Mountain blizzards, the lack of available beds, and declining skill sets…all are issues for orthopedists who work in rural areas. And while these surgeons are masters at getting what they need to treat patients, sometimes things go awry.
Taos, New Mexico
Dr. James Lubowitz, Founder of the Taos Orthpaedic Institute and a team doctor for the U.S. Ski and Snowboard Team, wants to make orthopedic treatment in rural areas easier on his patients. “Fifteen years ago I left ‘the city’ and moved to Taos, New Mexico. One of the first obvious differences between the two areas was in the transportation realm. Because a typical patient was driving two to three hours—even to remove stitches or get a new drug recommendation—one of my first steps was to establish satellite clinics throughout the area. It only seemed fair that if they were going to do all that driving, then we could get in the car once a month and drive two hours to a clinic.”
Dr. Lubowitz advocates for no excuses.
It is my philosophy that regardless of whether someone is being treated in an urban or rural setting, that person should receive the same standard of care. You may not have as many resources in ‘the country, ’ but dedicated orthopedists will do their best to get the appropriate care for their patients. For example, we don’t have an M.D. anesthesiologist at my hospital; instead, we use the services of well trained RN anesthetists. But, we have to consider the possibility that the sickest patients may be better served by an M.D. anesthesiologist. If someone comes in with severe problems, we transfer or refer the patient to a center with a higher level of care.
Because you can’t see an X-ray through the phone (although this is rapidly changing in our electronic age), Dr. Lubowitz and colleagues must sometimes rely on long distance specialists for input. “We have no pulmonologists or intensivists and often must consult these individuals via telephone. There are also no traumatologists here, but even in urban centers you may not have an orthopedic traumatologist at every single hospital.”
The orthopedic juggling act involved in caring for rural patients may remind some of a Hollywood film…except it’s planes, ambulances, and helicopters. Dr. Lubowitz explains, “Albuquerque is about 2.5 hours away. If the hospital there—the University of New Mexico—says they have no available resources, then we’ve got to get the patient in an ambulance, on an airplane or in a helicopter for the trip to Denver. While the University of New Mexico is usually happy to help us out, they may have no available beds. In fact, my understanding from several parties is that they may also not have enough nurses. We are fortunate that two years ago a couple of the hospitals in Denver stepped up and said, ‘We are never closed.’ But it’s a real nail biter in the winter when we have huge snowstorms. In those instances the planes can’t fly, and we just stabilize the patients and treat them to the best of our ability.”
So they work with what they have. “While there are certain things that all orthopedists should be able to do, ” says Dr. Lubowitz, “there are many complex fractures (acetabular, for example) that only a few specialists can do. And it’s not just the surgeon’s ability, but having a team with experience, as well as the right equipment, that makes the difference. Fortunately most fractures can wait 24/48 hours to be treated, i.e., until the snowstorm clears.”
Even when the skies are clear, however, the logistics of transporting patients are anything but simple. “Taos Hospital has a helipad, but sometimes for reasons of safety or availability, fixed wing planes are preferred. Then, we start by putting the patient in an ambulance and taking him or her to the Taos airport, where they are moved onto a helicopter or fixed wing plane that has come in from Colorado. If it’s a fixed wing plane, however, they can’t land at the medical center in Denver, so another ambulance has to meet them at the airport in Colorado. All of this can cost more than $10, 000.”
With these extra difficulties, how to do you attract and retain talent? Market forces and call schedules are big parts of the equation.
You don’t want too many orthopedists because then they can’t make a reasonable living. If there are only 60, 000 people (or 6, 000) instead of millions, you may not have enough elective surgery to build a practice. And if they’re going to be asked to be on call every night, that’s not a real draw. If someone is in a large urban hospital and all the orthopedists are taking call one night a month then that is very manageable. But if you’re in a small town where there is only enough elective work for one or two orthopedists can you reasonably ask someone to be on call 15 or 30 nights out of the month? I did it when I first graduated from residency and was 30 years old. Fifteen years later, however, I’m older, busier, and need more sleep—not to mention that I’m further in time away from residency where I did a lot of trauma.
But Dr. Lubowitz has developed a model that works. “We have been successful in bringing in partners and fellows who help with call while they train in sports medicine. The fact that Taos is a destination resort makes this possible. We use our four satellite clinics to increase the volume of elective surgery in sports medicine so that we can have enough work to attract doctors to cover the ER.”
