The trauma surgeon is a decathlete
With about 9,000 participants, the German Orthopaedics and Emergency Surgery Congress (which incorporates the annual meetings of a professional organisation for orthopaedic consultants, as well as two German societies - one for accident surgery, the other for orthopaedics & orthopaedic surgery) has become the biggest congress of its kind in Europe, providing a platform for the international exchange in this medical field. At this year's event (2-6 October, in Berlin) doctors and scientists discussed medical and associated political issues. Among the controversial topics was the introduction of a joint medical specialist field for orthopaedics and trauma surgery in Germany, and issues surrounding how this will affect these individual disciplines.
Fear for the quality of acute care for the injured and victims of accidents was expressed by Professor Vilmos Vécsei, traumatology and sports traumatology specialist and Head of the University Clinic for Trauma Surgery in Vienna (VV), as well as President and General Secretary of the European Trauma Society (ETS), and Professor Otmar Trentz, Director of the Trauma Surgery Clinic at University Hospital Zurich, and co-Congress President of the 1st joint EATES/ETS congress.
As an umbrella organisation of 10 international associations for trauma surgeons, the ETS works as an interface for the 10 central European countries that acknowledge the specialist medical field of trauma surgery (Austria, The Netherlands, Belgium, Switzerland, Hungary, Slovenia, Slovakia, the Czech Republic, Croatia and Germany). The ETS expresses much criticism regarding the merger between orthopaedics and trauma surgery in Germany. ‘At the moment it wouldn’t be wrong to state that the German-speaking countries are still at the forefront in the area of care for accident and trauma victims. We can’t really foresee what the merging of training for orthopaedics and trauma surgery will bring. However, we think that there will be a negative impact on the quality in both individual areas as the medical field as a whole expands. Orthopaedics and trauma surgery are like two different pairs of shoes – and how are we supposed to teach two different medical specialities in the same time frame that people used to have to learn just one,’ said Prof. Trentz. ‘The idea behind it is simple: Merging two departments means lower costs and fewer doctors to run that new department. But what has been overlooked is that this will make the number of patients decrease, so the need for doctors is still the same.’
In the past, the problem with trauma surgery was that there weren’t actually as many acute traumas to treat as there were departments for trauma surgery, so trauma surgeons increasingly ended up treating orthopaedic cases. This has resulted in the wrong perception - that orthopaedics and trauma surgery are one and the same thing. In some areas, such as surgery for sports trauma and geriatric trauma, it actually makes sense to treat patients with a joint approach, but this does not apply to the treatment of severe, acute injuries. This is where we need the trauma surgeon’s specialist skills and knowledge, and there will not be enough time spent teaching these skills in the new type of combined training.’
Prof. Vécsei: ‘The status of the trauma surgeon is somewhat paradoxical: He is the “specialist generalist”. On the one hand, the trend in Europe is that it is just this type of specialisation that’s required, because we assume this specialist knows his medical field extremely well. Over past years this has led to a specialisation of doctors around certain individual organs, including in surgery: We have shoulder surgeons, knee surgeons, hand surgeons etc. However, in the care of acute trauma patients, it is important to be able to look at the patient as a whole, so what is needed is a generalist who knows the whole body and can lead and coordinate a team of doctors. So, if you like, a trauma surgeon is a decathlete, not a 100-metre sprinter. However, even this is a type of specialisation, but not recognised as such. Instead this important area is being “de-specialised”.’
‘One objective for the ETS was to achieve the introduction of the term European Trauma Surgeon, which would imply that all European countries would have to establish this speciality, whereas it is currently voluntary. This would be an important step on a way to a harmonisation of European standards. However, to achieve such a resolution requires the agreement of ten European countries, which we don’t yet have. A unified, high expectation of quality in trauma surgery is very important because, in the long term, this is also likely to lead to cost savings. A trauma case that has been badly treated and cared for could cause follow-on costs running into millions, something which we tend to overlook in all the health/politics discussions in Europe.’
Harmonising European training standards
Professor Wolfhart Puhl, President of the European Federation of Associations of Orthopaedics and Traumatology (EFORT), who welcomes the merger of orthopaedics with trauma surgery in Germany, also hopes for standardisation in training and treatment across Europe.
EFORT was founded to focus the activities of European orthopaedic surgeons and harmonise medical training standards - a bit of a ‘Sisyphus’ task because university degree courses and practical training in European countries vary significantly. ‘Getting European countries to sing from the same hymn book initially requires information input from the individual countries,’ said Professor Puhl. ‘This would enable us to draw up an accurate profile of the services and tasks involved, which would satisfy everyone’s wishes and needs. These are very long processes and likely to take a few years before we achieve a result. It is right that orthopaedics and trauma surgery are being merged in Germany. Of course, one has to ensure that this will be a merger of very high level. It goes without saying that German trauma surgeons deliver top quality work, and so do orthopaedic surgeons. But both individual disciplines tend to have a wrong image of one another’s medical field. This problem will have to be addressed with a new type of training.
‘In terms of the concern about acute care in emergencies, I think this kind of care does not have to be provided exclusively by trauma surgeons. They may not like hearing this, but actually there are a number of suitable candidates for trauma patient management. There are clinics where this work is undertaken by an anaesthetist, who is also quite capable in this work. In severe polytrauma everything is about preserving life, something that in which an anaesthetist is well trained, and he can then gauge and direct further diagnostic procedures. Once the initial acute management has been successfully completed individual specialists can then go to work.’
‘Know-how is another thing. It must be said that trauma surgery training in Germany is particularly good. This is something that must not be allowed to get lost. But the key point here is the standardisation of requirements that should be harmonised across Europe. Based on a study, we know there are particular problems in training in the muscular-skeletal system. But this is a general problem and one that can be solved by standardising the parameters of medical training at university.’
‘In my view we will have come a significant step closer towards our objective of harmonisation in around ten years time and the healthcare systems in the individual countries will also have become more standardised within this period of time. This means stable quality across all Europe, with standardised guidelines and indications. Cost pressures will, of course, increase continuously, another reason to try to harmonise the teaching of knowledge and to digitalise it - another objective EFORT has set itself.’
Report: Meike Lerner/European Hospital
17.11.2006
