BIG T Trauma Series Ep. 20: Defining the Value of an Acute Care Surgeon

Time is really the only capital that any human being has and the only thing that he can't afford to lose. Those are the wise words that have been attributed to none other than Thomas Edison. And with that we launch into our latest episode of the Big T Trauma Podcast on Behind the Knife. Today we are going to discuss what it means to be a full time acute care surgeon. Patrick: How many weeks of call? How many night shifts? What's an acute care surgeon's worth? And does coding a patient in the ICU at 1 a. m. increase it? How about responding to a level one trauma at 2 a. m. and then yoinking out some dead gut at 3 a. m. Now we all love it, correct? But what is the value of that care? Patrick: that we provide is a question that I've always been curious about, especially when I stumble out of the call room at 5 a. m. with bloodshot eyes and a sore back after spending another night not sleeping and just in general destroying my health. Of course, I do love it. That's why we do it. I swear. But let's get into our introductions with that. Patrick: I'm Patrick Georgoff, trauma surgeon at Duke. I'm joined by my friends, Dr.

Teddy Puzio, trauma surgeon at Red Duke Trauma Center, the University of Texas in Houston, where he's also assistant PD of the acute care fellowship and Dr. Commander. Jason Brill, Trauma Medical Director of the U. S. Indo Pacific Command and our most venerable guest, Dr. Patrick: Pat Murphy. Dr. Murphy is an Assistant Professor of Surgery at the Medical College of Wisconsin. He completed his medical training in Canada, his fellowship at Indiana University, and he holds an MPH from Johns Hopkins University. Pat is the Associate Medical Director of the Acute Care Surgery Service at NCW, and as part of his research, Dr. Patrick: has looked at what defines full time employment in trauma and acute care surgery. Pat, welcome to Behind the Knife. This has been a long time coming. Thank you. So can you get us started by briefly walking us through the history of acute care surgery? Because this is really a relatively new specialty. Patrick: Yeah. Thanks for having me on. This is a topic I'm very passionate about and if you ever find me at a conference or In person, I'll talk

you're off about this. So the history of ACS is really interesting because we're still living through it. It's still an evolving specialty. Patrick: And I think this, depending on your perspective. You might look at it as the, newest subspecialty in general surgery or the oldest, the kind of the generalist of general surgery and, prior to all the subspecialization of surgery, there just was a true generalist who took call and did everything. Patrick: And that really changed with the, advent of vascular surgery, urology, plastics, orthopedic, all these branches of general surgery, which have only increased, we've narrowed even within general surgery. And with this subspecialization, there was a patient group that was left behind and that's the emergency general surgery patient. Patrick: And around this time, in the late 90s, early 2000s, trauma was becoming more non operative. And so, the unmet need of the emergency general surgery patient collided with that reality. And, I love this quote, there's a, from the Institute of

Medicine in 2006. Basically, they identified that with the subspecialty boom, many surgeons didn't want to really do on call work anymore. Patrick: And there was really an unmet need for emergency surgical services. And so that's how trauma captured the emergency surgery population. And they were already doing surgical critical care. And those are the three classically described pillars of acute care surgery, which is the nomenclature that was used in the early 2000s and we still use. Patrick: There was a meeting between Mary College Surgeon, WST East and West, and this is where the specialty was born in the early 2000s. And since then, two other pillars, I think, have been added. Surgical rescue and elective surgery and then burn has been folded in as well in more recent years. Patrick: So that's the history of the specialty. Yeah, I have a quick question before we get

into the FTE work that you've done, Pat. How often are you explaining this concept still to non surgeon colleagues? I know this was the AAST's child in terms of marketing and messaging, but I wonder what your take is on whether that's been received by non surgeons. Patrick: Yeah, that's a really fascinating question, because I think with the fact that our specialty has really only been around for 20 years, there still is a kind of nomenclature and branding challenge within our specialty. Our own journal is not the Journal of Acute Care Surgery, it's the Journal of Trauma and Acute Care Surgery. Patrick: And I think if you ask people, what kind of surgeon they are, you get a lot of answers. mix. And some people say I'm a trauma surgeon. Some people say I'm an acute care surgeon. And I think that has led to a lot of the

