Rural General Surgery - population limitations

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acbyrd

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Ladies and Gents,

Does anyone know of research data available for assessing the physician and/or surgeon needs for communities based on population? I've made a half-hearted attempt to search for it in journals with no success.

My hometown has 7,000 in the city limits and about 21,000 in the county. We have a small hospital with about 30 beds. Currently, we have full-time ER coverage by an emergency medicine group from a nearby town. Other than that, there are 4 family physicians and 4-5 nurse practitioners in our town. We have a couple of specialists that rotate through town on a weekly basis (radiology, ortho, and we used to have a cardiologist rotating through).

Based on these numbers, do you think a GS could keep a pretty full appointment book in this county? Two of the family docs say that they could keep a GS busy. What do you think? What would it be like to be the only GS in town? We don't even have a hospitalist.

Can I get your thoughts?

Thanks!
Byrd
 
Yes, rural general surgeons are in very high demand and that is where you can get good stipends etc during residency.

This is provided the local hospital doesn't have a bad reputation. If it does that will take alot to overcome.

If the locals aren't scared of the hospital though a GS could do pretty well there.

That GS may not be you, that may be a little too close to home for you. Would the people be comfortable sending you their wives/daughters/husbands/sons? That's why it's sometimes better to go to a different small town, because if you grew up there it could be uncomfortable for you and the patients to practice there.
 
Also unless you make some arrangements for coverage, you can look forward to call q1. That wouldn't be any fun.

The more common arrangements I've seen is for smaller locales to have 2 GS's. That way they can split call q2. I'm not sure the population required to support an average general surgeon however.
 
OTD, I 'preciate your insight concerning the issue of operating on my friends / axquaintences. How would this be different from the family docs who care for those that they grew up with? I guess I know a lot of people, but I've been gone for 12 years.

I've got a contract with my hospital already. They're paying me a pretty significant sum right now during medical school. I have to go back and work a month (they didn't specify an employer or a field of medicine -- only that they want me to work in the county) for every month they pay me now.

The q1 call doesn't sound so sexy.
 
I believe that estimates are that it takes a population of 20,000 to support a general surgeon. You might find this article interesting...http://archsurg.ama-assn.org/cgi/content/full/140/1/74 check out its reference list for more relevant articles.

This is a Canadian position paper, but it also notes that you need about 15-25K in population to support a general surgeon: http://www.srpc.ca/librarydocs/surgerytraining.html

I would also be careful about listening to what FPs think you need to support yourself; there is a common belief that surgeons make a lot more money than they do. They don't generally realize that you don't get paid for post-operative care, that the reimbursement for many surgical procedures is less than what they can imagine. When you find yourself in a community doing mostly small potatoes type of work, you will have to work VERY hard to support yourself. No one is going to stay in your little town for their big fancy cancer operation, or their stuff that they think should be done at the Not So Far Away Big Name Place. Gallbladders and appendices can only come out once per patient; you might get a few repeat hernias, if you're lucky. 😉

If you can get a local hospital to guarantee you a salary, that might be feasible but very often these are not the great deals they seem to be (ie, the hospital will find a way to make money off you; if they are paying you $250K, you can bet you are billing twice or three times that amount).

Finally, IMHO there is a difference in public perception when it comes to medical and surgical management. Your former neighbors might be happy to have you rewrite their Lovastatin prescription and listen to their lungs when they have a cough, but when it comes to slicing them open, they may be a fair bit more wary about young Johnny they used to see racing his tricycle down the road.
 
Excellent advice. I think that everything ya'll said makes perfect sense. Maybe med peds is the way to go afterall!
 
I did a month of rural general surgery as a 4th year med student. I worked with a guy (the only show in town) who has a population eerily similar to what you're describing. He seemed to be doing fine for himself, and had a great relationship with the FP's in town. He operated 3 days a week, and did 2-4 cases per day. His non-emergent practice was limited to appy, chole, hernia and breast cases. He also did colonoscopies and EGD's.

The greatest thing about this guys' practice was that this town was so in need of a surgeon, they hired him to be on call M/W/F evening until 8pm, and then every other weekend only. When he wasn't on call, emergent cases got shipped to the nearest large medical center (1.5 hours away). I can count on one hand the number of emergent things he dealt with during the time I was there.

And because of the small size of the town and area of the country (midwest) cost of living was dirt cheap. Which probably makes it easier to do well on a lower salary than other, larger metropolitan areas.
 
