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February 1999

Should General Surgeons Provide Critical Care?

Arch Surg. 1999;134(2):125-129. doi:10.1001/archsurg.134.2.125

A BASIC tenet of general surgery training is that the best perioperative care is provided by a well-trained general surgeon. Consequently, providing optimal care to patients in the intensive care unit (ICU) has been an integral component of surgical education and practice.15 Dedication to providing optimal ICU care has allowed general surgeons to contribute heavily to the evolving field of critical care medicine. Much of our current understanding of shock resuscitation, inflammatory response, wound healing, immunosuppression, nutritional support, treatment of infections, and many other topics were derived from research done by general surgeons. General surgeons rightfully deserve continued leadership in critical care and the professional recognition that they are more than operating room technicians. Unfortunately, many nonsurgeons view the aforementioned as unfounded surgical rhetoric. In fact, most practicing surgeons (with the exception of those involved in trauma and burn care) have abdicated their ICU responsibilities to nonsurgeons.6,7 For a variety of reasons, the traditional involvement of general surgeons in critical care has eroded. An explosion of knowledge and technology has promoted organ-specific medical specialization (eg, pulmonary, cardiology, renal, and infectious diseases), and general surgery has been partitioned into areas of special regional interests (colorectal, vascular, thoracic, endocrine, breast, and hepatopancreatobiliary). Due to a lack of ongoing exposure, some surgeons are intimidated by the ever-changing ICU environment. Additionally, the "global surgery" fee forbids extra payment for high-acuity ICU care. Since there is no financial penalty, many surgeons consult organ-specific medical specialists to provide routine critical care, allowing for increased operating room participation and more billing opportunities. Unfortunately, this also resulted in the loss of surgical autonomy and increases ICU expenses with unnecessary tests and professional fees. Intensive care units are expensive cost centers that must be controlled, and surgeons are not providing the leadership. Board-certified intensivists are becoming increasingly vocal that they are better qualified to provide ICU care for surgical patients and that they can do it more cheaply. This commentary will address these issues and suggest potential solutions.

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