Orthopedic care in the rural setting means the doctor is in

Call coverage is a key consideration when starting a rural orthopedic practice.

Access to health care, let alone orthopedic care, may be hard-won in a rural setting where there is a shortage of physicians and limited options for patients in terms of health insurance and transportation to office visits.

“In rural areas, the health care work force shortage is, in some ways, approaching a crisis point across the board, from nurses and [certified medical assistants] CMAs to doctors of all types,” Carrie Henning-Smith, PhD, MPH, MSW, assistant professor of health policy and management at University of Minnesota School of Public Health, told Orthopedics Today.

The most notable efforts to address this shortage have been among primary care physicians (PCPs), Henning-Smith said, because they may be eligible for loan forgiveness and financial incentives for working in areas in which there are health care provider shortages.

Source: Gina Papa

Research has shown fewer orthopedic surgeons practice in rural areas compared with urban areas, as well as an increased trend for specific orthopedic procedures to be performed in urban area hospitals vs. rural hospitals.

A study published in the Journal of Bone and Joint Surgery in September 2018 showed academic hospitals in New York City had an increased volume of patients who underwent meniscectomies and meniscal repairs and patients who received allograft during meniscal procedures were almost exclusively concentrated in urban areas near New York City compared with the rest of New York state.

Differing dynamics

The reasons for physician shortages in rural areas and regionalization of specific orthopedic procedures are multifactorial, and sources for this article say they may have to do with the different dynamics of rural and urban orthopedic practices.

Lawrence J. Iwersen, MD, orthopedic surgeon in Kalispell/Whitefish, Montana, said hospitals and practices in rural areas may lack backup medical specialties, be faced with tighter finances and experience a lag in technology compared with urban practices. In addition, they may not have as great an inventory of surgical equipment, instruments and devices as urban practices. It can greatly hinder a surgical procedure, Iwersen said, when the right equipment is not on-hand.

It is essential to establish the right relationship with the representative for the suppliers used for total joint or trauma cases, according to Iwersen.

“Each company ... has the equipment we need for specific cases and you have to recognize what you are going to need ahead of time,” he told Orthopedics Today.

Size matters

Rural hospitals are smaller than urban or metropolitan hospitals. In a rural setting, Iwersen believes it may be a friendlier process to see patients and easier to complete rounds after surgery, despite how challenging it is to perform more involved surgeries in this type of health care setting.

As a 15-bed critical access hospital in Mammoth Lakes, California, Mammoth Hospital, where Michael M. Karch, MD, FAAOS, is an orthopedic surgeon, hosts “Joint Week,” which is one week per month during which extra staff from other hospitals come in to help Karch with total joint replacements. This enables three to four TJRs to be performed per day in eight consecutive days. But due to its small size, limited bed space and inability to allow patients to have long postoperative stays, the hospital established a protocol that stratifies patients based on their risk and predicts of the length of each patient’s stay.

“Limited bed space and staff forced us to be critical of our outcomes, made us more efficient and reduced overall length of stay,” Karch said.

“We created the Multidisciplinary Reconstructive Committee that meets once a month. We have all of our patients that are in the queue for up to 3 to 4 months out ahead of time, and we review each patient,” Karch said. “We look for modifiable risk factors ... that we can change ahead of time to reduce the risk profile before they go to surgery so that we can predict how safe [the surgery will be] and how long they will be in the hospital afterward.”

When patients do not receive unanimous approval from the committee to undergo TJR, the staff works with patients to modify any risk factors and improve their overall health before they are rescheduled, such as losing weight, diabetes control, preoperative opioid cessation, depression modification or smoking cessation, Karch, a member of the Carilion Clinic/Virginia Tech orthopedic reconstruction team, said. “We are committed to providing university-level orthopedic care at a critical access rural hospital.”

Karch said, “That is something that I think, in a rural hospital, we have to do because we are getting these people from 6 hours away who were not necessarily in the best health.”