This is a really good informative post. One question I have however is what are these stipends you speak of?

I have heard of residents recieving stipends for their Pgy3 4 and 5 year but I have yet to meet a resident or practicing physician that has recieved this. The closest thing that I have ever heard of is a physician getting his student loan taken over by a town interest free and then having to write off the interest as income.

Anyone have any relevant information on this? I am definitely going to practice in a small rural town no matter what the specialty so this is definitely interesting to me.

Thanks
 
I have one of those stipends and it comes in really handy. They pay me every month.

I am a general surgery resident and they started paying me at the beginning of 2nd year.

You will need to get a HEALTHCARE contract lawyer to go over your contract because of Stark laws etc. If you don't get one well versed in healthcare law you will end up violating something with the contract, it's a minefield basically becase Congress just can't stand doctors. You gotta be real careful how it's worded etc so it doesn't look like a "kickback" or "bribe" to get you to admit to their hospital.

It can NOT limit where you practice or who you admit to and must be simply a stipend the hospital is willing to pay to get you to practice in their community, not practice in their hospital exclusively etc. The longest they can pay you is 5 years (which for me is 4 years in residency and 1 year of assured salary).

Terms differ greatly depending on how bad they want you. You don't have to take the first offer you get and it can take a while to get things all ironed out, I started working on this my intern year and things were settled in time for the beginning of 2nd year.
 
I'm a nurse, so I really can't speak to contracts and income, but I spent two years working in a hospital smaller and more rural than you described. The surgeon was quite busy. Keep in mind, he was also frequently the OB call for cesarean sections. If you're willing to do c-sections in a small town you'll never go out of business, because people will always have babies and FPs will always need someone to do sections. 🙂

From what I recall (I spent more time in OB and less time on the Med/Surg floor, so I'm no expert in the entire scope of surgery done there) much of his business was colectomies, mastectomies, cholecystectomies and various procedures on varicose veins. This was huge--probably because of so many factory workers in the area. He was definitely on call a lot, but I would say I called him for sections far more than the ER called him for anything else. The hospital only delivered 90 babies per year, so that gives you an idea of how few night call-ins there were.

As for whether or not people transfer out, it really depends on the community. For us, the nearest higher level of care was 70 miles so people had a tendency to want things done closer to home. If the nearest hospital was closer I imagine it would have been different. One thing to keep in mind, though: some older rural hospitals are very insular. Their policies, procedures, and staff education could still be running in the dark ages.
 
acbyrd said:
Ladies and Gents,

Does anyone know of research data available for assessing the physician and/or surgeon needs for communities based on population? I've made a half-hearted attempt to search for it in journals with no success.

My hometown has 7,000 in the city limits and about 21,000 in the county. We have a small hospital with about 30 beds. Currently, we have full-time ER coverage by an emergency medicine group from a nearby town. Other than that, there are 4 family physicians and 4-5 nurse practitioners in our town. We have a couple of specialists that rotate through town on a weekly basis (radiology, ortho, and we used to have a cardiologist rotating through).

Based on these numbers, do you think a GS could keep a pretty full appointment book in this county? Two of the family docs say that they could keep a GS busy. What do you think? What would it be like to be the only GS in town? We don't even have a hospitalist.

Can I get your thoughts?

Thanks!
Byrd
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The best piece of advice I can give you is don't buy a house that is out of the range of the average home price for the city/county. The key here is the exit strategy if things go wrong.

If you move into the town of 7K and buy a $280K house, you might be able to afford it. The problem comes if you have to leave and try to sell that house. Maybe one person a generation from that town will have the money to buy it and actually want to live there. Chances are that person won't want your $280K lived in house, he will want to build one to suit his own fancy.

As soon as the hospital knows that you can't or won't leave town they will start screwing with you. Before you know it the hospital will want to become a "trauma center" and guess who gets to provide uncompensated Q1 trauma call. Right now you're saying "but I won't take uncompensated trauma call." The hospital will respond "Dr. X if you want to have privileges in our hospital you have a duty to serve the community. No trauma call = no privileges = no income for you = you have to move but you can't move and we know you can't because you bought that barn of a house. Would you prefer vaseline or KY? Astroglide is provided for an extra charge. Either way bend over now plz."