confusion outside of our specialty. And, even within our specialty, there's a lot of variability in what we do at centers around the country. Patrick: There's differences between level one and level three centers in terms of What that job looks like. And I think we're still trying to figure out what's the best model of care for patients. What's the best model of care for surgeons? And, the reality is that if you look at acute care surgery patients, they represent 20 percent of all hospital admissions in the U. Patrick: S. and 25 percent of all the costs. And so, it's an evolving thing, but I think it's really important to talk about it. And I think there is a lot of confusion as you identified, not only outside of our specialty, but talking to other surgeons. All my neighbors think I'm an ed doctor still. Patrick: Yeah I only swing through there on the way to the OR. So Pat, now that we've talked about the history

of acute care surgery it's evolving history history in the making right now. What prompted you to study the provider aspect of this in terms of hours, pay, what makes up a full time. Patrick: equivalent. In other words, what was the problem that you saw that needed to be addressed in a slightly more scientific way than it had been previously? So there's a few big reasons that I got into this work and it largely relates to when I was looking for my first job back in 2020. I was looking at job postings on all the typical job boards and I would read these postings and it would say what a nice city it was. Patrick: how close the airport was, how much penetrating trauma there was, and it didn't tell me things I was really interested in knowing. How much I was expected to work,

how much call I was going to do, what was the patient mix, how many operations would I be doing, and what I'd be paid. The things that I would normally look for in a job posting, if I was applying to be a computer programmer. Patrick: I would expect those things in a job posting. And they really weren't in there outside of the very few, which said a full time job is, 180, 12 hour call shifts. Like that's a good starting point for, is that what I want in my life? Or is that the right number? Too low, too high. At least it gave me some aspect of what the job was going to look like instead of. Patrick: How nice the city was also important. And, as I went down that rabbit hole, it was still unclear how much. I'd be expected to work and what the job would look like, like what was a full time job at that institution? Patrick: the answers were all over the place and You know related to that as I dug into this more I've

since learned that you know among surgeons trauma surgeons are the most burnt out we're third in depression among surgeons and the vast majority of literature Really shows a strong relationship between the type, volume and intensity of work we perform and those outcomes for surgeons. Patrick: And, it's not a problem that's going away. The AMA just released their 2024 report that said our shortage of surgeons is only getting worse. So, I'm looking at it from the concept of this really affects me and probably a lot of people who are listening to this and this is stability in the future of our specialty. Patrick: Yeah,, I think that's a good segue the question that really it boils down to that. We all ask, but I really want your opinion because this is something that we've struggled with. At my center too, is how do you define a full time equivalent for an acute care surgeon? Patrick: It's hard to know when you look at different

jobs, but what do you think that should look like? So how many calls per week? How many weekends per month? How do we define that? So, one of the challenges is when we all sit down and talk and we ask each other how much we work. Patrick: I might say, I work 26 clinical weeks and do 4 call a month. But, that doesn't give you any insight into what I consider a week. Is that 5 days, 4 days, 7 days? How long are those days? When I say four call, does that mean the overnight call 5 p. m. to 7 a. m. Or am I talking about 24 hour call? And so it can be really hard to compare apples to apples when we don't really have a definition of any of those things. Patrick: And so I like talking about our work in shifts. And I say that a bit reluctantly because I

don't view us as shift workers. I certainly don't view myself as a shift worker, but in terms of talking about our jobs and accounting for the time and effort we put into our work, I use shifts. And so my definition of a full time clinical job, a 1. Patrick: 0 FTE, is maximally 204 shifts a year. And I consider a shift anything between 10 and 14 hours. So that means if I work Monday through Friday, 7 a. m. to 5 p. m. on, say, the trauma service covering traumas, trauma call during the day, and cases and rounding, that's five shifts. If I do a Wednesday night, 5 p. Patrick: m. to 7 a. m., that's one shift I do. If I do a 24 hour call on Saturday, that's two shifts. And so that converts A lot of the inconsistent language into a very comparable language between centers

and the 204 number really comes from some work we did where we both asked people, how much is everyone working and we asked early career surgeons how much they want to work and 204 shifts is really around, what Someone who does purely elective surgery would work, be about, they took weekends off and holidays off, be about 220 ish days, after you account for vacation and CME. Patrick: Ours is a little less, which I think takes into account the fact that 43 nights of the year I'm away from my family. How do you factor in, intensity of shifts? Right? Is that a center specific definition? Patrick: Because at my center, I probably have. six different roles. And I can tell you that not all of them make me feel the same when I'm done, right? A call shift overnight we get crushed, but a daytime rounding on the floor, it's

