Summary: Currently, the market for orthopaedic stress berat surgeons is varied. The market consists of university employed, university private, medical group employed, medical group private, private employed, private contracted, and private. Each option has its positives and negatives. The orthopaedic stress berat surgeon needs to determine which setting is appropriate for his/her given needs and wants. An experienced mentor(s) is invaluable for advice and guidance. The surgeon then needs to find an administrative leader to initiate, implement, and evaluate certain processes to succeed.
INTRODUCTION
The orthopaedic stress berat surgeon (OTS) employment market is fluid and variable. The stress berat center setting can be level 1, 2, 3, or none. The organizational setting can be a university, a system, and/or a private stress berat center. The employment organization can be employed, contracted, private practice, or none.
The OTS employment pool is also varied. Approximately 2 decades ago, about 15–20 graduating orthopaedic surgery residents selected a fellowship in orthopaedic stress berat surgery. Today, for whatever reasons, there are over 70 orthopaedic stress berat surgery fellows graduating each year.
The OTS requires a full understanding of his/her wants/needs. The surgeon should then determine the hospital setting appropriate and complimentary to his/her wants.1–3 Inappropriate surgeon/hospital match, surgeon/practice match, surgeon wants, and/or hospital wants will result in an unproductive and disruptive environment. An experienced and objective mentor(s) is invaluable.4 Once this match is determined, the OTS should also determine the required or needed list to establish a successful environment for optimal stress berat care delivery and OTS longevity.
Hospital has to have a knowledgeable point person who can speak to the quality of work performed, acuity of care, and medical community benefits within the C-suite in clear metrics. This point person can be a surgeon, but the position requires linguistic abilities that hospital administrators can understand.5 The point person can also be a hospital direktur who has medical pelatihan such as a nurse or a physician. The bottom line is the medical work that must be understood at the administrative level. The C-suite is a term used to collectively refer to the hospitals’ top senior executives (Chief Executive Officer, Chief Operating Officer, etc.). Without access and interpretation at this level, none of the true benefits of the OTS can be maximized.
Success is then indeterminate without translation of the quality product within the hospital definition. Quality must be defined with certain metrics such as reduction quality, infection, fixation failure, nonunion, and unexpected readmissions. Staged procedures must be interpreted as an expected intervention instead of a complication or unnecessary event. Acuity of care can be defined as the Injury Severity Score and/or Anesthesia Society of Anesthesiologists physical status level. The acuity of care may also be interpreted as time from admission to surgical intervention. Appropriate surgical throughput will enhance patient satisfaction, hospital bed availability, and financial solvency. Clear medical benefits to the community must be defined. Regularly scheduled, educational community lectures on injury prevention are priceless. Having a mature OTS service line with quality comprehensive care will lessen out of community referrals. This stress berat service will create an entire employable division for the medical service industry and all the downfield revenues of medical care.
Hospital must have a bonafide orthopaedic service line capable of comprehensive management and developing meaningful operational reports. Using computer-based programs, registries, and care plans, the service line must determine volumes, implants, and complications. Without meaningful reports, data, and metrics, the OTS will never understand his/her quality, complications, and areas to improve. Furthermore, the reports will never be appropriately translated to hospital administrators for interpretation and quality metrics. The scenario of “garbage in, garbage out” is not helpful to anyone. To generate the data, standardized medical reports and intake forms must be complete or an employee must complete the vacant data points. The other area of input can be electronic medical records that can automatically or programmatically populate statistically based spreadsheets. An employee must generate, compile, and disseminate the data at regular and timely intervals so that interpretation and comparison can be performed.
Hospitals seek/demand a baseline level of volume from a stress berat program. A certain baseline level of volume will justify physician extenders, resources, and operating room availability. Because stress berat volume is episodic and seasonal in many areas, finding something to “fill” the allotted and provided operating room and orthopaedic inpatient unit is paramount. During busy stress berat seasons, these numbers will not be difficult to satisfy the administration. During “downtimes,” cases such as semi-elective nonunion or malunion reconstruction, geriatric fracture cases, and even hardware removal may satisfy the volume. During predictable busy times, performing semi-elective cases in the urgent stress berat room will create chaos, prolonged wait times, and upset people from the patients to the surgeon and everyone in between.
