Practical Solutions Practical Solutions to Practical to Practical

Problems In Rural Problems In Rural SurgerySurgeryDana Christian LyngeDana Christian Lynge

Assoc Prof SurgeryAssoc Prof Surgery

University of WashingtonUniversity of Washington

Recruiting the Rural Recruiting the Rural SurgeonSurgeon

Charles T. McHughCharles T. McHughBaileyville, MEBaileyville, ME

DemographicsDemographics

459 of 500 poorest counties are rural459 of 500 poorest counties are rural Populations: sparsePopulations: sparse

elderlyelderly

many w/no health care many w/no health care coveragecoverage

poorly educatedpoorly educated

high levels: abuse, neglect, high levels: abuse, neglect, poverty,poverty,

addictionaddiction

Personal TimePersonal Time

Cultural activitiesCultural activities ShoppingShopping Continuing intellectual growthContinuing intellectual growth Friends with similar interestsFriends with similar interests

ChildrenChildren

Adequate (for expectations) Adequate (for expectations) educationeducation

Exposure to cultureExposure to culture Recreation/Development of skillsRecreation/Development of skills

Unhappy SpouseUnhappy Spouse

Too far from urban amenitiesToo far from urban amenities Children’s issuesChildren’s issues

Spouse ExpectationsSpouse Expectations

Time with familyTime with family Greater integration of physician Greater integration of physician

spouse/parent in family activity and spouse/parent in family activity and developmentdevelopment

Nothing ChangesNothing Changes

Overwhelming patient care pressureOverwhelming patient care pressure Frequent call – not the “knife and Frequent call – not the “knife and

gun club,”gun club,”

but unable to make but unable to make plans and be plans and be

even a short distance even a short distance awayaway

Issues with spousesIssues with spouses

Employment of the spouseEmployment of the spouse Often a highly educated individual Often a highly educated individual

himself/herselfhimself/herself

ResultResult

““We’re outta here!”We’re outta here!”

CallCall

Often onerous and not much better Often onerous and not much better than residency, albeit usually less than residency, albeit usually less intense.intense.

ConfidenceConfidence

Often lacking in newly minted Often lacking in newly minted surgeonsurgeon

Desired guidance cannot provided Desired guidance cannot provided by “burnt out” senior partnersby “burnt out” senior partners

Veteran Surgeon Veteran Surgeon ExpectationExpectation

More time off and awayMore time off and away Coverage of post-opsCoverage of post-ops Relief from constant assistingRelief from constant assisting Not to give up their case load!!Not to give up their case load!!

Unrealistic and Realistic Unrealistic and Realistic Expectations Expectations

SpouseSpouse SelfSelf ““Partners”Partners” And, probably, the hospital if it is the And, probably, the hospital if it is the

employer.employer.

New SurgeonNew Surgeon

EmployedEmployed Expected to provide assistance and Expected to provide assistance and

relief for the established surgeonsrelief for the established surgeons Is often now “more surgeon” than Is often now “more surgeon” than

the area can support economically.the area can support economically.

Balance the Bottom LineBalance the Bottom Line

Develop/require undesirable tasks Develop/require undesirable tasks which are peripheral to the practice which are peripheral to the practice of surgery.of surgery.

Start a full scale endoscopy clinic Start a full scale endoscopy clinic utilizing the new surgeon.utilizing the new surgeon.

DiscontentDiscontent

Little contact with colleagues who Little contact with colleagues who are on the cutting edge/keeping upare on the cutting edge/keeping up

Few CME opportunitiesFew CME opportunities Inability/lack of time/money to get Inability/lack of time/money to get

away to meetings.away to meetings.

Nagging ThoughtsNagging Thoughts

I’m losing hold on my profession.I’m losing hold on my profession. If I act now, I can recover and If I act now, I can recover and

restore my standing and my self restore my standing and my self respect.respect.

ResultResult

““We’re outta here!”We’re outta here!”

