August 2, 2017
The American College of Surgeons (ACS) Board of Governors Surgical Care Delivery Workgroup revised the following statement. The original statement was developed by the Board of Governors’ Committee on Socioeconomic Issues in collaboration with the Board of Governors’ Committee on Surgical Practice in Hospitals and Ambulatory Settings. The ACS Board of Regents reviewed and approved the revised statement at its June 2017 meeting in Chicago, IL.
Compassion and our professional ethics mandate that all patients faced with a surgical emergency receive the care they need. The ACS fully supports access to emergency surgical care for all members of our communities, but major issues of surgical manpower and resource utilization represent a threat to continued access. The ACS presents the following analyses and recommendations.
Emergency surgical call serves to meet patient needs. The Emergency Medical Treatment and Labor Act (EMTALA) regulations support patient care by Medicare-participating hospitals and provide a funding stream to the hospitals by means of the Medicare system. By means of partnership and collaboration with other surgeons within and outside the same practice, surgeons generally have been able to provide such service.
Our population has aged steadily. The older the population, the more health care required, both emergent and nonemergent. In addition, a significant number of indigent patients use the emergency room as the sole avenue to medical care. At the same time, the number of surgeons produced by our graduate medical education programs has remained stable for nearly 30 years.* In general surgery, the ratio of surgeons to population has been declining steadily since 1985. Other specialties with even fewer providers believe they can no longer meet community demands for their services.* As a result, the chasm between expectations for access to emergency surgical care and the surgeon workforce available to provide such care continues to increase.
The ACS recognizes the need for emergency surgical care.† Hospitals, as mandated by the government, have entered into contracts with the community to provide care, sometimes with limited involvement of the actual care providers in the negotiations. Surgeons feel deeply obligated to care for all individuals who require care. However, the surgeons attempting to provide this care must also be practical in the face of increasing demands.
To be able to provide emergency care in a sustainable fashion, surgical practices must remain fiscally viable, professionally attractive, and competitive in retaining and hiring surgeons. The challenges to this effort are myriad. Emergency surgical care may involve greater risks than care provided during elective, scheduled operations due to an inability to ensure preoperative patient optimization. Emergency surgical patients often have a high risk for complications due to advanced disease states, associated risk factors, and underlying patient comorbidities. Patients and their families may have unrealistic expectations for postoperative outcomes due to an underappreciation of the urgent nature of the surgical disease. The time-sensitive need for intervention may limit the ability to counsel patients and their families on possible outcomes and include input from primary care and other physicians. Occasionally, the acuity of the disease process prompts a patient or family desire to “do everything” when a more palliative approach may be more appropriate. Due to the nature of patient presentation, emergency surgical care needs to be available on a 24/7 basis. On-call requirements may have a negative impact on the surgeon’s time with family and the ability to provide community service outside of the profession.
The obligation to provide emergency surgery call care must be balanced with the means to do so; cost shifting to the surgeon is an unacceptable option. Unfortunately, this service is increasingly being mandated, and compensation should be appropriate to the commitment. Hospitals and communities must work with surgeons to ensure that lifesaving emergency surgical care continues to be available.
*American College of Surgeons. Statement on the Surgical Workforce. Bull Am Coll Surg. 2007;92(8):34-35.