This system has been “successful in reducing our complication rate, reducing our ... 30-day [and] 90-day readmission rates and improving patient-reported outcome measures ... because the patient’s buy into their own health,” he said.

A way Geisinger Health System, in Danville, Pennsylvania, is working with patients who live in rural areas it serves is by helping them maintain a healthy lifestyle. Geisinger established a Fresh Food Farmacy program to improve health behaviors of residents in the community while educating them about the connection between nutrition, wellness and reducing the risk of type 2 diabetes and other medical conditions, Michael Suk, MD, JD, MPH, MBA, FACS, said.

“We have seen some significant positives...with regard to our diabetes management, our ability to address chronic disease early and frequently, and, ultimately, as it pertains to us in orthopedics, these are patients we are trying to preop appropriately in order to do the surgery if, and when, it is necessary,” Suk, chief physician officer at Geisinger System Services and chairman of the Musculoskeletal Institute and department of orthopedic surgery at Geisinger Health System, said.

Call coverage, subspecialization

Two challenges when running a rural orthopedic practice are call coverage and subspecialization, according to James H. Lubowitz, MD, founder of Taos Orthopaedic Institute in New Mexico, who said they both are related to the size of the catchment area, where a county with 30,000 residents would require approximately 1.5 full-time equivalent orthopedic surgeons.

That may be a difficult requirement to meet, he said.

“It is hard to find 0.5. You can certainly try and get late-career, semi-retired types, but that may not be consistent with the goal of serving a community over the long-term,” Lubowitz told Orthopedics Today.

Even a two-person practice requires surgeons to be on call every other night, which Lubowitz noted is not sustainable in the long-term.

The key is to have enough manpower, so each surgeon is on call at least every third night, which Lubowitz believes is more sustainable if the call is quiet, and reduces the risk of burnout. Orthopedic surgeons trying to establish a rural practice must realize they cannot do everything, he said.

“There is so much new information and so many new articles and conferences that it is almost impossible to be a generalist in these small towns,” Karch said. “The misconception is we have to do everything. Actually, you are going to provide better care sometimes in these small towns if you have a group of subspecialists that you can focus on that skillset.”

According to Lubowitz and Karch, each surgeon in their practices focuses on a different subspecialty. But even with that approach, Lubowitz noted it is still important to have good referral relationships for the subspecialties not covered by the hospital.

Iwersen said it is important for orthopedic surgeons to be able to handle trauma cases in addition to their usual subspecialty.

“You see trauma and you have to take care of it,” Iwersen said. “You do not have a trauma guy in the hospital who will take care of all of that. You have to do not only what you like to do, your specialty so to speak, but also handle the traumatic cases.”

Establish satellite clinics

As it became better established, Lubowitz realized Taos Orthopaedic Institute needed a bigger catchment area, so satellite clinics were started, first in areas that were also relatively rural and underserved, and ultimately, as related growth allowed subspecialization, in the state capital of Santa Fe.

“By having the satellite clinics, I perceived we expanded our catchment area from 30,000 to about 130,000,” Lubowitz said.

That led to the ability to support three fellows and three full-time orthopedic surgeons who were faculty and enough manpower such that the physicians could continue to specialize as above, as well as provide coverage to the local ED without burning out, according to Lubowitz.

Suk said it may be better to perform some of the more primary orthopedic cases closer to the patient’s home. For that, he said, Geisinger uses outreach clinics to which surgeons, physicians and physician assistants travel, which can be a 30- to 90-minute drive away.

The goal is to “provide that first level of care in communities in those areas and so the burden is switched,” Suk said. “Patients will travel here for that type of [care], but we travel to them.”

This dilemma is also solved by visiting consultant clinics (VCCs) in which a specialist physician makes regularly scheduled visits to an outreach site in a community that is too small to support a full-time specialist, according to Thomas S. Gruca, PhD.

