Who’s on Call? Emergency Cross-Cover of Surgical Specialties Is Growing

What complicates the issue is that each general surgeon will bring their own level of comfort and experience, which is almost always going to be more variable than the expertise of a specialist—expertise largely driven by experience. 

There are general surgeons who perform just as many emergency colon resections as colorectal surgeons, and so they may be comfortable managing such an emergency and have good outcomes. Data show that, overall, general surgeons perform more colectomies than colorectal surgeons in the US.⁸ But there are borderline cases where a specialized surgeon may be able to deliver superior outcomes as reported by the research.

“In some areas, it is clearly appropriate to send a patient to a colorectal surgeon when there is something that can wait 24 to 48 hours and is within the specialty of colorectal surgery, like left-sided cancers and inflammatory bowel disease,” Dr. Booth said.

Even for the emergency colectomies that are regularly performed by general surgeons, recent research indicates that procedures performed by colorectal surgeons result in less morbidity and mortality.⁹

But something worth keeping in mind, Dr. Booth said, is that the optimal outcomes from a specialist do not mean that a general surgeon won’t provide lifesaving care.

“While a colorectal surgeon may have lower surgical site infection rates due to their experience, an infection is, of course, preferable to a patient who loses their life because nobody was there to operate on them,” she said. “Improving outcomes of emergencies and complications is about optimization, where a general surgeon should be at least competent to address a patient’s needs, while a specialist should be able to provide definitive care.”

This is a core issue at play when considering the role of a general surgeon in an urgent or emergent situation—balancing the reality of a situation with the idealized view of the situation.

“Ideally, if you have someone with a colon complication, you will find a fellowship-trained surgeon who has performed thousands of colon surgeries to lead,” said Alexander R. Raines, MD, FACS, a general surgeon and associate professor at The University of Oklahoma Health Sciences. “But there isn’t always that surgeon in the area when and where the patient needs them, even while they have access to capable general surgeons who may have different but equally valuable experience.”

Dr. Raines agrees with the perspective that timing does, in general, take precedence over delaying care for a specialist, and knowing how to make the call on immediate surgery versus waiting is a skill in and of itself.

“This is where the art of medicine comes into play—what is that time cutoff? Surgeons love to have rules, spreadsheets, and flow charts that tell us exactly what to do and when to do it, but those do not always exist. Is the specialist an hour away or 5 hours away? Can surgery safely be delayed? You need to weigh all the factors, and it’s difficult because there is often not one right answer,” he said.

Importance of Resources

The prevalence of general surgeons performing emergency specialty operations points to an ongoing issue in healthcare throughout the US—limited resources to address the growing health needs of the population.

Surgery is incredibly resource-intensive, so access to these resources—which includes surgeons themselves—is paramount. But resources are not distributed equally, and not all practice settings are created the same.

“It’s not just the skills of cutting and sewing,” Dr. Raines said. “In fact, the cutting and sewing is usually the easy part. It’s the resources around it that can really make a difference. These emergency patients are often going to need an ICU to care for them. They may need other specialists like interventional radiologists or nephrologists or cardiologists to manage the other pathophysiology that exists alongside the surgical condition.”

The divide in resources is particularly clear when looking at access to care for patients in small and rural communities, a setting that often requires a general surgeon to oversee any kind of emergency or complication. From hysterectomies to carotid endarterectomies to thyroidectomies,¹⁰ a rural surgeon may be responsible for a variety of procedures and must be able to temporize the emergent condition before transferring the patient.

But in a strained healthcare system, surgeons working in rural, suburban, urban, or any area in between can find a patient in a situation that necessitates immediate action.

“I’ve taken calls from community hospitals where we’re not in their usual catchment area or their usual referral pattern, but they’ve called all their customary places, and all of them are full,” Dr. Regner said.

