Dr. Thomas Grogan, a self-described country doctor, enjoys the continuity of seeing his patients go from jungle gyms to skateboards to college athletics. As a pediatric orthopedist in Santa Monica, California and a member of the clinical faculty at the University of California, Los Angeles, this is no small feat, considering that he has seen over 34, 000 new patients during his career spanning the last two decades.
Born in California, Tom Grogan watched as his father changed history. “My dad was an insurance agent during the ‘70s, a time of malpractice crisis which saw numerous insurance companies leaving California. My dad developed the concept of a doctors’ co-op where physicians put money into a ‘pot’ in order to pay for malpractice claims. He organized the first physician co-op for malpractice coverage. In a sense, he saved the day for doctors.”
On the Path to Medical School
He took an educational sojourn “back East, ” then found an entrée into medicine…via the role of orderly. “After my freshman year at Princeton, I returned to California and was rather directionless. My best friend got me a summer job as an orderly at Stanford, where I met a general surgeon named Bob Jamplis. This gentleman convinced me that medicine was both intellectually challenging and a great way to spend your life. I was sold, returned to Stanford each summer during college, and have always kept in touch with Dr. Jamplis.”
Tom Grogan had an uphill battle with medical school applications, followed by an uphill battle with the weather. “In the ‘70s it was particularly difficult to gain entrance to medical school. I applied to 26 programs, and was admitted to three: the University of Cincinnati, Columbia, and the University of Southern California. When I visited the Cincinnati program, I really enjoyed the people and felt that it was a good fit. I had never even seen snow before, however, and was not prepared for the rough winters.”
“Toward the end of medical school I found myself interested in pediatric general surgery, and went to Boston Children’s Hospital for a rotation on this service. The Chief there told me that the best residency programs for pediatric general surgery were the University of Minnesota and the University of California, Los Angeles (UCLA). Into my mind popped visions of snowbanks versus warm beaches…UCLA was a no brainer.”
Becoming a Country Doctor
Dr. Grogan then endured medical school “Survivor” to earn his next career opportunity. “In 1980 I began a general surgery program at UCLA with 25 other interns. When the cutting was over, there were six of us left standing; much to my surprise I was named intern of the year. The Chief of orthopedics then approached me and said, ‘I have an opening for you in orthopedics.’ I jumped at the chance because while rotating through the services I had really enjoyed interacting with the orthopedic surgeons and ‘their’ residents.”
Drawn to working with children in part because of their innocence, along the way Dr. Grogan encountered what you might call the opposite of innocence: hubris. “Learning of my decision, the Chief of general surgery called me and said, ‘You are throwing your life away.’ That’s when I knew that I had made the right choice.”
The “country doctor” explains,
General surgeons must be the smartest in medicine, partially because their work is so metabolically complex. The problem is that because they live in such rarified air, they don’t spend much time with people. On the other hand, pediatric orthopedics is almost like being a general practitioner—you see kids with varying problems. I’ve discovered Lyme disease in one patient, and with another youngster who had taken a fall from the monkey bars, found that he actually had a ruptured spleen. Unlike with general surgery, in orthopedics patients keep coming back—first there are the toddler falls, then the high school soccer issues, then they get their first snowboard…and you get to have a sense of continuity and community.
Switching to orthopedics would entail flipping a switch in his head…to overdrive. “I had been planning for a certain schedule—finish my general surgery program, do a pediatric general surgery program, join an academic medical center—then all of a sudden I make this shift and must develop a new timeline. And UCLA didn’t have a place for me as a first year orthopedic resident—only as a third year. Suddenly I found myself supervising other residents for things that I didn’t know how to do. I hunkered down, however, and was eventually senior resident for two years and then chief resident for two years.”
A series of fellowships then fully launched Dr. Grogan into his specialty. “I did a sixth month fellowship at Los Angeles Shriners Hospital. That was followed by an NIH fellowship in adult reconstructive surgery at UCLA where I got to see the other side of the age spectrum. While it was interesting to work with older adults, it was tough because they can be hyper-focused on their medical problems. Children are the opposite—they don’t dwell on their problems and all they want is to get back to their lives.”
