A roundtable discussion

Recently, John M. Purvis, MD, a member of the AAOS Now editorial board, held a roundtable discussion on the pros and cons of being an office-based orthopaedist, who no longer performs surgery. Joining Dr. Purvis were Charles E. Baker, MD, who returned to practice with the Fondren Orthopedic Group, Houston, Texas, after 9 years of retirement; Robert E. Eilert, MD, emeritus professor of pediatrics at Children’s Hospital Colorado, Denver; Frank B. Kelly Jr, MD, founding partner of Forsyth Street Orthopaedic Surgery and Rehabilitation Centers in Macon, Ga.; and Noah S. Finkel, MD, a private practitioner in Huntington, N.Y.

Dr. Purvis: I’d like to start by finding out why you made the change from a surgical to an office-based practice. Was it primarily for elective reasons such as decreasing stress and lifestyle changes, or did mandates such as credentialing requirements, impairments, or staff bylaws factor in the decision?

Dr. Kelly: I stopped operating about 8 years ago, primarily due to the stresses of practice. At that time, I was performing seven to eight total joint replacement procedures a day, and it caught up with me. The combination of worrying about my patients, having some that didn’t do as well as I had hoped they would, the burden and stress of malpractice litigation—it all made me reconsider what I was doing.

Dr. Finkel: The big issue for me was the rapid change in surgical technology. As a solo orthopaedist in a community where there were no specialists, I was trying to keep up with technology. I found it stressful to have to learn minimal incision surgery and arthroscopic rotator cuff repairs—in part because I didn’t see all that many. That became really stressful because there wasn’t enough time to learn it all. Plus, malpractice was a real issue in New York.

Dr. Eilert: My way of easing out of practice was to gradually step down and offload responsibilities. I really wanted to stop at the top of my game.

I still am an active member of our group. I just practice one day a week. I go to the operating room (OR) occasionally to help out with a case but I don’t do any primary surgery.

Dr. Baker: Back in 1993, my group of five physicians broke up over a disagreement about capitation for medical care. I was 60 years old, had practiced general orthopaedics for 30 years and wasn’t ready to retire. I started a solo practice, which by 2000 was a six-man group—five orthopaedists and one sports medicine general practitioner. My wife, our office manager, was working 12 hours a day, 6 or 7 days a week. We had 55 employees, X-ray, a magnetic resonance image (MRI) scanner, and a physical therapy section. It just became too much of a job for us to handle. I was also dissatisfied with all the interference in medicine by the government and by health insurance companies, so I just decided to quit. I gave my associates a 1-year notice and retired at the end of that year.

For the next 9 years, I focused on family and travel. But then Bill Woods, the CEO at Fondren Orthopedic Group, approached me and asked if I was tired of being retired. We made an agreement for me to work 3 days a week. I primarily see new patients who can’t get in to see an orthopaedic specialist on a timely basis. If someone has a surgical issue, I’ll usually have the patient in the appropriate orthopaedic surgeon’s office by the afternoon.

Dr. Purvis: Dr. Finkel, your transition must have taken a lot of forethought and discussion. What worked best for you, or is there one thing you might do differently?

Dr. Finkel: I have to say that there was no one specific event. Someone I didn’t know very well asked me how long I thought I’d live, and I said 85 or 90. And then she asked, “How many really good years do you think you have left?” And I said “About 15.”

I’d been a solo practitioner for 25 years at that point, taking call, performing about 10 surgeries a week, and that question was my tipping point. I told my wife, who was also my office manager, “This is the time. I’m exhausted, sleep deprived, and under a lot of stress. It’s time to take the next step.”

Dr. Eilert: At some point you have to make a transition. Some people just stop and walk out of the office. Some people stop but come back for a variety of reasons. My plan was to step down slowly, as my mentor, Dean McEwan, did. As a pediatric surgeon, you see your patients’ children and have a long-term involvement with families.

I felt that it was time to get out of the OR while I was still competent, and being an office orthopaedist has worked out beautifully. I’ve pursued some other interests, and I still keep in touch with the residents for teaching and with my group.

Dr. Purvis: How did your decision affect your relationships with your patients, your associates, and your referring caregivers?

Dr. Baker: Well, I’ve been back in practice now for 3 years and every week, more of my old patients find out that I’m back and come in for a consultation. I lost a good portion of my physician referral base, primarily because I wasn’t doing surgery.

But the physicians that I’m working with couldn’t be nicer. If I have a patient who needs to see a specialist that day, they will agree to see that extra patient. It’s very satisfying to be able to diagnose and refer a patient all in the same day so the patient doesn’t have to miss another day of work.

Dr. Kelly: When I first decided to stop operating, some of my long-term patients expressed their disappointment that I wouldn’t be doing their joint replacements. I felt like I’d deserted them and was disappointed myself. But they’ve come to understand the situation and have been very supportive.