Think it won't happen to you? I've seen it happen over and over again to my former classmates and other residents from the program and also to family members. Just do yourself a favor and make sure that you are portable.
 
GSresident said:
The best piece of advice I can give you is don't buy a house that is out of the range of the average home price for the city/county. The key here is the exit strategy if things go wrong.

If you move into the town of 7K and buy a $280K house, you might be able to afford it. The problem comes if you have to leave and try to sell that house. Maybe one person a generation from that town will have the money to buy it and actually want to live there. Chances are that person won't want your $280K lived in house, he will want to build one to suit his own fancy.
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This happens SOOOOOOOOOO often. It happened to my family. We bought a house for roughly $300k. Real nice house for the money. Over 15+ years we probably invested another $50,000+. It took about 2 years to sell and we had to go down to around $345,000. Not one of the wiser investments. After inflation it was a nice little hit we took. We had doctors move in and buy houses more than ours, only to want to leave. They end up losing more money than they probably owe for med school... I am from a small-ish area. It is a fairly large hospital since it is the main provider for our county, but also several surrounding counties. We have 3 GS's and they are overloaded beyond belief. They spend 3 days a week in the OR and will do the upper limit of cases time allows from 5 a.m. till 7 p.m. or so. They make solid cash, but they certainly do their fair share to earn it.
 
GSresident said:
The best piece of advice I can give you is don't buy a house that is out of the range of the average home price for the city/county. The key here is the exit strategy if things go wrong.

This is good advice. One of my former chief's got stuck with a house in a rural community where he thought everything was going to be wonderful and it wasn't. I heard he had to take a big loss to get out.
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You guys give a lot of great insight. Thanks to those of you with actual rural GS experience. Kimberli Cox said that people in a rural community would not want me to operate on them if they knew me when I was a kid. My wife and I ate dinner with a family in town who felt that that is not true. This guy's brother-in-law is a GI guy, and he has done scopes on him. He said it wasn't akward at all because he knew that the GI was a professional. They thought that surgery in your own home town would not be such a problem.

What do you do about anesthesiology in a small town? We DEFINITELY can't afford a full time anesthesiologist. Do you just get one to rotate through on OR days?
 
Countryboy75, I went to my little hospital before I even got accepted into medical school. At that time, they still had enough faith in me to put me on a stipend. I'm getting 1800/mo now. They said they would do it for no more than 7 years (which is plenty of time, and I can always renegotiate). They said in writing that I was not required to admit patients to their hospital. They said all they want is for me to practice medicine (any specialty) in our town. I have a 1:1 payback schedule.

Yes, I did get a lawyer to review it, but he was just a general practice lawyer. He still seemed to be knowledgeable about the laws.

My wife isn't crazy about moving back to my small town, but she doesn't mind the checks coming in every month from them! We also can repay the stipend at 8% if something changes. However, they told me that they would not give me the stipend only to make money off the interest. They just want me to come back.
 
Percival said:
You guys give a lot of great insight. Thanks to those of you with actual rural GS experience. Kimberli Cox said that people in a rural community would not want me to operate on them if they knew me when I was a kid.
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Actually I did not say that.

The OP asked if there was a problem being a physician in a small town where one had grown up. I said that there *might* be and that it could perhaps be more difficult as a surgeon than a PCP. This was not meant to imply that this was an absolute.

My wife and I ate dinner with a family in town who felt that that is not true. This guy's brother-in-law is a GI guy, and he has done scopes on him. He said it wasn't akward at all because he knew that the GI was a professional. They thought that surgery in your own home town would not be such a problem.
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I'm sorry, but there is a hell of a lot of difference between doing scopes and actually cutting someone open, and the general public recognizes that. I don't think you can compare the two. That said, you probably won't have a problem but given the fact that almost everyone who returns to their community to practice or stays in the hospital where they did residency states that there was some problem, makes me believe that ignoring the possibility is unwise.

At any rate, my experience or that of the family you know is not to be taken as gold; YMMV.
 
Thanks for all the replies both PM and on the board,

I think once I get my MD in about a year and a half I will start looking more into the stipend thing. Perhaps I will also start looking into loan repayment as I will be 250k in debt. Hopefully Hillary and/or Obama's socialized medicine plan won't put me in the poor house...which in my neck of the woods is called a trailer park.

In response to the idea of working in your own hometown however, I have found that for me this is not an option. I have been discovering this over the last year or so.

