December 2000 Bulletin


Write to The Editor, AAOS Bulletin, 6300 North River Road, Rosemont, Ill. 60018-4262

Ancillary services

This letter is in response to the article on ancillary services as a means of increasing practice income in the Bulletin (October 2000). Specifically, this is directed at the comments by Dr. Bert in discussing the efficiencies of having one’s own surgicenter. We have a similarly sized private practice group of 12 surgeons in a similar market and have experienced the same decreasing incomes. We too are evaluating ancillary services and I appreciate the article and Dr. Bert’s willingness to share his experience.

However, I have a hard time with the "typical day" scenario of 42 patients and seven procedures completed by 3 p.m. Doing the numbers (as HCFA or OIG is likely to do one day) leaves a fully allocated 10 minutes per patient, including those operated upon. Being of sound body and somewhat sound mind, I can see several follow-up patients easily at this pace, but cannot do new or complex patient evaluations, pre-op consults with histories and physicals, nor most operations in 10 minutes. I certainly cannot talk to a patient’s family post-op, dictate the note and see five office patients in a 25-minute turnover time. I may be missing some aspect of this "typical day" due to constraints on the article’s length, but my patients and families simply expect more time from the physician.

Without a lot of help from nurse practitioners and similar high-paid employees and two hours of evening dictation, this schedule seems untenable in the long run. If indeed it takes additional high-paid employees to manage this volume, one must consider the expense side of the practice as well as the income side to find an appropriate balance. One must also consider the patient’s perception of quality which is often linked to face time with the physician.

Jim Blasingame MD
La Jolla, Calif.

This letter is regarding the article "Ancillary Services Tap New Income" in the Bulletin (October 2000). I was particularly concerned about the comments of Jack Bert MD, regarding his example of a typical day, specifically, May 16, 2000. To paraphrase, he saw 42 patients in his clinic and completed seven outpatient surgery cases, starting at 7:30 in the morning and finishing by 3 p.m.

This would average out to just under 10 minutes per patient encounter. If we consider that the arthroscopies must have taken more than 10 minutes each, then many of the patients in his clinic were being seen for one minute or less. If this is the case, there is no way Dr. Bert is communicating well with his patients as espoused in the same issue of the Bulletin.

I consider myself an efficient physician, but there is no way I could practice effective medicine by operating that rapidly or spending so little time with my patients. Perhaps Dr. Bert is making significant use of physician extenders, which was not particularly outlined in the article. I would be interested to have Dr. Bert provide a few more specifics regarding the exact logistics of how he makes it through his day at such an ultra-efficient pace.

Steve Meadows, MD
Delray Beach, Fla.


I totally concur with the comments expressed by Drs. Blasingame and Meadows. The material presented at the Bones Society annual meeting however did not address the questions posed in their letters. In order to become a more efficient practitioner, a significant commitment both personally and professionally is necessary. Fred Taylor, who died in 1915, developed the assembly machine in the late 1800s and literally revolutionized the manufacturing process to make it significantly more efficient. He was quoted as saying that "to improve the performance of a machine it is mandatory to improve the performance of the workers that run the machine." It therefore becomes critical that the orthopaedist must improve his personal performance in order to achieve maximum efficiency. This involves learning how to focus on the patient and their chief complaint and then rapidly diagnose the patient’s condition. The orthopaedist must then delegate responsibility to "physician extenders" consisting of a strong clinical care team to complete the patient care process.

In all the highly efficient orthopaedic practices that I have visited, the orthopaedist has had a personal secretary, a physician’s assistant and a well-trained X-ray technician. The role of the secretary during the clinic is to schedule surgery, test, consults, assist in informed consent and direct the patient to the front desk to arrange follow-up appointments. He or she must also do whatever is necessary to improve patient flow. The physician assistant (PA) interviews and examines all new patients after the patient fills out an extensive patient information sheet. The PA takes out sutures, does all cast work, does steroid injections, fits braces and splints, fills out workers’ compensation forms and does whatever is necessary to improve patient flow. The X-ray technician escorts patients to the exam room and removes sutures, takes off casts and fits braces and splints in addition to his or her X-ray duties.

By delegating the care of the patient to the clinical care team, it allows the orthopaedist to focus on the patient and his chief complaint and thus reduces "physician encounter time." However, by maintaining appropriate "team encounter time," the patient will feel satisfied with their clinical experience. We have documented this conclusion by patient satisfaction surveys since initiating this technique.

I strongly believe that high quality care can be delivered in an efficient fashion with the addition of highly trained competent personnel working intimately with the orthopaedist.

Jack M. Bert, MD
St. Paul, Minn.


There is no doubt that our country and its educational process have made much progress during all of our lifetimes. Despite the progress, there are some activities that are very discouraging.

An example was illustrated in the "In the News" and "Letters" sections of the October 2000 AAOS Bulletin. On page 4, the "diversity goals" paragraph included the statement "welcoming qualified women and minorities into their residency programs." In the "Letters" section, altogether too much verbiage on the same subject appeared as authored by Drs. David Bradford, Augustus White and Raymond Pierce.

Instead of affording "women and minorities" special considerations, I suspect a majority of our citizens feel that every institution should admit students who are qualified rather than on a basis of how they look, speak or their social background. Notice that I said "students," not women or minorities, or other "special" qualifications such as red hair or post-polio handicaps.

Considering the committee’s current trend or the media’s eternal crusades on race and gender, I suppose blind or deaf participants will be on their lists in the future. As is evident, the latter considerations don’t make any sense at all. The qualifications that do make sense are those based on academics and a desire to learn and serve the people.

The failure to follow a fair admission doctrine can be illustrated on personal level. My son has enjoyed an outstanding education experience except for one instance. He has a BA in Psychology, a Masters in Counseling and a PhD in Neurobiology. His postgraduate work was in association with world renown instructors and over 25 papers under his authorship have appeared in many notable scientific journals. His application to medical schools included endorsements from an untold number of department heads and other associates from across the country.

One particular application also included letters from several members of our own family who are graduates from the school. That school also received an application from a minority PhD candidate from my son’s same program. As a fellow student, our son knew of the other applicant’s much lower qualifications and that he had only a few publications to his credit. During his interview with the admission committee, he was told that he was accepted on the spot. There were no acceptance committee meetings at a later date followed by the usual wait on an acceptance letter, as is customary. He was in the upcoming class, period.

In contrast, the same school did not even grant my son an interview. Their explanation, "they had their filled quotas." Happily, our son is now in his third year at another school and is in the top 5 percent of his class. He plans to continue his research, writing and teaching in the field of psychiatry.

Do I like quotas? What do you think? Is it fair to select someone during an interview, someone who might be less academically qualified over another? What do you think? Do I think people should be spending their time dreaming up schemes on how to better discriminate against more qualified students because they are not a female or of minority origin? What do you think? Are altogether too many people developing ultra paranoiac feelings to the extent that they can’t sit down and work out problems in a civil way? What do you think?

What ever happended to the well-known "K.I.S.S." (keep it simple stupid) theory? I assure the authors and their readers that it will work more often than not.

Charles B. Gillespie, MD
Albany, Ga.

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