1 Introduction

Acute care surgery [ACS] as a model of care and a focused area of specialisation is gaining traction globally [1,2,3]. ACS is typically seen as a natural evolution of the specialty of trauma. If anything, this evolution is a necessity. There is a diminishing generation of true blue generalist surgeons. Previous generations of well trained surgeons, with broad clinical experience and a wide range of surgical skills; are now being replaced by sub-specialists—surgeons whose practice are focused on a limited area [3].

This problem is further amplified by the introduction of limits on working hours. In response to limited work hours, many leading governments have called for more doctors to be trained, in a shorter timeframe. There is competition for clinical experience and less time to obtain it [4].

These dilemmas are magnified in trauma surgery. Good trauma surgeons rely on a breadth of clinical experience and must be accustomed to operating on a wide range of organs. The patients received by trauma surgeons are potentially in terrible physiological states, as opposed to well optimised elective patients. The surgeons will constantly be required to make complex decisions rapidly.

Furthermore, injury patterns have changed. Legislative interventions against the use of firearms, drink driving and speed, whilst enforcing the use of safety belts, have made roads safer. Better organ imaging and the increased skill sets of interventional radiologists have supported the adoption of non-operative management of solid organ injuries.

These changes mean that trauma surgeons have much less operative experience; and are now seen as doctors who make decisions during resuscitation and critical care. Many of these trauma surgeons have little choice, but to refer much of their operating to their subspecialty colleagues.

1.1 Restructuring is desperately needed

Esposito et al. showed that nearly 90% of trauma surgeons felt trauma surgery required re-structuring to survive [5]. There is indeed an urgent need to restructure and solve the problems above.

The solution must fulfill several needs:

  1. 1)

    Trauma surgeons must be trained across all fields and organs to develop a full skill set.

  2. 2)

    Trauma surgeons should be trained in the latest laparoscopic and robotic skills, and not just open surgery. This will lead to further and greater advancements in the field.

  3. 3)

    Trauma surgeons need to have a constant operative load to keep their skills fresh and sharp.

  4. 4)

    Trauma needs to be an attractive discipline, in order to bring in the best and brightest talents. This means giving surgeons an opportunity to learn the newest and latest skills, whilst ensuring a good work life balance.

The answer therefore, lies in the introduction of Acute Care Surgery [ACS]. ACS is run very differently in each country. However, the crux of ACS would be that surgeons not only receive and handle trauma patients, but also handle their fair share of elective and emergency general surgery cases as well.

As the ACS model varies in each country, it is this author’s opinion that in the ideal ACS system, surgeons will be:

  1. 1)

    Exposed to a wide range of operative procedures – both as part of emergencies, as well as electives.

  2. 2)

    The trauma surgeon will get a high operative load on a weekly, if not daily basis, to remain fresh and sharp.

  3. 3)

    The introduction of electives under the ACS umbrella is also critical to ensure trauma surgeons will be trained in the latest laparoscopic and robotic skill sets. For patients’ benefit, this mix up is also crucial. If ACS surgeons can handle multi-organ issues and also utilise advance laparoscopic and robotic skills; they can advance research and development in emergency work [6].

  4. 4)

    If the electives can incorporate oncological surgeries, the trauma surgeon will gain intimate knowledge of vasculature and delicate surgical anatomy.

1.2 Global outcomes

Countries adopting the ACS model may run their systems differently. Nonetheless, globally the ACS model has been shown to reduce time to surgery and complication rates, particularly for common conditions such as appendicitis and cholecystitis [7, 8]. For cholecystitis patients, a reduction in conversion rate and a 40% increase in index-presentation cholecystectomies were noted [9]. The productivity of the department as a whole also improved, with greater utilisation of the theatre and intensive care unit (ICU) [10]. Some studies reported reductions in length of stays (LOS), complications and costs compared to those in standard care units [11, 12]. Apart from patient driven outcomes, some studies have also shown improvements in in-house operative teaching, and greater consultant presence in the theatre [13].

1.3 Early days of ACS in Singapore

In Singapore, the recognition of these problems have led to Trauma being remodeled into Acute Care Surgery. Whilst the first steps have been taken, the road ahead is still far from smooth. Whilst there are 19 acute hospitals in Singapore, only Singapore General Hospital [SGH] has adopted a true acute care model. That is to say, SGH has established an ACS service and is actively training specialists to serve as full fledged ACS surgeons. Every other hospital has either not established ACS, or have tried and failed to do; or has an ACS service but manned by subspecialists.