Gruca, from the Tippie College of Business at University of Iowa, works with data on VCCs in Iowa that have been collected yearly since 1989. He said 45% of orthopedic surgeons participated in a VCC arrangement in 2014. Orthopedic surgeons drove 32,000 miles per month, on average, to see patients, which provided a more comfortable treatment setting for patients and better coordination with local health care providers.

Gruca and his colleagues saw the number of counties in Iowa with monthly access to an orthopedic surgeon increase from 35 to 88 counties (of a total of 99 counties) due to VCCs.

“On a monthly basis, VCCs allow 670,000 more Iowans to see an orthopedic surgeon within a short, 30-mile drive of their home towns,” Gruca told Orthopedics Today.

As of July 2018, about 37% of orthopedic surgeons in Iowa participated in a VCC arrangement that provides 4,224 clinic days per year. They drive 29,046 miles per month to see patients at primarily rural sites.

Differences in follow-up protocols

Follow-up protocols may need to be more flexible in rural settings based on the type of surgery and outcomes, according to Lubowitz, who said he usually would see patients 2 weeks after knee arthroscopy and on an as-needed basis after that as long as patients were participating in supervised physical therapy, until they returned to full activity. Patients who underwent ACL surgery would be usually be seen at 2 weeks, 6 weeks, 3 months and 6 months.

“However, although high-risk patients, like young athletes and female athletes would necessarily be seen at 6 months, a 40-year-old skier doing well at 3 months who lived 2 hours away or more might be told to continue rehabilitation and follow-up as needed. I might tell them if they had any problems to call me, but I might be more lax about that last visit,” Lubowitz said. “Telecommunications with the physical therapist could well serve as a surrogate for a face-to-face office visit.”

Karch noted follow-up at his clinic is consistently done for all patients at 14 days, 1 month, 2 months and 3 months. Karch and Suk said they use telemedicine for patients who live farther away.

“What is different about [follow-up care] is we tend to leverage things like telemedicine more frequently than perhaps my urban colleagues [do],” Suk said. “As an example, a 2-week postoperative visit for a hip fracture would be more routinely done here through a telemedicine visit to check the wound and make sure any questions are answered.”

For follow-up, however, select patients sometimes visit Karch’s colleagues with practices that are closer to where patients live.

“Most patients come back to us, but they see us in one of our satellite clinics to make it easier for them, so they drive 200 miles less, or through video,” Karch said.

Partnerships, education are key

A partnership with PCPs and other health care specialists can help optimize care in a rural setting, Suk said.

According to Karch, PCPs and physical therapists in rural areas who are educated about orthopedic care may be better equipped to refer patients to appropriate specialists and for postoperative care.

Attracting more physicians to these rural areas through financial incentives similar to what PCPs receive may further increase the number of orthopedic surgeons who work in rural areas after medical school, according to Karch.

“My impression is [these rural areas] can be adequately served. It just takes a little more work on the part of the orthopedist, as well as their team,” Karch said.

Maintaining highest standard of care

Despite the dynamic differences in its practice model, rural hospitals are often expected to keep up with their urban counterparts, which is a task that can be daunting, particularly with limited resources. But, Lubowitz believes this is not only possible, but necessary, to achieve and maintain high standards of care for patients.

“If there is evidence-based medicine to support using new and even expensive technology, one might have to fight the good fight, but it is achievable,” Lubowitz said. “It takes energy and will. I think it is the same in urban hospitals. There are limited health care and financial resources.”

Orthopedists who wish to go into private practice in a rural area must be informed through reading, actively seek current practice-related information and be directly responsible for the education of their staff, Karch said.

Lubowitz recommends strategically considering how the challenges of ED call coverage will be managed.

Establishing or joining a rural practice that has partners may help with challenges, like call coverage, according to Iwersen.

“It is nice to have partners for call reasons and to talk about cases,” Iwersen said. “I do not want to discourage people from going off by themselves, but as a new resident, I would recommend [going] where there are partners.”

