Can trauma surgeons survive business medicine

Although it may be apocryphal, it is said that the Chinese have a curse that states, “May you live in interesting times.” We live in interesting times. Hospitals across the country are facing financial difficulty and trauma centers are the first area examined for closure. Trauma centers in Pennsylvania, West Virginia, and Las Vegas have closed, at least temporarily, because of problems with specialist coverage. The insurance crisis in many of our states has created a situation where even physicians who are willing to care for trauma patients cannot get professional liability coverage, forcing them to either move to more physician friendly states, to come up with new alternatives such as physician or specialty owned carriers, or even to go bare. A flaw in the Medicare reimbursement formula has lead to a 10% decrease in physician payments over two years. And, even though Medicare does not pay a large role in trauma reimbursement, we all know that as Medicare does, other carriers rapidly follow. Leapfrog and other consumer groups are demanding “quality care” and are determining what that quality is, whether we agree with it or not. This quest for quality has lead to the 80 hour workweek for residents, which leads us to wonder how we will do the work we need to do and says nothing of how we will educate residents with these limitations. Finally, despite these restrictions, we still face the issue that medical students are not choosing surgical residencies as they did before, and surgical residents are not choosing trauma fellowships for training. How can trauma surgery and trauma surgeons survive in the current economic environment of medicine? Surely there have never been such interesting (and dangerous) times for our field? As most presidents do in preparing their presidential addresses, I went back and reviewed the addresses of my predecessors to gain historical perspective and to reexamine their wisdom. In doing that, I learned once again that there are no new problems in medicine—whatever problems appear new at the time have almost certainly been considered in the past, even if the tools were not available to address them. This also applies to the problems I am considering today. Our first president, Kimball Maull, talked about the disconnect between the public perception of trauma and the actual problem that trauma presents to society. Our second president, Burton Harris, talked about the problems of the redefinition of surgery and the surgical specialties, the lack of interest of many surgeons in doing trauma, and most fearsome of all, the evil effects of business on the field of medicine. Len Jacobs talked about the forces of diversification and specialization which were affecting trauma care and noted that “Uncompensated trauma care and maldistribution of trauma centers Submitted for publication May 7, 2003. Accepted for publication May 12, 2003. Copyright © 2003 by Lippincott Williams & Wilkins, Inc. From the Division of Trauma/Critical Care, University of Tennessee Medical Center, Knoxville, Tennessee. Presidential address presented at the 16th Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 15–18, 2003, Ft. Myers, Florida. Address for correspondence: Blaine L. Enderson, MD, MBA, FACS, FCCM, Professor of Surgery and Chief, Division of Trauma/Critical Care, University of Tennessee Medical Center at Knoxville, Department of Surgery, University Memorial Hospital, 1924 Alcoa Highway, Knoxville, Tennessee, 37920-6999; email: benderso@utk.edu.