Published 9/1/2008

Readers address emergency care, “unforgiveable” errors

Mr. Binder (“Will reimbursement policies create an access crisis?” July 2008 AAOS Now) makes it clear that our response to decreased reimbursement has been to increase productivity, but that may not be sustainable. The article shows how much the pay for our work has been cut and refutes those who suggest that we don’t work as hard as we used to.

It struck me how this subject can be discussed in such a rational way while the on call issue, which involves largely the same set of problems, cannot. Total joint surgeons are not suggesting that others lack professionalism for not doing their share. It seems reasonable to say that we will get fewer joint replacements if we pay less for them. Strangely, it is harder for people to understand that we may get less call when we expect to get it for free.

Medicare has gotten more service for less money with their current strategy, and other insurance companies that follow its lead also benefit. Why should they change a strategy that works?

Doctors, like everyone else, will ultimately follow the incentives. At some point, working harder to stay in the same place will no longer be worthwhile. If that time comes while there are still enough doctors, a system change could rapidly fix the problem. If we wait until there are not enough doctors, it will take years to recover. We will do better for our patients to let the crisis happen than to try to keep the system functioning as it is.

Robert H. Sandmeier, MD
Portland, Ore.

Clearly, based on feedback I have received personally and subsequent letters as published in AAOS Now, the issues faced by all of us providing emergent orthopaedic services on call are diverse, impact each of us in a different manner, and must be addressed by the entire orthopaedic community in a head-on and constructive manner…

The issue is not the solo practitioners in a rural community providing orthopaedic services. All of us should be aware of and grateful for what they do. Care “in community” should always be the goal when possible. At the same time, no one can or should be expected to provide on call availability 24/7, 365 days a year. All of us need (deserve) a life “outside of work.”

Nor at issue is the expectation of being able to access resources to ensure care beyond the scope of routine orthopaedic practice. Complex or subspecialty-based issues (as opposed to core orthopaedics) are often best cared for by those with specialty training and interest in such problems. Referral for issues beyond our comfort level is good patient care. Those with additional or subspecialty training should be receptive to and recognize the compliment implicit in the request to refer patients.

Many of these problems have solutions. Establishing efficient referral patterns for anticipated times of orthopaedic unavailability benefits all parties. Surgeons on the “sending” end can retrieve some control of their lives; the receiving service can anticipate additional demands on practice and resources. Most important, the patient is not left as the pawn in the middle. Surgeons in smaller communities should have an expedient means of optimizing care for their patients. No one on the “receiving end” will (or should) question an arrangement that fairly addresses the dynamics of each practice when the end result is best care of the patient…

The issue seems to be those [who] choose to selectively “care” for patients. Is it appropriate to never be available for emergent services? Is routine fracture management the purview of the secondary referral centers? Does subspecialty training preclude the ability to provide basic orthopaedic care? Although the equipment complexity and ancillary services required to provide good patient care continue to escalate, should that preclude taking care of our own problems “in house”? Finally, when did the care of simple fractures in pediatric patients become the responsibility of the pediatric orthopaedist and a tertiary facility?

My letter clearly touched a nerve for many (and different nerves depending on one’s professional interests and practice settings). Hopefully, debate and interaction by those with different viewpoints allow us to improve the situation. Better a vigorous debate than smoldering resentment.

Thomas K. Miller, MD
Roanoke, Va.

Editor’s Note: For more on the trauma/on-call coverage issue, see “To pay or not to pay”), “Getting paid for taking call”, and “Managing the call schedule”.

I could not throw away the May 2008 AAOS Now because I am so appalled by David Attarian, MD, getting on board with this whole “preventable adverse event” campaign…Just because the federal government or other well-intended individuals wish to avoid the so-called unavoidable [events], they are not [always] unavoidable…

I do not know how a hospital can completely avoid in-hospital trauma. Accidents happen and should not suddenly become unavoidable or “unforgivable” just because they occur in a hospital setting. Although hospital care-givers cannot babysit every patient, reasonable protections should be in place.

As practitioners accept this unattainable goal of perfection, our ability to do even a reasonable job is undermined, and the burnout factor increases, as does the distance between patients and physicians who state “I don’t do that” or “I can’t do that.”

Catheter-acquired infections are not entirely avoidable. Surgical site infections cannot be eliminated and “indicated antibiotic prophylaxis” is a disputed regimen in some cases…

Medicine is not an exact science. Human nature includes bias. If we cannot avoid bias, maybe we should embrace it. If we cannot avoid mistakes, maybe we need to live with that fact. We should not be embarrassed or run away from the fact that it is an imperfect science. In my opinion, to simply condemn individuals or consider mistakes “unforgivable” is the only fact that is indeed “unforgivable.”

Daniel J. D’Arco, MD
Pottsville, Pa.

Will MOC split orthopaedics?
The American Board of Orthopaedic Surgery (ABOS) has now instituted Maintenance of Certification™ (MOC) requirements for recertification of any orthopaedist certified after 1985. The new pathways are more difficult than previous, and our profession is about to experience of wave of orthopaedists who decline recertification rather than jump through these new hoops.

I work at a hospital with 26 orthopaedic surgeons on staff. Eight of our orthopaedic surgeons in their 50s—almost one third of our staff—do not intend to apply for recertification when their certificates expire, because of the new labyrinthine MOC requirements.

These eight do not intend to stop practicing; on the contrary, with the economy in decline, reimbursements in decline, and costs rising, they plan to practice 15 to 20 years more. They feel ostracized and betrayed by the profession in which they “played by the rules” for 30 years. Their practices will not suffer. In my 25 years of practice, only one patient has asked if I am board-certified.

The ABOS should adopt a classification of “Emeritus Certification,” available to anyone who has completed 30 years of successful board certification. The practitioner would have to submit yearly evidence of CME and a yearly fee. After 30 years of experience, such surgeons are not a danger to the public [and] know full well how to stay within their capabilities. The ABOS could plainly state that this is a lesser status than regular Board Certification.

The ABOS has stated that MOC is not in final form; let us hope they make changes to avoid this coming disaster. If left unchanged, the current system will lead to alternative orthopaedic societies, the splitting of our profession, and a sad future.

David W. Aiken Jr., MD
Metairie, La.

Editor’s note: For more on MOC, see “Debunking the myths of MOCTM”.