In 1986 Dr. Grogan headed to Germany for trauma training…and got an education in systems. “I went to Munich on an AO Foundation fellowship, where I experienced quite a different environment in the German trauma hospital. The professors would ponder new devices, say, ‘Eureka!’ and send off instructions to the machine shop. The device would be made promptly and put it in the patient. This has its downsides, of course, but in some cases it’s wonderful.”
On his return to Los Angeles, Dr. Grogan found that all of the pieces of the orthopedic pie were in place…save one. “I joined the Shriners faculty, then became Assistant Chief of Orthopedic Surgery, a position that involved clinical research and resident education. The one thing missing was patient interaction. In 1988 I developed a part-time private practice in Santa Monica, which I took full-time in 1992. Since then the majority of my practice—80%—has been working with children. I don’t do as many surgeries as I used to, which allows me to give more time to my patients.”
“Give” being the operative word in many cases. “Six years ago I dropped all insurance plans, something that was frightening at first because I didn’t know if patients would still come. For the first two years, patients ‘fell off’ by 15 to 20%, but then things rectified themselves. At this point I provide about 15% of my care at no cost to patients.”
Orthopedists should realize that our patient base is our greatest asset because you keep seeing them as they get older. They depend on you to teach them to heal and to avoid injuries in the future. When you take care of your community, they take care of you. I have become a country doctor.
Researching Athletes’ Anatomies
A country doctor who squires in new research. Dr. Grogan, “In one of my recent studies I found that 73% of wrist fractures in snowboarding accidents occur in the non-dominant hand. This reflects an innate desire to protect the dominant side; it also suggests that our dominant side is slightly stronger, thus less likely to fracture.”
“I’ve been especially interested in determining which players are best suited to which sports and which positions. Athletes can be inclined toward femoral anteversion (neck of the femur leans forward) or retroversion (neck of the femur leans backward). Those in the former category tend to be suited for tennis or sports that involve speed and agility, while those in the latter group are often inclined towards power sports such as snowboarding or pitching. By understanding their natural anatomy, you can predict what sports they should play. In a study involving female soccer players, we plotted hip version against the position played. We found that soccer players tend to play those positions as defined by their natural anatomy. The bottom line is that when you try to push someone into a sport or position that their body isn’t designed for, it’s not a good thing…you can’t make a pitcher into a shortstop.”
Advice for Fellow Orthopedists
But you can make a country doctor into a practice management expert. Dr. Grogan, Chair of the 2010 Practice Management symposium for AAOS, notes, “While 25% of orthopedic surgeons are in solo practice, AAOS tends to be largely comprised of academicians and those in large group practices. In the past most orthopedists didn’t have many problems running their practices because we had high revenues. Now there are tremendous economic pressures, with Medicare and insurers cutting back. The typical practice has six or seven employees, and while overhead doesn’t decrease much, if you cut revenues it can dramatically affect salaries.”
Detailing his own experience, Dr. Grogan adds, “In my office every new patient generates $561 of revenue. This means that customer service is critical to our bottom line. Patients want a live person to answer the phone; they want someone to be nice to them, as well as attentive. I have an amazing, empathic woman who runs my front office. Since I’ve hired her, my new patients have increased by 300 per year.”
So they might look forward to seeing her, but whom do they really want to see? The doctor.
Access is key…even when it is not convenient. Many of my colleagues aren’t interested in being available after hours, but I know my patients hate going to the ER, and if I can, I will be there for them. I am available on Saturday mornings for emergencies, and leave open time for such occurrences during each work day. A lot of doctors feel they are successful if their scheduler says, ‘Sorry, we don’t have any appointments for four weeks.’ But that is not success in the patient’s mind because it isn’t what they want; they want to see you.
They also want to know how much they will have to pay to see you. “If you call most orthopedic offices, they cannot tell you how much XYZ services cost. My son is actually helping me with a ‘secret shopper’ survey where he calls different offices saying that he has a broken wrist, and inquires how much a visit and cast would cost. Out of the 22 he has called thus far, only two have been able to tell him what it costs. We must be more transparent in this field.”
Not only does he hold himself and his field to certain standards…he has done so with his children. “Along with my wife, a nurse anesthetist, I’ve raised three very responsible children, who are now ages 23, 21, and 19. The eldest graduated from Wesleyan, and is now considering medical school. My son is an environmental science major in Chicago, and my youngest daughter is now at Wesleyan. I am a private pilot and have owned three planes in the past—up in the clouds is a great place to clear your head.”
