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 Table of Contents  
Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 147-149

Workforce, work hours, and workforce vitality: Toward new models of trauma coverage

Department of Surgery, Division of Trauma and Surgical Critical Care, St. Luke's Hospital and Health Network, Bethlehem, University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Date of Web Publication21-Apr-2017

Correspondence Address:
Michael D Grossman
Department of Surgery, Division of Trauma and Surgical Critical Care, St. Luke's Hospital and Health Network, 801 Ostrum Street, Bethlehem, PA, 18015
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAM.IJAM_96_16

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There are growing problems with the supply of trauma surgeons and/or willingness to participate in trauma care. Solutions proposed include the use of nonsurgeon providers and the development of an acute care surgery model to enhance the attractiveness of training in the field. We propose that immediate modification of clinical operations within trauma centers may address some of these problems and improve patient care and safety. The use of structured shift work models with efficient systems for communication and handoff may improve workforce utilization and vitality both in the near and far term.
The following core competencies are addressed in this article: Interpersonal and communication skills, Practice-based learning and improvement, Professionalism, Systems-based practice.
Republished with permission from: Grossman MD. Workforce, work hours, and workforce vitality: Toward new models of trauma coverage. OPUS 12 Scientist 2008;2(3):1-2.

Keywords: Clinical coverage models, shift work, trauma, workforce vitality, work-hours

How to cite this article:
Grossman MD. Workforce, work hours, and workforce vitality: Toward new models of trauma coverage. Int J Acad Med 2017;3, Suppl S1:147-9

How to cite this URL:
Grossman MD. Workforce, work hours, and workforce vitality: Toward new models of trauma coverage. Int J Acad Med [serial online] 2017 [cited 2022 Aug 14];3, Suppl S1:147-9. Available from: https://www.ijam-web.org/text.asp?2017/3/3/147/204977

  Introduction Top

In addition to the creation of an acute care surgery model intended to enhance the appeal of training in trauma surgery, recent publications in the Emergency Medicine and Trauma literature suggest that there is an opportunity to reassess the roles played by “classically” trained trauma surgeons and emergency physicians (EMPs).[1],[2],[3] Other authors point to an “unattractive” field of trauma surgery and widening gap between supply and demand for trauma and critical care coverage.[4],[5] While EMPs cannot completely fill these gaps even if they were so inclined, they might provide a valuable partnership for surgeons in remodeling trauma care.[6],[7] The validity of fellowship training to enhance the skills of EMPs in this regard has been discussed as has the utility of the American College of Surgeons standard requiring a surgeon physically present to participate in all trauma resuscitations.[1],[4]

While these discussions are ongoing, it is reasonable to consider different models of care for trauma surgeons that might enhance the appeal of the specialty. Such models are in existence and have proven successful alternatives to more traditional approaches. These can be viewed as modifications to the operating system before replacing the machine.

With the initiation of the 80 h workweek in resident education, there has been increased attention focused on the concept of shift work. Although problems with communication and handoffs have been identified, it seems clear that the shift concept inherited from our colleagues in Emergency Medicine is here to stay.[8] Traditional trauma coverage schemes have utilized 24 h continuous shifts often spilling over into the next 24 h period resulting in 30–36 h “days.” While it is physically and emotionally possible to provide these shifts, it may not represent a safe or “attractive” practice pattern and may not be sustainable over the long term.[8],[9],[10]

At the St. Luke's Regional Level I Resource Trauma Center, we have begun to utilize a night float system for in-house attending coverage that extends from 17:00 to 09:00 h and provides the day before and after the night shift as free time. This time can be considered as administrative time or academic time. Night calls are bunched into float segments leaving consecutive weeks free of night call. Providers express that they feel refreshed and invigorated when they arrive at the hospital for a shift and that they can be productive during their nonclinical hours. The effect is to remove the float from the daytime coverage scheme during the week reducing redundancy of staff available during weekday daytime hours.

Continuity of care is provided by covering services such as Intensive Care Unit, trauma and emergency surgery in weeklong blocks. To facilitate an orderly handoff and establish effective transfer of information from the off-going night float to the day team, there is an established 1.5 h morning report. This report takes the form of a daily educational conference, in which all new admissions are presented, and established patients are reviewed to determine a plan of care for the day. Radiographic and laboratory studies can be reviewed through a large wall mounted monitor interfaced to the hospital digital radiology and laboratory systems. All information is summarized on a patient list updated at least twice per 24 h period.

