Practical Solutions to Practical Problems by chenmeixiu


									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
   459 of 500 poorest counties are rural
   Populations: sparse
                 many w/no health care coverage
                 poorly educated
                 high levels: abuse, neglect, poverty,
                Personal Time
   Cultural activities
   Shopping
   Continuing intellectual growth
   Friends with similar interests
   Adequate (for expectations) education
   Exposure to culture
   Recreation/Development of skills
              Unhappy Spouse
   Too far from urban amenities
   Children’s issues
           Spouse Expectations
   Time with family
   Greater integration of physician spouse/parent
    in family activity and development
             Nothing Changes
   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
   Employment of the spouse
   Often a highly educated individual
   “We’re outta here!”
   Often onerous and not much better than
    residency, albeit usually less intense.
   Often lacking in newly minted surgeon
   Desired guidance cannot provided by “burnt
    out” senior partners
     Veteran Surgeon Expectation
   More time off and away
   Coverage of post-ops
   Relief from constant assisting
   Not to give up their case load!!
          Unrealistic and Realistic
   Spouse
   Self
   “Partners”
   And, probably, the hospital if it is the employer.
                 New Surgeon
   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
   Develop/require undesirable tasks which are
    peripheral to the practice of surgery.
   Start a full scale endoscopy clinic utilizing the
    new surgeon.
   Little contact with colleagues who are on the
    cutting edge/keeping up
   Few CME opportunities
   Inability/lack of time/money to get away to
            Nagging Thoughts
   I’m losing hold on my profession.
   If I act now, I can recover and restore my
    standing and my self respect.
   “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,
   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
           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 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
 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 sub-
  specialist at a large medical center to be done
 The impact of long travel on patients and
 Firstand 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
   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
   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
   To solve a problem, one must first understand the
     Where are we in terms of income?
    General Surgeons-                    Median Incomes of the
        First year average salary is       competition:
         $220,000                         Anesthesia $321K
        >3 years experience $267,000
                                          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

At present the salary or income for a
rural general surgeon needs to be in
the $250,000 range with potential for
expansion to higher levels depending
on amount of work done
   Solo Practice- Most autonomy, highest risk to
    personal finances and most labor intensive for
    the owner of the practice
   Group Practice- Single or Multispecialty
   Employment- Hospital based
According to Bureau of Labor
Statistics physician owned practices
have a slightly higher income than
salaried surgeons
            Employment Model
   Designed to give mutual financial security to the
    hospital and physician
   Must allow medical professional autonomy
   Should be flexible to the local environment
    (employed surgeons competing against a
    majority of private practitioners doesn’t work)
         Employment for the Rural
   Frequently a small town has no competing
    general surgeon
   Hospital has more need of the surgeon than in
    urban settings as percentage of revenue stream
   Seems best suited in the not for profit hospital
    setting which is typical in rural areas
             Contract Structure
   Straight salaries are “out”
   RVU based salaries are “in”
         RVU Contract Structure
   Base Salary + Bonus structure based on w-
    RVUs ($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
   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

        John Kole, M.D.
Grand Itasca Clinic and Hospital
     Cohasset, Minnesota
        Alternatives to “Permacall”

   Remuneration
   Regional call sharing
   Practice sharing
   Scheduled locums
   Scheduled off call (ship out) periods
   PAs/NPs

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