“They’re trying to find someplace to get the patient safely, and every time they call a hospital and hear a ‘no,’ that’s another 5 minutes or 10 minutes that that patient is not receiving care. And if they’ve made four, five, six attempts at transfer calls—that patient may be in that emergency department now for up to an hour or longer and still not have any resolution or direction on how to get out of that situation,” he continued.

When surgeons and beds are limited, it is critical that a competent and qualified surgeon is available wherever a patient ultimately arrives when their emergency can no longer wait to be treated. 

Growing the Workforce, Skills

While general surgeons can address many of the specialized emergent needs of surgical patients and complications, a specialty surgeon can be expected to provide better outcomes, on average. An obvious potential solution would be to increase the number of specialists who are trained and available throughout the US, as there is a recognized deficiency.¹¹ The sheer scale of such an undertaking, however, calls into question its feasibility.

Looking at the urgent colectomy as an example, the numbers are stark. A recent study of more than 70,000 urgent colectomies from 2020 to 2022 showed that 76% were performed by general surgeons, meaning colorectal surgeons performed only a quarter of the procedures¹² while also having fewer complications and mortality.

But there is another important figure to consider—there are only about 2,000 board-certified colorectal surgeons in the US.

“You probably would need double the number of colorectal surgeons in the US to have all emergency colon pathology taken care of by colorectal surgeons,” Dr. Regner said. “And that’s just not doable in the foreseeable future.”

With 2024 match data showing that 117 positions for colorectal surgery were filled that year,¹³ there would need to be a notable increase in positions and no specialists retiring to reach the goal of having twice as many colorectal surgeons practicing in the US in the next 10 to 20 years.

Demand for bariatric surgery has increased markedly alongside obesity rates in recent decades (a recent and potentially temporary dip due to availability of GLP-1 agonists notwithstanding¹⁴), with more than 100,000 additional surgeries taking place in 2022 versus 2016.¹⁵

“The number of bariatric surgery patients is rising astronomically, while the number of bariatric surgeons is not,” Dr. Raines said.

With complications relatively high in this population, patients are going to need specialty care, and either more specialists will need to be trained or “surgeons are going to need to be able to be familiar with those conditions,” he explained.

Another consideration is that, even if more specialists are trained and hired throughout the US, the increased prevalence may not be uniformly beneficial across patient populations. While access is one part of the problem, there needs to be some consideration of the fact that what keeps an expert an expert is performing a high volume of surgeries and the ability to maintain that volume, Dr. Booth noted.

“Even if we could produce enough colorectal surgeons to have them in every small community, individual surgeons are going to lose their expertise if they’re not practicing a high volume of colorectal care,” she said.

One solution that may be more attainable in the near future is to increase the abilities of existing surgeons to address the gaps in emergency surgical care, and this is an area where organizations such as the ACS play an important role.

To recognize and bolster the provision of emergency surgery that can fall into a general surgeon’s responsibilities, the ACS and The American Association for the Surgery of Trauma created the Emergency General Surgery Verification Program (EGS-VP).

Launched in 2022, the EGS-VP addresses disease areas that have overlap with other specialties, such as gastrointestinal obstruction, diverticular disease, pancreatitis, and acute gastrointestinal bleed,¹⁶ and follows the model of a trauma center to guarantee that qualified surgeons are available at any time to handle an emergency. 

An endocrine surgeon, gastrointestinal surgeon, or colorectal surgeon may be the ideal providers of definitive treatment, but surgeons at a hospital accredited by the EGS-VP are qualified to provide lifesaving care across the diverse scope of this area.

Another element that will be key to addressing gaps in access to emergency surgery is dedication to lifelong learning, which may be particularly important for general surgeons.

“There are very busy general surgeons who went through residency when bariatric surgery was not performed at such high volumes as it is now, but does that absolve them from the responsibility of knowing how to take care of bariatric anatomy? No, they are just as responsible as a fresh graduate. That’s when providing ongoing education pathways becomes important,” Dr. Raines said.