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AAOS Now

Published 4/1/2013
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John D. Campbell, MD, MBA

The Orthopaedic Surgicalist: A New Paradigm

Is this the answer to a shortage of orthopaedists?

In the early 1990s, physicians had no experience with the term “hospitalist.” Now, more than 20 years later, it is a familiar title for physicians who provide in-hospital acute care.

Before the hospitalist model, primary care physicians would perform that function when their patients were admitted to a hospital. But this was often problematic.

For example, primary care physicians with private outpatient practices might have to cancel the outpatient clinic, stop normal activities, and respond when a patient was admitted to the emergency department (ED). Hospital administrators noted that each physician managed the same medical problems differently. Some physicians were more efficient than others; some had more complications than others. Frequently, the physicians with the highest inpatient volumes had more consistent outcomes.

The hospitalist model solved many of these problems. Primary care physicians in communities with a hospitalist program have a more controlled lifestyle, more efficient office practices, and often experience a net increase in income. Their hospitalized patients often get care more promptly than if they had to wait for a primary care physician juggling both an elective practice and acute care patient management.

The hospitalist model has grown exponentially, driven by pressure from primary care physicians for better work hours and data demonstrating that hospitalists improve efficiency, quality, and patient satisfaction. An estimated 40,000 hospitalists practice in the United States; more than 70 percent of all U.S. hospitals have hospitalist programs.

The problems in orthopaedics
The success of the hospitalist model for primary care raises the question of whether it can be applied to other specialties. Certainly, many specialties share problems similar to those faced by primary care physicians, including increased concerns about workforce, quality of life, and quality of care issues.

The United States has approximately 20,000 practicing orthopaedic surgeons—and their average age is 53.8 years. Each year, 670 orthopaedic residents enter the workforce, but this number is offset by the number of practicing orthopaedists who retire, resulting in a zero net gain and potentially a loss in the total number of practicing orthopaedists. Additionally, approximately 90 percent of graduating residents pursue a specialty fellowship, further reducing the availability of orthopaedic surgeons to provide community care.

The impact is particularly acute in the delivery of emergency care. In January 2009, the American Orthopedic Association’s Report on the Crisis in the Delivery of Orthopedic Emergency Care: A Call to Action outlined the failure of the traditional model of providing call coverage by the private practice orthopaedist. Similarly, a survey by the American College of Emergency Physicians found that three out of four ED medical directors reported that their hospitals have inadequate on-call specialist coverage. Another survey reported that 42 percent of ED administrators believed that the lack of specialty coverage in the ED posed a significant risk to patients.

Many market forces contribute to this shortage. In the past, orthopaedists would participate in call coverage for a community hospital to build their practices. Most hospitals included provisions in their by-laws requiring participation in the call rotation, and most orthopaedists depended on the community hospital for access to an operating room and ongoing referrals of patients through the ED.

Managed care changed the dynamics of care for the unassigned ED patient. Unless the hospital or the surgeon is “in network,” patients may be directed to a different facility. As a result, the impetus for physicians shifted from participating in the call rotation to participating with the managed care contract.

Most hospitals now pay orthopaedic surgeons to take ED call, but this does not guarantee that all hospitals will have continuous coverage—either for ED admissions or for surgical emergencies for in-hospital patients.

Stretching the hospitalist model
Similar ED coverage problems exist with general surgery. To address this issue, the American College of Surgeons has introduced the Acute Care Surgery specialist. Studies have shown that acute care surgeons can respond more promptly, thus shortening the average length of stay and lowering the cost of treatment. In communities with acute care surgery specialists, elective surgeons saw a decrease in acute surgical cases—but their elective cases increased, on average, by 23 percent, yielding more income than if they were still covering the ED.

Could an orthopaedic surgicalist (as opposed to an orthopaedic hospitalist) have the same result? The term orthopedic surgicalist makes it clear that a surgeon is providing the services. The orthopaedic surgicalist model could solve the ED coverage problem, while allowing most orthopaedists to have very efficient elective practices.

Such a model would provide continuous ED coverage for all acute orthopaedic problems. Each hospital would have a team of surgicalists who are integrally involved with the community orthopaedists. These surgicalists would manage all acute orthopaedic problems, while referring elective cases to community orthopaedists. Patients would not have to wait until the on-call physician’s clinic is completed for surgery, and community orthopaedists would not have to reschedule elective surgeries or clinics to care for the acute orthopaedic patient.

Such a model would have many benefits. Orthopaedic surgicalists would have a controlled lifestyle, with work shifts that enable them to focus on the patient at work and to enjoy life when off the clock. Surgicalist teams would adhere to very specific processes so that patient care would be continuous. All postoperative acute care patients would be managed by the surgicalist in an outpatient clinic that is limited to postfracture and postsurgical follow-ups.

Community orthopaedists would no longer have to juggle their lives, practices, and on-call responsibilities. Information from communities that have instituted orthopaedic surgicalist programs have found that community orthopaedists, while giving up the ED volume, see an average 20 percent increase in their elective surgical volume, probably due to their more predictive and less disruptive schedules, without the responsibility of ED coverage.

Hospitals would also benefit. One study has shown that for every $1.00 an orthopaedic surgeon collects from the ED, the hospital generates $7.80 in facility services. A 2010 survey found that the estimated hospital facility revenue from a single orthopaedic surgeon was $2,111,764 (an amount that includes inpatient and outpatient procedures, patient admissions, referrals, procedures, and tests). As in the acute care surgery program, hospitals could see their ED surgical volume increase by 50 percent or more—a significant increase in incremental income.

The orthopaedic surgicalist model is a win–win–win scenario. Patients win because orthopaedic surgicalists are available to take care of their problems quickly. Community orthopaedic surgeons win because they can now have a controlled elective practice with no disruptions after hours or during busy clinic or operating days. Hospitals win because they can provide excellent acute care orthopaedics.

Orthopaedic surgicalists can align with hospitals to improve processes, decrease lengths of stay, and reduce readmissions. After reading this article, are you ready for this new paradigm in providing acute care orthopaedics?

John D. Campbell, MD, MBA, is a practicing orthopaedic surgeon and the president/CEO of Synergy Surgicalists, an acute care orthopaedic surgicalist management company. He can be reached at johnc@synergysurgicalists.com