Faculty Practice Solutions Center Research Articles

Compensation, Productivity, and Other Demographics of Academic Divisions of Endocrinology, Diabetes, and Metabolism.

The landscape for academic endocrinology divisions has continued to evolve rapidly;thus, finding reliable data that can be used as benchmarks has become more difficult. Resources are available for salary and relative value units, with the Association of American Medical Colleges, Medical Group Management Association, and Faculty Practice Solutions Center the most commonly used databases. However, details regarding how these data are collected and what they include are unclear. For example, does the income include bonus and/or incentive payments? How are work relative value units defined (individual rendering vs supervising advanced practitioners or fellows or residents)? How is a clinical full-time equivalent defined? In addition, other important data that would be relevant to running an academic division of endocrinology are not available from these, or any other resources, including support staff numbers and compensation or fellowship funding and training information. Therefore, an unmet need exists for reliable data that divisions can use to help shape their visions and goals. To address this demand, the Association of Endocrine Chiefs and Directors, in collaboration with the Endocrine Society, developed a detailed survey for members to address the financial, productivity, composition, and educational issues that they regularly face. Twenty academic institutions throughout the United States completed in the survey in 2018. In the present report, we have provided the results of the survey and some initial interpretations of the findings. Our hope is that the information presented will prove useful as academic endocrinology divisions continue to evolve.

The Evolving Practice Patterns of Academic Endocrine Surgeons: A Cross-sectional Analysis of the Faculty Practice Solutions Center Database 2014 to 2017.

To examine the evolution of an academic endocrine surgeon's practice over time. Amid growing recognition that surgical volume and specialization are linked to better outcomes, endocrine surgery is one of the youngest fields to develop its own formal fellowship training program. However, 3 decades after the emergence of endocrine surgery as a distinct specialty, the medical community and public still have a limited understanding of endocrine surgeons and what they do. We performed a cross-sectional analysis of endocrine surgeons identified in the Faculty Practice Solutions Center Database from 2014 to 2017. Trends in annual number of endocrine surgeries performed, number of all surgeries performed, total work relative value units generated, and patient payer mix stratified by years of practice were evaluated. One hundred thirty-nine endocrine surgeons practicing in 103 institutions over 4 years were analyzed. The proportion of endocrine-specific operations increases over time. A typical academic endocrine surgeon meets the high-volume threshold for thyroidectomies early in their career, but does not reach the thresholds for parathyroidectomies or adrenalectomies until after 4 years. Increased productivity as reflected by adjusted work relative value units does increase over the first 15 years of practice, but also decreases as the proportion of endocrine-specific practice increases. The greatest proportion of endocrine surgeons' patients are insured by commercial plans (46%-50%), and payer mix is stable across all levels of practice. Although endocrine surgeons perform a high-volume of endocrine-specific operations, practice patterns are heterogeneous and suggest that most surgeons have to grow their endocrine-specific practice over time.

PO494 Comparing Responsiveness of Three Physical Activity Measures In a Cardiac Rehabilitation Program: A Prospective Study

Both pediatric urologists and pediatric surgeons perform hernia repairs, hydrocelectomies and orchiopexies. We hypothesized that surgeons perform more incarcerated and female hernia repairs while urologists perform more orchiopexies and hydrocelectomies.The Vizient-AAMC Faculty Practice Solutions Center® database was queried from January 2009 to December 2014 to identify patients 10 years or younger who underwent the above procedures performed by pediatric specialists. Age, gender, race, insurance, geographic region and surgeon volume were examined.In the study 55,893 surgeries were identified: 26,073 primary hernia repairs, 462 recurrent hernia repairs, 3399 laparoscopic hernia repairs, 9414 hydrocele repairs and 16,545 orchiopexies. Pediatric surgeons performed 89% of primary hernia repairs with an annual median surgeon volume of 4 cases/year. Pediatric urologists performed 62% of hydrocelectomies and 83% of orchiopexies with annual median surgeon volumes of 6 and 24, respectively. Pediatric surgeons performed all procedures in younger patients and performed more female and incarcerated hernia repairs.Pediatric surgeons operate on younger patients and treat more patients with inguinal hernias while pediatric urologists care for more boys with undescended testes and hydroceles. This knowledge of referral patterns and care between specialties with overlapping expertise will allow improvements in training and access.Cost Effectiveness Study, Level of Evidence III.

