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Specialists raise concerns about the future of U.K. trauma treatment
More government involvement, advanced courses and a nationally recognized specialty in trauma may improve the situation.
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Experts warn that few training opportunities, subspecialization and a lack of level 1 centers may jeopardize the future of trauma care in the United Kingdom.
James M. Ryan, FRCS, a professor of conflict recovery at the University College Hospital in London, described trauma training in the United Kingdom as “patchy” and “variable.”
“Culturally, we’ve never had what you would recognize in the United States … or in Europe … as the ‘trauma surgeon,’ which is unique,” Ryan told Orthopaedics Today. Instead, surgeons manage wounds regionally; orthopaedists oversee musculoskeletal injuries, while neurologists attend to head trauma.
The country remains without a trauma specialty, in part, because many believe that a well-trained surgeon can handle any trauma case, Ryan said. Yet, trainees gain limited exposure to trauma injuries, due in part to a national decrease in traffic accidents.
“We are seeing [somewhat of] an increase in the number of shootings and stabbings, but we are seeing that, overall, hospitals’ exposure to measured trauma is minimal,” he said.
Today’s trainees are also less willing to pursue a career in trauma, the president of the British Trauma Society, Peter V. Giannoudis, MD, a professor of trauma and orthopaedic surgery at St. James University Hospital in Leeds, told Orthopaedics Today. He cited a survey of orthopaedic surgeons by the British Orthopaedic Association (BOA), which found that although 72.9% expressed a special interest, only 7.3% of the total identified had a special interest in trauma. Furthermore, a recent British Trauma Society (BTS) regional survey of surgeons in training indicated that only 20% of respondents had an interest in trauma.
“[We] are moving rapidly towards the subspecialization era where, despite the fact that surgeons go through a generalist training in orthopaedics or trauma, [they] eventually end up subspecializing in one specific aspect, for instance shoulder surgery, knee surgery or revision hip arthroplasty,” Giannoudis said.
Trauma care “fractures”
The rise of the specialty surgeon marked the end of the general surgeon era, Ryan said.
“With the advent of specialization and subspecialization, trauma care has become more and more ‘fractured,’” Ryan said. As a result, “There are no generalists around who can manage the totality of trauma.”
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Giannoudis agreed that the specialization trend could further complicate patient care.
“The way that things are going is that we’re going to have a poor traumatized patient and you will have 6 or 7 physicians dealing with his injuries,” he said.
The country’s lack of designated trauma centers also highlights the vulnerability of British trauma care.
“[We] have failed to convince the government that we should adopt the American system [and] that we should develop level 1 trauma centers in the United Kingdom,” Giannoudis said. He noted that concerned experts suggested sectioning the country into 30 regions and building a level 1 trauma center in each area. Although Giannoudis expects a new center to be completed in Leeds this year, he said that the country is a “far way” from implementing centers in every region.
The recent London bombings put the country’s emergency response groups in the spotlight, but Ryan said that decades of successfully managing terrorism have made it difficult to hold the public’s attention. “They say, ‘Look, we’ve coped for 30 years with terrorist attacks. We’re good at this,’” Ryan said. “We say, ‘But, you’ve only had very small numbers and very few of the survivors come in with major torso or liver and chest injury.’ And that’s where we’re lacking in training.”
Solutions
Changes in education and government involvement may improve the state of trauma care. Ryan suggested study-abroad programs in large cities to increase trainee’s experience and additional courses for those in centers that handle trauma cases.
“But, as a minimum, they should be basically run though an internationally recognized, definitive surgical trauma skills course, where they will be exposed to surgical anatomy related to trauma that they would not see day to day,” he said. He also said that the government should cover the fees for international courses.
A nationally recognized subspecialty in trauma care may increase the pool of experienced trauma surgeons. “That’s the only way to make sure that the foundation will be in place to deal with the threats from subspecialization and about people not having any interest at all to focus on the management of trauma.”
Ryan said trauma care in the country is gradually improving, but government action is needed. “We need to energize our ministers,” he said. “We need to scare them a little bit to say, ‘Don’t take the complacent view.’”
For more information:
- Tai NRM, Ryan MJ, Brooks AJ. The neglect of trauma surgery. BMJ. 2006;332:805-806.