Practical Solutions to Practical Problems In Rural Surgery

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

Recruiting the Rural SurgeonCharles T. McHughBaileyville, ME

Demographics • 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 • Cultural activities • Shopping • Continuing intellectual growth • Friends with similar interests

Children • 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 himself/herself

Result • “We’re outta here!”

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

Confidence • 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 Expectations • 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.

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

Result • “We’re outta here!”

Training the Rural General Surgeon 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 pregnancy • Orthopedic emergencies

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 80% go on to fellowship training after residency

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 surgeon or two

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 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 well • The impact of long travel on patients and families is often overlooked

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

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 asset in some cases

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 problem

General Surgeons- 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 ** Where are we in terms of income? * 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 • 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 Environment • 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 comment.

CALLJohn Kole, M.D.Grand Itasca Clinic and HospitalCohasset, Minnesota

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

Practical Solutions to Practical Problems In Rural Surgery