From AAHKS 2016
Making the transition from residency to fellowship? Here’s some of thing things Dr. Fraser is thinking about (PS: PROS is one of them).
Dr. Brian Cunningham: Hey guys, back here live from ACS 2016 meeting. We are very fortunate today to be joined for a few minutes by one of the bright young minds in arthroplasty, Jamie Fraser, currently a fellow a the Rothman Institute. Jamie, how is that experience been like?
Dr. Jamie Frasier: The transition from Resident to Fellow has been great for me. I think just seeing a different practice pattern and specifically where I am at Rothman Institute, they have a very efficient system, forward thinking. They are twenty years ahead of, I would say, the average private practice in the states right now. Just seeing how that system can evolve and become, even if you can’t emulate it, where you might end up, right away, it is good to see that in action.
Cunningham: What do you think are some of the big differences that you have noticed, if you could pick out a couple?
Frasier: I think the true team aspect of the care delivery. It is really the system, I mean, the surgeon is a key cog in that system, but I am talking about everybody from the help in the OR’s to the help in the clinic, to people that are taking the phone calls. Things to make everybody operate at the top of their license so a mid-level provider should be doing mid-level provider things, assistants in the office should be dealing with everything that they can deal with and that trickles up the line so that a surgeon is efficient seeing patients that are surgical candidates.
Cunningham: Optimizing [crosstalk]
Cunningham: I know Dr. Bozic talks about that a lot. From a volume standpoint, how do you guys structure your OR days?
Frasier: Pretty much every surgeon at my Fellowship is two-rooms so they have a flip room and you will do between six and ten cases a day depending on the primary revision and it is efficient, so the days will end anywhere between two and six in the afternoon, with the cases. It is very efficient but not rushed at all. I was surprised to see that coming from a practice pattern in my earlier training that was lower volume, one-room kind of thing, to see that system work and not be chaotic, has been interesting.
Cunningham: That is great. Are you guys doing any same day joints at Rothman?
Frasier: Yes, they are definitely pushing the envelope and getting their feet wet starting with the easier patients, younger, healthier patients, especially the hips. Some of the surgeons are up, I guess, around 20, 30, 40% same day. The knees are a little bit slower but they are just starting to dabble in it but I am excited. I think patients can definitely do it. Again, the key is having the system so that everybody from the nurses in the PACU telling them, “Hey, this is the plan, PT is going to be here, we are going to get you out this afternoon.” Basically from the first conversation you have with the patient setting that expectation for a same day discharge, if that chain of interactions gets interrupted, it won’t happen.
Cunningham: How do you guys monitor outcomes?
Frasier: That is a good question. I do a lot of the clinical work. There is a lot of that that happens at Rothman Institute that I don’t even see. The patients do get iPads and in the clinic they will typically be entering different PRO measures. Whether they get them at home, I presume that happens to and they are dabbling with tele-medicine and instead of having a patient come all the way in, we have a lot of traveling patients so, instead of having them come all the way in, you can do that over the internet. I think that is the future but they are half way there, sort of. I think most of the data entry is on the iPad in the office.
Cunningham: What do you envision the role for PROs in your practice when you start?
Frasier: I think PROs is really A. How you play the game, moving in to the next several decades of American healthcare especially in orthopedics so I think you A. Have to do it. My anxieties about is which PROs do I use, how much is it going to cost, where do I store that data and how can I access it? I have seen a ton of different ways to do that and I still haven’t figured out what is the best way. Trying to answer your question.
Cunningham: What are your thoughts about some of the challenges as young surgeons starting out? You have never done it the old way. There hasn’t been the classic pay-per-service model. What are your thoughts on some of the challenges on reimbursement and are we going to risk-strategize? Is everybody going to get paid the same for outcome despite how sick some one is? How do you think about that as you start out?
Frasier: I think about that a lot. I think as a surgeon and some one that has spent a lot of time in training and just getting out and seeing your first patient in clinic, what you want to do is take care of that patient. You want to make the right decision for them, you want to put them in a position to succeed, and that falls back on a lot of the systems so ideally, you can get in a well run organization where a lot of that is passively done behind you so you are job as a surgeon is see a patient, make a decision, and give them a good operation but I think the surgeon needs to be involved more and more in the management of the patient and as the payment structures change, largely for the better, but the devils in the details for all these contracts. Risk adjustment is probably the biggest topic at this meeting. For the last three years running, that has been the biggest topic and patient deselection. I think in a lot of situations, patient deselection is a good thing. There are patients that shouldn’t have a total joint unless modifiable risk factors are addressed but there are some patients that you come in and there femoral head disintegrated and the best thing for them even though they are not optimized is the quicker total joint than a later one.
Cunningham: Do you think there is a component of that same process going on when you are comparing hip fracture patients to elective patients?
Frasier: For sure, yes. We just saw a couple good talks on the increased risk in the hip fracture patient. Again, this falls in to the system category. When are you doing a hip fracture patient? If that patient is triaged the next day and gets put on your joint lineup and you have your joint team there, I think that is great. I think their outcome aside from their own comorbidities would be very similar. The problem is, in addition to more comorbidities in that population, I think they get sub-optimal care. It is someone at the end of a day, maybe they have been at a different hospital or a clinic and then you are doing it at six, seven pm, with a team that doesn’t do joints. Nothing about that team approach for a hip fracture patient is the same as the rest of that bundled population. Those are unanswered questions but they are being addressed on our end and I think it is important to approach payers and say, “Hey, these are different populations that end up at the same operation.”
Cunningham: It is one of those things I think about, if you are a trauma guy, should you be doing total joints for a femoral neck fracture? I don’t know what the answer is. I know that I won’t do it as well as somebody like you that is going to do four or five hundred joints a year, but does that mean that I let somebody sit over the weekend and then try to talk to somebody on Monday? It is a tough question.
Frasier: I think the best model is what you are saying. You should do what you are good at. You should do what you do a lot of. Some places I have been are kind of like that so in my Fellowship Institution, there is a separate arthroplasty call, so any patient that needs a arthroplasty surgery, there is 24/7 seven days a week. Someone available to do that case that is specialized in arthroplasty. That is ideal, you can’t do that in most community settings because they are just not enough hands on deck. I think that is the ideal.
Cunningham: That is a great model. So, the arthroplasty call, they don’t take any of the trauma calls, bumps and bruises, septic native joints, all that stuff is the trauma person but if there is somebody that needs an arthroplasty or a prosthetic fracture, do they manage that too?
Frasier: Exactly. If it goes the ED, pari-prosthetic fracture is a good example, immediately that call goes to the arthroplasty team. If it is a vegary, it usually goes to the trauma call and then gets triaged …
Cunningham: Hard stuff, okay.
Frasier: Yes, if it is a hip fracture but if it is a neck fracture that is non-displaced, it will be pinned but it needs … [crosstalk]
Cunningham: Trauma takes care of what trauma can take care of.
Frasier: Exactly. It is not a perfect system. After hours, there are still delays based on other departments have cases going so it is never going to be perfect and that is the nature of trauma.
Cunningham: Did that system develop out of the payment pressures or was that in place before hand because it seems like a really smart thing to do for bundled payments. To have that much-qualified person doing that rather than me, with a 25% complication rate for total joints.
Frasier: It is a good question and the answer is I am not sure. I don’t know if even that is a bundled payment model although that would be a good way to bundle your hip fractures if you are going to bundle them.
Frasier: I don’t know the origin of it.
Cunningham: Fascinating. Well, I think we might be out of time. Dr. Fraser, one of the fantastic young minds in trauma, or arthroplasty. Thank you for stopping by.
Frasier: Appreciate it. Any time.