The current state of acute care surgery workforce and practice models: A joint statement by the American Association for the Surgery of Trauma, the American College of Surgeons Committee on Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association

ABSTRACT

Acute care surgery (ACS) is a specialty that includes trauma, emergency general surgery, and surgical critical care. It has become a vital surgical specialty in the United States, providing surgical services, rescue functions, disaster response, and other important services. Despite its key role in patient care and hospital operations, ACS faces challenges to its sustainability. This overview targets readers who wish to understand the structure and scope of ACS and who work with or manage these practices. The goal is to provide an overview of ACS, its current challenges, and suggestions for developing the specialty. This consensus statement was created by the Acute Care Surgery Workforce Workgroup, which includes representatives from various national surgical organizations. The article combines current ACS models, staffing and compensation practices, and institutional value. It relies on expert agreements and national trends. Several key themes are examined. The value of ACS is shown through better patient outcomes, efficiency, cost savings, and support for institutional missions like disaster preparedness and education. Current ACS programs differ significantly in structure, but two main staffing models exist: traditional (historic) and time delineated. Each model has its own advantages and challenges regarding workload, sustainability, and academic involvement. Regardless of the staffing model, most physician compensation often depends on the measurement of work relative value units. However, these do not fully capture the extent and intensity of ACS work. Additional challenges for the specialty include inconsistencies in terminologies, the absence of board certification, and varying compensation standards. Acute care surgery is a crucial specialty that provides significant value to patients, hospitals, and health care systems. To maintain sustainability and quality, health care leaders need to consider the complexities of ACS practice discussed in this article as well as local demands. Staffing and compensation models should be sustainable and optimize for patient care. Recognizing both clinical and nonclinical contributions of ACS surgeons is essential for resilience and further development of the specialty.

This manuscript provides an overview of the Acute Care Surgery and serves a practical guide around building or growing ACS practice models. The document and manuscript are products of the Acute Care Surgery Workforce Workgroup, an initiative of the AAST, ACS-COT, EAST, and WTA.

This article is based on a consensus statement created to describe the current state of academic acute care surgery (ACS) models in the United States. It is intended for readers who may not be well versed in the unique structure and scope of ACS but work with or manage these practices. The aim is to offer an overview of ACS, its current challenges, and recommendations for growing the specialty.

The document and article are products of the Acute Care Surgery Workforce Workgroup, an initiative of the American Association for the Surgery of Trauma, and includes members from the American Association for the Surgery of Trauma, the American College of Surgeons Committee on Trauma, the Eastern Association for the Surgery of Trauma, and the Western Trauma Association. An executive summary is provided in Table 1.

TABLE 1.

Executive Summary

Value Provided by Acute Care Surgeons
Expertise and readiness	Acute care surgeons deliver specialized care to support high-acuity readiness 24 hours a day, 7 days a week
High standards of practice	ACS surgeons uphold the highest standards of practice and benchmark externally to ensure quality care
Revenue generation	ACS is a significant driver of revenue, including substantial downstream financial benefits for health care institutions
Consultative support	ACS surgeons support patients from all specialties and engage in interdisciplinary care
Continuity of care	ACS surgeons care for complex patients throughout the hospital, coordinating care across specialties
Improved patient outcomes	Adding an ACS practice leads to improved patient outcomes and reductions in hospital length of stay
Current ACS Staffing Models
Time-based models	ACS surgeons are assigned a specific number of shifts or weeks per month
Traditional, non–time-based models	Workload is divided within group based on the number of surgeons on the roster
Considerations Affecting ACS Compensation Models
Downstream revenue	ACS generates downstream revenue that may not be captured when looking only at ACS (e.g., orthopedics for trauma)
Nonbillable services	ACS surgeons provide services that are not always billable (e.g., 24/7 trauma call coverage regardless of patient volume)
Salary benchmarking	Competitive salary benchmarking demonstrates variability in how the specialty is defined across available surveys
Labor market dynamics	Labor market dynamics for ACS surgeons are influenced by the specialty's unique demands, including 24/7 coverage and care
E&M billing and care complexity	Much of ACS's work involves E&M services, which often underestimate complexity of care

The ACS model of care has driven advancements in patient outcomes, resource optimization, and the overall understanding of acute surgical conditions. however, the rapid growth of the field has presented workforce challenges, creating the need to for deliberate consideration of model design to support informed decision-making that benefit health care systems and patients.

