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Practical Solutions to Practical Problems In Rural Surgery Dana Christian Lynge Assoc Prof Surgery University of Washington.

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Presentation on theme: "Practical Solutions to Practical Problems In Rural Surgery Dana Christian Lynge Assoc Prof Surgery University of Washington."— Presentation transcript:

1 Practical Solutions to Practical Problems In Rural Surgery Dana Christian Lynge Assoc Prof Surgery University of Washington

2 Recruiting the Rural Surgeon Charles T. McHugh Baileyville, ME

3 Demographics 459 of 500 poorest counties are rural 459 of 500 poorest counties are rural Populations: sparse Populations: sparse elderly elderly many w/no health care coverage many w/no health care coverage poorly educated poorly educated high levels: abuse, neglect, poverty, high levels: abuse, neglect, poverty, addiction addiction

4 Personal Time Cultural activities Cultural activities Shopping Shopping Continuing intellectual growth Continuing intellectual growth Friends with similar interests Friends with similar interests

5 Children Adequate (for expectations) education Adequate (for expectations) education Exposure to culture Exposure to culture Recreation/Development of skills Recreation/Development of skills

6 Unhappy Spouse Too far from urban amenities Too far from urban amenities Children’s issues Children’s issues

7 Spouse Expectations Time with family Time with family Greater integration of physician spouse/parent in family activity and development Greater integration of physician spouse/parent in family activity and development

8 Nothing Changes Overwhelming patient care pressure Overwhelming patient care pressure Frequent call – not the “knife and gun club,” Frequent call – not the “knife and gun club,” but unable to make plans and be but unable to make plans and be even a short distance away even a short distance away

9 Issues with spouses Employment of the spouse Employment of the spouse Often a highly educated individual himself/herself Often a highly educated individual himself/herself

10 Result “We’re outta here!” “We’re outta here!”

11 Call Often onerous and not much better than residency, albeit usually less intense. Often onerous and not much better than residency, albeit usually less intense.

12 Confidence Often lacking in newly minted surgeon Often lacking in newly minted surgeon Desired guidance cannot provided by “burnt out” senior partners Desired guidance cannot provided by “burnt out” senior partners

13 Veteran Surgeon Expectation More time off and away More time off and away Coverage of post-ops Coverage of post-ops Relief from constant assisting Relief from constant assisting Not to give up their case load!! Not to give up their case load!!

14 Unrealistic and Realistic Expectations Spouse Spouse Self Self “Partners” “Partners” And, probably, the hospital if it is the employer. And, probably, the hospital if it is the employer.

15 New Surgeon Employed Employed Expected to provide assistance and relief for the established surgeons Expected to provide assistance and relief for the established surgeons Is often now “more surgeon” than the area can support economically. Is often now “more surgeon” than the area can support economically.

16 Balance the Bottom Line Develop/require undesirable tasks which are peripheral to the practice of surgery. Develop/require undesirable tasks which are peripheral to the practice of surgery. Start a full scale endoscopy clinic utilizing the new surgeon. Start a full scale endoscopy clinic utilizing the new surgeon.

17 Discontent Little contact with colleagues who are on the cutting edge/keeping up Little contact with colleagues who are on the cutting edge/keeping up Few CME opportunities Few CME opportunities Inability/lack of time/money to get away to meetings. Inability/lack of time/money to get away to meetings.

18 Nagging Thoughts I’m losing hold on my profession. I’m losing hold on my profession. If I act now, I can recover and restore my standing and my self respect. If I act now, I can recover and restore my standing and my self respect.

19 Result “We’re outta here!” “We’re outta here!”

20 Anne M. Williams, MD FACS Glasgow, MT

21 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 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 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 A number of prominent surgeons are promoting the concept of “Acute Care Surgery” as an alternative solution

22 But, in rural areas … The general surgeon performs a fairly broad range of traditional general surgical procedures 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 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 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 Urologic emergencies– eg. torsion, outlet obstruction, trauma Head and neck, airway emergencies Head and neck, airway emergencies OB/GYN emergencies – C sections, ectopic pregnancy OB/GYN emergencies – C sections, ectopic pregnancy Orthopedic emergencies Orthopedic emergencies

23 The rural surgeon is often also The gastroenterologist The gastroenterologist The oncologist The oncologist The critical care specialist/consultant The critical care specialist/consultant The wound care specialist The wound care specialist The pain management consultant/specialist The pain management consultant/specialist The proceduralist in general The proceduralist in general Most also practice with limited or no local surgical support, so options for consultation and relief are limited Most also practice with limited or no local surgical support, so options for consultation and relief are limited

