Dear OTW Readers:
Are resident work hours “the most critical issue in orthopedic education today?”
Alarm Bells Going Off Over Resident Training!
L. Scott Levin, M.D., F.A.C.S., chair of Orthopaedic Surgery at the University of Pennsylvania, is ringing the alarm bells with regard to the ACGME (Accreditation Council for Graduate Medical Education) work rules for residents. Dr. Levin tells OTW, “This is the most critical issue in orthopedic education today. Things such as the mandatory sleep times interrupt patient treatment continuity…without even knowing if things such as this make a difference.” While Dr. Levin says that it is too late for pushback, he adds, “The only thing that is going to make a difference is if training programs around the country approach hospital systems and demand ancillary support for patient care. The fact is that these rules are essentially making residents into shift workers. You have people unfamiliar with the details of a case covering patients at night—and that can easily lead to medical errors.”
ACGME Living in a Fantasy World?
Another concerned orthopedist tells OTW, “The ACGME is not living in the real world. I have seen no evidence in the literature of a statistically significant change in untoward events since these work hour restrictions went into effect. What has changed is that residents are not as well trained when they finished their programs. They go home and spend time with their families; they do recreational things. It used to be all about being a resident and learning; now families are doing better but the experience of trainees has been lessened. There is just not as much fire in their bellies. Do they care? Yes. But it’s more like a job than an all consuming profession or calling.”
Residents Respond
“Don’t hang residents out to dry, ” says a current trainee. This resident tells OTW, “The biggest thing that residents are seeking is more business training in terms of contracts, how to find a good practice, coding, etc. My friends and I talk a lot about how it would be helpful to have such things as part of the academic curriculum. As it is now, we’re in a ‘trial by fire’ situation, grabbing help where we can. I know a resident who secured an offer from a practice, signed a contract, and received a signing bonus. But he got burned by the contract. As he completed his training he found that they kept changing the rules…he eventually had to return the signing bonus, leaving him with substantially more debt. We could really use some sort of resource…someone who could guide us with regard to contracts and the like.”
Big Fight Looming in New Jersey
There is a new PIP (Personal Injury Protection) coding and fee schedule proposed by the Department of Banking and Insurance in New Jersey that, says our source, could affect reimbursements for treating victims of car accidents. Says a surgeon to OTW, “The changes will negatively affect the reimbursement primarily of spine procedures and the facility fee they generate in ambulatory surgical centers. The fact is that these are accident victims who are unhappy to begin with. From the doctor’s perspective, this person lands on your caseload, the results may not be what they wanted, you don’t get paid properly, lawyers come calling and you may get sued…where is the motivation? The spine surgeons may reduce their exposure to these patients. The New Jersey Orthopaedic Society has sent flash letters to its members to organize and work to improve the schedule.”
Polymer Over Metal?
OTW hears, “A lot of people are talking about the recent article in the Journal of the American Academy of Orthopaedic Surgeons about Mayo Clinic going back to using all-polyethylene tibial components that work as well, if not better than the more expensive metal backed ones. They also have a longer track record and are significantly less expensive. In recent years they have been relegated to the Neanderthal pile, but this article points out that the old all poly tibial components worked well. But the cynic in me says that some companies think, ‘Why sell a simple tibial component if we can sell one that is five times as expensive?’ Unfortunately, most residents and fellows buy into the concept that if it is new and expensive it must be better—never having seen the old work well. They don’t know it, they don’t like it. Even when they are presented with evidence showing that some of the ‘old stuff’ worked well, most of them still want to use a $20, 000 implant. So much is forgotten under the spell of a new designs, new instruments, planned obsolescence, profit motive and the lack of a historical perspective doomed to repeat the mistakes of the past, etc…..but more to the point we are not talking about mistakes, we are talking about what worked well at much less cost.”
Hot Button Issue — LCD
An orthopedist looking at the changing economic landscape for surgeons and clinics tells OTW, “In my state, LCD (Local Coverage Determination) is a hot button issue. LCDs detail what must be documented in order to perform surgery. My fear is that if these guidelines are not followed to a ‘T’ then that will be an excuse for Medicare to deny payment. Worst case scenario? You do a joint replacement and both you and the hospital are denied payment because third party payers say you didn’t do ‘XYZ’ exactly right. AAOS has been working with us on this, but the real issue is the bureaucrats at the federal level…in the end they have complete control.”
Death of Private Practices?
Another orthopedist blowing a bugle about government control tells OTW, “Private practices are on death’s door…and I think that is exactly what the feds want. Because of shrinking reimbursement and the administrative cost of healthcare reform, many more doctors are choosing to become employed physicians. Take the cost of converting to electronic medical records. If your practice is large, you’re easily talking about shelling out several million dollars in order to make this transition. There are not many practices that can handle those kinds of expenditures. I think the federal government wants all doctors to be employed, with the money flowing through the hospital systems as opposed to the doctors. Patients are the only ones who can stop this…they will gravitate toward—and then demand—excellence.”
Gary Henley, Former CEO of Wright Medical Group Lands
He’s now around the board table at TransCorp Spine…the company has just named Henley as executive chairman of the board. Henley has 29 years in the ortho and medical device industry; years ago he worked at CeCorp, Inc., developing micro-cameras to work in conjunction with surgical microscopes for cataract procedures. He also spearheaded the development of devices such as arthroscopic cameras, light sources and other surgical products and accessories. OTW wishes Henley all the best…
Sunny Gupta, D.O., Newest Sports Medicine Physician at the Rothman Institute in Philadelphia, Pennsylvania.
Dr. Gupta, who completed a sports medicine fellowship at Thomas Jefferson University Hospital, has been a team physician for a variety of sports teams on a professional, high school and collegiate level. He has a special interest in cutting edge treatment options and musculoskeletal injury prevention. He was previously the director of spine care and a physical therapist at Healthsouth Corp in Danbury, Connecticut. Best wishes, Dr. Gupta!
Emailing Rwanda…Vail-Summit Orthopaedics Surgeon Dr. Peter Janes and his wife (a nurse), continue to stay in touch with (and advise) those they helped on a recent Global Health Initiatives trip to this East African nation.
Dr. Janes tells OTW, “Rwanda has no formal orthopedic programs or training; there are only about five orthopedic surgeons in this country of 9 or 10 million people. They need a well defined curriculum, and regularly scheduled groups of consistent visitors who will teach, not just do surgery and leave. Most fulfilling moment? When, after having to cancel a 14-year-old boy’s surgery, we were able to transfer him and fix the fracture at a different hospital a week later in Kigali. I want to give a great deal of credit to Lew Zirkle and his SIGN nail program that continues to grow and mature around the world. Work in developing nations requires patience, some understanding of their cultures and expectations, realizing the resources that are available or not, and being able to work creatively with those limited resources. In the West we have, and waste, so very much. Leave your egos at home.”
Zimmer, Dr. Neil Sheth and GEANCO Collaborate in Nigeria.
One orthopedist for four million people. That is the situation in Anambra State, Nigeria. Dr. Neil Sheth, a surgeon with the OrthoCarolina Group, is one of the generous medical professionals traveling to Anambra with The GEANCO Foundation to help patients with disabling joint diseases. Zimmer Holdings, Inc. will support the mission by donating orthopedic implants and other surgical products. As he boarded his flight, Dr. Sheth told OTW, “One of my mentors from Penn was Dr. Enyi Okereke, a Nigerian who passed away in 2008; we were so close that I did his eulogy. It was his life and legacy that motivated me to help in Nigeria. Orthopedic conditions in that country are extraordinarily severe, and I hope to be able to make a substantial difference in patients’ lives.”
