Surgeons are 'ghosting' the ED, ortho leader says

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The continuing wave of orthopedic and spine procedures to ASC settings has one surgeon concerned about the impact that will have on both surgeons and patients.

Joel McClurg, MD, PhD, is a consultant and former orthopedic surgeon at Richmond, Ind.-based Reid Health. He recently connected with Becker's to share the big trends he is following in orthopedics. 

Note: Response was lightly edited for clarity and length.

Question: What orthopedic and/or broader healthcare trends are you currently following?

Dr. Joel McClurg: I think the long-term trend I am most interested in right now is how orthopedic surgeons and surgical specialists, in general, will be ghosting the ED in the years ahead and the dire effects that will have on patients' access to care. It will undoubtedly increase our ED colleague's stress and discontentment. The market forces that have decoupled surgeons from hospital-owned operating rooms will decrease surgeon participation in broader hospital-based responsibilities. The die was cast when CMS removed many musculoskeletal procedures from the inpatient-only pool, allowing for more flexibility in where these procedures can be performed. Increasingly more complex procedures are now reliably performed in the ASC setting. Many of the million total joint replacements performed yearly in the U.S. are now eligible to be performed in nonhospital-based ambulatory care centers. Spine procedures such as two-level anterior cervical discectomy and fusion, robotic decompression and straightforward fusions are the next dominos to fall. With all of this care migrating to independent or, at best, co-owned ASCs, the need for surgeons to participate in ED calls and to act as hospital consultants will likewise be impacted. Other hospital-based physician responsibilities, like committees and strategic planning, will go unmet. This more balanced relationship is good news for surgeons as they look to negotiate with hospitals on a broad range of issues. Many younger surgeons will rarely, if ever, set foot in a hospital under this evolving paradigm.  

This physician migration will leave the often onerous hospital-based patient care responsibilities in the ED and on the floor naturally falling to fewer and fewer providers. In my experience as a surgeon and consultant to ASCs, the trend has been to resolutely negotiate fewer hospital calls, even in co-owned facilities. In independent ASCs, there are often no hospital-based call or consulting responsibilities. These developments will predictably cause increasing transfer rates and potential delays in care. There are not enough traumatologists to pick up the ED call slack, especially in smaller markets. Other care models could see substantial development, like orthopedic hospitalist programs, but the same provider availability and willingness issues will prevail.  

Physicians disproportionately lead the best-rated hospitals in the country. We need more qualified physician leadership at all levels, most pressingly at the executive level. This is unlikely to happen with the migration of surgeons to ASCs and fewer of us spending time in a hospital or on hospital staff. That trend concerns me a great deal.

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