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AAOS Now

Published 6/1/2013
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Timothy J. Bray, MD

Orthopaedic Traumatology—More than Just Surgery

Surgicalists address only one part of trauma care

Orthopaedic traumatology is an increasingly rewarding and demanding profession that requires mastery of specific, complex surgical techniques for outstanding patient care. Additionally fellowship graduates must master the business skills required for both personal and professional success and the leadership skills to work with industrial partners, community hospital providers, and professional organizations.

Traumatologists not only provide all the services of orthopaedic trauma patient care, they also operate community businesses that provide jobs and benefits, support community philanthropy, and even cover the local high-school football game. They are the backbone of this nation’s community orthopaedic trauma programs.

The issue of surgicalists
In a recent AAOS Now article (
“The Orthopaedic Surgicalist: A New Paradigm,” April 2013), John D. Campbell, MD, MBA, suggested that the use of hospital-based orthopaedic trauma surgicalists would solve access to trauma care problems and assist hospitals in becoming more efficient and economically productive. Unfortunately, this has not been shown to be true, nor does the practice model withstand close scrutiny.

Contrary to Dr. Campbell’s understanding, pay-for-call programs do work, because traumatologists are contractually obligated to the hospital to provide these services. Furthermore, the appropriate organization of call schedules can substantially reduce the inconvenience of taking call.

Many “for-hire surgicalists” are new graduates with little experience. They take temporary jobs with these for-profit businesses, live out of town, are employed by for-profit hospital systems, and give little back to the economic stability of the community in which they work. As this less expensive model drives veteran orthopaedic traumatologists out of town, many communities may be left in shambles when the hospital changes ownership and eliminates the surgicalist business model.

In medicine, the hospitalist model has had low patient satisfaction scores regarding patient/physician relationships. Will a similar situation occur with surgicalists? Will patients receive coordinated postoperative follow-up? Will patients who require nonsurgical fracture care or treatment for sprains and strains be able to find care? Will collegial comanagement of complex hand, foot, or arthroplasty problems occur?

Will appropriate relationships develop with other members of the local medical community, especially with regard to medico-legal ramifications? Will the surgicalists assimilate into the orthopaedic community and deliver quality patient care, or will they just sit in the operating room lounge waiting for the next case?

Quality improvement programs are also an issue. It is difficult, in the best of circumstances, to design and implement a community quality improvement program among colleagues who are actually interested in the process of care improvement. How do surgicalists, who have moved from hospital to hospital as their contracts and needs change, participate in quality improvement? Who monitors them and how are substandard performers disciplined?

Orthopaedic surgeons, including traumatologists, are trained to provide the full range of musculoskeletal services, from the initial patient encounter to long-term follow-up. How can the surgicalist know if the procedure achieved the intended goals without serial radiographs and committed follow-up? And who will do that follow-up?

Work to be done
Current orthopaedic trauma surgicalist companies have neither an interest nor a desire to provide the quality and satisfaction needed in today’s environment, let alone deal with minimizing readmission rates, complications, or managing quality assurance programs. They have no idea of the impact of such a change on community trauma care. Before this care model is adopted nationally, the owners of these businesses need to establish metrics, publish their results, and provide long-term follow-up on the challenges of such a novel program.

A recent publication noted the disastrous impact on midcareer traumatologists who were fired due to economic changes. Most likely, this involves someone who has worked and supported a community for 20 years, has a home and kids in the local school, and has provided compassionate service with the support of the medical staff. Certain hospital systems, however, have adopted a corporate mentality that eschews experience, commitment, and stability for younger, cheaper employees who are viewed as interchangeable units in the healthcare delivery machine.

To combat this onslaught, orthopaedic surgeons clearly need to develop business acumen, implement added-value programs, and demonstrate leadership skills.

The new—and real—paradigm
Orthopaedic traumatologists are being taught business leadership skills to assist in the improved management of their services to all hospitals, including university, community, and health maintenance organizations. These newly trained specialists are well-versed in practice and hospital fundamentals, governance, alignment, compliance, accountability, negotiation, and personal career growth.  

Recent objective data prove that orthopaedic trauma services are profitable for hospitals, when they are viewed as individual profit centers. Surgicalist models have yet to prove that they contribute more to increase hospital profitability or efficiency when compared to more traditional models of care.

The political landscape
Orthopaedic traumatologists need to align their educational, clinical, and research interests with their professional societies such as the AAOS and the Orthopaedic Trauma Association (OTA) rather than their hospital societies. When physicians are being paid by hospital systems, or have other business/political alignments, membership in physician societies suffers. When membership declines, the ability of these groups to fund research and educational programs, support political action committees (PACs) and advocacy programs, and provide member services is affected. Under the surgicalist model, employed physicians may change alliance to organizations that do not advance the goals and professional standards of the AAOS or OTA.

The Patient Protection and Affordable Care Act authorized $224 million in federal funding for trauma and emergency medical services programs and activities, including authorization for a national Trauma Center Stabilization Act. It would make sense for granting agencies to find nationally recognized trauma programs rather than simple surgicalist programs to engage in outcome research for the advancement of patient care.

As hospital systems gain in political strength over individual orthopaedic practices in many communities, it is imperative to critically review the unintended consequences of hiring emergency surgical providers. Collaborative hospital partnerships with the entire orthopaedic staff can bring constructive change. Implementing a separate, hospital-based emergency surgical service places more stress on other orthopaedic services during negotiations. The old adage “divide and conquer” is a common tactic that creates an unfavorable business position between the hospital and the community’s existing orthopaedic surgeons.  

Conclusion
It is vital that trauma surgeons take meaningful steps to halt the progression toward a nomadic existence, constantly uprooting family and curtailing continuity of care. Stability is beneficial to all stakeholders—patients, residents, healthcare institutions, surgeons, and their families.

Orthopaedic traumatology is more than just providing surgical care to a hospital, as suggested under the surgicalist model. As orthopaedic traumatologists, we care for our neighbors, support our communities, run businesses that create jobs, and contribute to economic growth to help provide opportunities for families to grow and pursue their dreams. We also support our medical organizations, research, and education; we give to PACs that help protect the well-being of the trauma patient.

Whether the owners of these new business models can guarantee the same level of commitment from their employees is yet to be determined. Young surgeons should be more interested in learning to partner with hospitals to develop mutually beneficial business opportunities than to become hospital employees. We have worked too hard to become orthopaedic surgeons. We should not let ourselves be demoted to providers of emergency services at discounted rates or be seen as nothing more than journeyman technicians.

Timothy J. Bray, MD, is a community traumatologist in Reno, Nev., and a past president of the Orthopaedic Trauma Association.

References

  1. Bray TJ: The Community Orthopaedic Traumatologist. OTA Presidential Address 2010. J Orthop Trauma 2011 Jan;Vol 25, No.1.
  2. Bray TJ: Design of the Northern Nevada Orthopaedic Trauma Panel: A model, level-II community-hospital system. J Bone Joint Surg Am 2001 Feb;83-A(2):283-289.
  3. Hill A, et al: Why Veteran Orthopaedic Trauma Surgeons are Being Fired. J Orthop Trauma 2013, in press.
  4. Althausen PL, Coll D, Cvitash M, Herak A, O'Mara TJ, Bray TJ: Economic viability of a community-based level-II orthopaedic trauma system. J Bone Joint Surg Am 2009 Jan;91(1):227-235
  5. The Patient Protection and Affordable Care Act. http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf Accessed May 14, 2013.