24 Today’s residents … With the 80-hour work week restrictions, emphasis is on team care rather than sole individual responsibility 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 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 Most training is done by sub-specialists in large programs, with resultant bias Being a “general surgeon” isn’t a Great Thing Being a “general surgeon” isn’t a Great Thing 80% go on to fellowship training after residency 80% go on to fellowship training after residency

25 Health Care Reform & RuralAmerica There is much speculation that mid-level practitioners are going to play an increasingly large role in providing primary care 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 This is already happening to a great extent in the rural areas General surgery is one aspect where mid-levels cannot totally replace physicians 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 surgeon or two Many rural areas, therefore, may find themselves depending on a few primary care physicians, many mid-level practitioners, and a general surgeon or two

26 This will add pressure on the general surgeon to provide more of the ancillary care that mid-levels can’t provide This will add pressure on the general surgeon to provide more of the ancillary care that mid-levels 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 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 There will be more need for the surgeon to provide more comprehensive care of her/her patients as well

27 Surgeon Shortage Is Here Shortages in both urban and rural areas now and getting worse Shortages in both urban and rural areas now and getting worse Our system can’t run on sub-specialists alone Our system can’t run on sub-specialists alone Fewer available to take general surgery call in urban and suburban areas Fewer available to take general surgery call in urban and suburban areas Less willing to go to rural areas Less willing to go to rural areas Not every procedure has to be done by a sub- specialist at a large medical center to be done well Not every procedure has to be done by a sub- specialist at a large medical center to be done well The impact of long travel on patients and families is often overlooked The impact of long travel on patients and families is often overlooked

28 First and foremost, we have to change our mindsets at the highest levels 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 General surgeons are fully capable of doing most procedures safely and well Need to instill pride back into General Surgery 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 Need to incorporate ideas from both the SCORE curriculum and the Acute Care Surgery concept in moving forward in revitalizing General Surgery

29 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 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 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 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 Develop mentoring programs to help new surgeons or even older surgeons in rural areas Develop mentoring programs to help new surgeons or even older surgeons in rural areas

30 Many of these concepts will be difficult to incorporate into the existing practice and culture of current training programs 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 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 asset in some cases Post-residency fellowships will also be a valuable asset in some cases

31 Reimbursement and the Rural Surgeon Tyler G. Hughes, MD FACS McPherson, Ks

32 The Good Ol’ Days Hang out your shingle Hang out your shingle Take good care of patients Take good care of patients Collect what you can Collect what you can Make a decent living Make a decent living

33 I’m not sure it was ever that easy

34 No Bucks- No Buck Rogers 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. 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. 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.

35 Good point- So how?

36 William Osler To solve a problem, one must first understand the problem To solve a problem, one must first understand the problem

37 Where are we in terms of income? General Surgeons- General Surgeons- First year average salary is $220,000 First year average salary is $220,000 >3 years experience $267,000 >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

38 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

39 Options Solo Practice- Most autonomy, highest risk to personal finances and most labor intensive for the owner of the practice Solo Practice- Most autonomy, highest risk to personal finances and most labor intensive for the owner of the practice Group Practice- Single or Multispecialty Group Practice- Single or Multispecialty Employment- Hospital based Employment- Hospital based

40 According to Bureau of Labor Statistics physician owned practices have a slightly higher income than salaried surgeons

41 Employment Model Designed to give mutual financial security to the hospital and physician Designed to give mutual financial security to the hospital and physician Must allow medical professional autonomy Must allow medical professional autonomy Should be flexible to the local environment (employed surgeons competing against a majority of private practitioners doesn’t work) Should be flexible to the local environment (employed surgeons competing against a majority of private practitioners doesn’t work)

42 Employment for the Rural Environment Frequently a small town has no competing general surgeon 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 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 Seems best suited in the not for profit hospital setting which is typical in rural areas

43 Contract Structure Straight salaries are “out” Straight salaries are “out” RVU based salaries are “in” RVU based salaries are “in”

44 RVU Contract Structure Base Salary + Bonus structure based on w- RVUs ($X/RVU) Base Salary + Bonus structure based on w- RVUs ($X/RVU) Adaptable to both mature and new practices Adaptable to both mature and new practices Provides security to both parties Provides security to both parties Prevents “retirement” on the job Prevents “retirement” on the job Allows salary expansion based on hard work Allows salary expansion based on hard work

45 RVU model cont’d 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. 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.

46 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.

47 CALL John Kole, M.D. Grand Itasca Clinic and Hospital Cohasset, Minnesota

48 Alternatives to “Permacall” Remuneration Remuneration Regional call sharing Regional call sharing Practice sharing Practice sharing Scheduled locums Scheduled locums Scheduled off call (ship out) periods Scheduled off call (ship out) periods PAs/NPs PAs/NPs


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