PCT6TH Posted August 30, 2015 Report Share Posted August 30, 2015 I always hear that OR time is tight but I really don't understand how it works. Let's suppose Dr.X is a fresh graduate of a surgical residency program ........ and let's say that it is ophthalmology. Dr.X has managed to find work in a clinic. Today a patient came in to Dr.X and was diagnosed with cataract. The patient needs to undergo a surgical procedure and would like Dr.X to perform his operation. Now can someone explain to me what happens after that ? Why can't Dr.X perform the operation on his patient ? Link to comment Share on other sites More sharing options...
Fresh fry Posted August 30, 2015 Report Share Posted August 30, 2015 I'm not a 100% sure what you are asking but I will try to answer what I think you are after. A surgeon does not join a clinic they get privileges in a hospital and OR time which is usually allotted by seniority. A busy senior surgeon may get 2 days a week where as a junior surgeon may get a day every 2 weeks or two half days a week, it all varies depending on where they are practicing and how many other surgeons they have. The clinic the surgeon works at or the "practice" they belong too may have a certain share of the OR time and dish it out or the hospital might do this through a coordinator when multiple surgical practices share OR time. Unfortunately there is no one-size-fits-all answer because it is different every where you go. A surgeon who belongs to a practice will take direct referrals or will be on the clinic list to take the next generic referral that comes in to the clinic. Sometimes they divvy up the generic consults by weeks or by who has the most open schedules but generally new surgeons who have a general scope of practice will get the less desirable cases by generic referral. That all changes if the new surgeon is specialized or has a fellowship with a unique skill set because they generally take on the cases that they have special training for. There is so much politics to this to get into on one post. A surgeon then has to triage their referrals, who can wait for a first visit and who needs emergent surgery. This is why it is important for family docs to write a good referral if they want their patients seen quickly. The surgeon will then slot people into his OR schedule after the initial consult visit. Depending on how much OR time they have this could be right away or it could be way down the road. Most surgeons will also make their schedule to try and fill a full day in the OR. They don't book multiple major cases unless they are very efficient as OR times are very strictly controlled for staffing/nursing/anesthesia issues. For instance, if you book 5 cases and only have 3 done by 2 pm they will just cancel your last 2 and patients really hate that. A new surgeon will usually book 1 or 2 major cases for the morning and then a few small quick cases for after. Emergent cases get handled by whoever is on call and there is a waitlist that the on call doc will pick away at. This is very political too as some sites have dedicated ORs for certain specialties and others just have a general OR that every specialty has to fight to get access too, you do not want to be the OR coordinator between two dueling surgeons. In short, for non-emergent cases, a patient will be referred to a surgeon. The surgeon will receive the consult and triage for the first visit and assessment after which they will book someone in their OR when time is available and the person actually could benefit from surgery. Surgeons will on occasion refer cases to other surgeons, usually in the same practice if that person has more available OR time and the wait is very long, but there are many facets to this that I won't go into now. Hope that helps. Link to comment Share on other sites More sharing options...
rmorelan Posted August 30, 2015 Report Share Posted August 30, 2015 related to all of that - you have to actually GET privileges at the hospital - you cannot just open a clinic anywhere and say to the local hospital ok here I am I want OR time etc. They will say no - we already have enough surgeons and our OR time is filled. The hospital and the underlying surgical group there have all the power basically. You won't get access to anything at all unless they want you to. When budgets are tight - like they are now - there is a lot of reason NOT extend privileges to anyone new. Remember with OR procedures the surgeon makes the money when the operation is done but the hospital LOSES money paying for everything etc. So the next step post graduating is to try to find a hospital that will do exactly that - find some place to grant you privileges and therefore OR time. That in many fields is the struggle - and without it you are sitting on the side lines, unlikely you would even open a clinic for that matter as you cannot do anything ultimately to help the patients if surgery is required ha. Link to comment Share on other sites More sharing options...
PCT6TH Posted August 31, 2015 Author Report Share Posted August 31, 2015 related to all of that - you have to actually GET privileges at the hospital - you cannot just open a clinic anywhere and say to the local hospital ok here I am I want OR time etc. They will say no - we already have enough surgeons and our OR time is filled. The hospital and the underlying surgical group there have all the power basically. You won't get access to anything at all unless they want you to. When budgets are tight - like they are now - there is a lot of reason NOT extend privileges to anyone new. Remember with OR procedures the surgeon makes the money when the operation is done but the hospital LOSES money paying for everything etc. So the next step post graduating is to try to find a hospital that will do exactly that - find some place to grant you privileges and therefore OR time. That in many fields is the struggle - and without it you are sitting on the side lines, unlikely you would even open a clinic for that matter as you cannot do anything ultimately to help the patients if surgery is required ha. Thank you rmorelan .......... I thought that I can just talk to the hospital to arrange an OR whenever I needed to perform a surgery. Apparently this is not the case. But then the real question is: what decides who gets privileges ? Just seniority ? But doesn't that mean that all new surgeons will not have any OR time ? What is the point of a surgical residency if at the end of the day I can't even perform a surgery ? What happens if I finish my program and then go on for a year or so trying to find a job ? Even if I do manage to find a job at the end, I would have already lost a great deal of my surgical skills due to lack of training !!! Who made up this system and how can we change it ? Link to comment Share on other sites More sharing options...