32: Reoperation rates for stress urinary incontinence and pelvic organ prolapse in women undergoing a mid-urethral sling in academic centers within the United States

The aim of this study was to look at reoperation rates for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women who underwent a primary mid-urethral sling with or without concurrent POP repair. We hypothesized that women undergoing an SUI procedure with concurrent prolapse repairs would have decreased rates of reoperation for both prolapse and stress urinary incontinence. We also theorized that concurrent hysterectomy would be associated with lower rates of reoperation for POP and SUI, while prolapse repair with mesh would be associated with higher complication rates but lower rates of reoperation. The Faculty Practice Solutions Center (FPSC) is an academic hospital consortium database with information from over 60,000 physicians. This database was used to identify a cohort of patients who were treated surgically for SUI with a mid-urethral sling, with or without concurrent prolapse repair between 2009 and 2011. These patients were followed until 2014 for any subsequent SUI or POP surgeries and for any mesh complications that occurred during this time period. Patient variables (age, region, insurance) as well as surgeon volume were analyzed. Concurrent prolapse repair was analyzed based on anatomic involvement (anterior, apical, posterior, or “complete”). Sub-analyses were performed to evaluate the differences in secondary procedures. Of the 20,484 patients who underwent an SUI repair with or without concurrent POP repair, 7.2% required reoperation within the follow up period. There was a significantly higher rate of reoperation in those women who underwent concurrent prolapse repair (8.6 vs 6.3%). Women who had a concurrent prolapse repair had a 2-to-5-fold higher hazard of undergoing a repeat prolapse repair. Concurrent hysterectomy was performed in 15% of patients. While its addition did not lower the hazard of requiring any secondary surgery, it lowered the rate of repeat prolapse surgery in patients who received a concurrent ‘complete’ repair (HR = 0.48). Prolapse mesh was placed in 5% of patients. Its use resulted in a higher hazard of requiring any additional surgery (HR = 1.4), and specifically, increased the hazard of requiring repeat prolapse repair (HR = 1.5). Post-operative fistula, although rare (0.4%), had a significant association with older patients (HR = 2.1) and prolapse mesh (HR = 2.7) placement. Medicaid insurance was associated with higher risk of requiring secondary surgery (HR = 1.3). With over 20,000 patients and up to a 5 year follow-up, this is one of the largest cohort studies performed on the surgical outcomes of mid-urethral slings with or without prolapse repair surgery. While the overall reoperation rate was low, the addition of prolapse repair surgery with the initial sling procedure was associated with higher reoperation rates. In contrast, the addition of a hysterectomy lowered the risk of secondary surgery in some patients. This data allows for a clearer understanding of reoperative rates for patients undergoing mid-urethral sling placement with or without prolapse repair.

Pediatric inguinal and scrotal surgery — Practice patterns in U.S. academic centers

PurposeBoth pediatric urologists and pediatric surgeons perform hernia repairs, hydrocelectomies and orchiopexies. We hypothesized that surgeons perform more incarcerated and female hernia repairs while urologists perform more orchiopexies and hydrocelectomies. MethodsThe Vizient-AAMC Faculty Practice Solutions Center® database was queried from January 2009 to December 2014 to identify patients 10years or younger who underwent the above procedures performed by pediatric specialists. Age, gender, race, insurance, geographic region and surgeon volume were examined. ResultsIn the study 55,893 surgeries were identified: 26,073 primary hernia repairs, 462 recurrent hernia repairs, 3399 laparoscopic hernia repairs, 9414 hydrocele repairs and 16,545 orchiopexies. Pediatric surgeons performed 89% of primary hernia repairs with an annual median surgeon volume of 4 cases/year. Pediatric urologists performed 62% of hydrocelectomies and 83% of orchiopexies with annual median surgeon volumes of 6 and 24, respectively. Pediatric surgeons performed all procedures in younger patients and performed more female and incarcerated hernia repairs. ConclusionsPediatric surgeons operate on younger patients and treat more patients with inguinal hernias while pediatric urologists care for more boys with undescended testes and hydroceles. This knowledge of referral patterns and care between specialties with overlapping expertise will allow improvements in training and access. Levels of evidenceCost Effectiveness Study, Level of Evidence III.