Exhibit 1. Members of the St. Luke's Regional Level I Resource Trauma Center Physician Group. Top (left to right): Dr. Marc Portner and Peter Thomas. Bottom (left to right): Dr. Brian A. Hoey, James Cipolla, Michael D. Grossman, Nathaniel McQuay Jr, and William S. Hoff.

Large physician groups present complex dynamics, particularly when the variable of resident participation and education is factored in. Our own model is attending physician based with a strong interrelationship between attendings and a dedicated, core group of advanced practitioners. The advance practice model in trauma care has become well established.[11],[12] Our relationship affords significant autonomy to the advanced practitioners in the management of our ward service and outpatients and includes these practitioners as valued members of the team with an equal stake in decision-making and group operations. Thus, the morning report brings all team members together and allows efficient handoffs whereby all team members understand the practice patterns of their teammates, share accountability with them, and trust that in their absence, high-quality patient care will be provided. This has a salutary effect upon individual and team morale.

The model is helpful in maintaining improved morale and may actually result in better patient care as the float seems more inclined to engage proactively in rounding, family communication and teaching during what have been traditionally considered “off hours.” If improved morale results in increased faculty retention or ability to recruit new faculty, it has achieved the purpose of improving workforce vitality. This in turn offers a potent solution at the local level to the supply–demand issues facing trauma centers and affords a potential advantage to those who employ such a model.


Justifications for re-publishing this scholarly content include: (a) The phasing out of the original publication after a formal merger of OPUS 12 Scientist with the International Journal of Academic Medicine and (b) Wider dissemination of the research outcome(s) and the associated scientific knowledge.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ahmed JM, Tallon JM, Petrie DA. Trauma management outcomes associated with nonsurgeon versus surgeon trauma team leaders. Ann Emerg Med 2007;50:7-12, 12.e1.  Back to cited text no. 1
Steele R, Gill M, Green SM, Parker T, Lam E, Coba V. Do the American College of Surgeons' “major resuscitation” trauma triage criteria predict emergency operative management? Ann Emerg Med 2007;50:1-6.  Back to cited text no. 2
Pascual J, Sarani B, Schwab CW. American College of Surgeons criteria for surgeon presence at initial trauma resuscitations: Superfluous or necessary? Ann Emerg Med 2007;50:15-7.  Back to cited text no. 3
Kozar RA, Shackford SR, Cocanour CS. Challenges to the care of the critically ill: Novel staffing paradigms. J Trauma 2008;64:366-70.  Back to cited text no. 4
Nathens AB, Maier RV, Jurkovich GJ, Monary D, Rivara FP, Mackenzie EJ. The delivery of critical care services in US trauma centers: Is the standard being met? J Trauma 2006;60:773-83.  Back to cited text no. 5
Rotondo MF, Esposito TJ, Reilly PM, Barie PS, Meredith JW, Eddy VA, et al. The position of the Eastern Association for the Surgery of Trauma on the future of trauma surgery. J Trauma 2005;59:77-9.  Back to cited text no. 6
Hoey B, Hoff WS, Grossman MD. Letters to the Editor (Future of trauma care). J Trauma 2006;60:459.  Back to cited text no. 7
Okie S. An elusive balance-residents' work hours and the continuity of care. N Engl J Med 2007;356:2665-7.  Back to cited text no. 8
Richardson JD, Miller FB. Will future surgeons be interested in trauma care? Results of a resident survey. J Trauma 1992;32:229-33.  Back to cited text no. 9
Esposito TJ, Leon L, Jurkovich GJ. The shape of things to come: Results from a national survey of trauma surgeons on issues concerning their future. J Trauma 2006;60:8-16.  Back to cited text no. 10
Nyberg SM, Waswick W, Wynn T, Keuter K. Midlevel providers in a Level I trauma service: Experience at Wesley Medical Center. J Trauma 2007;63:128-34.  Back to cited text no. 11
Hoff WS, Cipolla J, Wainwright GA, Szoke A, Gillard JN, Stehly CD, et al. Performance evaluation of mid-level practitioners at a Level I trauma center. J Trauma 2008;63:1429.  Back to cited text no. 12

This article has been cited by
1 Emergency Trauma Providers as Equal Partners: From “Proof of Concept” to “Outcome Parity”
Kathryn C. Kelley,Alex Alers,Charles Bendas,Peter G. Thomas,James Cipolla,Brian A. Hoey,William S. Hoff,Rebecca Wilde-Onia,Holly Weber,Stanislaw P. Stawicki
The American Surgeon. 2019; 85(9): 961
[Pubmed] | [DOI]


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