dh79 Posted August 31, 2015 Report Share Posted August 31, 2015 Thank you rmorelan .......... I thought that I can just talk to the hospital to arrange an OR whenever I needed to perform a surgery. Apparently this is not the case. But then the real question is: what decides who gets privileges ? Just seniority ? But doesn't that mean that all new surgeons will not have any OR time ? What is the point of a surgical residency if at the end of the day I can't even perform a surgery ? What happens if I finish my program and then go on for a year or so trying to find a job ? Even if I do manage to find a job at the end, I would have already lost a great deal of my surgical skills due to lack of training !!! Who made up this system and how can we change it ? Surgery is done for the benefit of the patients, not the surgeons. Generally, when there is a need, the OR's become available. There are lots of junior surgeons operating a lot. It all depends on the need which then drives the required manpower and hiring. Link to comment Share on other sites More sharing options...
GrouchoMarx Posted August 31, 2015 Report Share Posted August 31, 2015 Responses to need are delayed and over or undercorrect by the time the response is finished. The future rarely matches predictions. It is hard to predict need. The system exists to maintain itself within its framework. ORs are expensive. Expanding them will cause reductions in funding to other parts of the hospitals including administration. Allowing private ORs will challenge the national system and is prohibited. I foresee another 'brain drain' if only to allow surgeons to work. Skill atrophy is real and not working causes this. Link to comment Share on other sites More sharing options...
PCT6TH Posted August 31, 2015 Author Report Share Posted August 31, 2015 Does the same problem exist in the US ? Link to comment Share on other sites More sharing options...
GrouchoMarx Posted August 31, 2015 Report Share Posted August 31, 2015 Does the same problem exist in the US ? No, to the best of my knowledge. Their system is profit based so surgeons bring in patients and thus profit to hospitals. Hospitals build more ORs to get more surgeons to have more referrals brought in. Hospitals like this because they charge facility fees (that are usually far too pricey to begin withn but thats another discussion). Canada sees surgeons and ORs as cost centers due to the central planning nature of our system. There is a pie and each patient care procedure cuts a piece of out of it. ORs will not expand until the voter base is affected enough to put up a fuss. Then we will see new hips and knees for all. Plus I have not seen or heard of patients being harmed by a lack of urgent surgical care. The govt overcorrected for surgeons years ago and now we have a surplus. I think this is mainly in elective surgeries where there are issues however. Link to comment Share on other sites More sharing options...
PCT6TH Posted August 31, 2015 Author Report Share Posted August 31, 2015 Can you tell me more about the US system please ? How is it profit based ? Does this mean they have no heath insurance like us ? People just walk in to a hospital & pay for whatever they need ? Link to comment Share on other sites More sharing options...
jnuts Posted December 30, 2015 Report Share Posted December 30, 2015 The significant difference in the US is that hospitals can bill insurance companies for peri-operative costs at whatever rate they decide to bill. For example, when a patient needs an appendectomy the hospital will bill the insurance company for everything. Each disposable laparoscopic port, every 15 minutes of OR nursing time, every single single-use syringe, and cleaning costs for every single item of linen, will get itemized and billed to the patient directly by the hospital. Often this bill goes directly to the patient who is left to fight with the insurance company themselves about what is and isn't covered; occasionally it goes to the insurer directly if hospitals think the given insurer will pay them with a minimum of fuss. Though this is a gross over simplification ignoring pre-existing bundled payments, 'network' arrangements or HMOs, and medicare/Medicaid; you can see how hospitals are generally free to price their ORs at a level that maintains profitability (or organizational cost-neutrality for not-for-profit hospitals). If a surgeon wants to book a case the hospital tends to look at it as an opportunity to make money because they bill everything back to the patient who can then get that money back from their private insurer. Funding for hospitals in Canada (specifically Ontario where I'm most familiar) is dramatically different. Until 2012 100% of the funding for each hospital came from the Ministry of Health in the form of a global operating budget. The amount of this budget was mostly based on how much the hospital received the previous year and has nothing to do with the number of patients treated, type of patients treated, or specific procedures performed. Once the global budget amount got to the hospital, the hospital was free to allocate the funds as it sees fit provided they meet their contractual service requirements with the government. In this system hospitals will do whatever they can to avoid spending money in operating rooms. The hospital agreements with the Ministry of Health mostly require specific emergency services. For example, Hospital X is required to have 24-hour general surgery services. In order to recruit and maintain that service a hospital will have to recruit general surgeons and what they have to offer is elective operative time. In the vast majority of cases hospitals do not pay surgeons directly but they offer them the opportunity to make money by giving them clinic space and services and elective OR time that they can use to see and treat patients and bill the provincial insurer directly for those services. Operating rooms are very expensive for the hospital to run; the cost is estimated at $70-$100/minute or $72 000/12 hour day). All of that money goes to the nursing, healthcare-aid, facility, and equipment costs (including implants). The surgeon, physician surgical assistant, and anesthetist