different. So, should those be thought about as the same? Patrick: Right. And I think that has come up quite a bit and, maybe a more contrasting example is if you were at a trauma center that sees less volume. So say you're a level three rural trauma center that sees a low volume. A Saturday 24 hour call, you might see a couple of trauma activations, none of which need no R, and you round it on five patients. Patrick: That hits very differently than maybe 24 hour call where you work at a level one center where those 24 hours, you're lucky if you see your call room or eat. And so how do you compare those two things? And I don't know the answer to that. And I think most of the strategies is a local consideration where people spread the hurt equally. Patrick: And so they recognize that there are differences in intensity between the

different jobs that they have. So they try to spread them equally among the staff in terms of one person doesn't always do surgical ICU. Like there's a relatively equal spread of the distribution for each of their faculty. Patrick: That's how most people have handled it in my experience. Pat, do you have any ideas about how to standardize that? Right? Because I mean, I totally agree with Teddy. I have plenty of anecdotes for the level three that I'm at where I can be busy for the level three, but. It's no big deal for those 24 hours. Patrick: And then I go to the level one that I work at in 12 hours can crush my soul. I rebound quickly, but still it happens. Yeah, I think some of the intensity Aspects has to be addressed locally. And I think I can give you an example of how that might be considered. So say you have a surgical ICU of 25 patients. Is that appropriate for one person? To cover Monday through

Friday, 7 a. Patrick: m. to 5 p. m. Is it right for one person to round on 25 surgically critically ill patients? The answer is probably no, cause we recognize that's too high volume. They're too complex and no one wants to be the 25th patient rounded on in that environment. And so what I think some centers are doing now are recognizing and looking at the intensity of that work. Patrick: And trying to lower that or make their services a little more equivalent. So one strategy there might be to say, we actually need to surgical ICU teams. And so we're going to lower that volume and intensity down to 12 patients per surgeon. And we're going to add the faculty, from residents and advanced practice providers to support that. Patrick: Similar, when do you decide to go into have two trauma faculty in house overnight? That's You do it when

you view it's not safe. I don't have a great cutoff. It's one of those, when you see it. But I think a lot of centers, once they reach a certain volume of work density, they've made that decision to go to two faculty in house. Patrick: We have two faculty in house here. I don't think you convince anyone to go back to one faculty because we don't think it's safe for patients or us. Yeah, and Pat, I want to push a little bit on some specifics. So let's take an average level one trauma center in which you're doing a three plus part mission of EGS trauma. Patrick: Let's say it's a bit busy by whatever definition, three, four, 5, 000 plus traumas a year and you're rounded in ICU and take a week, seven day week, 10, 12 hours a day., what's the average number of weeks that acute care surgeons work at large, trauma centers? Let Yeah. So the

average of what is currently being done based on our work is 24 to 28 weeks a year and four to five call a month. And that is part of where, I converted to 204 shifts based on some additional study, which we asked people how much they actually want to work instead of what people were currently working, what was that answer for how many weeks do people want to work Patrick: it was closer to 24 and four call. And part of the issue is if you tell someone, Hey, I only work 24 weeks a year, they're like, what are you doing in the other 24 weeks or remaining, weeks of the year. Yeah. That doesn't sound very appetizing to most. When people say that, I always say like, well, you want to come shadow and see what this feels like. Patrick: Yeah, the reality is it depending on your setup, like, and I'll fall back to what a lot of places I think are

trying to do are if you, if your setup is service weeks, doing overnight call when you're on a service week disrupts the patient continuity because your post call, you're trying to go home for your rest. Patrick: And. You can't really provide a lot of that continuity to that inpatient service So if you get rid of weeknight calls when you're on service That means in those other weeks, you're not on service. You're doing a tuesday thursday call. You're doing a monday thursday call That week is destroyed like if cases meetings There's other work that's happening in those Weeks, that's why I like looking at it As shifts, because it, I think it's a higher number and D I think it better encapsulates the volume of work we're actually doing. Patrick: Yeah. And we'll talk about this some more too, but that's certainly not fully appreciated. I've come to