OVERVIEW AND SCOPE OF ACS AND THE WORKFORCE

The clinical scope of ACS includes trauma, emergency general surgery (EGS), and surgical critical care, with some centers also providing burn care. Elective general surgery is performed to varying degrees, depending on institutional needs. Acute care surgery evolved from the foundations of both Trauma and General Surgery. The history of ACS as a specialty began in the early 1990s when leaders in the field contemplated how to ensure the future of trauma care.^1–4 Its foundational concepts were later conceptualized in 2003 and then formally defined in 2005.^5,6 Acute care surgery has since matured into a comprehensive specialty focused on rescuing and managing patients with acute surgical illnesses. Several challenges faced by the specialty as it continues to evolve will be discussed hereinafter, but one ongoing challenge has been consistency in nomenclature. Some institutions refer to ACS as “Trauma and Acute Care Surgery,” while others use only “Trauma” or will specify the individual practices of EGS, trauma, and surgical critical care. For the purposes of this document, ACS is addressed in its formal conceptualization, encompassing EGS, trauma, and surgical critical care. It is also important to note that the specialty itself has no board certification—this is reserved for surgical critical care only. This absence of formal certification underscores the breadth of expertise expected of ACS surgeons, who must be prepared to meet a wide range of urgent clinical needs.

To meet this broad clinical demand, ACS surgeons must maintain a diverse and highly specialized skill set. Beyond managing acute surgical conditions, they often provide vital support to other specialties such as overseeing surgical intensive care units, assisting with obstetrical emergencies, and offering surgical expertise for patients in medical ICUs.

The demand for such broad-based surgical expertise is substantial. Each year, over 23 million people sustain injuries, leading to nearly 3 million hospitalizations.⁷ Simultaneously, more than 3 million patients are admitted with conditions such as perforated viscus, appendicitis, acute biliary disease, necrotizing soft tissue infections, and other general surgical emergencies.⁸ These numbers underscore the critical role ACS plays in managing high-acuity patients and delivering timely effective care.

THE VALUE OF ACS

Before discussing the structure and implementation of ACS programs, it is important to understand the value ACS services bring to hospitals, health systems, and medical schools. One of its most important contributions is the delivery of high-quality care. High-quality care is often externally validated through such programs as the American College of Surgeons' verification for trauma and EGS, and the American Burn Association's verification for burn care. These certifications also enhance institutional reputation, signaling to the market the quality of care provided.^9,10 As further evidence to this fact, one patient survey revealed that medical specialty verification is preferred to other surveys. In the survey, which was conducted by Brunswick Insight, the American College of Surgeons Surgical Quality Partner Diamond was preferred to the US News and World Report by a margin of 55% to 34%.¹¹

Acute care surgery programs also support improved efficiency and cost savings.^12–17 Surgical complications significantly increase the cost of hospitalization, with studies showing that a single major complication can add nearly $20,000 to the cost of care​.¹² The expertise of ACS surgeons, combined with the implementation of advanced surgical care practices, reduces complication rates and improves rescue from complications, resulting in both better patient outcomes and lower costs.^13,14 Acute care surgery programs support significant revenue generation both through procedural income and by driving downstream revenue. Downstream revenue is derived through ACS-driven utilization of hospital resources such as diagnostic services, intensive care units, and specialty care, including orthopedics and neurosurgery. Acute care surgery practices often implement standardized care pathways and documentation tools, which have been shown to enhance contribution margins and improved patient throughput.^13–17

There are other indirect ways in which an ACS service improves efficiency.¹⁸ For one, the presence of an ACS service has been shown to improve the efficiency of non-ACS elective practices.¹⁸ By taking on call responsibilities, ACS surgeons allow elective general surgeons to focus on their scheduled cases, optimizing departmental productivity and revenue.

Acute care surgery also delivers value through its broad scope and alignment with other institutional missions. These missions include disaster preparedness,^19,20 improving community standing through Trauma Center status designation,¹¹ engaging in community outreach (e.g., injury prevention and Stop the Bleed training), conducting team-based education and simulation training, and leading quality improvement initiatives such as the American College of Surgeons Trauma Quality Improvement Program.

Furthermore, ACS maintains a hospital's readiness for emergencies and traumas. Acute care surgery is often likened to a fire department: available 24/7 to provide essential lifesaving services and uphold the infrastructure required for high-quality responsive care.

For schools of medicine, an ACS service model offers substantial value. Through ACS, surgical and nonsurgical trainees gain exposure to foundational surgical skills and “bread-and-butter” surgery and are given the opportunity to develop essential competencies in clinical decision making, technical skills, and critical thinking under pressure. For residents, especially those training in an era of increasing specialization, ACS services offer a unique opportunity to care for diverse patient populations, providing a sound educational base.

Together, these contributions establish ACS as a cornerstone of hospital operations and patient care, as well as a critical foundation for training students and residents.

APPROACHES TO ACS STAFFING MODELS

The implementation of ACS varies widely across institutions because of the challenges in balancing local clinical demands against sustainable staffing and operational models. To realize the full potential of ACS, institutions must navigate these complex and often inconsistent implementation strategies. While ACS staffing models continue to evolve, many have not yet adapted to rising patient complexity, volume, and financial pressures. Furthermore, there is variation not only between institutions but also within them. In particular, the amount of work may vary between the trauma, EGS, and surgical intensive care unit services. This variability contributes to inconsistent practice patterns, uneven work relative value unit (wRVU) generation, and workload imbalances.

