Rural orthopaedists have a measurable impact

“I spent 20 years in a city environment, and I just love being in a small town with relatively low crime and no traffic,” says James W. Barber, MD, describing some of the benefits of being an orthopaedic surgeon in a rural area. “I’m close to work, and I really like being in a wide-open, rural area.”

Dr. Barber runs a small, solo orthopaedic practice in Douglas, Ga.—a town of about 16,000 people in the southern half of the state. The local hospital is an 88-bed facility located two-and-a-half hours from the nearest Level-1 trauma center.

“We have a very tight community. I think that’s probably true for most rural areas. I can’t go to Wal-Mart without running into two or three patients. That can also be a bad thing,” he laughs, “but I enjoy having that neighborly connection with my patients. I hear about problems much earlier than I would if I were in a city environment. I also hear how well my patients are doing.”

That close relationship between patient and physician can be a powerful draw for an orthopaedist to relocate to a small town from a large city.

“I always wanted to practice where my skills would be needed,” explains Gregory M. Behm, MD, “not where there were 15 other orthopaedists fighting over the same patient.” Dr. Behm trained at the Campbell Clinic, but now practices in Hamilton, Mont. (pop. 4,691). He works at a 25-bed critical access hospital with two operating rooms.

“I always get a kick out of going to these outpatient centers in big hospitals,” he laughs. “They have six or eight operating rooms, and our whole hospital has two. People say, ‘Do you think we should open up an outpatient center?’ and I say, ‘We are an outpatient center.’”

A different set of challenges
The issue of resources is one that faces both urban and rural practitioners, although in different ways. Being the only orthopaedist in the area may ensure a solid patient base, but it also means you have little or no back-up.

“When I was planning to come here, I anticipated my practice would slow down,” says David B. Yanoff, MD, who relocated his practice in January 2005 from suburban Philadelphia to Salmon, Idaho (pop. 2,961). “It has to some degree, but it’s actually much busier than I or anyone thought it would be.

“I’m seeing many more patients and performing much more surgery than I thought I would. Part of that is from pent-up demand, I think. People were putting things off because they didn’t want to drive 6 hours round-trip to have their knee examined,” he says.

In addition to maintaining a busy practice, orthopaedists in rural areas—like their city counterparts—must also deal with the issue of emergency call. With fewer surgeons on staff at the local hospital, each surgeon has more call days per month. Although there may be fewer calls overall than in an urban center, the lack of a large surgical staff to distribute the load means that rural surgeons are likely to “make themselves available” even on their days off, just to ensure competent coverage. The problem is magnified for specialty physicians, such as orthopaedists or cardiologists.

“It just doesn’t look good for me or for the hospital if a patient comes into the emergency room with a broken arm, and is told that the orthopaedic surgeon isn’t taking call today,” says Dr. Yanoff.

“Our bylaws say that you only have to be on call one-third of the time,” says Dr. Behm, “but as the only orthopaedist, I just can’t do that. When I first came here, I was probably on call 75 percent of the time, if not more. I’ve recently cut back, and now I’m officially on call only 60 percent of the time. The reality is, however, that as the only orthopaedic surgeon, I end up seeing anyone with a musculoskeletal condition.”

Ensuring appropriate care
One issue that can place rural surgeons at odds with their urban colleagues is the treatment—or transfer—of emergency cases. Physicians at tertiary care centers may perceive some of these transfers as “dumping” of patients that the rural surgeon finds undesirable or inconvenient. Frustrations can arise at larger hospitals that have a large number of incoming patients with “routine” conditions.

The problem is exacerbated by the fact that a single large urban hospital could accept transfers from several rural hospitals. From the point of view of the larger facility, the number of patients being transferred can quickly spiral upward, even if each rural hospital transfers relatively few patients.

Because Drs. Barber, Behm, and Yanoff all trained and, in some cases, practiced in city hospitals, they have a unique understanding of both sides of the issue.

“I’ve worked in an urban environment,” says Dr. Barber, “and I definitely understand how urban physicians feel about getting transfers from a rural area. In some rural areas, a few patients are probably transferred for the convenience of the surgeon. But in most cases, when patients need to leave the rural environment, it’s for a very good reason.”

Those reasons can range from a lack of proper equipment and facilities—a small hospital can’t afford to stock a full complement of orthopaedic devices—to the simple fact that there may not be enough hours in the day for a single surgeon to handle all the cases.

“I’ve got patients waiting three weeks to get just a standard appointment,” explains Dr. Behm. “If I have a full clinic and an open fracture comes in, I can’t just cancel my clinic. I have to see those people, and may stay until 9 or 10 o’clock at night. Several times, I’ve had to reschedule everyone in the clinic to Saturday. That’s something surgeons in the city may not understand, because they don’t have to take call when they’re in clinic.”

“Generally speaking, I’m probably seeing and taking care of locally more than 95 percent of the orthopaedic problems that come in to the emergency room,” says Dr. Yanoff. “I take care of everything I can, but if I’m away, or the patient needs care beyond the capability of my hospital or my operating room to deliver, or if it’s something that one orthopaedic surgeon probably shouldn’t be doing alone, it’s in the patient’s best interest to be transferred to a larger hospital.”

“When I was in the emergency room at the trauma center,” says Dr. Behm, “and a transfer case came in, I used to wonder ‘Why can’t those guys pin a supracondylar fracture?’ Now, having met several older surgeons serving in rural areas, I realize that they probably didn’t do many of them during residency and it’s probably been 5 years since they’ve done one.”

Filling a need
In some regions, the issue of transfers, as well as a shortage of surgeons able or willing to take call is being addressed through the creation of trauma networks designed to distribute the patient load. Additionally, some rural surgeons believe that they could benefit from simply opening a better dialog with their urban colleagues.

“Georgia has a shortage of orthopaedic surgeons,” explains Dr. Barber, “in both rural and urban areas. Tertiary care facilities face the same problems we do meeting the needs of orthopaedic emergencies, so we do at times face difficulties transferring patients. We’re working very hard on establishing a trauma network in Georgia so we can alleviate some of those difficulties.”

“Obviously, if I go away, there’s no orthopaedic coverage at this hospital,” Dr Yanoff says. “But the fact is, as much as I enjoy doing what I do, and as much as I enjoy taking care of my patients, I’m not going to work 52 weeks a year. I think AAOS fellows could benefit from a committee that looks at the issues that specifically affect rural orthopaedic surgeons, and how to help them deal with those issues.”

“Fundamentally, I feel like I’m serving a purpose in an underserved area,” says Dr. Barber. “Without a doubt, I’m filling a need by serving in a rural area where there are fewer healthcare options. When I was in a more urban environment, I didn’t feel that same connection to serving my patients.”

“It’s a very rewarding practice,” agrees Dr. Yanoff. “In a small area like this it’s possible for one physician to actually have a visible, measurable, positive impact on the community.”

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org