Level I trauma centers is 25% better compared to patients treated in nontrauma facilities argues strongly for such a system, and the availability of surgeons trained in and committed to the care of the injured. The magnitude of this difference in outcome must be taken into context, in that there is at present no data to support a comparable difference in outcome in national comparisons of centers for managing cancer or heart disease. Those differences may exist but have not been demonstrated. Furthermore, when considering the impact of reduction in death and disability from injury, which is responsible for more years of productive life lost than cancer and heart disease combined,³ the impact of trauma centers is further magnified. Finally, when considering the growing global importance of injury as a health problem, the adoption of organized trauma systems and the training of sufficient numbers of surgeons skilled and interested in care of the injured become more compelling.⁴

However, there is an increasing realization that the future availability of surgeons skilled and interested in management of the injured will be inadequate to meet the needs of the US health care delivery system.⁵ Early indications of this problem were noted by Richardson, Esposito, and Trunkey⁶,⁷,⁸ who found a lack of interest in trauma as a career choice for surgical residents. Several obvious perceptions contributed to this lack of interest, including time and call demands, unappealing patient population, and financial impact. Whether these perceptions are supported by evidence does not matter much because practice or subspecialty preference is more subjective than objective decision.

Review of surgical journals, web sites, and letters to program directors demonstrate a large number of open positions for trauma surgeons, or surgeons willing to cover trauma as part of their practice. Notably, many of these postings have been present for months or years. This suggests either that the position is not appealing, or that there are too few surgeons capable of or interested in filling that position. It is not feasible to accurately track the number of open trauma positions, or the number of surgeons taking such jobs. It is also difficult to determine how many trauma fellowship positions are filled because there is no official registry, although many are posted on several web sites. Surgical Critical Care (SCC) training is often associated with preparation for a career in trauma. Review of the number of SCC residencies and the number of residents in these positions over the last 6 years shows a 27% increase in the number of training programs and a 20% increase in the number of trainees from 2001 to 2006 (see Table 1). The actual number of SCC training positions is difficult to calculate, but usually only two thirds are filled.

Table 2 shows the number of surgeons who take the American Board of Surgery (ABS) examination in SCC for the years 2003 to 2005. Notably, fewer than half the first-time candidates finished their training the previous year. It appears that as many as a third of SCC trainees may never take the examination for certification. These findings suggest that some, perhaps a significant proportion, of SCC training positions are occupied by trainees who may not be eligible for examination by the ABS. Most importantly, what is not known is how many of these SCC-trained and SCC-certified surgeons are in a clinical practice that includes trauma coverage.

The concern for the number of surgeons participating in trauma care now is compounded by the anticipated fundamental changes in the training of surgeons of all types, changes in the practice of trauma surgery, and the changes in the trainees themselves.

Significant decreases in the number of applicants to general surgery resulted in the failure to fill approximately 7% of general surgery residency positions in 2001. Although the numbers of US senior medical students matching into general surgery increased somewhat since then, probably in part due to the 80 hour per week work limit, subspecialties requiring general surgery training have continued to have problems filling their training positions. Thoracic surgery, vascular surgery, and pediatric surgery have all had reductions in the number of US-trained applicants.

This has led thoracic and vascular surgical program directors more to primary board certification, which does not require completion of general surgery training. The impact of these changes in established subspecialties is overshadowed by the anticipated restructuring of what has been “general surgery” into subspecialties. The proposed new subspecialties include surgical oncology, gastrointestinal (GI) surgery, transplantation, acute care surgery, and some formats of general surgery, possibly comprehensive general surgery and/or rural surgery. The exact divisions and training paradigms have not yet been determined, but the changes are in development. The reality of increasing knowledge and differing skills in each subspecialty, the pursuit of fellowship training in one of these areas by approximately 75% of all present graduating general surgery trainees, the cost in time and money for the present 5 years of general surgery before specialization, and the actual practice patterns of established surgeons continue to push
toward this change, despite real concerns. These concerns include further fragmentation of patient care and major imbalances in workforce in the future.

The result of many of the proposed new paradigms will produce new surgeon subspecialists with only limited experience in trauma management whose certification will not include comprehensive trauma care, and who will not be able to be credentialed in trauma care at their hospitals.⁹ In such a training structure, only surgeons trained and certified in either acute care surgery, or possibly comprehensive and/or rural general surgery, will be credentialed to comprehensively manage acutely injured patients. Given that training in comprehensive general surgery will be focused on preparing surgeons for practice in communities without large specialty hospitals, the number of trauma-capable surgeons to staff urban trauma centers will be significantly impacted. As the more broadly trained general surgeons who provide much of the trauma care leave practice, the care of injured patients in the United States will suffer greatly.

The practice of trauma surgery has changed considerably in the last 25 years, and will continue to change. These changes are due to the frequency and types of injuries seen, as well as the methods of treatment.

Trauma has traditionally been perceived to be the management of penetrating trauma and motor vehicle crashes. Recent data has found that the incidence of penetrating trauma is down as much as 70% in some locales. Because most patients with major penetrating torso injuries require surgical interventions, this decrease in incidence has led to a decrease in operative procedures for trauma surgeons. At the same time, the surgical management of blunt truncal injuries has changed to more frequent nonoperative management. Hepatic, splenic, and renal injuries are most often managed nonoperatively.¹⁰

Although the drop in penetrating trauma and improved outcomes in some cases of blunt trauma managed nonoperatively has led to decreased trauma deaths, it has decreased the attractiveness of trauma surgery because of reduced operative activity.¹¹ The shift of trauma surgeons is out of the operating room (OR) and into the intensive care unit (ICU) to manage complex patients who require only orthopaedic and neurosurgical operations, or to meeting rooms to handle the increasing demand for policy changes, quality reviews, and process documentation. Although the critical care management role of the trauma surgeon has become more involved and comprehensive, it is difficult to interest enough young surgeons in a specialty with a low frequency of operative intervention, to meet the needs of trauma centers. Notably, as trauma surgeons bemoan their reduced operative activity, they continue to publish studies of nonoperative management of injuries in which the only outcome benefit is no surgery.

The demographics, and more importantly, the expectations, of surgical trainees continue to change. Graduating medical school classes have approximately the same number of men and women. General surgical training positions continue to attract more men than women, but the difference is decreasing. Studies have identified some impact of gender on the volume and type of practice activity. However, the differences are not large, and are mostly related to competing time demands for child rearing on women surgeons.¹²