When you go from a busy surgical practice to an office-based practice, you actually have time to take better care of patients. I’ve become a better listener and a better communicator. I think that they appreciate that and that’s why many have stuck with me.

My partners have been very supportive, and it’s worked out well. I can work in urgent patients and pick up some on postoperative problems if one of my partners is not in the office that day. I’m also a ready source of operative referrals. I’ve been able to refer patients to ancillary situations, for an MRI scan or physical therapy. So I’ve been able to help generate revenue.

I just simply don’t see referring physicians like I used to, and I miss the interaction with them. They still refer patients to me, but not surgery patients. I don’t have the tight relationship I once had, and that’s been a drawback of an office practice.

Dr. Finkel: I rarely go to the hospital, so my referral base has definitely changed. My referring physicians have aged with me and many of them are now retired. With hospitalists and intensivists, how I get patients has changed dramatically. Most of my current patients are really patient referrals or my long-term patients. That’s a definite difference.

Dr. Purvis: What’s the one thing you miss the most about not performing surgery?

Dr. Baker: Well, I can’t limit it to one thing, but I can limit it to two. First, I have basic carpenter instincts, so I really miss the challenges in surgery and the instrumentation and all that. I really love to be in surgery.

The second thing I miss is the gratitude that pleased patients show toward you when you’ve done a good job and enabled them to get up and walking again.

Dr. Kelly: Likewise, what I miss the most is the gratification and the thank-yous I got from patients. The second thing I miss is just being around the OR team. The camaraderie in the OR was always a lot of fun.

Dr. Finkel: I definitely miss the intense relationships that developed in dealing with patients throughout the surgical process. I still have intense relationships with patients, but they’re definitely different than taking someone through a really stressful situation.

I also miss the OR team—and I definitely miss the carpentry and the physicality. I miss the eye/hand issue, like holding a needle-holder and putting in a suture.

Dr. Eilert: Well, I compensate by sneaking back to the OR and visiting with people. I still have a locker and I try to visit regularly, but probably I miss the people more than anything else.

Dr. Purvis: What about the business aspects of your transition? Not doing surgery can result in a significant loss of revenue. How have you been able to compensate?

Dr. Kelly: Well, I do have three sources of ancillary income—as a partner in an ambulatory surgery center, a part owner of an MRI unit, and from physical therapy in our office. I have occasionally done some independent medical evaluations (IMEs); they’re not much fun, but a separate overhead expense applies to them—much less than our regular overhead expense—so that’s been an extra source of income. I was also able to negotiate a break on my general overhead, which also helps. Finally, my malpractice insurance is about 25 percent of what it was before.

I’m also very diligent about evaluation and management coding. Sometimes we leave money on the table by not taking time to properly code what we’ve done.

Dr. Finkel: Solo practice is definitely tougher without surgery, but my hours are about the same. I just don’t have to get up in the middle of the night or on weekends. I saved about $100,000 on my malpractice premiums. I see about 140 patients and do six or eight IMEs a week. Unfortunately, the IMEs pay better than medical care does.

I’m more careful about coding correctly, and I’ve also given back some of my office space to the landlord. I pull in all of my resources to lessen my overhead.

Dr. Eilert: Being in an academic practice, I don’t have any overhead. Because I have a contract with the state, my malpractice insurance is basically zero. I still practice with the university so the money that I have in the TIAA/CREF plan is not subject to distribution, which is a plus. I’m basically salaried for the one day that I practice, which is quite nice.

Dr. Baker: My primary reason for going back to work was not to make a lot of money. I mainly went back because I missed the interaction with patients and other doctors and I felt it would help me keep my mental acuity. Based on my age, I have to take the required minimum out of my IRA every year. I don’t have a lot of expenses such as a mortgage or car payments.

Dr. Purvis: Is the current recession going to alter your plans for the future? Would you consider returning to surgery?

Dr. Kelly: I do not think it will alter my plans, although the current economic environment has possibly reduced the volume of patients that we see. I certainly don’t intend to go back to surgery after
8 years away from the OR.

Dr. Finkel: The economy has definitely changed what goes on in my office. People can’t meet their copayments or pay for physical therapy, so we try to arrange for MRI scans that are not costly and are in the community. The economy has changed how we think about getting care for our patients.

Dr. Baker: The only way I’d ever go back to surgery is either as a patient or as an observer. My individual practice is growing, but the patient mix has changed. We are seeing more people on Medicaid than we were a few years ago. But the economy has not affected the number of people that I see or the amount of money that I’m taking home.

Dr. Purvis: When you gave up surgery, did you see a change in the types and numbers of patients, and were you prepared for their diagnoses and treatments?