Benchmarking Academic Anatomic Pathologists: The Association of Pathology Chairs Survey

The most common benchmarks for faculty productivity are derived from Medical Group Management Association (MGMA) or Vizient-AAMC Faculty Practice Solutions Center® (FPSC) databases. The Association of Pathology Chairs has also collected similar survey data for several years. We examined the Association of Pathology Chairs annual faculty productivity data and compared it with MGMA and FPSC data to understand the value, inherent flaws, and limitations of benchmarking data. We hypothesized that the variability in calculated faculty productivity is due to the type of practice model and clinical effort allocation. Data from the Association of Pathology Chairs survey on 629 surgical pathologists and/or anatomic pathologists from 51 programs were analyzed. From review of service assignments, we were able to assign each pathologist to a specific practice model: general anatomic pathologists/surgical pathologists, 1 or more subspecialties, or a hybrid of the 2 models. There were statistically significant differences among academic ranks and practice types. When we analyzed our data using each organization’s methods, the median results for the anatomic pathologists/surgical pathologists general practice model compared to MGMA and FPSC results for anatomic and/or surgical pathology were quite close. Both MGMA and FPSC data exclude a significant proportion of academic pathologists with clinical duties. We used the more inclusive FPSC definition of clinical “full-time faculty” (0.60 clinical full-time equivalent and above). The correlation between clinical full-time equivalent effort allocation, annual days on service, and annual work relative value unit productivity was poor. This study demonstrates that effort allocations are variable across academic departments of pathology and do not correlate well with either work relative value unit effort or reported days on service. Although the Association of Pathology Chairs–reported median work relative value unit productivity approximated MGMA and FPSC benchmark data, we conclude that more rigorous standardization of academic faculty effort assignment will be needed to improve the value of work relative value unit measurements of faculty productivity.

Adolescent varicocele: A large multicenter analysis of complications and recurrence in academic programs

After varicocelectomy a wide range of recurrence rates have been reported from 0 to 18%, and rates of post-operative hydrocele formation between 0 and 29%. Controversy exists as to the appropriate approach for varicocele treatment, whether open, laparoscopic, or percutaneous embolization (PE) is best for young men. The literature on treatment of adolescent varicocele is limited to high-volume single surgeon, single institution, or small multi-institution series. Our goal was to evaluate the retreatment and complication rates from numerous institutions to determine more generalizable results. The Faculty Practice Solutions Center database was queried to identify males under age 19 years with a diagnosis and/or treatment of varicocele between January 2009 and December 2012. Patients were followed until December 2013 (1-5 years follow-up) to determine if they had occurrence of outcome variables: retreatment, diagnosis, or treatment of hydrocele. Associations of the variables age, race, insurance type, geographical region, surgeon-volume, and surgical approach, with outcome variables were analyzed using a mixed-effects Cox proportional hazard model. Of 6,729 patients with a diagnosis of varicocele, 1,036 underwent open (405), laparoscopic (530), or percutaneous embolization (PE) (101) treatment by 213 physicians. Retreatment rates after open, laparoscopic, and PE treatments were 1.5%, 3.4% and 9.9%, respectively. Race, region, insurance type, and age were not independently associated with outcomes. The incidence of hydrocele after open, laparoscopic, and PE treatments was 4.9%, 8.1%, and 5%, respectively. No approach was independently associated with diagnosis or treatment of hydrocele. Young age was associated with a significantly higher rate of hydrocele formation. For each year of age, there was a 14% decreased rate of hydrocele formation. Although this series contains the largest cohort of patients, physicians, and institutions, we were limited by the inability to determine actual recurrence rates. Only patients receiving retreatment at the same institution within the 1-5 year follow-up period were captured. As such, the true rate of varicocele recurrence may be higher. The retreatment rate is influenced by the physician's threshold to retreat and the patient's desire to undergo another procedure. Despite its limitations, this is the first study to compare open, laparoscopic, and percutaneous approaches to varicocele treatment. Percutaneous embolization has a significantly higher retreatment rate compared with either open or laparoscopic varicocelectomy. Retreatment and hydrocele formation after open and laparoscopic approaches were not significantly different. This supports a surgeon and family choosing an approach based on patient characteristics and surgeon preference.

Rise in microsurgical free-flap breast reconstruction in academic medical practices.