An orthopedic surgeon who is considering a practice in a rural setting should “keep up your skills and know your limits,” Lubowitz said. “From my point of view, in the United States there is one standard of care and that cannot be compromised just because you may be farther away from a major urban center or a level-1 trauma center.”

Features of rural care

Despite the associated stresses of working in a rural area hospital or practice, Suk believes there is great satisfaction in living and working in a rural environment. “As an orthopedic surgeon you can find a tremendous amount of satisfaction by either being a general orthopedist or by linking it to a larger entity, like we are, where you can be a subspecialist within a rural community,” he said.

Practicing in a rural setting provides experience in leadership and the opportunity for orthopedic surgeons to build their own program.

“Rural living results in a balanced lifestyle choice for someone who, as in my case, becomes academically involved and travels to a number of meetings and courses that are generally held in major urban centers,” Lubowitz said. “You can have the best of both worlds when you travel to cities and return home to a rural area.”

Depending on the state, rural areas may present orthopedic surgeons with the kinds of cases that would not be seen in an urban setting, according to Iwersen, who has treated patients after bear maulings, mountain lion attacks and injuries received during an array of outdoor recreational activities.

“We are in the mountain area, so we have an incredibly active outdoor community that snowmobiles and hunts and fishes and they get...different traumatic problems because of that,” Iwersen said.

He continued, “It is not just a car accident. It is a fall off a cliff or it is a fall off a horse that will lead to different injuries that are unique.”

What the orthopedic surgeons who spoke with Orthopedics Today seem to enjoy most about working in a rural practice is they get to know their patients better and may more frequently run into patients and their families outside of work. However, with that may come added expectations for orthopedic surgeons to “make some effective change in their community and become a leader in their community, not just in the hospital,” Karch said.

“While all doctors, I would hope, do their best to treat people well and respectfully, I think that is critically important in a small town because you are a member of that community,” Lubowitz said. “Even if you want to be a subspecialist who only does sports knee, which was my goal and how my practice developed, you are still the community doctor. That is a little bit different than being in a major urban center where you may not feel the same connection.” – by Casey Tingle

• Reference:
• Fresh Food Farmacy. Available at: https://www.geisinger.org/freshfoodfarmacy. Accessed Oct. 5, 2018.
• Fu MC, et al. Clin Orthop Relat Res. 2013;doi:10.1007/s11999-013-3131-3.
• Gruca TS, et al. J Bone Joint Surg Am. 2016;doi:10.2106/JBJS.15.00946.
• Suchman KI, et al. J Bone Joint Surg Am. 2018;doi:10.2106/JBJS.17.01341.

• For more information:
• Thomas S. Gruca, PhD, can be reached at 108 John Pappajohn Business Building, 21 E. Market St., Iowa City, IA 52242; email: thomas-gruca@uiowa.edu.
• Carrie Henning-Smith, PhD, MPH, MSW, can be reached at UMN Rural Health Research Center, 2221 University Ave. SE, Suite 350, Minneapolis, MN 55414; email: henn0329@umn.edu.
• Lawrence J. Iwersen, MD, can be reached at 111 Sunnyview Ln., Kalispell, MN 55901; email: larry.iwersen@gmail.com.
• Michael M. Karch, MD, FAAOS, can be reached at 85 Sierra Park Rd., Mammoth Lakes, CA 93546; email: mkarchsmd@gmail.com.
• James H. Lubowitz, MD, can be reached at PO Box 1930, Taos, NM 87571; email: jlubowitz@icloud.com.
• Michael Suk, MD, JD, MPH, MBA, FACS, can be reached at 100 North Academy Ave., Danville, PA 17822; email: mediateam@geisinger.edu.

Disclosures: Gruca, Henning-Smith, Iwersen, Karch, Lubowitz and Suk report no relevant financial disclosures.

Click here to read the , “What approaches would help close the gap in orthopedic care provided in rural areas?”