recognize that whether you're talking about the C suite, whether you're talking about other surgeons who long ago stopped taking a call or non surgical, colleagues, I thoroughly believe that's not fully appreciated. Patrick: How about RVUs annually? Do you have any good information on that? Obviously It's hugely different depending on what type of a practice you have, what collection patterns are. What the emphasis is on billing at your institution is an RVU model or a salary model all that matters But do you have a ballpark RVU that a 24 to 28 week a year ACS surgeon might bring in. Patrick: Yeah, so i'll give you a number with a few caveats Work RVUs for our specialty Have always Interested in me because Patrick: We don't control our volume. So just consider the pillars that I spoke about. Surgical rescue, critical care, trauma and emergency general surgery. We're going to come back to surgical rescue in a minute here, but yeah, I

don't cause appendicitis. I don't shoot people. I don't cause someone to need the surgical ICU. Patrick: So unlike elective surgery, I don't control my volume in any meaningful way. The hospital still requires someone to be on call and take care of that group of patients. And so it, there's a disconnect there. So why would it be that I am judged on my volume or billing when I have no reasonable control over it? Patrick: That has never made sense to me. So if I'm covering 24 hour call and on trauma and no one gets shot, I view that as a win. And The reality is the hospital still needed someone to be on call for trauma, even though no trauma happened. Patrick: So what are some ballpark numbers that are being around? The average at a level one would be around 6500 RVUs. And I

will say that I actually like work RVUs as a measure of divisional productivity, because it gives you a good sense of what the volume of work your division is responsible for. And I think that's a good thing that helps everyone see the amount of work your division does. Patrick: And it allows for comparison between other groups who, elective surgery groups who do use the WorkRVU as their main source of productivity measure. And it also, I think, allows some reflection within groups. Such that if you have two surgeons who are working the same amount of time on the same services And their RVUs are wildly different That's helpful information because that means someone's you know Either doing something really right and capturing all their billing as they should or someone's missing billing that they should be doing or just under billing and That's not good either. Patrick: And so the RVU can

be really helpful in that circumstance both for divisional productivity and looking at individuals who work a similar amount to, cause they all should be around the same, some nights you're busy, some nights you're not, and that should balance out over a year. It seems like as much as we wanna standardize it, in my mind what I hear you saying, again, it goes back to like it's somewhat of an institutional definition, right? Patrick: And this fact that you look at it as a group makes sense, right? Because when I hear you talking about that, I think about, there are some components of my job that I don't do very often, that it doesn't really generate that much money. A an example would be, like if I do ICU weeks consistently, my RVU generation is. Patrick: Way higher for that month. So partners that do less critical care may have less RVU billing, but as you said, they're not Doing less work. They're just doing less Avenue generating work maybe so it makes sense to

look at your own group individually But have some frame of reference when you compare to others. Patrick: Yeah, the Unfortunate thing is the RVU is the gold standard and that's how they decide how much you should be paid Which why should I Be paid more or less when I again don't control the volume of my work So i'd like to go back for a second to something that patrick brought up in surgical rescue as being within the realm of responsibility for Acute care surgeons and I would put that forward as the perfect example of The on call mentality of an acute care surgeon, like ready to serve whoever walks in and yet produces almost no measurable work RVUs, right? Patrick: So when I go down to the ED and I crike somebody because nobody can get the airway like that, I don't really bill much for that. And yet we have an emergency.

Rescue airway team specifically designed for that because the hospital recognizes that's value care. Right. But the ENTs and the elective surgeons, they're all upstairs doing cases, so they can't run down and do that but the trauma team does. Patrick: So can you further define surgical rescue and how that looks in centers and how we should define that as a group? And I think you're really getting into some of the. intangible value that our specialty can bring to hospitals that is not captured adequately by work RVUs, but is the benefit of having someone dedicated not only to surgical emergencies through the emergency room and trauma, but also their presence is valuable and meaningful to prevent disasters like airways. Patrick: So, for those listening, surgical rescue is really the intervention when patients are

experiencing A disruption from the expected course postoperatively, that's typically how it's defined, and the real main tenets are early recognition that something unexpected is happening to that patient, time critical intervention, that's why it's really helpful to have someone in house, and a dedicated system to take care of that, like an airway team, that is meant to take care of that group of patients. Patrick: And it's really a broad scope. It's not just the airway. It's also hemorrhage control and resuscitation and really builds upon the search, surgical critical care training. Most of us have Patrick: Pat, I want to shift gears a little bit. We've been talking a lot about work and RV use, and I think it's suffice to say in this realm, we should talk a little bit about money. And you talked about historically, right. Before the acute care surgeon. We had people that just took a call and that was part of their job. Patrick: But now that we are a specialty where