For me it started when my grandmother had a morphine pump put in for chronic and severe pain and two days after the pump was put in she developed "a burnin sensation in my belly and a rash all over ma body". So my grandfather calls me at 2 a.m. because he is afraid to bother the doctor (trust me these are old rural folks) and asks me what I think is going on and I tell them to go to the E.R. since it sounds like an allergic reaction to the morphine pump. So they go to the ER, they give her a shot of Kenalog and put her on 50 mg of diphenhydramine. She gets better, until the diphenhydramine runs out and then the rash and burning sensation reappears. So I get another call from grandpa and I tell him to give her a benadryl before going to bed and get an appointment for the next day to see her pain specialist and tell him about the reaction she was having.

No big deal right?? Well then my uncles call a family meeting about this because grandpa called me for medical advice and reams me out in front of all my aunts and uncles without me even being there.

Pretty disheartening when your own family does not trust you.

Now granted I am still only an M3 but to me this is not exactly out of my scope of practice, in fact this IS in my scope of practice as I am an EMT in my town and I would have done the same thing if I was called to their house in an ambulance.


My family also gets remarks like "HE is going to be a doctor? That kid who used to deliver my paper/ detail my car/ hang my kitchen cabinets/ take care of my grandma at the home? ALREADY???

I talked about this with my parents as they pretty much thought I would practice I this town. And I tend to agree with my mother when she says " a profit has no honor in his homeland"
 
countryboy75 said:
Perhaps I will also start looking into loan repayment as I will be 250k in debt. Hopefully Hillary and/or Obama's socialized medicine plan won't put me in the poor house...which in my neck of the woods is called a trailer park.
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There will be either socialized medicine or continued drops in reimbursement for things that people need. For some reason, the idiots in this country got it in their heads that need = right at least when it comes to healthcare. If I were you I would buy a trailer because you'll already be paying for a 250K house.

Whenever someone pipes off about wanting socialized medicine I say "I can't wait for socialized medicine because they will never socialize cosmetic surgery. This means I won't have to pay my office workers health benefits. Less overhead means higher profits for me." You should see the looks on their faces. If the conversation goes any further I ask them what they think Ford, GM, and Wal Mart will do with the extra money they have left over when they don't have to pay health benefits anymore. Give it to the poor? Who knows what the practical result of all this mess will be but it is a good way to get people thinking about it.

No big deal right?? Well then my uncles call a family meeting about this because grandpa called me for medical advice and reams me out in front of all my aunts and uncles without me even being there.
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By the time you are done with your surgery residency you'll be considerably older. If you are any good you will develop a presence (for lack of a better word) and very very very few people will mess with you after that. Go where you want to but just don't buy a house more than 10K over the average home value for the area.
 
Fellas, I'm TOTALLY against socialized medicine. I tend to take the side of smaller government and fewer regulations on any given political issue.

HOWEVER, I do believe (trying to be optomistic) that if they reduce doctor reimbursements too much, people won't go to medical school, and the nation will have a crisis. Unless they plan on fully socializing the entire government and MANDATING that the smartest kids go to medical school, they're going to have to keep reimbursements protected somewhat. What I'm saying is that things will correct themselves in the long run. Doctors will always make good money. They may not always make half a million, but they will always make good money.

By the way, I don't think we're on the brink of socialized healthcare. If anything, we're on the brink of mandatory health insurance. That's my 2 cents.
 
By the way countryboy, your concerns I think have more to do with providing healthcare for your family more than they do practicing in your home town. On another thread, people said that it is generally NOT a good idea to provide healthcare for your family within reason (if they have something obvious like a UTI or the flu, or poison ivy [my personal soft spot], then they said it was OK).

You (like me) have quite a long time before you're ready to move back, so things may have changed and their opinion of you may have improved by then. Hang in there.
 
I'm a radiologist in a rural critical access hospital. We have 25 beds (+ some 'observation stretchers) and a regular medical staff of about 16 (10FP, 3IM, 2GS, 1rad) and some orthopods, opthos, GI and uros that come on a monthly basis. The town has about 1800 locals but the hospital serves a rural catchment area of about 25k year around (60k in summer).
Our 2 GS run very different practices. One is a maniac with a very busy bariatric practice and is probably atypical for a community this size. The other one is a classic small-town surgeon who limits his elective cases on anything that doesn't have a potential to get him called back at night. He does plenty of colonoscopies, EGDs, breast work, central lines, ports, hernias, lap-choles ingrown toe-nails etc.

