In the ER, Baby-Faced Doc Is No Death Sentence

Organization, not experience, plays the chief role in trauma patients' survival.

Aug. 18, 2009— -- The next time you are in a fender bender and the doctor who meets you in the emergency room looks younger than you are, don't fret. New research suggests that the experience of your trauma physician matters less to your survival than does the overall organization of the trauma center you go to.

Researchers in the trauma surgery program at Johns Hopkins University in Baltimore, Md., reported Monday in the journal Archives of Surgery that having an experienced trauma surgeon is not necessarily better for you than having one who is just out of general surgery training -- at least in terms of your survival following a major trauma injury.

The study, led by Dr. Elliott Haut, assistant professor of Surgery and Anesthesiology and Critical Care Medicine at Johns Hopkins, looked back at death rates among 13,894 trauma patients at a single facility from 1994 to 2004. Before 1998, the center was staffed only with novice surgeons. But in 1998 a more senior surgeon, who spearheaded a new set of policies to organize the emergency department and improve patient care, was hired as director of the center.

After excluding patients with injuries too severe to have any reasonable chance of surviving, the death rate following the policy changes implemented in 1998 was reduced from 1.8 percent to 1.2 percent in the hands of only novice surgeons. But more importantly, the death rate after 1998 for patients of the more experienced doctors was 1.3 percent, a rate almost identical to the one achieved by less experienced trauma doctors.

In Emergency Department, Organization Trumps Physician Experience

In short, the hospital you end up at, not your particular doctor's experience, seems to be more important to overall survivability from a traumatic injury.

While the improvement in survival following the changes in policy seemed relatively small, the authors said they could, in fact, be substantial after accounting for the large number of mostly young and otherwise healthy lives involved at all of the trauma centers nationwide. And the study confirmed what trauma surgeons have suspected for some time, at least in terms of a trauma center's structure.

Dr. Jay Doucet, associate professor of clinical surgery and director of the surgical intensive care unit at the University of California, San Diego, compared the results of the study to the performance of fighter pilots.

"Let's say you have a highly trained fighter pilot, but you send him against a tough enemy, flying an obsolete aircraft in a disorganized air force ... what outcomes can you expect?" he said. "Organized trauma centers in an organized trauma system save lives," Doucet said.

"It's the organization and resources of a major trauma center that are often the most important factors responsible for improved results," agreed Dr. Michael West, professor and vice-chairman of surgery at the University of California San Francisco.

The study did have some limitations, notably in its use of survival as the primary measure of experience. Dr. David Feliciano, a trauma surgeon at Emory University, in his invited commentary accompanying the article, noted that details of the most complex surgical cases and of how avoidable the deaths were in this study, would help to better answer the questions regarding experience.

"Mortality is also likely to be the factor least impacted by surgeon experience," West said, noting that the amount of blood transfused, number of complications, length of hospital stay, and number of infections would also help to better gauge experience.

Another weakness of the study comes from the numbers themselves, West said. A study that makes a conclusion based on a "lack of statistical significance" is weaker than a study that makes a conclusion based on the presence of one and would require either much larger numbers of patients or much greater differences between the groups than those present in this study to be meaningful.

More Research Needed to Determine Best ER Approach

The potential minimizing of the importance of specialized trauma training in the study also bothered West. With greater proportions of general surgery training being spent on other topics, today's graduating residents spend less time dedicated to trauma. In fact, he predicted that today's graduating general surgeons will probably be less prepared for major trauma than the ones in this study from only a few years ago.

West also pointed out that other advances in medicine, such as improved CT scanning technology and the now-routine use of ultrasound, could account for at least some of the improvement seen after 1998.