we have taken over all of the emergency general surgery call and the trauma call, are these shifts that we should be getting paid extra for as part of this, and considering that we spend time in the hospital disrupting our circadian rhythm, Patrick: how do you think about that? Patrick: I think there's a few ways to approach that. And I think we have to recognize that healthcare in 2024 looks very different from healthcare in 1990. Surgeons and physicians are more likely to be employed by a hospital system now more than ever, compared to private practice environments, where that relationship, I think, was very different, both in determining how much Someone should work and how they were compensated for that work. Patrick: And so it depends on your perspective I think a lot of places have taken Different approaches to this depending on how their funds flow And

so I can give a few ways you might consider this one is you can just say All shifts are equal ICU trauma emergency general surgery And we're going to assign an hourly wage to that work You And that makes the math really easy for what your salary is, depending on how many shifts you work. Patrick: And that's a very transparent way to do it. If you work less shifts, you make less money. If you work more shifts, you make more money. And it's not tied to the volume that you generate while you're working. There are models where they say, this is your base salary. And call is going to pay this distinct number. Patrick: And sometimes it differentiates duration and type of call. Whether it's in house or at home. So I think the answer is, yes, your work should be accounted for entirely. How you should be paid, whether you're on call or working during the day, I think is

very institutional dependent and depends on many things. Patrick: But I think that you should be viewed as part of the infrastructure as the hospital. So, you shouldn't have to be profitable to exist do you think we should get paid more for night shifts? For taking that burden off of whoever may have held it before? Yeah, and should my schedule, have a proposition 65 warning on it? Patrick: For, all of the carcinogens it's flooding my system with, right? Not only for a pay, but, kind of disruption to the rest of our lives and longevity as surgeons. That's a little tongue in cheek, but still, I know some people are asking it. Yeah. I think most places have not differentiated between night, day, weekend, and holiday work, and I suspect there's many reasons for that lack of distinction. Patrick: The way most have gotten around that is just, again, spread the hurt equally.

If you have FTE for some other non clinical job, most places continue to do the same amount of nighttime work as everyone else. And you just do less of the daytime work clinically. And so do I think Nights and weekends and holidays should come with a premium. Patrick: Yeah, just like I think the work rv for a hawk gallbladder should pay more than a elective biliary colic. I want to go back for just a second and it ties into this, but that surgical rescue concept, I think that's pretty new to a lot of our listeners. I know for me, when I first heard about it, it was something brand new. Patrick: How do you put value on that from a hospital perspective, right? Like, I think that's one of the things that we struggle with, right? That second in house person may not be making extra money for the hospital, but they are there

and make it safer for patients. And we are able to rescue patients more often. Patrick: Like, how do you put worth into that? Yeah. And to add on to that too, let's talk about pitching the C suite. Like when it comes to administrators and you're talking about value added to the healthcare system, what is that? Yeah. To plug a document that may or may not be out by the time this podcast is released a few of the larger organizations are putting together a document on the value of an acute care surgeon. Patrick: And, to some of the points that have been made Not a lot of people know what we do or the value we bring. And the classic measure of our value is the work RVU. And they don't see that you spent a whole Saturday away from your family and only generated 50 RVUs. They just see you only generated 50 RVUs. Patrick: And so if you, Ways to potentially show that value

meaningfully. Keeping track, prospectively of, here's where I prevented disaster. Did a surgical airway. I was there to resuscitate someone. They didn't die because I was there. Like, when someone gets shot and you're there to save their life, you know what the value of a life is worth? Patrick: It's unmeasurable. People have assigned a dollar amount to it, but it truly is unmeasurable, and that was because you had someone in house available, whether they generated zero RVUs or a hundred. And so keeping track of your value with some numbers, I think is very helpful for people. And similarly, I think we do have to shift a little bit to not only think about the money we bring in, but the effect the work has on us. Patrick: In that it might not be profitable to bring in a second surgeon in house, but if you stop a

surgeon from quitting because the work is too intense, That's a money save. Turnover is incredibly expensive to replace a trauma surgeon. And so, I think we do have to be cognizant of our own health, and turnover in a group is not good. Patrick: And that's very costly. So there's different ways to frame it, and I think the best approach, in general, to frame our specialty is, we're firefighters. That's how we should be viewed. We're a public service. That is needed for a hospital. Firefighters aren't paid by the fire. We shouldn't be paid by the patient. Patrick: We should be viewed as the hospital infrastructure and when you go to staff a division, instead of taking the work that you're currently doing and dividing by the surgeons you have and saying this is what's reasonable for everyone in the group to work, you should say let's capture all the clinical

