The Carrot or the Stick?

[Forrest Robleto]

Pret,

Having lived in Maine for 10 years I can tell you that rural Maine is nearly
always redundant.

Respectfully,

Forrest

On Jan 2, 2008 9:20 AM, Bjorn, Pret <pbjorn at emh.org> wrote:

> 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
>
>
>
>
>
> are just a handfuAnd
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-- 
V/R

Forrest Robleto
R House Health & Safety
www.RHouseTraining.com
FRobleto at RhouseTraining.com
609-792-9047