As of 2022, ACS is still in its nascent days at SGH. At present there are only 3 consultants and 3 junior associate consultants, with the latter still in training before they can become fully independent. The ACS team is further divided into 4 sub teams [A, B, C and D]. Each team is helmed by a full fledged consultant. Due to the lack of full time ACS surgeons, the last team [team D] requires a subspecialty consultant to helm the team.

Each team will absorb all emergency patients in a 24 h time span. With the team’s consultant being readily available for that 24 h. For the full 24 h, the ACS surgeon is on call. He or she is updated on all admissions, especially sick patients and patients requiring surgery. The on call team consisting of the on call medical officer and registrar will review the incoming cases, and update the ACS consultant. The consultant subsequently decides if the patient needs surgery, and if he or she needs to return to hospital to conduct or supervise the surgery.

The next morning, the ACS surgeon and his or her ACS team, conducts a hand-over round with the on-call team. Thereafter the incumbent ACS team continues to manage the patient accordingly. In addition to the daily emergency work, the surgeons also run their elective clinics and elective operating theatre lists. The latter usually consists of hernias, cholecystitis, skin lumps and endoscopies.

On average, SGH receives approximately 700–800 ACS patients per month [14]. We have been able to demonstrate that there are reductions in the length of stay [median 3.1 days versus 2.8 days, P = 0.012]. ACS patients also have had shorter times to obtain a CT scan and to receive surgery [median 1 h, 1.2 h respectively p < 0.05]. There was also an increase in the presence of a consultant in OT in the ACS period [21 vs 10%, P < 0.001]. [15]

Comparatively, during the pre-ACS days; the old system meant that every subspecialist surgeon would cover the daily general surgery call, in addition to their routine subspecialty elective work. Each surgeon would adhere to a call roster that was planned centrally. Many a times, the call dates would not consider the subspecialist’s personal clinic and theatre schedules. Simply because such a massive call roster was typically planned weeks to months in advance.

As a result, the general surgery call usually took a backseat, in comparison to the subspecialist’s daily plans. This was the result of the subspecialists’ perception of the general surgery call, and also due to the fact that the system did not enable the subspecialist to block their time to handle the call and post-call periods. This meant that the surgeons were less inclined to return to hospital to conduct or supervise cases overnight, as they needed rest for the next day’s subspeciality theatre or clinic. Post-call rounds were also left very much to the devices of the team’s managing registrar.

In comparison to the old system, the ACS system would be a much welcomed service from a systems and workflow perspective.

1.4 The road ahead is challenging

The system in Singapore is however, far from perfect. Although ACS is beginning to show positive results from a systems and workflow point of view; its future is uncertain. Of the 19 acute care hospitals, ACS is only sustained in its true form, in Singapore General Hospital.

The biggest challenge facing ACS in Singapore, is that it is still widely deemed to be an unpopular specialty. Many residents still elect to sub-specialise, rather than join the ACS service. The lack of incoming talent, and the label of an unpopular specialty, threatens ACS’ very existence.

What issues lie ahead of ACS?

  1. (1)

    The remuneration is no different from the sub-specialties, and yet ACS surgeons have to remain on call frequently, including the weekends. And on the post-call days, the ACS surgeon rounds all the new patients – with no telling how busy that day or week is going to be. This is different from subspecialty practice whereby returning to work at night or on weekends, is becoming rarer. That is because their ACS colleagues have assumed that responsibility. The uncertainties and the need to work graveyard hours are off-putting to most young surgeons.

  2. (2)

    ACS surgeons’ skills for minimally invasive surgeries are limited to laparoscopic hernias and cholecystectomies. Due to the nature of the ACS work, and the fact that SGH has several sub-specialities, ACS surgeons rarely get an opportunity to practice laparoscopic or robotic skills for other organs. Without exposure to oncological cases, ACS surgeons also do not develop the exquisite dissection skills and intimate knowledge of anatomy.

  3. (3)

    The ACS surgeon is thus deemed to be inferior to the subspecialists, in terms of surgical knowledge and skills. This is magnified in Singapore because many young surgeons aspire to a life in private practice. The ACS surgeon is deemed to be too unskilled to be able to achieve success in private.

  4. (4)

    It is a vicious cycle. If ACS is deemed to be unattractive, less talent will be drawn to this specialty. This will increase the workload on the existing ACS surgeons. Ultimately, this gives less time for ACS surgeons to develop research, innovation and less opportunities to develop minimally invasive and elective surgery skills. And that cycle will only deepen.

Since 2016 when SGH first introduced ACS as a service, we have seen positive results. ACS is a much needed service. However each country and its health system is unique. Each system has its nuances, and its system’s doctors have their own aspirations and cultures. In Singapore, for ACS to become a truly recognised and established practice, there are many more challenges ahead. ACS’ future is exciting, but its road to success, is anything but guaranteed.