demand that we have and let's divide by what we think is reasonable for a human to work in our specialty and that's going to tell us how many surgeons we need. Patrick: That's a rational way to staff a division. And I think if you go to hospital administration and you come to some definition before you can talk about staffing, let's just, let's decide what a full time job is for us and say, you say, let's just pick a number 204 shifts. Great. Or 50 hours a week. Patrick: Great. Whatever you want to decide locally. Okay. How many shifts do we have? We have 2000 shifts a year because we have, four people during the day and one overnight, however you want to divide your workup. You need 10 clinical FTS. That doesn't mean you need 10 surgeons. You probably need more than 10 surgeons because they often have other jobs. Patrick: One of the big benefits of this approach is there's a lot of

transparency about expectations and when You're asked to do non clinical work and they say we want 0. 2 of an FTA to run the medical clerkship I know exactly what that means because you told me a full time job was 200 shifts a year So 0. 2 you want me to dedicate 40 shifts of my time to that task You That's perfect. Patrick: Everyone knows their expectations. It's very transparent. And when I work more than 200 shifts, because someone got sick, they took a paternity leave, things happen. We can decide what's that what is that worth? And so I know that if I work more, I'm going to be compensated more too. And that transparency, I think really can improve. Patrick: Surgeon satisfaction. Pat I really liked that ballpark sort of metric that you came up with in terms of deciding what might be right for a division and starting that discussion. I also want to go back for a

second to what you were talking about with with quality and safety, right? I think a lot of the discussion so far has been from the provider perspective, but nothing changes. Patrick: a hospital structure like patient outcomes and patient safety, or at least it shouldn't, in my opinion. So what what work have you done or what ideas do you have? For approaching this problem from that perspective. You mentioned prospectively studying the number of rescues and lives saved, poor outcomes prevented. Patrick: I think that's awesome. Tell me a little bit more about that. Like, how can we I mean, maybe it's marketing, maybe it's selling it this, but I think there's a perspective that's very valuable there from the patient side. If my parents go into a hospital where all the surgeons are overworked, underpaid, they're all exhausted, and they show up at two in the morning and they don't get looked at for hours and hours later because that hospital doesn't have a good acute care surgery

service. Patrick: I mean, I care about that for my family. So can you elaborate a little bit on that? Here's, so I view most of this from a systems lens in that it's, I think, hard at times to attribute a specific patient outcome, good or bad, to a specific instance or a specific staff. And I think trauma has done one of the better jobs of this in that trauma systems that, that we currently function in, the accreditation system, the measurement of patient outcomes, the design of our trauma system has really shown to benefit patients. Patrick: And that has expanded to, the acute care surgery model. That Surgeon of the Week model for emergency general surgery diagnosis has demonstrated patient benefits, like decreased length of

stay, quicker ORs. And that's by virtue of having a dedicated system to care for that group of patients, where I'm not trying to do too many things at once. Patrick: Like, if I have a full day of clinic book And an appendicitis comes in at five in the morning, they're going to wait all day. And that's an inappropriate prioritization of patients. And so our specialty has recognized that we should be dedicated to this group of patients and build a system to care for them. Patrick: And I think that includes looking at how we should staff that system, both at our level and at all the other levels like advanced practice providers and residents and what's right. I think. Looking at, whether you have 10 faculty or 5 faculty and saying our patient outcomes are worse because we have 5 faculty, I don't know if that's really a

helpful discussion, because the reality is the surgeons are going to work themselves to death for the sake of the patient. Patrick: Like, it's not going to be this steady decline as you lose faculty, the patient outcomes are going to get worse. I don't think. I think the surgeons are going to step up and it's going to take a toll on their own health until they leave their job. And I don't think patient outcomes are going to measurably suffer. Patrick: The surgeons are just going to work more and more. Pat, I have a question for you going back to the example you gave. So, at my center, the goal would be to define an FTE for ourselves. And then my academic obligations would protect me a certain amount, right? So as you gave that example, I would do fewer shift because I have a protected amount of time. Patrick: But my question to you, and I guess as for the listeners who are maybe going to go out and look for jobs in the world, you've