Anne M. Williams, MD FACSAnne M. Williams, MD FACS

Glasgow, MTGlasgow, MT

First, Define General First, Define General SurgerySurgery

Too often at present, General Surgery is Too often at present, General Surgery is considered the part of surgery that considered the part of surgery that isn’tisn’t part of another specialty – and the pie is part of another specialty – and the pie is getting progressively more dividedgetting progressively more divided

The American Board of Surgery is working The American Board of Surgery is working on the SCORE program to define the on the SCORE program to define the “core” and “scope” of General Surgery“core” and “scope” of General Surgery

A number of prominent surgeons are A number of prominent surgeons are promoting the concept of “Acute Care promoting the concept of “Acute Care Surgery” as an alternative solutionSurgery” as an alternative solution

But, in rural areas …But, in rural areas … The general surgeon performs a fairly broad The general surgeon performs a fairly broad

range of traditional general surgical proceduresrange of traditional general surgical procedures The general surgeon is usually the endoscopist in The general surgeon is usually the endoscopist in

the communitythe community The general surgeon is often called upon for a The general surgeon is often called upon for a

number of procedures no longer in the general number of procedures no longer in the general surgery realmsurgery realm Urologic emergencies– eg. torsion, outlet obstruction, Urologic emergencies– eg. torsion, outlet obstruction,

traumatrauma Head and neck, airway emergenciesHead and neck, airway emergencies OB/GYN emergencies – C sections, ectopic pregnancyOB/GYN emergencies – C sections, ectopic pregnancy Orthopedic emergenciesOrthopedic emergencies

The rural surgeon is The rural surgeon is often also often also

The gastroenterologistThe gastroenterologist The oncologistThe oncologist The critical care specialist/consultantThe critical care specialist/consultant The wound care specialistThe wound care specialist The pain management consultant/specialistThe pain management consultant/specialist The proceduralist in generalThe proceduralist in general

Most also practice with limited or no local Most also practice with limited or no local surgical support, so options for surgical support, so options for consultation and relief are limitedconsultation and relief are limited

Today’s residents …Today’s residents … With the 80-hour work week restrictions, With the 80-hour work week restrictions,

emphasis is on team care rather than sole emphasis is on team care rather than sole individual responsibilityindividual responsibility

Vast decrease in the number of teaching Vast decrease in the number of teaching assistant cases done by senior residents, so assistant cases done by senior residents, so relatively few cases done without an attending relatively few cases done without an attending present and directing the casepresent and directing the case

Most training is done by sub-specialists in large Most training is done by sub-specialists in large programs, with resultant biasprograms, with resultant bias

Being a “general surgeon” isn’t a Great ThingBeing a “general surgeon” isn’t a Great Thing 80% go on to fellowship training after residency80% go on to fellowship training after residency

Health Care Reform & Health Care Reform & RuralAmericaRuralAmerica

There is much speculation that mid-level There is much speculation that mid-level practitioners are going to play an increasingly practitioners are going to play an increasingly large role in providing primary carelarge role in providing primary care

This is already happening to a great extent in This is already happening to a great extent in the rural areasthe rural areas

General surgery is one aspect where mid-levels General surgery is one aspect where mid-levels cannot totally replace physicianscannot totally replace physicians

Many rural areas, therefore, may find Many rural areas, therefore, may find themselves depending on a few primary care themselves depending on a few primary care physicians, many mid-level practitioners, and a physicians, many mid-level practitioners, and a general surgeon or twogeneral surgeon or two

This will add pressure on the general This will add pressure on the general surgeon to provide more of the ancillary surgeon to provide more of the ancillary care that mid-levels can’t providecare that mid-levels can’t provide

Procedures such as central lines, Procedures such as central lines, thoracentesis, paracentesis, percutaneous thoracentesis, paracentesis, percutaneous drainage of abscesses, minor office drainage of abscesses, minor office procedures will be beyond the procedures will be beyond the scope/comfort zone of most mid-levels and scope/comfort zone of most mid-levels and the surgeon increasingly called on to the surgeon increasingly called on to perform these tasksperform these tasks

There will be more need for the surgeon to There will be more need for the surgeon to provide more comprehensive care of provide more comprehensive care of her/her patients as wellher/her patients as well