It is actually the small fry that seems to make the best money in GS. That big tumor operation that costs you hours to do and ties you up for hours in follow-up pays less than if you had spent the same time removing ingrown toe-nails (derms have figured that one out, freeze a wart here and shave a mole there and you can make that next boat payment).

A problem in rural communities is the high proportion of 'goverment work' and plain unpaid. Being a ranch-hand doesn't pay so well, so you are likely to see plenty of self-pay and most of the kids on medicaid or SCHIP.

I second the recommendation not to buy a big-azz house. It will be a millstone around your neck if that great opportunity doesn't turn out to be so great. I suggest not to buy a house at all if you can help it for the first year or two. If you go out on your own (e.g. with a recruitment loan from the hospital), your first years taxable income won't be that high and the tax benefit is low. After a year or two you will be able to tell whether this is a long-term proposition and by then you will have a good idea about where to build and who to hire (chances are, all the local builders or tradespeople had 'work done' by you at that point).

By the way. If you are a department of one, JCAHO doesn't require the hospital to put you on-call or to provide call coverage. While it would be your best business interest to be available, you can legally arrange your practice in a way that you are not on-call q1. Oh, and don't think call is the same as at your academic teaching institutions. In the community, nursing actually has the capability to follow orders, take phone orders and discern the important from the stuff that doesn't need immediate attention. At least in our situation, an after-hours appy doesn't come to the surgeons attention until CT and bloodwork are done, an admission H&P has been entered in the chart by the on-call FP and the OR staff is on their way in.

If you contemplate this, make sure the hospital has the OR facilities, equipment and staffing you need to get your job done. If not, get a budget and a staffing committment put into your recruitment contract. I am not a surgeon, but if that 30 year old monopolar cautery they have rusting away there is not sufficient, you don't want to have to argue with the hospital CEO on whether they can get it in the budget 4 or 5 years from now.

The service area you are describing sounds a bit smallish to support a GS. There might be other hospitals in the area that need GS coverage. In our area, we have some surgeons who do itinerant work. It is a bit scary because you have to enter into follow-up agreements with the local PCPs and you won't be able to do anything substantial if you know you will be 80 miles away at 10 pm when the patient hits the ER bleeding. So this kind of work has be very limited to the cheap and cheerful stuff. One of our GS goes to a smaller place and cranks out a day of colonoscopies and breast biopsies every other week.

Oh, and make sure you know whose turf you are infringing upon. The surgeon one town over might be quite happy about the referral stream he gets from this community. Also, the local docs have an established referral pattern, don't expect that just because you are there, people will automatically refer to you.
 
Percival said:
Countryboy75, I went to my little hospital before I even got accepted into medical school. At that time, they still had enough faith in me to put me on a stipend. I'm getting 1800/mo now. They said they would do it for no more than 7 years (which is plenty of time, and I can always renegotiate). They said in writing that I was not required to admit patients to their hospital. They said all they want is for me to practice medicine (any specialty) in our town. I have a 1:1 payback schedule.

Yes, I did get a lawyer to review it, but he was just a general practice lawyer. He still seemed to be knowledgeable about the laws.

My wife isn't crazy about moving back to my small town, but she doesn't mind the checks coming in every month from them! We also can repay the stipend at 8% if something changes. However, they told me that they would not give me the stipend only to make money off the interest. They just want me to come back.
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Percivil, you might want to have someone well versed in the "anti kickback" law go over your contract. It's way complicated. Bottom line is the general lawyer that wrote my origional contract didn't know all the ins and outs of the "stark" (I think) law and had us violating several provisions. The worst part is this was the HOSPITALS lawyer who I thought would know. Yes, it's that complicated.

The lawyer I ended up using (and the hospital gladly paid for because their lawyer had such a dangerous contract) basically contacted the AG of the US about it, and all he does is physician law. 5 years is the longest a hospital can pay, and that had to go to court to be OK'd. Their reasoning is becasue that is the length of a GS residency. There were also limitations on total amount (had to be within so much of how much they would spend recruiting a liscensed physician to the hospital if they didn't pay you to come etc) and meeting criteria for medically underserved. Seems congress had a huge bee in it's bonnett when it wrote this making it very difficult to have a prepractice contract without it being considered bribery. Pay you too long, violation, pay you more than the cost of a headhunter agency to get them a practicing physician, violation. Even the wording has to be so so or it's a violation.

