03/22/2014 Barry Mullen, DPM
Surgical Allowance (Simon Young, DPM)
From my perspective, this boils down to,
"different strokes for different folks" and has
little bearing on reimbursement. Why generalize
and attempt to extrapolate quality with time? I'd
argue any randomly judged parameter ie. surgical
time vs given procedure, works along a bell curve.
That curve's median, along with other surgery
parameters, such as difficulty, associated medico-
legal risk, etc. is what is likely utilized to
assess reimbursement levels...at least I'd hope
so.
I'm fortunate to have trained with what I perceive
as the "BEST" surgeons our profession had to offer
in the early 80's. They all evolved from the
"father" of podiatric surgery, Dr. Earl Kaplan.
One notorious surgeon consistently performed
Austin bunionectomies in 15 minutes! He wowed
incoming residents with his speed, while his
technique rivaled those of the best attendings at
our residency program. Since I've also tutored
residents over the years, taught at NYCPM,
assisted countless other surgeons, I'd hope my
former students and colleagues validate my
clinical acumen and quality.
From that experience, I believe I harbor a keen
sense of what constitutes quality surgical
technique. My partner, who didn't train at Kern,
and consistently does excellent work, routinely
performs EPFs under 10 minutes. Regarding that
particular procedure, he's much faster and BETTER
than I. Out of curiosity, yesterday, I focused on
teaching my "student training" assistant about the
concept of assistant anticipation. I told her what
instrument I would need just before I needed it.
I used this as a lesson to demonstrate just how
efficient she could be, and how that efficiency
equates to an enhanced outcome for the surgeon and
makes her more desirable as an assistant. As she
gains experience and watches how other surgeons
perform, she'll learn their routine and anticipate
for them equally as well. So, like my residency
training, where one must become an outstanding
assistant prior to touching a scalpel i.e., never
looked away from the surgical field, I had
instrument after instrument slapped into my
awaiting palm. Result = 2 arthroplasty procedures
in 14 minutes with zero compromise in technique.
What's the point? Shorter OR time = reduced
anesthesia, wound exposure and tourniquet
utilization. Better for the patient?! Given the
same outcome, does reduced OR time equate to
enhanced quality? I think so. Does it afford
additional OR utilization equatable to greater
profit generation for that facility, or, in the
case of a residency program, allowing additional
time units for greater case loads = additional
surgery exposure for panting residents wanting to
gain as much surgical experience as possible?
Absolutely.
The bottom line is ALL surgeons differ, while a
bell curve exists relative to surgical time for
every procedure we perform. The lone CONSTANT
amongst us is we ALL took an OATH holding each of
us accountable to attempt to perform our task at
the highest level for EVERY patient we encounter,
irrespective of race, creed and socio-economic
status. If someone consistently accomplishes that
in half the time I can, without compromising
technique and quality care delivery, then all the
power to them. AND, if I were defending a surgeon
who incurred a poor outcome from what is
mistakenly perceived as a "rush" job, I'd
certainly successfully defend it by documenting
the other 99% excellent outcomes that same surgeon
achieved performing the same procedure within the
same time frame! That surgeon's past history =
his/her time NORM.
So, let's not extrapolate time with quality. One
surgeon may be witness, perhaps even mentor, to a
breed of surgeons who consistently take longer to
achieve their results. That doesn't necessarily
equate to inferiority, it simply takes them longer
to achieve similar outcomes relative to others who
might have benefited from outstanding training and
simply work more efficiently than what the former
surgeon considers, or perceives, as a surgical
time "standard." You're just a blip on a bell
curve and there is no such concept, especially
when the end result is often the same, perhaps, in
some cases, even better. One could argue that
taking too long to complete a given procedure
exposes one's patient to greater risk and
potentially poorer outcomes.
Barry Mullen, DPM, Hackettstown, NJ,
yazy630@aol.com
