Physiatry in a Orthopaedic Practice Can Be A Win-win for Surgeons and Patients

Twenty years ago, when I was offered the opportunity to join the Peachtree Orthopedics Clinic (POC) in Atlanta, I was honored to be recruited by one of the area’s premier orthopaedic practices. The leaders of POC recognized the need for my services as a nonsurgical specialist. As it turns out, I was the group’s first full-time physiatrist.

In 1998, most orthopaedic practices had surgeons who were generalists and only a smattering of subspecialists. POC was different. Most of its physicians subspecialized, with only the more senior, “old-school docs” serving as generalists. All physicians took call and shared responsibilities. For example, a spine surgeon might trade a 3 a.m. hip fracture with a joint specialist, or a hand surgeon would send an acute radiculopathy to the spine surgeon.

All physicians were busy, but they were spending too much time on things that did not allow them to do what they really wanted, which was to operate. Hiring a physiatrist helped solve that problem. More patients were brought into the practice, and surgical patients were effectively steered to the appropriate specialists.

This practice model proved to be highly successful, so much so that POC hired three more physiatrists over the next five years. Admittedly, there were some growing pains along the way. Physiatrists did not have to take call, which caused resentment among several surgeons. Some even went so far as to propose that physiatrists should pay not to take call. Furthermore, the physical medicine and rehabilitation doctors, myself included, often were treated like second-class citizens, simply because we could not fix things like the surgeons could.

Fortunately, cooler heads prevailed over time. The physiatrists demonstrated their value to the practice. Because we did not take hospital call, we did not mind coming in early or staying late for patients in clinic. Each of us saw about 400 patients per month and “teed up” the surgical cases for our surgeons.

Because we are trained to evaluate and treat musculoskeletal conditions in general, physiatrists often serve as gatekeepers for an orthopaedic practice. We can determine quickly whether a case is surgical or not. We also can evaluate patients who may have multiple body parts affected; provide nonoperative care; and direct them to the appropriate subspecialists, if needed. By the time they arrive for surgical consultation, radiographs, MRIs, and other diagnostic studies are already completed. Decisions about surgery can be made on the first visit with the orthopaedic surgeon.

After physiatry was introduced to the practice, POC was able to capture much of its nonsurgical business. Electromyography (EMG) studies that were previously referred to neurologists remained in-house. Care became more efficient, as studies often were scheduled almost immediately after they were ordered, with results coming back quickly for the referring physician. Patients often were startled at how fast they could get back for surgical decision-making. Similarly, epidural steroid injections were performed by POC physicians, rather than sent out to anesthesia groups. It became clear that the physiatrists were instrumental in making the group’s orthopaedic care more efficient and effective, which we all can agree is what patients and surgeons want.

Workers’ compensation represents a good percentage of POC’s overall business. To be successful, getting injured workers in the door quickly is imperative. Rapid transmission of office notes with work status returned to insurance adjusters also is paramount. Having physiatrists available to see such cases has helped this aspect of POC’s business grow. It should be noted that many insurance adjusters insist that an MD see their injured workers, not a physician’s assistant or a nurse practitioner.

The addition of physiatrists can enable orthopaedic practices to offer a variety of additional services, including acupuncture, electromyography, and epidural steroid injections, to name a few. The additional services can increase the group’s orthopaedic care, making it more efficient and effective.

The addition of physiatry services at POC changed the thinking of the practice’s orthopaedic surgeons in many ways. Physiatrists brought a level of expertise that the practice did not have before. In particular, we provided insight on cases where there might be neurologic involvement. For example, if a patient came in with hand numbness, we could decipher whether he or she needed to see the hand surgeon for an elective carpal tunnel release or a spine surgeon for an emergent cervical myeloradiculopathy. When a rotator cuff repair was not recovering as expected, we could determine whether there was a suprascapular neuropathy. Over time, the surgeons-versus-nonsurgeons mentality has melted, and we are all now colleagues, rowing our boat in the same direction.

Like any business, money matters. Financially, physiatrists can pull their own weight. On busy clinic days, we see routine patients, perform independent medical examinations, and provide second opinions. We order and read our own radiographs. Most of the in-office procedures that the surgeons perform, we do as well. One of our physiatrists even offers acupuncture to select patients. Most biologic therapies also can be performed by physiatrists.

POC’s ancillary business has grown as a result of the increased access physiatrists provide. Most patients who visit an orthopaedic practice do not need surgery, but most need physical therapy to recover. MRI studies are necessary for patients with suspected structural/surgical conditions and for those who do not improve with conservative management. Although EMG studies and interventional pain cases may not pay as much as surgical ones, they present in greater volume. The pain cases hit the bottom line not only for evaluation and management services but also for our surgery center as well.

Philosophically, patients like that there are nonsurgical specialists in the group. They want to hear about less invasive treatment options. They like the emphasis on exercise as a means to recovery. Many patients believe that all surgeons want to do is operate. Having nonoperative specialists in our group shows patients that we take conservative care seriously. Additionally, when a nonsurgical specialist tells a patient that a condition does require surgery, the patient may be more apt to accept that opinion, as they know the physiatrist has no vested financial interest in the surgery. Furthermore, patients may consider surgery less overwhelming when they know they have explored nonsurgical options first.

Integrating physiatry into an orthopaedic practice can be highly successful, although it does require careful planning and some cultural changes. When recruiting physiatrists, ensure they have a strong interest in musculoskeletal care. Fellowship training in sports medicine, family practice, or pain medicine will make for better candidates. Let them know what you are looking for, and listen to what they think they can bring to the table. If done properly, adding physiatrists will make your practice more patient-friendly, dynamic, and intellectually diverse.

David Schiff, MD, is double board certified in physical medicine and rehabilitation, as well as pain medicine. He has been with POC since 1998.

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