Detailing the behind the scenes struggle to cover all the specialties in a rural area, Dr. Lubowtiz says, “When I first moved to Taos 15 years ago as a fellowship trained surgeon there was one other orthopedist and he wasn’t very busy. I did general orthopedics, along with my specialty, sports medicine. However, a sophisticated patient didn’t want to see me for a hip replacement because there was a guy in Albuquerque whose entire focus was hip. I did my best and achieved good outcomes, but, as is always the case with being a jack of all trades, the volume is not very high…and the more volume the better the outcomes.”
“I realized, ” states Dr. Lubowitz, “that not only did I like ACL reconstruction more than bunion work, but that my ACL results were better than my bunion results. An increasing number of patients came to me as they began to realize that I was a specialist. Over the years, I restricted my elective practice to knee surgery, and just this year I stopped doing total knee replacement surgery and now only do knee arthroscopy and ligament reconstruction. Other doctors on the hospital staff, such as those in primary care and emergency medicine, are frustrated because our community needs a foot and ankle specialist; they think that if I’m an orthopedic surgeon then that should be good enough. However, my opinion is that best outcomes for patients are the primary priority, and if the community requires and can support a foot and ankle subspecialist, we should recruit such an individual.”
I have brought in a partner who does upper extremity work, along with basic hand surgery, ” adds Dr. Lubowitz. “We must refer complex hand problems to Santa Fe, however, meaning that the hospital loses these economically productive cases. There is not much to be done, however, if there is not enough work to support a full time foot and hand specialist. And if you have only generalists in rural areas then the outcomes won’t be as good. There is also a real risk of creating two standards of care, with moneyed patients traveling out of town to larger centers and those without means having no choice but to see a generalist. The ‘least best’ option is to say, ‘I’m sorry, but we don’t provide these services.’
When asked why the average urban/suburban orthopedist should care about rural orthopedics, Dr. Lubowitz says, “Rural orthopedists need to rely on their colleagues in larger centers to help them take care of problems outside the scope of their practice or comfort level. By and large, if a hand specialist in an urban setting is consulted by a rural orthopedist about a hand patient, he or she is very appreciative because it may increase business. Sorting out the issues in rural orthopedics can also benefit our urban colleagues by preventing patient ‘dumping.’ Overworked city orthopedists who are approached to help rural colleagues may say, ‘Why can’t you do it yourself?’ The upshot is that rural surgeons often don’t feel supported, while urban surgeons feel dumped on. The federal Emergency Medical Treatment and Active Labor Act (EMTALA), the law that regulates patient transfers, contains anti dumping provisions. But of course it doesn’t address misunderstandings and poor communication between orthopedists.”
Shining further light on the back-and-forth that goes on between urban and rural orthopedists, Dr. Lubowitz says, “We sometimes feel that when we send a trauma patient to Albuquerque they feel dumped on. But the urban orthopedists may not be aware of the denominator…they’re paying attention to how many patients we transfer not how many we keep. For example, a patient had fractures of both femurs—major trauma. It wasn’t that the orthopedists in Taos couldn’t put rods down the femurs, but this is a much sicker patient who requires a bigger team and greater resources. However, the ‘receiving’ doctor in Albuquerque might not appreciate that while we’re sending them that patient we’re keeping people with unilateral femoral fractures, hand fractures, and hip fractures. Unfortunately, I think there is tendency for our urban colleagues to think, ‘They’re being lazy. They should be doing this.’ But, alas, it is human nature to remember the one time someone did something that frustrated you—even if it was three or four years ago—and not remember the other 364 days that they didn’t need your help.”
Ontario, Canada
A primary concern for Dr. Mohit Bhandari, the Research Chair in Musculoskeletal Trauma at McMaster University in Canada, is the issue of skill drop-off in rural areas. “Those individuals who choose to work in rural settings will likely find that the communities can’t sustain them; so, they lose their skills. Then they will get to a point where they start referring patients because they haven’t seen xyz problem in three years. The well-regarded epidemiologist, Ellen McKenzie, Ph.D., has done research involving large hospital database registries in which she asks, ‘Does the number of patients seen in a given hospital affect the outcomes?’ She has found that in fact the more patients seen, the better the outcomes you have, meaning that in general, rural areas suffer.”
