title: Trauma/critical care surgeon: a specialist gasping for air.
abstract: BACKGROUND
  In the last 10 years, trauma/critical care has become less attractive because of the decreasing surgical caseload, the nocturnal work hours, and the economics of the practice. Nevertheless, during the same period, the number of verified trauma centers has significantly increased. This study assesses the economic drive behind this dichotomy.
  
  
  METHODS
  Over a 1-year period, we collected financial data on 1,907 trauma patients for both Level I trauma centers and trauma/critical care surgeons. Financial data, including payor source, cost, reimbursement, margin, and reimbursement-to-charge and reimbursement-to-direct cost ratios, were calculated.
  
  
  RESULTS
  For commercial- and government-insured patients, the reimbursement-to-direct cost ratio was 2-and 35-fold greater, respectively, for the trauma centers than for the trauma/critical care surgeons. For uninsured patients, the addition of local government funds allowed the trauma center to cover direct cost with no margin. In contrast, even with the addition of supplemental salary dollars from the institution, for every dollar in direct cost generated by the trauma/critical care surgeons in caring for uninsured patients, they recovered 55 cents, or a loss of 45 cents per direct cost dollar spent.
  
  
  CONCLUSIONS
  The economic dichotomy that exists between trauma centers and trauma/critical surgeons is significant. It drives institutional growth and, at the same time, discourages surgeons from entering the subspecialty. As physician reimbursement decreases and the number of uninsured patients increases, this economic dichotomy will amplify. Over the next decade, without a significant adjustment, the subspecialty is in danger of extinction.
authors.affiliation: Department of Surgery, University of Louisville, Kentucky 40292, USA. jlrodr02@louisville.edu
authors.forename: Jorge L
authors.initials: JL
authors.lastname: Rodriguez
authors.forename: A Britton
authors.initials: AB
authors.lastname: Christmas
authors.forename: Glenn A
authors.initials: GA
authors.lastname: Franklin
authors.forename: Frank B
authors.initials: FB
authors.lastname: Miller
authors.forename: J David
authors.initials: JD
authors.lastname: Richardson
mesh_terms: D002321:Career Choice; D004180:Direct Service Costs / Q000706:statistics & numerical data; D005251:Fees, Medical / Q000706:statistics & numerical data*; D005380:Financing, Government; D006302:Health Services Research; D017722:Hospital Charges / Q000706:statistics & numerical data*; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000706:statistics & numerical data*; D007629:Kentucky; D007902:Length of Stay / Q000706:statistics & numerical data; D008505:Medical Staff, Hospital / Q000191:economics*; D014193:Trauma Centers / Q000191:economics*; D014194:Traumatology / Q000191:economics*; D014481:United States