Previous studies have examined national trends in breast reconstruction, using various data sets demonstrating increases in implant-based reconstruction and decreases in autologous reconstruction. However, academic breast reconstruction practices have never been specifically characterized. The University Health Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database contains comprehensive, factual billing and coding data from 90 academic medical centers in the United States, and has been used to characterize practice patterns of various academic surgical specialties. To describe breast reconstruction trends unique to academic surgical practices, using the Faculty Practice Solutions Center database. Annual data for defined breast reconstruction procedures (current procedural terminology codes: 19340, 19342, 19357, 19361, 19364, 19366, 19367, 19369, and 19380) performed by university plastic surgeons during calendar years 2007 to 2013 were included in the study. From 2007 to 2013, a 2-fold increase in the number of breast reconstruction procedures was observed (from a mean of 45.3 to 94.2 procedures per surgeon). During this period, implant-based reconstructions and autologous reconstructions rose in tandem (28.9-44.6 and 11.4-19.3, respectively), with a preserved 2.5:1 ratio between the 2 categories each year. When compared to reconstructions overall, the proportion of both implant reconstruction and autologous reconstruction procedures declined, since revision and other types of reconstructions increased (11% of all reconstructions in 2007 vs 32% in 2013). With regard to autologous reconstruction, microsurgical free flaps (mostly comprised of deep inferior epigastric artery perforator flaps) have supplanted latissimus flaps as the favored modality and comprised 13% to 14% of breast reconstruction cases overall from 2011 to 2013. In contrast to national trends, university-based plastic surgeons are performing a growing number of microsurgical free flaps as the preferred method for autologous breast reconstruction. Whereas implant-based reconstructions still predominate in academic practices, the trend of increasing preference toward implant-based reconstructions has slowed in recent years and revision reconstructions are on the rise.

Congenital Adrenal Hyperplasia: Current Surgical Management at Academic Medical Centers in the United States

Controversy exists on the necessity for and timing of genitoplasty in girls with congenital adrenal hyperplasia. Our knowledge of surgical preferences is limited to retrospective series from single institutions and physician surveys, which suggest a high rate of early reconstruction. We evaluated current surgical treatment for congenital adrenal hyperplasia at academic centers. We queried the Faculty Practice Solutions Center database to identify all female patients younger than 18 years with a diagnosis of congenital adrenal hyperplasia between 2009 and 2012. Procedures were identified by CPT codes for vaginoplasty, clitoroplasty and other genital procedures. Reconstruction type, age at surgery and surgeon volume were analyzed. We identified 2,614 females in the database with a diagnosis of congenital adrenal hyperplasia who were seen at a total of 60 institutions. Of infants younger than 12 months between 2009 and 2011 as few as 18% proceeded to surgery within a 1 to 4-year followup. Of those referred to a pediatric urologist 46% proceeded to surgery. Of patients who underwent surgery before age 2 years clitoroplasty and vaginoplasty were performed in 73% and 89%, respectively, while 68% were treated with a combined procedure. A medium or high volume surgeon was involved in 63% of cases. Many patients with congenital adrenal hyperplasia in the database did not proceed to early reconstructive surgery. Of those referred to surgeons, who were possibly the most virilized patients, about half proceeded to early surgery and almost all underwent vaginoplasty as a component of surgery. Abouttwo-thirds of the procedures were performed by medium or high volume surgeons, indicative of the surgical centralization of disorders of sexual development.

The modern acute care surgeon: characterization of an evolving surgical niche.

Trauma and emergency surgery continues to evolve as a surgical niche. The simple fact that The Journal of Trauma is now entitled The Journal of Trauma and Acute Care Surgery captures this reality. We sought to characterize the niche that trauma and emergency surgeons have occupied during the maturation of the acute care surgery model. We analyzed the University Health System Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database for the years 2007 to 2012 for specific current procedural terminology (CPT) codes. This database includes coding and billing data for more than 90 academic medical centers throughout the United States. We analyzed frequency counts and work relative value units (wRVUs) generated for specific codes to characterize the average trauma and emergency surgeon's work experience over time. We found that acute care surgeons generated 42.4% of wRVUs from procedural work and 57.6% from cognitive work. For cognitive work, critical care services generated the most wRVUs per year (25.2% of total), and subsequent hospital care was the most frequently performed activity (1,236.6 codes generated per year). For procedural work, laparoscopic cholecystectomies produced the most wRVUs per year (2.4% of total), and placement of a nontunneled catheter was the most frequently performed procedure (42.2 times per year). The average acute care surgeon performed the following numbers of procedures per year: 29.6 cholecystectomies and 20.0 appendectomies; 7.7 wound vacuum device changes; 5.9 implantation of mesh procedures; 4.9 splenectomies and 0.4 splenorrhaphies; 2.6 perirectal abscess drainage procedures; less than one component separation fascial hernia repair; and less than one video-assisted thoracic surgery. The modern acute care surgeon is a hybrid of critical care medicine physician and ever-evolving surgical interventionist. Acute care surgeons continue to do traditional trauma work while increasingly performing acute care surgeries. The work of acute care surgeons serves a growing role and fills a valuable niche in our health care system.

