Data from the U.S. Centers for Disease Control and Prevention (CDC)6 and Institute of Medicine (IOM)7 suggest that injury is a leading cause of death and disability responsible for a substantial burden on health care resources. Currently injury incurs huge expenditures, and will continue to do so in the future. The proportion of the population over age 65 is projected to increase exponentially after 2010, likely increasing the need for critical care expertise if the elderly are to be managed optimally.8 Likewise, realizing the benefit and cost savings associated with the continuous presence of trained intensivists in ICUs, the LEAPFROG initiative will also create an increased need for critical care specialists.9 The danger of major terrorist events and war looms over American society. Such events will result in trauma and burn injuries while burn surgeons and burn centers are already in short supply.

Data compiled by the American Trauma Society8 show that along with the graying of America comes the graying of the surgeon. The average age of fellows of the American College of Surgeons is 58.5 years. The average reported age of retirement is 62. Others report that many general surgeons plan a reduction in workload in the near future, and predict an impending shortage of experienced physicians.

Until this past year, there has been a precipitous decrease in applications to surgical residency programs. The recent resurgence of interest in these surgical training programs is believed by many to be related to the imposition of resident work hour restrictions, which have “leveled the playing field” between surgical programs and other less rigorous training programs. Meanwhile, the number of certificates issued by the American Board of Medical Specialties for physicians in specialties that offer a “controllable lifestyle” have been increasing consistently.

Applications to at least one major trauma fellowship training program have declined fourfold over the past five years.8 Only 50% of ACGME approved surgical critical care fellowships filled their first year position in 2005.

Applications to medical school have generally been declining with a larger proportion of successful applicants being female. Women now comprise about half of current medical students and 24% of surgical residents. Students currently leave medical school having incurred, on average, debt in excess of $109,000.12 A number of factors related to gender, marital status, perceived future income, lifestyle and social prestige, among others, are influential to medical student specialty choice.13-15 These factors must be considered as we develop the training path, as well as the practice model, for any new specialty related to surgery, trauma, and critical care. They should also guide the focus of recruitment efforts that will need to be initiated.

In addition to a potential physical lack of surgical personnel, there may be a functional shortage as well. Surgical subspecialists do not want to take trauma call. Two thirds of emergency department (ED) directors have reported inadequate on-call specialist coverage in one survey reported by Vanlandingham and Morone.16 Another poll of hospital administrators and ED managers revealed that 16% would seek care at a hospital other than their own if seriously injured. The reason cited for this by 63% was lack of surgical specialty back up. The number of respondents believing that specialty coverage was inadequate rose from 21% to 26% between 2000 and 2001, and the number expressing the view that such a deficiency represented a significant health risk to patients rose from 13% to 20% over the same period.

A SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis done by Mann et al.17 showed that lack of human resources was a significant threat to state trauma systems, second only to finances. A national survey of surgeons conducted by the Robert Wood Johnson Foundation revealed that 26% of respondents preferred not to treat trauma patients and that 50% would abandon emergency call if it were not mandated to maintain staff privileges.

Workload for specialist physicians has reportedly increased by 10%, with a corresponding increase in income of only 6% between 1999 and 2000. In an American Trauma Society survey of trauma care physicians, only 15% reported that they earned more income in 2003 than 2001, with 42% and 43% reporting earning the same or less, respectively.

Opinion surveys from national and regional samples conducted by the Eastern Association for the Surgery of Trauma (EAST), the American Association for the Surgery of Trauma (AAST) and others18-29 provide the majority of information on issues believed to be cogent in this analysis. A national profile of general surgeons including trauma as part of their practice is displayed in Tables 1 and 2.

In a survey of practicing trauma surgeons who are members of either the AAST, EAST or Western Trauma Association (WTA), 88% of respondents were male and 88% were married. Their average time in practice is 15 years, 49% reported trauma fellowship training, 56% practice at university hospitals, and 79% practice at Level I trauma centers. The median number of night calls is five per month, 63% take in-house call and 88% are married. These surgeons responded that their average workweek is 80 hours with 48% of that time devoted to clinical practice. Of their clinical activity, 30% involves trauma, 20% is surgical critical care, and is 10% general surgery. The remainder involves other activities, 10% of which are administrative. Satisfaction with their practice is reported by 72%, however nearly 90% were of the opinion their work as trauma surgeons was undervalued by society and the health care system.29 For surgical residents surveyed, trauma rotations are taken at all PGY levels; 70% are completed at their home institution and 95% at trauma centers. Surgical critical care is combined with trauma in 62%. Eighty-two percent favor inclusion of emergency surgery in the rotation and 63% favor inclusion of elective general surgery. The trauma experience was rated as good by 70% of respondents.

A proclivity to do research was expressed by 69% of responding residents. Eighty-three percent plan on doing a post-residency fellowship, but of these, only 17% plan on doing it in trauma/surgical critical care. Confidence with their ability to manage trauma after residency was voiced by 92% however, only 38% state they plan to include trauma care as part of their practice. Reasonable confidence with critical care after residency training was expressed by 96%, with 70% stating they plan to include it in their professional practice profile. These results echo Richardson’s26 finding in 1992, which showed 8% of surgical residents to be interested in a trauma fellowship and 18% expressing an interest in trauma as a career. His study also showed that 63% felt trauma is an attractive and rewarding career, if not for themselves, then for others, and that 81% characterized themselves as being interested in trauma care to some extent. In that study, in-house call was a major disincentive, with 78% reporting they would not be willing to take in-house call as an attending.