Physicians and Surgeons …
and Surgicalists?

A New Surgical Rotation
Introduces Third-Year Students
to Acute Care Surgery
By Robin Eisner
Among the many educational moments of his acute care surgery rotation, Daniel Birk’10 particularly appreciated two cases: one that seemed to come straight from a textbook and another that was quite atypical. Peter Downey’10 found it gratifying to watch a patient progress from acute appendicitis to laparoscopic surgery to being happy in the clinic. For Steven Sultan’10, it was learning why a surgery should or should not occur.
    They were among the first P&S students to participate last year in the new acute care surgical service rotation offered in the third year as part of the five-week general surgery clerkship. The rotation gives students an opportunity to learn the coordinated team approach the acute care surgery service provides to patients who need emergency operations; to patients who are critically ill and hospitalized and require surgery; and to patients with traumatic injury who need surgical interventions.
    In the general surgery rotation, medical students are required to develop clinical skills associated with preoperative and postoperative care and to assist in the operating room. They become part of the team caring for surgical patients by participating in rounds, outpatient visits, emergency room consultations, and night calls. Besides being assigned to NYPH/Columbia, students can go to affiliates for the rotation – Stamford Hospital in Connecticut, Mary Imogene Bassett Hospital in Cooperstown, N.Y., St. Luke’s-Roosevelt Hospital in Manhattan, and the Allen Hospital in Upper Manhattan. During the rotation, students must observe certain operations, including those involving the stomach, breast, large intestine, thyroid or parathyroid, and the vascular system. They also have to see a gall bladder removal and hernia repair and choose from a list of optional cases. Students participate in a wide range of surgical services, such as general, vascular, breast, colorectal/oncology, hepato-pancreato-biliary, and plastic surgery, depending on the site.
    Only NYPH/Columbia has the acute care surgery service. The first in the New York metropolitan area and among only a handful on the East Coast, the acute care surgery service began in July 2008.

What is Acute Care Surgery?
Acute care surgery handles a wide range of cases. The team performs emergency surgeries to treat acute conditions, such as appendicitis, intestinal obstructions, hernias, and cholecystitis. For critically ill inpatients at a tertiary care institution like NYPH/Columbia, the service may operate on conditions that arise, such as a perforated colon, which is an acute emergency that does not need to go to the colorectal surgical service, says Tracey Arnell, M.D., assistant professor of surgery, vice chair of medical education in surgery, and co-director of the acute care surgery service. By also caring for the appendicitis patient, acute care surgeons allow surgical specialists to dedicate time to research interests. And although NYPH/Columbia is not a level 1 adult trauma center, each year the facility treats approximately 1,800 trauma cases, including stabbing and gunshot wounds, falls, and car accidents, which now fall under acute care surgery. The service coordinates care, as needed, with other medical specialties.
    Acute care surgery takes cases previously seen by different divisions in the hospital and streamlines them into one service. Research shows the approach decreases lengths of hospital stays, reduces complications, and improves the patient’s experience.
    The evolution of acute care surgery during the past five years can be compared with the establishment of emergency medicine as a discipline three decades ago. Physicians in pediatrics, internal medicine, cardiology, and OB/GYN, for example, covered emergency rooms, but emergency care improved when dedicated emergency medical residencies were established and emergency room attendings took over ERs. Similarly, the acute care surgical service has expertise to better care for its patient population. Still emerging as a field, only a handful of U.S. hospitals offer acute care surgery fellowships to provide advanced training in emergency, trauma, and critical care surgery after a surgical residency.
Acute care surgery takes cases previously seen by different divisions in the hospital and streamlines them into one service.
    Besides improving patient care, in-house acute care attending surgeons, or surgicalists, as they are called, benefit other surgeons and physicians in the hospital. “Surgeons, in settings like ours, take care of increasingly specialized patients, such as those needing transplants or cardiothoracic or liver related interventions,” says Lee Goldman, executive vice president for health and biomedical sciences and dean of the Faculties of Health Sciences and Medicine. “The typical surgical practice involves long periods in the operating room, making surgeons less available to attend immediately to the postoperative needs of their complicated patients. A surgicalist can help in these cases and they also can address general emergency surgical consultations and cases from other services and from the emergency department.” Dr. Goldman in the late 1990s developed the concept of a hospitalist, or an in-house physician, who manages inpatient care on medical services and sometimes on surgical specialty services.
    With the acute care surgery service, medical students and residents are learning a new approach to treating acute surgical cases. “Our students need to get a sense of general surgical problems,” Dr. Goldman adds. “They cannot just focus on the most complicated surgical patients that are treated in a tertiary/quaternary facility like ours. The acute care surgical service shows them general surgery cases, which they need to know as physicians, especially if they do not pursue a career in surgery.”
    Akuezunkpa O. Ude, M.D., assistant professor of surgery and director of the surgery clerkships, agrees that the acute care surgical service is advantageous to students. “Students assigned to NYPH/Columbia now have the opportunity to see the management of emergent and trauma surgical cases under the auspices of the acute care surgery service,” she says.
    A student on an acute surgery clerkship learns more about diagnosis than on other surgical clerkships, where patients usually have already been diagnosed. One skill students learn is how to evaluate abdominal pain, which comprises the bulk of complaints by patients seen in the acute surgery service.
    “If the medical student is with the acute care consult team from scratch, they see a patient with abdominal pain or leg pain and learn how to evaluate the problem and understand that not all these patients end up with operations,” Dr. Arnell says. “Students also have the opportunity to follow a patient preoperatively, operatively, and postoperatively to gain a broader perspective on what most surgical problems are about.”