Endocrine surgery in present-day academia

Endocrine surgery is a specialty that is evolving constantly. In this study, we sought to delineate the practice patterns of surgeons taking care of endocrine diseases in present-day academic centers. A review of the Faculty Practice Solutions Center database was conducted for the years 2005, 2009, and 2013. Practice patterns were determined by International Classification of Diseases, 9th Revision and Current Procedural Terminology codes, and analyzed for practice composition, regional variability, and volume of endocrine operations. Of 97 national academic centers, 52 were identified to have 120 practicing American Association of Endocrine Surgeons (AAES) surgeons in the study. On average, endocrine operations comprise ∼65% of the AAES surgeon's practice, and 51% are considered high-volume surgeons for thyroidectomy, parathyroidectomy, and adrenalectomy. Most non-AAES surgeons who perform endocrine operations are otolaryngologists (24.5%) and other general surgeons (18.5%). Overall, non-AAES surgeons perform the majority of endocrine operations at academic institutions (61.6%), and low-volume surgeons perform most of these operations (55.6%). Research has shown that high-volume surgeons have improved outcomes. Even in academia, however, the majority of endocrine operations are performed by low-volume surgeons, suggesting that there is an opportunity for expanding the number of surgeons with expertise in endocrine surgery in present-day academic centers.

Physician preference is a major factor in management of vesicoureteral reflux.

Known factors affecting the management of vesicoureteral reflux (VUR) include reflux grade, infection frequency, age and gender. We hypothesized that provider preference is highly associated with management. Utilizing the national billing database, Faculty Practice Solutions Center, a multivariable logistic regression model, was applied to analyze the association of pediatric urologist treatment patterns, patient age, gender, uni- or bilateral disease, insurance type, presence of nephropathy and race with the type of VUR treatment a patient would receive. We identified 59 pediatric urologists who managed 7,882 new reflux patients from 2009 to 2011. Over this 3-year period there was wide variation in surgical utilization between surgeons (mean 50 %) but minimal change for each surgeon (5 %). For every 100 new reflux patients, median utilization of reimplantation surgery and injection of dextranomer/hyaluronic acid copolymer (Deflux) was 26 and 20 %, respectively. Age ranked highest in predicting surgical versus non-surgical management, while a surgeon's historic Deflux utilization rate ranked highest in predicting surgery type. Older age, female gender and white race also increased the odds of Deflux utilization over reimplantation. A surgeon's historic Deflux utilization was the most important predictor of VUR surgery type. Although data on reflux grade were not available, analysis of patient and surgeon characteristics suggests that surgeon preference is the first or second most critical factor in determining a patient's treatment.

Urinary Diversion during and after Pediatric Pyeloplasty: A Population Based Analysis of More than 2,000 Patients

We evaluated the use and efficacy of intraoperative urinary diversion with ureteral stent or nephrostomy tube during pyeloplasty in children. The Faculty Practice Solutions Center® national billing database was queried to identify all pediatric pyeloplasties performed from 2009 to 2012. Patient variables, surgical approach, use of intraoperative stent/nephrostomy tube and return for postoperative stent/nephrostomy tube or second pyeloplasty were obtained. A total of 2,435 children underwent open (1,792) or laparoscopic/robotic (643) pyeloplasty, with intraoperative urinary diversion rates of 45% and 83%, respectively. Comparing patients with and without an intraoperative stent/nephrostomy tube, 5.6% and 7.4%, respectively, returned to the hospital for urinary diversion. Multivariable analysis revealed no association with surgical approach, but higher surgeon volume (p <0.01) and use of an intraoperative stent/nephrostomy tube (p <0.01) were associated with decreased odds of requiring postoperative urinary diversion. Second pyeloplasty rate was 3.8% and was not associated with surgical approach or use of intraoperative stent/nephrostomy tube. Intraoperative stent/nephrostomy tube use and increased surgeon volume were each independently associated with a significant but small decrease in risk of postoperative stent/nephrostomy tube placement. Use of an intraoperative stent/nephrostomy tube was not associated with rate of second (redo ipsilateral or contralateral metachronous) pyeloplasty.