Thinking you are busy is not good enough. You must seek out the hospital direktur to determine this “sweet spot” number of cases. In a transparent system, have the hospital calculate and provide the number of cases required for the hospital to be satisfied and financially solvent. When those downtimes are experienced, work to grow your business. Giving lectures based upon evidence-based practices concerning education, quality outcomes, and patient outcome to outer lying communities will enhance your referral process and numbers. Seeing a face with a name and surgical skill will cement the relationship. Answering the phone and saying yes to appropriate patient referrals will facilitate future referrals.
Predictable and Consistent Institutional Process With Regard to Patient Throughput Is Essential
Throughput begins in the emergency department (ED) and ends with the patient discharge. The ED should have a dedicated and qualified person to serve emergent patient referrals and volume in an emergency basis. The injured patients require coordination with radiology for diagnostic imaging and bed management for timely admission. Outside referrals may be fast-tracked to preassigned or prearranged beds to avoid ED delays and duplicate charges. The stress berat service, intensive care unit, hospitalist medical service, and orthopaedic floors require communication as to the status of the injured patient, timing of surgery, optimization of associated injuries and comorbidities, extent of surgical intervention, and length of surgery expected. Obtaining surgical consents from family members when available is paramount to avoid delays. Geriatric, long bone, and other simple fractures should be operated within 24 hours of admission. Once operated, patients require consistent physical therapy and pain management processes based upon the care plans to facilitate care and avoid delays. An experienced care manager or discharge planner is invaluable concerning patient home situation, insurance status, family engagement, timing of potential discharge, and appropriate skilled nursing facility requirements. Such trivial problems as pain medicines, deep vein prophylaxis, weight-bearing status, and timing of outpatient follow-up can delay discharge, increase costs, and impede new patients to be admitted.
Ability to Affect Change in the Orthopaedic Sector With Regard to Technology, Implantable Devices, and Resource Allocation
The OTS is more capable than anyone to determine which implant to use and why. The implant should be consistent upon fracture pattern, cost effective, and evidence based. Using expensive implants without evidence to their effectiveness may potentially drive monies away from patient care resources and out of the system to corporate implant costs. For an effective system to be deployed, the hospital and surgeon should enact a transparent process of implant costs and charges. Trading away an expensive personal implant of choice without inherent advantages over a similarly effective less costly implant can positively affect the system. Surgeons underestimate the true cost of implants and resources. Having the hospital provide the OTS with true costs and evaluating these costs with your preferences can lead to a productive relationship.
The hospital supplies resources to provide patient care. These resources should be used wisely, effectively, and economically. Because the OTS lifestyle can be inconsistent, efforts to create consistency will provide less episodic issues. Downtime or idle providers do not generate patient care, billing, or job satisfaction. Creating instruction, quality assessment, and/or team building can even out the idle time and enhance job satisfaction. Periods of extreme business, increased patient volumes, and accelerated throughput can stress the resources and potentially create poor job satisfaction. Prioritizing of emergencies, creating a chain of command, and setting limits to daily hours worked can maximize resources. Furthermore, extended periods of volume increases can prompt diversion to other partners, which can be instituted for limited periods and is not desired, and initiate the hiring process for an additional OTS.
Ample Manpower (Physician Assistant, Nurse Practitioner, and Resident) to Maintain Consistent Care Pathways
Despite the fact that the OTS determines the indications for operative versus nonoperative intervention, performs the surgery technically, and leads the patients through the postinjury convalescence, the daily care of patients requires a consistent care plan. The consistent plan of care begins with the administrative assistant, secretary, and medical assistant and ends with the physician extenders (physician assistant, nurse practitioner, and residents). Consistent care pathways provide a blueprint for care to avoid variation. Variation creates inconsistency and guessing and can potentially lead to errors in care.