Currently, there are two general types of ACS staffing models used in the United States. These models have not been formally named but for the purposes of discussion here will be referred to as the “traditional (historic)” and the “time-delineated” models. In the traditional (historic) model, a group of ACS surgeons shares in-hospital acute care responsibilities without predefined commitments to a specific number of shifts or service weeks. Coverage is determined by dividing the total workload based on the number of surgeons in the group. This model may be seen in smaller institutions or where the ACS surgeons serve as the general surgeons for the hospital. Advocates for this model cite fewer patient hand-offs and smoother transitions of care. They think that there is also the potential for higher income. As a result, this model supports smaller group sizes with high productivity, which may align with departmental or hospital goals.

Critics of this model cite that sustainability in the modern era may be more difficult. Furthermore, these models are often associated with high clinical workloads that can limit time for academic, research, or educational efforts. Higher workload has also been associated with higher rates of burnout and turnover.^21,22

The second category includes the time-delineated models. Time-delineated models specify the amount of clinical work each surgeon is expected to perform in terms of time. There are two types of time-delineated staffing models, which are based on what unit of time is specified. The first is a week-based model where surgeons are assigned a specific number of service weeks per year. There are no standards for weeks per year, but there are some emerging national trends.²³ However, whether these published trends represent the ideal benchmark is yet to be determined.

More recently has been the use of shift-based (or “session-based”) models. Workload is defined by a specific number of sessions or shifts per month or year (e.g., 15–18 12-hour shifts per month). Sessions often account for all clinical duties including clinic and call, with workloads calculated to align with institutional or school of medicine workweek definitions. Proponents of this model allow precise workload management and offers transparency regarding staffing needs. Workload is clearly quantified, making it easier to determine staffing needs and allocate resources. This model also allows for time to supports nonclinical missions, such as research and education, by providing flexibility and protected time for these activities.

Critics of time-delineated models note that there is a risk of being too rigid, which may be problematic, as programs may require flexibility to adapt to changes in staffing or patient volumes. How an organization decides to manage and measure nonclinical time requires careful consideration, as there are no existing standards for accounting for academic or administrative work in these models. Another factor distinguishing the current practice of shift/session-based models versus week-based ones is that week-base models may not consider weekend and night, which can lead to overburdened schedules and increased burnout, especially in programs with high patient volumes.

No single model has emerged as dominant because ACS programs continue to evolve in response to local demand and culture. The evolution of ACS models also reflects an ongoing exploration of what the ideal structure for an ACS service should be. Regardless of the model used, implementing guardrails is critical to mitigate the risks associated with each model. For example, including limits on consecutive night shifts can be used in either model to ensure the quality of care.

Approaches to ACS Compensation Models

The unique nature of ACS work highlights the need for compensation models that address the breadth and complexity of the specialty. The following principles aim to address challenges and offer solutions for fair and effective ACS compensation models.

Salary Benchmarks for ACS Staffing and Compensation

Salary benchmarks are a common tool for guiding compensation decisions, but the application of these benchmarks to ACS presents unique challenges because of several reasons. The first, as discussed previously, is the variability in practice models present today, which leads to the absence of a standard definition. For instance, some ACS practices focus primarily on elective general surgery with limited trauma responsibilities, while others, such as those in county hospitals, may emphasize trauma and EGS with minimal elective work. Current benchmarking surveys, such as those conducted by Association of American Medical Colleges, Medical Group Management Association, SullivanCotter, and American Medical Group Association, include categories like “Trauma Surgery” or “Surgicalist.” This relate to ACS but may not be equivalent in terms of service mix or volume (Table 2). As a result, these categories often lack the clear definitions needed and may not accurately reflect the scope of an ACS practice.

TABLE 2.

Summary of the Four Most Common Salary Benchmarking Surveys as It Relates to ACS

	AAMC	MGMA	SullivanCotter	AMGA
Methods	Annual faculty survey	Annual medical group survey	Industry-wide annual survey	Survey of large medical groups
Practice settings	Academic medicine	All settings, primarily group practices	All settings	Large medical groups
Definitions relevant to ACS	Trauma/critical care surgery grouped together	Trauma and general critical care (nonsurgical) separate subcategories	Trauma and surgical critical care separate subcategories	Trauma surgery (includes critical care) and surgicalist

AAMC, Association of American Medical Colleges; MGMA, Medical Group Management Association; AMGA, American Medical Group Association.