That said, it's so convoluted that it may be different for a med student than a resident so you may just be OK.

Of course even if your contract does violate STARK laws unless they have a reason to come looking at you or the hospital they probably would never know you or it exists so you are likely still OK.😀
 
countryboy75 said:
Thanks for all the replies both PM and on the board,

I think once I get my MD in about a year and a half I will start looking more into the stipend thing. Perhaps I will also start looking into loan repayment as I will be 250k in debt. Hopefully Hillary and/or Obama's socialized medicine plan won't put me in the poor house...which in my neck of the woods is called a trailer park.

In response to the idea of working in your own hometown however, I have found that for me this is not an option. I have been discovering this over the last year or so.

For me it started when my grandmother had a morphine pump put in for chronic and severe pain and two days after the pump was put in she developed "a burnin sensation in my belly and a rash all over ma body". So my grandfather calls me at 2 a.m. because he is afraid to bother the doctor (trust me these are old rural folks) and asks me what I think is going on and I tell them to go to the E.R. since it sounds like an allergic reaction to the morphine pump. So they go to the ER, they give her a shot of Kenalog and put her on 50 mg of diphenhydramine. She gets better, until the diphenhydramine runs out and then the rash and burning sensation reappears. So I get another call from grandpa and I tell him to give her a benadryl before going to bed and get an appointment for the next day to see her pain specialist and tell him about the reaction she was having.

No big deal right?? Well then my uncles call a family meeting about this because grandpa called me for medical advice and reams me out in front of all my aunts and uncles without me even being there.

Pretty disheartening when your own family does not trust you.

Now granted I am still only an M3 but to me this is not exactly out of my scope of practice, in fact this IS in my scope of practice as I am an EMT in my town and I would have done the same thing if I was called to their house in an ambulance.


My family also gets remarks like “HE is going to be a doctor? That kid who used to deliver my paper/ detail my car/ hang my kitchen cabinets/ take care of my grandma at the home? ALREADY???

I talked about this with my parents as they pretty much thought I would practice I this town. And I tend to agree with my mother when she says “ a profit has no honor in his homeland”
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That sucks man.
 
Very interesting thread

There will be either socialized medicine or continued drops in reimbursement for things that people need. For some reason, the idiots in this country got it in their heads that need = right at least when it comes to healthcare. If I were you I would buy a trailer because you'll already be paying for a 250K house.

Whenever someone pipes off about wanting socialized medicine I say "I can't wait for socialized medicine because they will never socialize cosmetic surgery. This means I won't have to pay my office workers health benefits. Less overhead means higher profits for me." You should see the looks on their faces. If the conversation goes any further I ask them what they think Ford, GM, and Wal Mart will do with the extra money they have left over when they don't have to pay health benefits anymore. Give it to the poor? Who knows what the practical result of all this mess will be but it is a good way to get people thinking about it.
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I am eternally frustrated by the continued talk of socialized medicine. People have no problem accepting that they must pay car insurance or their cable bill or their electricity bill, however, when it comes to healthcare, everyone seems offended that they should be expected to pay for this. People will pay $200 to get their hair done, but then bitch about the co-pay they had to pay for their ER visit/doctor visit.

The american public really needs to be informed about how socialized medicine really works. They need to recognize that their mother/father will have to wait 6yrs to get their hips replaces, won't be allowed to have transplants after age 60, etc.

The problem with Americans is that they want everything. They want free healthcare for everyone, but then they want every possible procedure/test done when it comes to them/their family members.

HOWEVER, I do believe (trying to be optomistic) that if they reduce doctor reimbursements too much, people won't go to medical school, and the nation will have a crisis. Unless they plan on fully socializing the entire government and MANDATING that the smartest kids go to medical school, they're going to have to keep reimbursements protected somewhat. What I'm saying is that things will correct themselves in the long run. Doctors will always make good money. They may not always make half a million, but they will always make good money.
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I think you are being too optimistic. It does not take very long to make a sweeping policy change (ie institution of social security by FDR). Changing that policy back once it becomes institutionalized or fixing any flaws in that policy takes decades. If clinton or obama institute their brands of socialized medicine, it will take decades to fix what they set in place
 
