itinerant surgeons

[franksolich]

http://articles.latimes.com/1987-09-14/news/mn-5093_1_surgeons

I knew this guy, when I was growing up in the Sandhills of Nebraska.

My father was a hospital administrator, in addition to being a registered nurse-anesthetist, and worked with him on a case-by-case basis, along with the general practice physicians in town.

The idea of itinerant surgeons was a hot issue even back then, 10-15-20 years before this newspaper article appeared in 1987.  It was controversial because such surgeons came in and cut and sewed up, and left post-operative care to the family physician.

It was a necessity because small towns in Nebraska generally didn't, and don't, have the resources and population to support a local surgeon.....not to mention the "market" was pretty scant.

It was convenient because the patient was being treated by people familiar to him, in a setting familiar to him, close to his own place and people.

So I myself could never understand what the big deal was.

I'm copying and pasting the whole article, because it's nearly 25 years old, and the usual copyright rules apparently don't apply (the way I understand the copyright rules).

----------

Surgical Society's Rules Put Country Doctor in a Dilemma

September 14, 1987

GRAND ISLAND, Neb. — Once a week at 3 a.m., Dr. Robert Koefoot opens his office, makes a pot of coffee, reads the morning newspaper and then drives off into the darkness--a medical renegade.

The moon and an infrequent passing car provide the only light, an occasional deer or raccoon the only sign of life on the flat central Nebraska farmland as Koefoot drives north to St. Paul, population 2,000.

By 4 a.m. he is performing his first operation of the day--in defiance of the American College of Surgeons.

Koefoot, a third-generation physician, is an itinerant surgeon. His are the only general surgical services available to the 35-bed Howard County Community Hospital, which serves the St. Paul area 22 miles north of Grand Island.

He has traveled the lonely Nebraska blacktops from Grand Island to nearby towns for decades now--fixing hernias, removing appendixes, amputating limbs--but he leaves post-operative care in the hands of the family physicians who live in the towns--the doctors who referred the surgical cases to him in the first place.

Referrals Violate Rules

That arrangement violates the bylaws of the American College of Surgeons, the only major professional medical organization that prohibits so-called itinerant practice. It requires its members to follow up cases personally or to delegate postoperative care to other qualified surgeons.

For 10 years, Koefoot has waged a one-man crusade against this restriction. He challenged the College of Surgeons as a member and, after he was expelled from the prestigious organization, from a federal courtroom in Chicago. So far, he has been unable to get the rule changed, but the legal fight is continuing and so is his practice of itinerant surgery.

"They picked on the wrong fellow," said Koefoot, who has been joined in his fight by the Kansas City-based American Academy of Family Physicians.

The dispute between Koefoot and the 47,000-member surgeons' organization is as much a matter of Koefoot's ego as of medical principle, but it underscores the difficulties of providing specialized medical services in rural areas that have a chronic shortage of doctors, particularly specialists.

Critics of the surgeons' group's prohibition say that the economic well-being of country hospitals, already suffering from cuts in federal programs, shrinking populations and competition from regional medical centers, is further hurt by such a policy.

Position of College

The College of Surgeons contends that patients are better served by surgeons who provide postoperative care or delegate it to other qualified surgeons who will be nearby in case complications develop.

The issue, the group's lawyers say, is assurance of quality care. " 'Itinerancy' is not going back and seeing the patient, no matter where he is. Elements of time and distance are irrelevant," said Paul G. Gebhard, attorney for the College of Surgeons. "It isn't traveling . . . . There are fellows in Nebraska who travel some distance, and who see their patients regularly (after surgery)."

Koefoot said: "People in rural areas should have surgical problems solved by a competent, trained surgeon (and) they should also have the opportunity to have their surgery (near their) home, in the rural hospital. Without (income from) surgery these hospitals would not remain open."

"The surgeon is more than a 'hewer of flesh,' " the surgeons' association argues in court documents. "The college believes that the surgeon has a moral, ethical and legal obligation to give patients upon whom he has operated his personal attention, and to attend his patients postoperatively."

'Happening More Now'

"Itinerant medicine is essential," insists Robert T. Van Hook, executive director of the National Rural Health Assn. "Radiology, pathology, ophthalmology, cardiology--almost all the sub-specialties in internal medicine are out there and being practiced on an itinerant basis. It's happening now more than it was 10 years ago."

Because he refused to stop practicing itinerant surgery, Koefoot was suspended from the College of Surgeons in 1979 and expelled two years later. He filed suit, claiming his right to due process was violated by the disciplinary procedures. That claim is being considered by a federal judge in Chicago who presided over a seven-week trial earlier this year.

Koefoot and the family practitioners who attend to his patients also contended that the ban on itinerant surgical practices was anti-competitive, restrained trade and violated federal antitrust law. On that issue, a jury ruled against Koefoot and in favor of the College of Surgeons.

A surgeon does not have to join the American College of Surgeons. In fact, many do not belong, but membership is considered important in the medical profession.

