Transcript Practical Solutions to Practical Problems

Practical Solutions to
Practical Problems In
Rural Surgery
Dana Christian Lynge
Assoc Prof Surgery
University of Washington
Recruiting the Rural Surgeon
Charles T. McHugh
Baileyville, ME
Demographics
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459 of 500 poorest counties are rural
Populations: sparse
elderly
many w/no health care coverage
poorly educated
high levels: abuse, neglect, poverty,
addiction
Personal Time
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Cultural activities
Shopping
Continuing intellectual growth
Friends with similar interests
Children
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Adequate (for expectations) education
Exposure to culture
Recreation/Development of skills
Unhappy Spouse
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Too far from urban amenities
Children’s issues
Spouse Expectations
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Time with family
Greater integration of physician spouse/parent
in family activity and development
Nothing Changes
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Overwhelming patient care pressure
Frequent call – not the “knife and gun club,”
but unable to make plans and be
even a short distance away
Issues with spouses
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Employment of the spouse
Often a highly educated individual
himself/herself
Result
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“We’re outta here!”
Call
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Often onerous and not much better than
residency, albeit usually less intense.
Confidence
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Often lacking in newly minted surgeon
Desired guidance cannot provided by “burnt
out” senior partners
Veteran Surgeon Expectation
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More time off and away
Coverage of post-ops
Relief from constant assisting
Not to give up their case load!!
Unrealistic and Realistic
Expectations
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Spouse
Self
“Partners”
And, probably, the hospital if it is the employer.
New Surgeon
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Employed
Expected to provide assistance and relief for the
established surgeons
Is often now “more surgeon” than the area can
support economically.
Balance the Bottom Line
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Develop/require undesirable tasks which are
peripheral to the practice of surgery.
Start a full scale endoscopy clinic utilizing the
new surgeon.
Discontent
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Little contact with colleagues who are on the
cutting edge/keeping up
Few CME opportunities
Inability/lack of time/money to get away to
meetings.
Nagging Thoughts
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I’m losing hold on my profession.
If I act now, I can recover and restore my
standing and my self respect.
Result
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“We’re outta here!”
Anne M. Williams, MD FACS
Glasgow, MT
First, Define General Surgery
 Too
often at present, General Surgery is
considered the part of surgery that isn’t part of
another specialty – and the pie is getting
progressively more divided
 The American Board of Surgery is working on
the SCORE program to define the “core” and
“scope” of General Surgery
 A number of prominent surgeons are promoting
the concept of “Acute Care Surgery” as an
alternative solution
But, in rural areas …
 The
general surgeon performs a fairly broad
range of traditional general surgical procedures
 The general surgeon is usually the endoscopist in
the community
 The general surgeon is often called upon for a
number of procedures no longer in the general
surgery realm
 Urologic
emergencies– eg. torsion, outlet obstruction,
trauma
 Head and neck, airway emergencies
 OB/GYN emergencies – C sections, ectopic
The rural surgeon is often also
 The
gastroenterologist
 The oncologist
 The critical care specialist/consultant
 The wound care specialist
 The pain management consultant/specialist
 The proceduralist in general
Most also practice with limited or no local surgical
support, so options for consultation and relief are
limited
Today’s residents …
 With
the 80-hour work week restrictions,
emphasis is on team care rather than sole
individual responsibility
 Vast decrease in the number of teaching assistant
cases done by senior residents, so relatively few
cases done without an attending present and
directing the case
 Most training is done by sub-specialists in large
programs, with resultant bias
 Being a “general surgeon” isn’t a Great Thing
Health Care Reform & RuralAmerica
 There
is much speculation that mid-level
practitioners are going to play an increasingly
large role in providing primary care
 This is already happening to a great extent in the
rural areas
 General surgery is one aspect where mid-levels
cannot totally replace physicians
 Many rural areas, therefore, may find themselves
depending on a few primary care physicians,
many mid-level practitioners, and a general
 This
will add pressure on the general surgeon to
provide more of the ancillary care that midlevels can’t provide
 Procedures such as central lines, thoracentesis,
paracentesis, percutaneous drainage of abscesses,
minor office procedures will be beyond the
scope/comfort zone of most mid-levels and the
surgeon increasingly called on to perform these