Dr. Finkel: I’ve always been a very conservative surgeon, taking my time in getting patients to an OR unless it was an acute situation. What’s changed is that my patients seem to be aging with me. I’m seeing an older population, with fewer acute injuries. I’m not seeing any major trauma.

Dr. Eilert: Children’s orthopaedics is primarily nonsurgical and office-based, so it wasn’t much of a change. I don’t take patients who need a long-term relationship with their orthopaedist. I mainly see the problem patients.

Dr. Baker: I’m seeing fewer patients—about 15 a day. But more than half are new patients. I spend a lot of time with them.

Dr. Kelly: It was a big change for me—going from a practice that was 95 percent hips and knees to seeing a little bit of everything. I had to relearn how to be a general orthopaedist. It’s been a fairly interesting experience.

Dr. Purvis: Any particular emotion with all this transition that’s been significant for you?

Dr. Eilert: Well, you realize you’re getting old. Fortunately, I have many young friends who keep me young. You see a lot of the “worried well,” but just giving people hope and reassurance is very satisfying and a lot less stressful than operating on somebody.

I love being in the office. I love still practicing medicine. I feel like I’m still a benefit to society, a useful person.

Dr. Baker: I was very happy to retire, but very pleased about going back and doing something that interests and benefits me, my associates, and my patients. I hate having to get up in the morning and go over there, but once I get there, I enjoy the day.

Dr. Kelly: For the first 6 months to a year after I stopped operating, I had an empty feeling, almost like I wasn’t a complete doctor. But after a while, you realize that you can help a lot of patients without surgery, which gives you a feeling that you’re making a contribution.

Dr. Finkel: For me, the transition was very significant because, for the first time in my life since medical school, I actually had a predictable day. The fact that I could sleep all night without getting called was a wonderful gift.

Dr. Purvis: That’s great to hear. What would you say to someone who is thinking about making this transition?

Dr. Kelly: I think that anyone who’s considering this should talk to folks like us who’ve been there and find out what has worked for us and what has not worked for us. Because the main procedure we’re doing now is patient interviews, the Academy’s communication skills workshops are fantastic. Learning how to communicate with patients and how to listen to patients has really been valuable to me. I would hope at some point that the Academy would consider offering a course on office orthopaedics. It would be nice to go to a meeting and not necessarily talk about the newest type of surgical procedure, but learn about some of the things that office orthopaedists do.

Dr. Finkel: Before I made my decision, I had a long conversation with Dr. Kelly about his experiences, which was very helpful. I thought that if he could do it and be comfortable and at peace with it, it was certainly something that I could achieve.

Dr. Baker: If I were asked about opening an office-based practice, I would want to talk with the individual for several hours about expectations and try to give him or her a good factual basis of what the practice is like.

Dr. Eilert: I’ve seen several fellows do this, so I knew what I was getting into. My partner quit a couple of years before I did, and we set up his office practice and worked through the details, so I knew what worked well within our total practice setting. I’m happy to talk to people about this topic.

Dr. Purvis: Now that you have a more open schedule, what are you doing to fill the time?

Dr. Kelly: When I stopped operating, I thought I’d finally be able to improve my golf game. But instead of playing golf, I got more involved with organizational orthopaedics, with the Board of Councilors. I served on the Academy’s Board of Directors and as chair of the Communications Cabinet. I became involved with our local medical society, served on the board of trustees for the Orthopaedic Research and Education Foundation, and am on the AAOS Now editorial board. My work hours are about the same; I just don’t get paid as well.

Dr. Finkel: I have gotten involved in a yoga practice, and I’m learning to play the banjo. I may have to reinvent myself when I actually step down from the whole practice, because I don’t see a transition from this decision not to do surgery to the next step of closing my practice. So I am trying to find out who I’m going to be as an adult.

Dr. Eilert: I play golf one day a week. I do orthopaedics one day a week. I do sculpture and painting, and I take some classes. I think surgery is an art, so I just switched what kind of art I was doing.

Dr. Purvis: It sounds like everybody fills the schedule pretty easily. Can an orthopaedic surgeon find happiness and satisfaction with a postoperative career?

Dr. Kelly: Absolutely—although it does take a period of adjustment. But not having to take call, being able to sleep through the night, and lower stress levels add up to absolute happiness and probably a good way for some folks to transition to retirement.

Dr. Finkel: There’s no question you can be happy and satisfied. The longer you’ve been in the game and the practice, the easier that transition becomes.

Dr. Eilert: I find it just great. Keeping in contact with patients, my colleagues, and the residents makes me feel alive. I’m just like a pediatrician now, and being a pediatrician is not a bad deal.

Dr. Baker: I enjoyed being retired for 9 years, and I’m really enjoying being back in practice. I appreciate the opportunity of being able to spend as much time as needed with each patient and not rushing to get through the day. And they really like it. They’re so appreciative of the time you spend with them, and that in itself is probably worth more than the money that I make.