Excluded From Directory

"The prestige of being a member of the American College of Surgeons is tremendous," Koefoot said. "That is the one surgical organization that, to me, is the most outstanding in the country. They have their yearbook, and that book is used for patient referrals. I think I have lost a tremendous amount of income because of (absence from the yearbook)."

"Certainly, within the medical community itself, physicians look at other physicians' certifications--whether they are board-certified or not--as to whether they'd want to refer a patient to them," said R. Michael Miller, vice president and general counsel of the 59,000-member American Academy of Family Physicians.

The Academy, whose members often take over the postoperative care of itinerant surgeons' patients, is helping to underwrite Koefoot's legal battle with the American College of Surgeons. The family physicians' group decided to support Koefoot because "we felt this rule regarding itinerant surgery challenged the competency of family physicians to provide competent postoperative care," Miller said.

While the controversy can be viewed as a dispute between a strong-willed country doctor and an equally strong-willed professional organization, it also highlights the growing problem of health care in rural America. In areas far from the nation's population concentrations there continues to be a shortage of doctors, particularly specialists, and hospitals are closing at an accelerated pace.

Rural Doctors Scarce

"Rural areas are losing doctors at a more rapid rate than before and replacing them at a slower rate, despite the increasing supply of doctors nationally," said Roger D. Tracy, director of community programs at the University of Iowa's College of Medicine.

"We're not Los Angeles or the Gold Coast of Chicago or Fort Lauderdale," Tracy said. "Certain things lead doctors to locate in nice climates and healthy health-market places. That makes it difficult to attract doctors to lesser-performing economies and more rural areas."

"Rural residents tend to be disproportionately elderly and disproportionately uninsured or under-insured," said Jan Shulman of the American Hospital Assn., explaining some of the realities that doctors and hospitals in the country face.

"You have a population which was largely self-employed, or small business people. They do not have the opportunity to get group health insurance the way many of us do as part of our jobs. If you're in a mining area or a farming area, probably the economics of your region are devastated at this point, and the chances are real good that if it's a choice between staying on your farm or buying insurance, you're going to stay on your farm. So a lot of people in rural areas have the bare minimum of insurance or have let their insurance lapse."

Lower Medicare Coverage

Medicare pays rural hospitals less than it pays city hospitals for the same services, according to the American Hospital Assn., and this is a contributing factor in the closing of an increasing number of rural hospitals, Shulman said.

In the last two years, country hospitals have been closing at a faster rate than urban hospitals. According to American Hospital Assn. figures, 38 of the 72 hospitals that have closed since the beginning of 1986 served rural areas.

Surgery is one way to keep these facilities alive economically, many medical authorities say. And, according to some, the only way to provide surgery is through itinerant practitioners.

"Hospitals need to fill their beds," said National Rural Health Assn. executive director Van Hook. "Itinerant medicine is essential to the rural hospitals . . . . Bringing in additional specialists helps improve the utilization of their facilities. It is critical to them."

He added: "Itinerant surgery is happening in every rural state, which probably means 35 of the states. It happens everywhere. It is not an unusual thing (but) most hospitals would be reluctant to admit they use itinerant surgeons. Even behind closed doors, they like to talk in kind of hushed tones about it, because you don't want to jeopardize your service and your surgeon has signed this little card that the college (of surgeons) puts out that says 'no, I don't practice itinerant surgery.' But they do."

"(Hospitals) could really make a contribution by acknowledging that it's happening and by trying to find ways in which it makes sense."

'Same Level of Care'

"The college has no interest in putting rural hospitals out of business or bringing surgical patients into big cities," said Douglas J. Polk, a lawyer for the surgeons group. "What the college insists upon is that rural patients receive the same level of care that city patients receive."

"The college simply doesn't want people wearing the label of the college, which insists on a certain level of care, and then not delivering that level of care," added College of Surgeons lawyer Gebhard.

St. Paul, where Koefoot still openly practices itinerant surgery, is like many rural communities. Once a flourishing agricultural area, its economy has gone from good to poor. There is no industry. Three banks in Howard County have been forced to close in the last two years, and the region's population has declined an estimated 25%. The little one-story hospital, built in 1955, replaced an old house as the community's medical center. Its surgical suite replaced a kitchen table that was used for operations.

"This hospital is the biggest industry in town. It's the biggest employer, along with the rest home, and we won't keep going without itinerant surgery," said Dr. Richard Hanisch, a general practitioner who works with Koefoot and says that "he brings in a lot of business."

"I don't understand why they think he's doing wrong," said Margaret Zocholl, a retired nurse whose husband was having a leg amputated by Koefoot. "If we can have (surgery) done here, why go to Grand Island?"

"It's quality. It's not unethical. It's not immoral," said Koefoot, "and our patients know it and their relatives know it."

[debk]

Because Bob was willing to travel to those towns and do surgery, the patients were able to remain in familiar surroundings. I remember when he was in this lawsuit against the ACS, he was furious.

Nowdays, the ex travels to those small towns to see patients, but I think his group out of GI has set up satellite offices with other specialists, in order to get around the technicalities of "itinerant" surgeons.

Coincidence...the Dr. Hanisch that is quoted at the bottom of the article? His daughter introduced the ex and I. 