Surgeon Shortage Is Here Surgeon Shortage Is Here Shortages in both urban and rural areas now Shortages in both urban and rural areas now

and getting worseand getting worse Our system can’t run on sub-specialists aloneOur system can’t run on sub-specialists alone

Fewer available to take general surgery call in urban Fewer available to take general surgery call in urban and suburban areasand suburban areas

Less willing to go to rural areasLess willing to go to rural areas Not every procedure has to be done by a sub-Not every procedure has to be done by a sub-

specialist at a large medical center to be done specialist at a large medical center to be done wellwell

The impact of long travel on patients and The impact of long travel on patients and families is often overlookedfamilies is often overlooked

First and foremost, we have to change our First and foremost, we have to change our mindsets at the highest levelsmindsets at the highest levels

General surgeons are fully capable of doing General surgeons are fully capable of doing most procedures safely and wellmost procedures safely and well

Need to instill pride back into General Need to instill pride back into General SurgerySurgery

Need to incorporate ideas from both the Need to incorporate ideas from both the SCORE curriculum and the Acute Care SCORE curriculum and the Acute Care Surgery concept in moving forward in Surgery concept in moving forward in revitalizing General Surgeryrevitalizing General Surgery

To help train rural surgeonsTo help train rural surgeons In training programs, find ways to promote more In training programs, find ways to promote more

independence in senior residents so they feel independence in senior residents so they feel prepared to practice in an isolated settingprepared to practice in an isolated setting

Find ways to allow more experience in related Find ways to allow more experience in related surgical areas such as GYN, ortho, urology, and surgical areas such as GYN, ortho, urology, and ENT, and non-surgical related areas like GI, ENT, and non-surgical related areas like GI, oncology as appropriateoncology as appropriate

Do not allow the push for more OR time to Do not allow the push for more OR time to compromise learning the other procedural compromise learning the other procedural aspects of care, or cutting into clinic experience aspects of care, or cutting into clinic experience too deeplytoo deeply

Develop mentoring programs to help new Develop mentoring programs to help new surgeons or even older surgeons in rural areassurgeons or even older surgeons in rural areas

Many of these concepts will be difficult to Many of these concepts will be difficult to incorporate into the existing practice and incorporate into the existing practice and culture of current training programsculture of current training programs

It will probably be best to have interested It will probably be best to have interested programs work with the RRC and ABS to set programs work with the RRC and ABS to set up rural training tracks, where residents can up rural training tracks, where residents can be exposed to both a broader range of be exposed to both a broader range of experience as well as faculty who demonstrate experience as well as faculty who demonstrate what a good general surgeon can dowhat a good general surgeon can do

Post-residency fellowships will also be a Post-residency fellowships will also be a valuable asset in some casesvaluable asset in some cases

Reimbursement Reimbursement and the Rural and the Rural

SurgeonSurgeonTyler G. Hughes, MD FACSTyler G. Hughes, MD FACS

McPherson, KsMcPherson, Ks

The Good Ol’ DaysThe Good Ol’ Days

Hang out your shingleHang out your shingle Take good care of patientsTake good care of patients Collect what you canCollect what you can Make a decent livingMake a decent living

I’m not sure it was ever I’m not sure it was ever that easythat easy

No Bucks- No Buck No Bucks- No Buck RogersRogers

Until we no longer need money to buy Until we no longer need money to buy groceries, clothes, cars, houses and the rest groceries, clothes, cars, houses and the rest health care providers (formerly known as health care providers (formerly known as doctors) will have to make money.doctors) will have to make money.

Given the rigors of the surgical life, to Given the rigors of the surgical life, to attract young men and women away from attract young men and women away from other specialties and practice environments, other specialties and practice environments, the income of the rural general surgeon the income of the rural general surgeon must be in line with that of the must be in line with that of the “competition” or the hassle factor of “competition” or the hassle factor of practice must be reduced.practice must be reduced.

Good point- So how?Good point- So how?

William OslerWilliam Osler

To solve a problem, one must first To solve a problem, one must first understandunderstand the problem the problem

Where are we in terms of Where are we in terms of income?income?