been around the block doing this research. You gave double AST grand rounds on this topic. How often is that occurring at centers, right? Do most centers have A good handle on what an FTE is, and did most people get like an actual reduction and protected time in their schedule to do academic stuff? Patrick: Or is that just are we just talking about something? That's not really a reality. And people shouldn't expect that when they're sitting at the table, negotiating for their job, I think most, one of the reasons that I'm happy this podcast is happening is because this is being discussed more and rightly so for all of the reasons we discussed and. Patrick: That means that because people are thinking about it, not only from the staffing perspective, how many surgeons do I need to meet this clinical demand? There's also the

recruitment aspect in that if two centers that are, within 10 miles of each other, and one says a full time job is 230 shifts a year, and one says a full time job is 180 shifts a year, well, you might attract different people to those jobs. Patrick: And you might be able to retain them for a different amount of time at those jobs And so having that definition and that discussion is happening more and I get the sense from talking to people that People are asking this more and more like I, I want to know how much I'm expected to work. Patrick: And I don't view that as a bad thing. I don't think people are asking that in that they don't want to work. They're asking that because they want to be transparent about their expectations of them and their system. They just want to know what good looks like. And what do you expect me to do so I can meet those expectations or exceed them?

Patrick: I think framing it the other way, where it looks like. Or might be perceived like you don't want to work. That's why you're asking. I don't think that's the reason when you take a group of providers surgeons apps, etc that acs service or division is that a profitable venture? Patrick: The profitability of, a division, let's say a division of acute care surgery. Patrick: Is very dependent on funds flow payer mix and the type of work that they are expected to do, which is not standard across institutions outside of, the pillars we've spoken of. And so it's hard to characterize in a meaningful way, but again, you don't expect a fire department to be profitable. Patrick: That's not the point of the fire department.. And so it's

nice if they are like, I think that's a benefit, but I think that's the wrong way to look at it. Because the reality is that by having that our service, that means that the surgeon who does advanced colorectal surgery doesn't have to be up all night taking out gallbladders and appendixes. Patrick:. And so they can do the work. During the day, maximally, they can maximize their efficiency for what their expertise is and what they were trained to do. That's a benefit that's never going to be captured in RV use. Same with surgical rescue. Same with whole concept of like, I can get a patient to surgery at 10 a. Patrick: m. because I'm free from my elective duties, so they can go home at 1, which saves everyone money, but is not, again, not captured in RVUs, but that's a

value that our service brings. And similarly, by virtue of our existence, you can have a level 1 trauma center and do all the advanced orthopedic procedures on those trauma patients. Patrick: which are not captured in my RVs, but there are many RVs to the hospital that otherwise would not exist if you did not have trauma surgeons. Yeah, that requires some real depth of understanding to advocate for a division or individual surgeons and this, again, somewhat new world of acute care surgery. Patrick: So with that, Pat, any closing thoughts to wrap this up? Yeah, I'm really happy that this discussion is happening more and I don't claim to have all the answers about what a full time job is. I do bring my own bias because I work as a an acute care surgeon. A lot of this information is from mixed quantitative qualitative research. Patrick:

And, I think something that we haven't talked about that has been brought up that I think is an important thing to talk about as we discuss You know, one side of what a full time job is. How much should we work? I think there's other considerations that come up. Like, what's the minimum that we can work to maintain our competency? Patrick: And I think this is particularly true in our specialty where we're divided three ways. And if you go down to, say, a 0. 5 FT. And you're going to say that's 100 shifts a year, but 60 of those shifts are trauma and ICU where you don't operate a lot. So how do you maintain your competency as a surgeon? Patrick: I don't know the answer to that either, but it should be considered, I think, as we have these discussions, is I think we need an upper limit of kind of what's reasonable, but we should probably consider a lower limit in

what competency looks like in our specialty. And I think some surgeons have internally addressed this at times, like if your FTE goes down really low, some focus on just one of those service lines to say, I'm going to be really good at trauma and just do trauma and Do much less of the other ones so I can maintain my competency in trauma surgery but I don't know what the right number is and it's probably individualistic So i'm really happy we're having this discussion. Patrick: It is I think nuanced and what I really hope people take away Is that you should have this discussion where you work and it doesn't have to be my definition But you should have an idea what a full time job is at your place You Patrick: this is pat murphy signing off till next time dominate the day.