Who Performs Complex Noncardiac Thoracic Surgery in United States Academic Medical Centers?

We hypothesized that general thoracic surgeons (GTS) predominantly perform complex noncardiac thoracic surgery in academic hospitals compared with cardiac surgeons (CS), general surgeons, and surgical oncologists. Fiscal year 2007-2008 to 2009-2010 coding and work relative value unit data from the University Health System Consortium and Association of American Medical Colleges Faculty Practice Solutions Center database, which includes 86 academic institutions, was analyzed. Procedural groups for pneumonectomy, other pulmonary resection (including lobectomy, bilobectomy, segmentectomy, sleeve lobectomy, and video-assisted thoracoscopic surgery lobectomy-segmentectomy), and esophagectomy were evaluated. Of the 1,989,055.3 total work relative value units generated for complex noncardiac thoracic surgical procedures during the study period, 77.5% were generated by GTS, compared with 9.9% by CS, 8.9% by general surgeons, and 3.7% by surgical oncologists (p<0.001). General thoracic surgeons averaged 2.1 pneumonectomies, 51.1 other pulmonary resections, and 12.2 esophagectomies per year compared with 2.1 pneumonectomies, 9.4 other pulmonary resections, and less than 1 esophagectomy per year for CS. General surgeons and surgical oncologists averaged no more than 1.6 cases per year for all categories (all p<0.001, except for pneumonectomy, in which GTS versus CS was not significantly different). To determine the use of parenchymal-sparing operations, we looked at the ratio of sleeve lobectomy to pneumonectomy and found higher usage of parenchymal-sparing techniques by GTS, relative to pneumonectomy, compared with all other groups (p<0.001). General thoracic surgeons averaged 16.0 video-assisted thoracoscopic surgery lobectomies per year compared with approximately 1 per year for all other groups (p<0.001). General thoracic surgeons had a 47.1% increase in video-assisted thoracoscopic surgery lobectomies per year compared with 27.4% for CS. In academic hospitals, noncardiac thoracic surgery is performed mostly by GTS, supporting academic GTS as a distinct specialty. These results may help determine hospital referral and credentialing policies, and plan general and cardiothoracic surgery residency curriculum.

Trauma Surgery to Acute Care Surgery: Defining the Paradigm Shift

Trauma surgery is gradually evolving into acute care surgery (ACS). We sought to better define this evolution by using work relative value units (wRVU) to characterize the current practices of trauma and ACS. Fiscal year 2007-2008 data from the UHC-AAMC Faculty Practice Solutions Center database, which is comprised of coding or billing data from 85 institutions was used. We compared averages for trauma surgeons with general, oncology, and vascular surgeons. Trauma surgeons are distinct from other surgical specialties; only 43% of their total wRVU were procedural compared to 69% to 75% for vascular, surgical oncology, and general surgeons. The total procedures for each specialty were similar: trauma 660, general surgery 715, surgical oncology 713, vascular 835, but trauma surgeons performed more bedside procedures. Of the top 20 total wRVU generating procedures, 20% of trauma surgeon's were bedside compared to 0% of a general surgeon's. The wRVU or surgeon for cholecystectomy were comparable between trauma and general surgery (388 vs. 452); both groups perform about 75% of the cholecystectomies laparoscopically. With respect to appendectomies, wRVU or surgeon for trauma surgeons (180) exceeded general surgeons (128). Each group performed approximately 65% laparoscopically. Trauma surgeons are distinctly different from their colleagues, with a greater emphasis on intensive care unit "cognitive" work. The number of procedures performed by trauma surgeons is comparable to other disciplines but with more "bedside" procedures. Trauma surgeons' high appendectomy wRVUs may be a reflection of the transition to an ACS model. The characterization of trauma surgery as nonoperative and intensive care unit-based is in part substantiated but there are indications of a paradigm shift toward more operative experience with transition to an ACS model.