NOLC symposia spotlight issues of concern

The American Association of Orthopaedic Surgeons (AAOS) 2011 National Orthopaedic Leadership Conference (NOLC), held in Washington, D.C., in April, focused on several issues of concern to orthopaedic surgeons. The May issue of AAOS Now included summaries of two symposia organized by members of the AAOS Board of Councilors (BOC) and Board of Specialty Societies (BOS)—one on the Independent Payment Advisory Board (IPAB) and the other on implementation of the Patient Protection and Affordable Care Act (PPACA). This article summarizes the other two symposia that were held—on ancillary services and on sleep deprivation and fatigue management in orthopaedics.

Ancillary services
Moderated by James J. York, MD, a member of the BOC Committee on State Legislative & Regulatory Issues, the session on ancillary services examined both state and federal threats to physician ownership of in-office ancillary services, such as imaging and physical therapy.

Dr. York, a BOC representative from Maryland, discussed efforts to preserve in-office diagnostic imaging. He described the development of the Maryland courts’ interpretation of the state patient referral law and how that interpretation has affected the legislative process. At the time of the symposium, the Maryland state supreme court had ruled that physicians could not refer patients to in-office diagnostic imaging services. The Maryland Orthopaedic Association is working with a coalition of medical specialties in the state to pass legislation that will enable physicians to provide in-office diagnostic imaging services.

Cara Scheibling, of Oxford Outcomes, Inc., a health economics firm, reviewed the theory and evidence used by those who charge that physician ownership is a primary factor in the increased utilization of ancillary services. She pointed out that other reasons for increased utilization—such as consumer demand and practice variation—are frequently overlooked.

“For every argument based on overutilization, there is an argument that ownership results in improved quality and access, improved patient adherence to treatment plans, and reduced consumer transaction costs,” she noted.

According to Lisa Ohrin, a partner with Katten Muchin Rosenman LLP, the Medicare Payment Advisory Commission (MedPAC) has moved away from recommendations to restrict in-office ancillary services. Instead, the focus is shifting to requiring physicians who order more imaging studies than their peers to obtain preauthorization and to reducing payments to physicians who self-refer the same patient for multiple imaging studies.

It is not the federal “Stark law,” but the state-level “baby Starks” that are problematic, she cautioned. Although more than 30 states have such laws, only a few incorporate the federal law and are updated automatically to mimic it. She urged that physicians develop utilization data to persuade state policymakers of the value of physician ownership of ancillary services.

Sleep deprivation and fatigue management
Duty hour restrictions for residents have been in effect since 2003 and have caused concern among many specialties, especially with regard to hours of training. According to Stephen A. Albanese, MD, who serves as chairman of the Residency Review Committee for Orthopaedic Surgery, the most recent changes are due, in part, to a report by the Institute of Medicine that was highly critical of the (2003) Accreditation Council for Graduate Medical Education regulations. The new regulations call for shorter shifts for PGY-1 residents and a maximum of 6 nights on night float, but otherwise leave the 2003 requirements basically unchanged.

Dr. Albanese noted that the 2003 requirements resulted in significant changes to the shape of many residency programs. In addition to more use of night shifts, home call, and physician extenders, some programs are recruiting more residents and shifting some of the burden of care to faculty. Resident surveys show significant agreement that resident quality of life has improved, but senior residents believe that their education has been negatively affected, and surgical faculty report less job satisfaction, quality of life, and teaching time.

According to Lisa Soleymani Lehmann, MD, PhD, director of the Center for Bioethics of the Brigham and Women’s Hospital in Boston and a coauthor of a New England Journal of Medicine article on sleep deprivation and fatigue issues, surgeons have a duty to inform their patients about their sleep status and to offer patients the option of rescheduling elective surgery. The article also proposes that institutions not allow surgeons who have been awake for longer than 24 hours to perform surgery.

“Lack of sleep impairs psychomotor performance as much as alcohol intoxication,” said Dr. Lehmann. “More significantly, chronic sleep deprivation impairs an individual’s ability to recognize their own impairment. Clinicians may think they can accurately assess the risks posed to themselves or their patients, but that hasn’t been proven.”

L. D. Britt, MD, PhD, president of the American College of Surgeons (ACS), opposed the idea of mandatory sleep status disclosure to patients. In discussing the challenges of surgical training and the limitations of duty hours, Dr. Britt said residents must take personal responsibility for both their education and patient safety and be aware of their own fitness for duty. The ACS has developed an official position on duty-hour restrictions, which emphasizes the need for supervision and oversight. Residency programs should educate faculty and residents on fatigue management, adopt mitigating processes, and develop back-up procedures.

“No one wants an exhausted surgeon,” said Dr. Britt, “but surgeons need to know how to perform under some duress.”

Finally, Mark R. Rosekind, PhD, a member of the National Transportation Safety Board and a researcher in sleep deprivation and fatigue management, called for multiple solutions to this complex issue. “Most people do best with 8 hours of uninterrupted sleep,” he noted, but “cumulative sleep debt presents a bigger risk.”

Duty-hour policies are necessary, he suggested, but are only a first step and, by themselves, are not sufficient. Fatigue management programs need to be comprehensive, multifaceted, science-based, continually evaluated, and regularly updated. Policies need to be evidence-based, practical, and effective. Finally, such strategies must include a process that enables improved knowledge to be incorporated as it becomes available.

James J. York, MD, and Jeffrey Anglen, MD, contributed to this report.

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org