[thundley4]

It seems to me that the surgeon travelling would be easier on the patients, with the added benefit of patients being near family and friends during recovery.

[franksolich]

It seems to me that the surgeon traveling would be easier on the patients, with the added benefit of patients being near family and friends during recovery.

Well, that's what I always thought, too.

And besides, the patient's main local physician is in on the surgery too, seeing what's going on, and so competent for post-surgical care and treatment.

This was a sore point forty years ago.

[debk]

It seems to me that the surgeon travelling would be easier on the patients, with the added benefit of patients being near family and friends during recovery.

It's also financially better for the patient/family. The family is able to be with the patient without having to take time away from work, or in many cases out in that area, the family farm. Also the family is not having the expense of staying in a hotel, food, and gas to get to the larger town.

I was a volunteer at UVA Hospital when the ex was doing his general surgery residency there. At night after I got off work, I would go up to the children's floor and depending on the age of the child, I would read to them or play games with them as many of them were dropped off at the hospital and their parents went back home. This was back in the late 70's, and UVA was the trauma hospital(and public) for most of the state of Virginia, outside of the DC area and from 35 miles west of Richmond. Most of all trauma or severly ill people west of Charlottesville to as far away as Roanoke came there. If the parents had jobs or other children at home, they couldn't stay with the children, and in many cases....they just couldn't afford to stay there.

I don't remember if there was a Ronald McDonald House there or not at that time, if there was it was pretty small.  We have 2 RMcH's next door to each other, because there's a big Children's Hospital here. ("big" is a relative term). They are almost always full. My office helps out there, and I have met parents who've been there a much as a year or more with their children sometimes at the house and sometimes in the hospital depending on their situation.

It's really tough for families who live in small rural communities to get good medical care, because most doctors don't want to be in the boonies for a variety of reasons. Frankly, most of them have astronomical medical school debt and they can't afford to practice in a rural area. Not only can the community not support specialists, but malpractice insurance isn't based as much on location as it's based on specialty. Depending on the specialty, their malpractice insurance can be very close whether they are in Podunk Arkansas or New York City.

One of the reasons, that many OB /GYN's quit delivering babies when they hit a certain age, is because back in the 80's, some states were allowing lawsuits to be filed against OB's up until an individual reached the age of 21. There used to be ads on the tv here by lawyers - "is your child performing well in school? developmentally? etc. etc.. if not call the law office of John Smith, you may have grounds for legal action against your OB/GYN!"

[franksolich]

Not only can the community not support specialists, but malpractice insurance isn't based as much on location as it's based on specialty. Depending on the specialty, their malpractice insurance can be very close whether they are in Podunk Arkansas or New York City.

Whoa.  I didn't know that part; I thought maybe geography had something to do with rates.

Apparently not.

One of the reasons, that many OB /GYN's quit delivering babies when they hit a certain age, is because back in the 80's, some states were allowing lawsuits to be filed against OB's up until an individual reached the age of 21. There used to be ads on the tv here by lawyers - "is your child performing well in school? developmentally? etc. etc.. if not call the law office of John Smith, you may have grounds for legal action against your OB/GYN!"

Uh huh.

[debk]

Whoa.  I didn't know that part; I thought maybe geography had something to do with rates.

The insurance company looks at how many docs have lawsuits based on a particular specialty, what the issue was, what the chances are that the same problem will happen again, etc. It's a statistical thing. There aren't that many companies that will write malpractice insurance.

My stepmother was an agent in an independent office in Illinois, and they rep'd for a company that did write medical malpractice insurance. She worked up until the day she died, almost 20 years ago, and even back then, it was particularly tough on small town docs, because they couldn't afford their insurance. Or if they could, they only took out minimal coverage.

The problem is not just incompetence in doctors for such high rates, due to the increase in lawsuits. It's the suit happy ambulance chasers who advertise on tv and who take a minimum of 1/3 of the amount received, but even more so...it's the insurance companies who are willing to pay out without much investigation on the theory that settling out of court most likely will cost less than defending the doctor and running the risk of a jury settlement and paying court costs and attorney fees.

I think I've mentioned before, the ex was sued back when we were still married. The patient not only didn't follow post-op instructions but also did not come in for follow up appointments, because he decided he didn't need to. Fortunately the ex documented everything. Patient ended up with severe complications, resulting in more surgery. He went and got a lawyer and filed a lawsuit. Malpractice company appointed lawyer meets with ex and tells him, insurance company will pay this guy x number of dollars and this will all go away, all you have to do is sign on the dotted line. Ex said no, he didn't do anything wrong and wanted to take it to court. Attorney tried to talk him out of it. Ex stayed firm. Upshot was....judge threw it out of court, no grounds for the lawsuit. If ex had signed on the dotted line, not only would his insurance have shot up like a rocket, but some guy would have gotten several hundred thousand for no reason!!!!!

Most surgery specialties - especially plastic, anaesthesia, OB/GYN... have the highest rates.

It took my parents 4 YEARS to find an attorney who would file a malpractice suit against the doctor, and the hospital, for me getting badly burned by the hot water bottle they laid me up against right after I was born.