The care plan should begin with a plan for determination of OTS emergencies such as compartmental syndromes, open fractures, dislocations, and vascular injuries. Consistent radiographic imaging to confirm diagnoses will enhance quality, diminish errant unwanted imaging, and will drive cost efficiency. Knowing which patients to admit and which ones to arrange follow-up as an outpatient will avoid inadvertent admissions and patient wait times. Consistent use of implantable devices based upon the diagnosed fracture pattern will assure implant availability. Perioperative orders can be easily administered. Documented orders with weight-bearing status will confirm appropriate weight bearing and avoid physical therapy delays and potential discharge delays. Keeping beds full with patients ready for discharge can impede surgical throughput.
The physician extender is vital for care pathway implementation. They are the ground troops on the ground that provides continual patient care. Furthermore, the OTS should analyze the abilities of each extender. Obviously, a senior-level orthopaedic surgery resident is capable of much, including independence. However, an experienced physician assistant or nurse practitioner may perform consistently at a higher level of function with fewer errors than a junior-level resident. Expecting more than an extender can provide and limiting the talents of an exceptional provider are scenarios that do not foster the best working environment. The OTS should provide some mechanism to manage and quantify the quality of their extenders (10 “Tips and Tricks” to Providing Trauma Care Without Residents, Caron et al6).
That the Problem Is Quality and Value and Not Merely Coverage
Quality intervention and surgery can be relatively expensive up front, but downstream, the savings are immense. Lower unexpected readmissions, complications, and efficient surgical intervention will lead to less costly care. Less costly care will create OTS value to the hospital and the community. Having an unskilled person on call or operating does not provide quality to the patient, hospital, or the community. Errors and complications will lead to increased costs, medical–legal liability, community distrust, and referrals outside the community.
Developing a sustainable traumatology service requires a collaborative effort between provider(s) and institution. To initiate this collaboration, one has to understand how the institution both perceives the service, its value and its future, and measures the service within the organization.
If this is targeting new graduates, the strategy is sound but the tactics are difficult because undoubtedly the service is in the formative stages (quite possibly) or there is little institutional insight aside from the knowledge of a coverage need.
Hospital expectations in return for the provided baseline goods and services are that of a service consistent in its process and cost in addition to consistency with regard to volume and volume growth. Getting the necessary materials and support from any hospital would be predicated on the individual surgeon to deliver this predictability to these variables. Quite simply, it will require that one thinks and acts institutionally and not individually.
Understand the current method of stress berat care and why and where variations exist in cost and outcome.
Develop a mechanism for measuring the benefits of reducing such variations.
Creation of a transparent means of service line reinvestment (getting what you want and need).
Develop a collaborative volume-based strategy that satisfies both the clinical needs of the surgeons and the institutional business needs.
Henley MB. Finding your ideal job and negotiating your contract: where to get the information and numbers you need to know. J Orthop Trauma. 2012;26(suppl 1):S9–S13.
Agnew SG, Warren BJ. Orthopaedic stress berat career and employment horizons: identification of career destinations and opportunities. J Orthop Trauma. 2012;26(suppl 1):S18–S20.
Bozic KJ, Roche M, Agnew SG. Hospital-based employment of orthopaedic surgeons—passing isu terkini or new paradigm?: AOA critical issues. J Bone Joint Surg Am. 2012;94:e59.
Moed BR. Mentoring: the role of a mentor and finding one. J Orthop Trauma. 2012;26(suppl 1):S23–S24.
Ziran BH, Bray TJ. How to negotiate with your hospital. J Orthop Trauma. 2012;26(suppl 1):S14–S17.
Caron T, Finley J, Austin C. 10 “Tips and Tricks” to providing stress berat care without residents. J Orthop Trauma. 2013.
*Journal of Orthopaedic Trauma: October 2013 – Volume 27
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