Dr. V said:
Percivil, you might want to have someone well versed in the "anti kickback" law go over your contract. It's way complicated. Bottom line is the general lawyer that wrote my origional contract didn't know all the ins and outs of the "stark" (I think) law and had us violating several provisions. The worst part is this was the HOSPITALS lawyer who I thought would know. Yes, it's that complicated.
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There are basically two laws that these contracts have to stay clear of:

1. the anti-kickback provision: No recipient of medicare 'assignments' is allowed to pay another entity money to entice them to refer patients to him. In this case, the contract has to be written in a way that it doesn't creat an obligation for YOU to refer patients to the hospital (now, in rural communities a smart goverment lawyer could argue that you can't really send them anywhere else and hence any languange in the contract that rules out such an obligation is moot).
The main exemption to this law is that transactions between physicians and hospitals that are done at 'market rate pricing' are exempted. (E.g. if you rent a scope from the hospital once a week to do rectosigmoidoscopies in your practice and your and the hospitals accountant and some consultant have negotiated a 'fair' price for this service, you don't violate this provision). This is where the language about it not being more than a recruiter would charge for dragging a corpse into town comes from.

2. the Stark I and Stark II laws: No provider is allowed to refer patients to an entity in which he owns a financial interest and which generates income for him (e.g. in the form of that 1099 that the hospital sends you every year for the portion of the loan that has been forgiven).
This law has more holes and exemptions than any other law I am aware of. Again, there are 'safe havens' for transactions done at 'market rate' etc.

So, every contract regarding a recruitment and retention incentive has to be reviewed by an attorney familiar with those contracts. If you and the hospital violate any of these laws and it comes up during a medicare audit of the hospital or your practice, either of you run the risk of being excluded from medicare for a while. If you think a malpractice verdict or DUI is a black mark on your CV, exclusion from medicare makes you near unemployable. Oh, one other way for the feds to find out about it would be one of your local colleagues who is unhappy about your competition to tip them off.
 
f_w, you give great advice. Your area is clearly more rural than mine. Our town is 2-3x larger. However we don't have NEAR the MD coverage that you have. I wonder why that is...

I appreciate guys like you who share their practical experience in a positive way. So many doctors are bitter these days.
 
What do you do about anesthesiology in a small town? We DEFINITELY can't afford a full time anesthesiologist. Do you just get one to rotate through on OR days?[/quote]

You'll probably have a CRNA giving anesthesia under your supervision (with all the liablility on your shoulders, I might add).
 
Percival said:
f_w, you give great advice. Your area is clearly more rural than mine. Our town is 2-3x larger. However we don't have NEAR the MD coverage that you have. I wonder why that is...
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One reason is that we have a branch of a large multispecialty clinic in town. They are willing to subisidize this operation to some extent to generate referral business for their specialists.
 
gudog said:
You'll probably have a CRNA giving anesthesia under your supervision (with all the liablility on your shoulders, I might add).
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We have an independent group of CRNAs who practice to my knowledge under the 'general supervision' of an anesthesiologist whom they have contracted with.
 
f_w said:
We have an independent group of CRNAs who practice to my knowledge under the 'general supervision' of an anesthesiologist whom they have contracted with.
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The particulars vary from state to state, but where I am, a CRNA must be directly "supervised" by an MD.

This does not have to be an anesthesiologist.

Which means, in the absence of an anesthesiologist, the operating surgeon is "supervising" the CRNA. Supervision = liability, in my opinion.

I have not had the guts to put myself in this situation, and I hope I never will.
 
I am a general surgeon in a town of about 10,000 with a referral area of about 35,000. the situation that you described in your first posting sounds that it would be a good place for a surgeon or even two. right now, without a surgeon in the hospital, there are a lot of patients that are leaving town. once a surgical practice is established (2-3 years) then the total volume of the hospital and the PCP's in the area will also increase. if you are sure that you want to do this, then start working with the hospital now to continue the support to do the necessary modifications to the existing hospital to support you. as for the family comments, there is no way to get around that. my older sisters still look at me as their younger brother etc... some things will never change.

best of luck
 
rural surgeon said:
once a surgical practice is established (2-3 years) then the total volume of the hospital and the PCP's in the area will also increase.
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A busy surgical practice generates lots of 'spinoff' business for the hospital and the PCPs in town. One of the strengths of our little operation here is the presence of our surgeons who order plenty of tests and bind patients to the local community for their general medical care.
 
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