The Carrot or the Stick?

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Private practice has abandoned the trauma patient, so stop wasting time
on it.  

Hire your own surgeons, provide centralized support/billing/coding,
build them an attractive office, and encourage their niche interests
when they're not on call.  You'll find that many a surgeon can be
seduced and retained by the opportunity to focus on surgery rather than
business -- and that being fairly and reliably reimbursed takes the edge
off all the disincentives of trauma call.

Further, the employment contract can make its own demands -- not just
call, but CME, PI, etc.

It's a big step; but employed physician practices are the future.  And
if such practices are procedure-based (i.e., surgical), the financials
will be more manageable than you expect.

I whined for ten years before our hospital hired its first surgeon
(nothing to do with me: among many other influences, it was the only way
to make ACS verification feasible).  In the ten since, we've grown to
six, with a seventh on the way, plus orthopedics, ENT, OMFS, ...).  Our
brand new clinical office is already busting at the seams.  And this is
rural Maine.  

Pret Bjorn, RN
EMMC Trauma Program
Bangor, ME USA



-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of caesar ursic
Sent: Saturday, December 29, 2007 11:41 AM
To: Trauma &amp, Critical Care mailing list
Subject: The Carrot or the Stick?


I hope that the following leads to some healthy discussions, useful
suggestions and even novel philosophical treatises, rather than dogmatic
posturing... so here goes.....

How does one motivate general surgeons to participate in trauma care?
I'm
referring to mature (in a career sense, not necessarily chronologically
old),  board-certified general surgeons who are already established in
their
own various practice patterns within a hospital infrastructure, said
hospital being a level II or III trauma center.  I am not referring to
general surgery residents considering a 'career' in trauma/emergency
surgery.

Some background.  I am often asked by various hospitals in and around
New
Mexico who are either newly-designated or considering designation as
level
III trauma centers to 'advise' them in matters pertaining to trauma
service
function, maintenance, upgrades, lubrication and trouble-shooting.  And
one
of the most common problems I see is a lack of 'buy-in' or commitment
form
the general surgeons who form the core of the trauma program.  Overall
these
are very well qualified doctors; they have a good understanding of the
technical and cognitive approach to trauma care; they have trained in
busy
trauma centers as residents or fellows, and know the concepts; they are
ATLS-certified; they know their way around the retroperitoneum,
understand
damage control, and can open the chest if need be and address the
bleeding
heart or lung.

But they just don't give a damn.  They are committed to their own
practices
in general/vascular/GI/endocrine surgery, and taking trauma call is a
major
hassle to them.  They won't attend trauma committee meetings because
they
are operating that morning or they are making rounds or seeing their
patients.  They participate reluctantly or not at all in the Quality
Assurance/Improvement process;  they do not acquire trauma-related CME
education; they try their best to shunt initial ER care to the Emergency
Medicine physicians, who by necessity have become the primary caregivers
and
decision makers during the 'golden hour' in most cases of
seriously-injured
patients.  In short, the General Surgeons would just rather Not Be
Bothered.


Eliminating them from the trauma call roster is not an option.  These
trauma
centers are not large, university-affiliated hospitals with scores of
young
consulting/attending surgeons yearning to climb the ladder of promotion
and
willing to do whatever it takes to get there.  These surgeons are well
established in the community.  There are not a lot of them.  If one or
more
of the surgeons are removed from trauma call, the system will collapse,
because the remaining few would simply be overwhelmed.  Financial
incentives
are useless.  Paying extra $$ for full participation in trauma is
meaningless to surgeons who are already doing well financially and for
whom
trauma call represents potential misses in general surgery-related
payments,
which will always exceed the few hundred $$ to be made for a trauma call
shift.  No hospital will be willing to pay them what the surgeons truly
believe their time on call is worth (more than 1 to 2 thousand dollars,
I
can assure you).

Making trauma 'fun' and 'interesting' by implementing well-catered
educational sessions/grand rounds/case studies that involve the surgeons
motivate no one.  Their life is already too busy taking care of their
own
patients, attending their tumor board meetings and other various
functions.
"If I wanted to be a trauma surgeon, I'd be working over at the
University
Hospital right now, pal..."

The hospital administration won't threaten them.  Threaten them with
what?
The hospital desperately needs them to take care of a large general
surgery
patient population.  After all, the facts are the facts - only a minute
percentage of surgical emergencies presenting to the ER are
trauma-related.
Can't argue with those statistics, can you?  The State verifying
agencies
are only able/willing to issues vague statements like "we would like to
see
greater participation of your surgeons in the various components of your
trauma system ...blah, blah, blah...."

So basically, what I often see is a group of surgeons who do not like to
care for the injured although they know how to do it.  And since they
don't
want to, they cut corners, they avoid going the extra mile, they don't
invest themselves to the fullest, and care can and does suffer in subtle
but
real ways.  ER times are too long.  Operations are delayed.  Unnecessary
scans are ordered.  Surgical care is deferred to internists.
Participation
in Process Improvement is nil or minimal. Not really what the Green Book
describes as 'Optimal Care,' is it?

And neither carrots nor sticks seem to help.

Happy New Year.

CM Ursic, MD
Trauma Medical Director
St Vincent Regional Medical Center
Santa FE, NM
USA





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