tasks
 There will be more need for the surgeon to
provide more comprehensive care of her/her
patients as well
Surgeon Shortage Is Here
 Shortages
in both urban and rural areas now and
getting worse
 Our system can’t run on sub-specialists alone
 Fewer
available to take general surgery call in urban
and suburban areas
 Less willing to go to rural areas
 Not
every procedure has to be done by a subspecialist at a large medical center to be done
well
 The impact of long travel on patients and
 First
and foremost, we have to change our
mindsets at the highest levels
 General surgeons are fully capable of doing
most procedures safely and well
 Need to instill pride back into General Surgery
 Need to incorporate ideas from both the
SCORE curriculum and the Acute Care Surgery
concept in moving forward in revitalizing
General Surgery
To help train rural surgeons
 In
training programs, find ways to promote more
independence in senior residents so they feel
prepared to practice in an isolated setting
 Find ways to allow more experience in related
surgical areas such as GYN, ortho, urology, and
ENT, and non-surgical related areas like GI,
oncology as appropriate
 Do not allow the push for more OR time to
compromise learning the other procedural
aspects of care, or cutting into clinic experience
too deeply
 Many
of these concepts will be difficult to
incorporate into the existing practice and culture
of current training programs
 It will probably be best to have interested
programs work with the RRC and ABS to set up
rural training tracks, where residents can be
exposed to both a broader range of experience
as well as faculty who demonstrate what a good
general surgeon can do
 Post-residency fellowships will also be a valuable
Reimbursement and
the Rural Surgeon
Tyler G. Hughes, MD FACS
McPherson, Ks
The Good Ol’ Days
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Hang out your shingle
Take good care of patients
Collect what you can
Make a decent living
I’m not sure it was ever that easy
No Bucks- No Buck Rogers
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Until we no longer need money to buy groceries,
clothes, cars, houses and the rest health care providers
(formerly known as doctors) will have to make money.
Given the rigors of the surgical life, to attract young
men and women away from other specialties and
practice environments, the income of the rural general
surgeon must be in line with that of the “competition”
or the hassle factor of practice must be reduced.
Good point- So how?
William Osler
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To solve a problem, one must first understand the
problem
Where are we in terms of income?
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General Surgeons
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First year average salary is
$220,000
>3 years experience $267,000
Median Incomes of the
competition:
Anesthesia $321K
OB/GYN $247K *
___________________
Ortho- $342K
Total Joints- $491K
Sports- $479K
CV- $515K
Urology- $359K **
* Bureau of Labor Statistics 2008-2009 ** Allied Physicians Website 2006 data
Conclusion:
At present the salary or income for a
rural general surgeon needs to be in
the $250,000 range with potential for
expansion to higher levels depending
on amount of work done
Options
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Solo Practice- Most autonomy, highest risk to
personal finances and most labor intensive for
the owner of the practice
Group Practice- Single or Multispecialty
Employment- Hospital based
According to Bureau of Labor
Statistics physician owned practices
have a slightly higher income than
salaried surgeons
Employment Model
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Designed to give mutual financial security to the
hospital and physician
Must allow medical professional autonomy
Should be flexible to the local environment
(employed surgeons competing against a
majority of private practitioners doesn’t work)
Employment for the Rural
Environment
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Frequently a small town has no competing
general surgeon
Hospital has more need of the surgeon than in
urban settings as percentage of revenue stream
Seems best suited in the not for profit hospital
setting which is typical in rural areas
Contract Structure
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Straight salaries are “out”
RVU based salaries are “in”
RVU Contract Structure
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Base Salary + Bonus structure based on wRVUs ($X/RVU)
Adaptable to both mature and new practices
Provides security to both parties
Prevents “retirement” on the job
Allows salary expansion based on hard work
RVU model cont’d
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Allows for pay for call (embedded in the base
salary) without “killing the golden goose”. Rural
hospitals cannot afford to pay $1000- $2000/
day for call coverage.
The above is presented as an
example of a model working in rural
Kansas with two surgeons in a town
of 13,000 people with 30,000 in the
county service area.
No doubt there are other workable
models and the audience is invited to
comment.
CALL
John Kole, M.D.
Grand Itasca Clinic and Hospital
Cohasset, Minnesota
Alternatives to “Permacall”
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Remuneration
Regional call sharing
Practice sharing
Scheduled locums
Scheduled off call (ship out) periods
PAs/NPs