Student Experience
Besides learning to master the medical history and physical, “which is essentially the job of a third-year medical student,” Mr. Birk valued the surgical and medical knowledge he obtained on the acute care service, particularly in two cases. In one, the team determined a young man with Crohn’s disease (the descriptions of patients in this article have been changed to shield their identities) needed surgery to remove part of his diseased small bowel because it was obstructed. Under Dr. Arnell’s supervision in the OR, Mr. Birk made the incision and assisted in the resection of a part of the bowel.
Besides improving patient care, in-house acute care attending surgeons, or surgicalists, as they are called, benefit other surgeons and physicians in the hospital.
   “What was really fascinating is that once we resected the bowel, we called for a pathology consult and the pathologist did a gross dissection of the tissue,” says Mr. Birk, who is interested in pursuing surgery. “I was able to see what Crohn’s disease entails pathologically and how it followed what I had memorized from textbooks and heard in lectures. It was amazing to see the actual organ, the cobblestone appearance of diseased tissue, the inflammation, and how narrow the lumen was.”
    Mr. Birk also followed the patient’s progress on the wards, keeping track of his vital signs and monitoring his diet, blood laboratory values, urine output, bowel function, subjective state, and overall condition. Mr. Birk felt particularly empathic for this patient because he knows others with Crohn’s disease. “I knew what it might be like to deal with the pain of the disease and how it affects his work and social life.”
    While the Crohn’s disease case was textbook, another case was more challenging. An older man came to the ER with severe abdominal pain and the acute care surgical consult was called to evaluate. The emergency room staff had sent the patient for a CAT scan, but part of medical student training is to make a differential diagnosis based on the symptoms and signs, without the results from radiology.
    While Mr. Birk suspected the patient had appendicitis, he showed few classic symptoms. “He came in with pain on the lower left abdomen, a negative Rovsing, and a negative Psoas, but had an elevated white blood cell count and a fever,” he recalls. “It was difficult to diagnose his condition.”
    The CAT scan clarified the situation. “He had an extremely large appendix pointing in a different direction in his abdomen than most people and extending to the left,” Mr. Birk says. “If it weren’t for the CAT scan, I could not have diagnosed appendicitis. I scratched my head with a long differential diagnosis.”
    Mr. Downey’s experience with an appendicitis patient was more typical but meaningful to him because he saw the whole spectrum of care for a patient. A young woman came to the ER with the usual signs and symptoms of appendicitis. Mr. Downey took the history and performed the physical. Instruction by attendings from surgery and other rotations about the importance of the history and the physical examination resonated with him. “Attendings keep telling us that the most important information you get from a patient is from the history and physical examination. Imaging, they say, should be used to back up what you already know.”
    The consulting resident from the acute care surgery team and Mr. Downey determined the woman needed surgery. Mr. Downey wrote the admitting note and took the patient to the OR, where Dr. Arnell operated laparoscopically to remove the appendix. Mr. Downey participated by holding the tube with the camera and suturing the three small incisions created by the instruments. “It went well,” Mr. Downey says. “There were no complications. She went home in two days.” But what struck him was talking to the young woman in clinic 10 days later. “The intervention made a huge difference in her life. She went back to being a healthy college student.”
    For Mr. Sultan, learning about decision-making in surgery was his major takeaway from the acute care surgery rotation. “We spent a lot of time deciding when to operate, which is a great emphasis for a third-year student,” he says. “For people who don’t go into surgery, it gives an idea about the way surgeons think about a patient and the factors they are considering in potentially taking someone in for a procedure. It is exciting to spend time in the OR and to see how procedures are done, but it is also important to learn when to do a procedure.”
    Some cases might appear to need surgery when they do not. One example is an individual with an abdominal stab wound, who a resident thought should have surgery. The surgicalist disagreed. Certain cases can be handled without operating and by evaluating for injury with diagnostic studies. The victim did not get an operation and went home the next day with no internal injuries. New research studies and perspectives on treating acute surgical issues with non-operative management are being recognized in academic medicine.
“It is exciting to spend time in the OR and to see how procedures are done, but it is also important to learn when to do a procedure.”
   “Acute care surgery requires synthesizing information quickly and developing care plans on an emergent and urgent basis, often with many patients simultaneously,” says Dr. Arnell. “Caring for often complex problems is a team approach which requires the patient, family, surgical residents and attending, and physicians from the consulting and primary team be involved. These relationships, especially with the patient and family, need to be built quickly and communication is critical. The coordination of this team allows for efficient and rapid care of the ill patient. P&S students become an integral part of this team and contribute in a real way.”


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