General Surgeons-General Surgeons- First year average First year average

salary is $220,000salary is $220,000 >3 years experience >3 years experience

$267,000$267,000

Median Incomes of the Median Incomes of the competition:competition:

Anesthesia $321KAnesthesia $321K

OB/GYN $247K *OB/GYN $247K *

______________________________________

Ortho- $342KOrtho- $342K

Total Joints- $491KTotal Joints- $491K

Sports- $479KSports- $479K

CV- $515KCV- $515K

Urology- $359K **Urology- $359K **

* Bureau of Labor Statistics 2008-2009 ** Allied Physicians Website 2006 data

Conclusion: Conclusion:

At present the salary or At present the salary or income for a rural general income for a rural general surgeon needs to be in the surgeon needs to be in the $250,000 range with $250,000 range with potential for expansion to potential for expansion to higher levels depending on higher levels depending on amount of work doneamount of work done

OptionsOptions

Solo Practice- Most autonomy, Solo Practice- Most autonomy, highest risk to personal finances and highest risk to personal finances and most labor intensive for the owner of most labor intensive for the owner of the practicethe practice

Group Practice- Single or Group Practice- Single or MultispecialtyMultispecialty

Employment- Hospital basedEmployment- Hospital based

According to Bureau of According to Bureau of Labor Statistics physician Labor Statistics physician owned practices have a owned practices have a slightly higher income than slightly higher income than salaried surgeonssalaried surgeons

Employment ModelEmployment Model

Designed to give mutual financial Designed to give mutual financial security to the hospital and security to the hospital and physicianphysician

Must allow medical professional Must allow medical professional autonomyautonomy

Should be flexible to the local Should be flexible to the local environment (employed surgeons environment (employed surgeons competing against a majority of competing against a majority of private practitioners doesn’t work)private practitioners doesn’t work)

Employment for the Rural Employment for the Rural EnvironmentEnvironment

Frequently a small town has no Frequently a small town has no competing general surgeoncompeting general surgeon

Hospital has more need of the Hospital has more need of the surgeon than in urban settings as surgeon than in urban settings as percentage of revenue streampercentage of revenue stream

Seems best suited in the not for Seems best suited in the not for profit hospital setting which is profit hospital setting which is typical in rural areastypical in rural areas

Contract StructureContract Structure

Straight salaries are “out”Straight salaries are “out” RVU based salaries are “in”RVU based salaries are “in”

RVU Contract StructureRVU Contract Structure

Base Salary + Bonus structure Base Salary + Bonus structure based on w-RVUs ($X/RVU)based on w-RVUs ($X/RVU)

Adaptable to both mature and new Adaptable to both mature and new practicespractices

Provides security to both partiesProvides security to both parties Prevents “retirement” on the jobPrevents “retirement” on the job Allows salary expansion based on Allows salary expansion based on

hard workhard work

RVU model cont’dRVU model cont’d

Allows for pay for call (embedded in Allows for pay for call (embedded in the base salary) without “killing the the base salary) without “killing the golden goose”. Rural hospitals golden goose”. Rural hospitals cannot afford to pay $1000- $2000/ cannot afford to pay $1000- $2000/ day for call coverage.day for call coverage.

The above is presented as The above is presented as an example of a model an example of a model working in rural Kansas working in rural Kansas with two surgeons in a town with two surgeons in a town of 13,000 people with of 13,000 people with 30,000 in the county service 30,000 in the county service area.area.No doubt there are other No doubt there are other workable models and the workable models and the audience is invited to audience is invited to comment.comment.

CALLCALL

John Kole, M.D.John Kole, M.D.Grand Itasca Clinic and Grand Itasca Clinic and

HospitalHospitalCohasset, MinnesotaCohasset, Minnesota

Alternatives to “Permacall”Alternatives to “Permacall”

RemunerationRemuneration Regional call sharingRegional call sharing Practice sharingPractice sharing Scheduled locumsScheduled locums Scheduled off call (ship out) periodsScheduled off call (ship out) periods PAs/NPsPAs/NPs