For accurate benchmarking, there will need to be some changes for them to be helpful. The first step toward this aim will be to establish a standardized operating definition (or set of definitions) that reflects the specialty's scope and variability in practice. The second will be to develop fair market valuation methodologies that incorporate both tangible factors (e.g., productivity, time in service) and intangible factors (e.g., service intensity, quality, leadership).

wRVU-Based Compensation and ACS

Many surgical departments use wRVUs as the primary metric for measuring clinical productivity and determining compensation. However, this model inadequately reflects the workload of ACS surgeons. There are four key limitations to using wRVUs in this context. The first is that wRVUs fail to account for the cost of readiness. Surgeons on call are actively engaged in service even when operative or patient care volumes are low. The absence of billable activities during a shift does not equate to an absence of work, as ACS surgeons are often still overseeing care and are spending time in the hospital.

The second issue is that ACS surgeons often bill for nonprocedural work, using evaluation and management (E&M) codes. These codes credit fewer wRVUs than procedural services despite the fact they may be just as challenging (e.g., resuscitating a trauma patient). These “cognitive” services also provide a high degree of value despite being surgeons reimbursed at a lower rate. For example, nonoperative management of splenic injuries in select stable patients with blunt injury has been become a standard practice.^24,25 However, surgeon reimbursement for the cognitive skills involved in caring for these patients is minimal.²⁶ This is particularly challenging to recognize for surgical departments that are accustomed to a linear relationship between procedural work and procedures performed.

Furthermore, accuracy of E&M coding is more challenging given the complexity of coding rules and can lead to the risk of under- or overcoding.^27–29 In an audit by Centers for Medicare & Medicaid Services in 2024, 63.4% of the improper payments were due to incorrect coding. The remainder was due to improper documentation to support the codes.³⁰ The third issue arises when benchmark wRVUs are used to assign workload. As discussed previously, national benchmarks may not reflect local practice and E&M coding variability may worsen these differences. When local practice does not reflect the quoted benchmarks, misalignment may result leading to burnout. Furthermore, some ACS roles, such as surgical intensive care unit generate high revenue, whereas trauma at a nonbusy trauma center may not. A surgeon's wRVU therefore may depend on his/her distribution of coverage for those services. As a result, using wRVUs to measure an ACS surgeon's work may not reflect the true burden of that surgeon's work and could contribute to burnout.

There are several solutions to address wRVU-based challenges in ACS compensation models. One is to use time-based metrics for compensation systems rather than wRVUs. This would acknowledge the work required to maintain readiness, as well as the fact the ACS surgeon does not have control over the number of emergency cases or ICU patients. Another is to revise wRVU frameworks to incorporate the full spectrum of ACS contributions, including cognitive, triage, and care coordination efforts, and, in cases when wRVU targets are used to measure an ACS surgeon's work, ensure alignment between wRVU targets and the local workload to set achievable expectations that account for the nature of ACS work. This could also include implementing group-based, rather than individual-based, performance incentives to recognize and support the collaborative team-oriented nature of ACS care. Finally, it is also possible to consider using wRVUs as a basis for incentives or bonuses rather than as performance targets.

Work Intensity

The increasing intensity of ACS work, particularly as it has absorbed most nighttime call for general surgery, necessitates careful consideration of staffing and recovery. Emerging data suggest that recovery after a night on call is important to consider, as surgeons who reported being expected to work postcall were more likely to experience burnout.^31–34 There are currently no effective metrics for work intensity, which makes accommodating this factor challenging.

There are several potential solutions to this challenge, such as efforts to mitigate the effects of nighttime work using nighttime coverage models or scheduling recovery time after nighttime shifts. Institutions that prioritize recovery time and workload management will benefit from a healthier, more engaged ACS workforce capable of sustaining high-quality care.

Nonclinical Contributions and Institutional Mission

Because of the nature of their work, ACS surgeons often support the institutional goals through nonclinical work, which requires dedicated time and effort. These activities include such things as maintaining trauma center verification, disaster preparedness work, quality improvement initiatives, and engaging in community outreach, such as injury prevention programs or Stop the Bleed training.

A solution to this would be to ensure that nonclinical contributions are considered in workload calculations. For example, dedicating time for administrative activities would allow for ACS surgeons' contributions to be accounted for. By supporting nonclinical contributions, institutions can advance their nonclinical missions including education, research, and community engagement.

One solution is to ensure that nonclinical time is incorporated into workload calculations. For example, an organization can provide protected time for administrative responsibilities, which would allow ACS surgeons' work to be recognized. Supporting nonclinical efforts helps advance an organizations education, research, and community engagement missions.

CONCLUSION

Acute care surgery is an essential service that delivers significant value to patients, hospitals, and health care systems. Health care leaders play a pivotal role in shaping the future of this specialty. It is important to consider local demand and the variability inherent to ACS practices when developing staffing and compensation models. By doing so, institutions can ensure the resilience, sustainability, and excellence of their ACS programs. This will ultimately lead to the highest quality care for patients and a stronger health care system.