Using technology to link orthopedists is especially important in more remote areas. Dr. Bhandari: “At McMaster we are increasingly trying to give rural orthopedic surgeons access to experts via telemedicine. We have also found it helpful to build ties with tertiary care referral centers. That way, X-rays are easily sent to specialists on call.”
Dr. Bhandari: “McMaster, encouraged (and pressured) by outlying populations, came to realize that there was an increasingly urgent need for rural healthcare. Thus, the university created a medical school in the extreme north of Canada…one that only accepts individuals from the north. It has been a raging success.”
Trauma patients rolling into an urban ER can be relatively confident that the hospital will have the resources to treat them. Dr. Bhandari discovered firsthand how untrue this is for rural areas. “Twelve years ago I was teaching in a town of 500 whose hospital had an ER department that was lacking in staff. I was doing a talk on the resuscitation of trauma patients when the ER coordinator approached me and said, ‘We could use your help right now.’”
Along with the audience, I ran out and found a patient who had been hit by a car and had multisystem trauma. There were three or four family physicians on hand but no surgeons—most everyone was frozen with fear. I had no privileges at the hospital but was granted immediate permission because the patient would have died had a surgeon not stepped in. In five minutes, the patient went from being on his deathbed to having a chance for survival. It’s very frightening, but this can happen anywhere. Since then, every time I’ve been more than 100 miles from a major city I think, ‘Boy, if I’m in a serious accident, I just may not make it.’ The randomness of it all was quite an awakening.
Educated as to the significance of certain kinds of training, Dr. Bhandari says, “In extremely remote areas, orthopedics is handled by family physicians or technicians. These are people accustomed to seeing tumors, something that is not going to kill anyone in five minutes. What we need is a certificate program for training healthcare professionals on resuscitation. The bottom line is that the volume of patients is low. One orthopedist actually told me, ‘I can’t remember the last time I saw a multisystem trauma.’”
“The reality, ” says a philosophical Dr. Bhandari, “is that in many countries rural populations make up the majority of the population. The specialized needs and infrastructure of these areas deserve our attention.”
Central Louisiana
Dr. Steven Kautz, an L.A. orthopedist who chose “the other” LA—Louisiana—speaks firsthand of being, well, alone in the woods. “Several years ago I left the hectic pace of Los Angles behind and accepted a staff position at Natchitoches Regional Medical Center in central Louisiana. While the relaxed lifestyle is definitely an improvement, having a solo practice in a rural area is head spinning at times. With regard to call, the hospital staff knows that if I am in town they can call me and I will come.”
And that is much more available than many orthopedists want to be. Dr. Kautz: “For some people such work is not attractive because you have to be available most of the time. I do have exceptional support, however, as my colleagues in the ER know how to do most of the initial treatment and workups. Unfortunately I have no resources along the lines of plastic surgeons or vascular surgeons. If we get any pelvic trauma or life threatening injuries, our general surgeons are not going to care for these patients. We send them to Louisiana State University. The good news is that we have a helicopter pad.”
Exemplifying the flexibility required of rural orthopedists, Dr. Kautz notes, “I have had patients who required plastic surgeons to do soft tissue coverage work. I sent one patient to Texas and on another occasion I tried to send the person to a doctor in Baton Rouge, but the hospital couldn’t guarantee me a bed for five days. As fate would have it, the majority of plastic surgeons in the area are now doing non trauma (beautification) plastic surgery.”
So what’s unusual and superb about practicing in a rural area?
When I had a patient tell me that rubbing pig fat on a wound would prevent an infection, I was a bit skeptical. Oddly, it seemed to work. As for lifestyle, there is no orthopedic ivory tower. You should know that you’re going to run into your patients at the grocery store. Ideally, you would welcome such a sense of community. On one occasion my aunt was visiting from Los Angeles, and when we went to Walmart, a patient of mine approached me excitedly and told my aunt how happy she was with her operation and that her scar was barely visible. Such intimacy is not the norm for city people…like my aunt.
As it’s unlikely that spine specialists or shoulder savants will soon be flocking to the far corners of Arizona or the mountaintops of Georgia, it is important to bring creative thinking to play in addressing the orthopedic needs of rural populations. Dr. Urban, Dr. Rural…conference anyone?