bill the provincial insurer directly and are not included in this figure (or the estimates in the links provided below). Residents probably are but we get paid less than $7/hour so who really cares. Hospital budget committees will compare the cost to run an OR with the cost of a general ward bed at $150-300/day and an ICU bed at $5 000-$10 000/day and obviously view the surgical service as a place to cut back. In the operating room you can also claw back hours or types of procedures to make incremental budget gains. You can't do that with a ward bed that's either open or closed. Obviously, the operating room is a very tempting and unique target to make gains when the budget is tight. Once a surgeon enters into a contract to provide call services with the hospital, there is constant pressure on surgeons to minimize the number of elective cases they perform. Operating rooms run from 8-3PM most weekdays and then shut down. The ideal hospital in this system is one that can promise that it can do everything, but actually performs no surgeries. In Ontario this is a recognized problem for the government. There is pressure from the electorate that surgical wait times for elective procedures are too long (which obviously is the result of the funding mechanism above). Cancer cases--which get a lot of scrutiny on wait times--were the first to get funded outside of the global funding system. I have no idea how it specifically works but the result is that there’s a separate funding mechanism for operative cancer cases and there are no delays getting these cases to the OR (there are delays getting these patients into clinic). The Ontario government in 2012 stated that it wants to drop the 100% global operating budget model to 30-40% with the rest based of patient types and volumes treated by the hospital. They started this process with cataracts, hip, and knee replacements a few years ago. The idea was that instead of the operating room, staff, post-operative care and implant costs being funded from the global hospital operating budget, that the whole procedure would be packaged and the hospital could bill the government directly for the average cost (minus 10%) of the whole procedure. The decrease of 10% was to incentivize efficiency such that hospitals with lower real costs could turn a small profit on these procedures and do more procedures while inefficient hospitals would be doing them at a loss and do fewer. We’ll see how this plays out but in the first few years the capped funding for these procedures has run out well before the end of each year and the hospitals stop doing them for weeks to months at the end of every quarter. Personally, I’m not too optimistic that the new funding model will work any better. If you keep expanding it the end result is trying to centrally plan a dysfunctional economy that has a GDP larger than most provinces. I think it’s a bad idea. No matter what funding model you use, you can’t escape the reality that healthcare costs at their current level (let alone with projected growth) are an unsustainable economic drain to either a public or private system. Neither system naturally accommodates the health value of a given procedure. Neither system has expenditures track health outcomes or patient-health-dollars. Most elective operative procedures we still do are better modeled as a form of prophylaxis than an acute intervention but are routinely delayed to meet quarterly global budgets. The bottom line as it pertains to surgeons looking for jobs is that the old system still prevails. Hospitals employ surgeons to meet their contractual obligations with the Ministry of Health to provide mostly urgent services. All of the newly employed surgeons I've seen in residency have been selected to meet call obligations (and their subspecialty interests selected to not compete with established local surgeons). Elective operating room time is granted begrudgingly and in as small an amount as possible to meet these goals. The more surgeons floating around looking for jobs the less time the hospital needs to offer you. Here are some more fun resources if you'd like to read more: http://www.auditor.on.ca/en/reports_en/en09/409en09.pdf http://ether.stanford.edu/asc/documents/management2.pdf http://www.ncbi.nlm.nih.gov/pubmed/15942342 http://www.health.gov.on.ca/en/pro/programs/ecfa/funding/hs_funding.aspx https://www.oha.com/CurrentIssues/keyinitiatives/PhysicianandProfessionalIssues/QPSGT/Documents/Module%201%20-%201.3%20(Mar%2025%202013).pdf http://www.drdh.org/Documents/4_MOHLTC_Patient_Based_Funding_Overview.pdf Link to comment Share on other sites More sharing options...
JohnGrisham Posted December 30, 2015 Report Share Posted December 30, 2015 Can you tell me more about the US system please ? How is it profit based ? Does this mean they have no heath insurance like us ? People just walk in to a hospital & pay for whatever they need ? You'd be best served to look this up yourself...though jnuts provides a great primer Link to comment Share on other sites More sharing options...
FeministKilljoy Posted December 31, 2015 Report Share Posted December 31, 2015 My husband is doing his second surgical fellowship in the US. The patients are at the mercy of their insurance companies and the docs need to word their dictations and prescriptions properly so that their meds/procedure/hospital stay gets covered. The insurance companies are always looking for a way out of paying for things. Re: finding OR time. A lot of new surgeons, including my husband, can't find any in Canada. He's looking to start working this summer and is having no luck. 11 years of studying and sacrifice and over 170k of debt to become an OR assist... The struggle is real, yo. Link to comment Share on other sites More sharing options...
JohnGrisham Posted December 31, 2015 Report Share Posted December 31, 2015 My husband is doing his second surgical fellowship in the US. The patients are at the mercy of their insurance companies and the docs need to word their dictations and prescriptions properly so that their meds/procedure/hospital stay gets covered. The insurance companies are always looking for a way out of paying for things. Re: finding OR time. A lot of new surgeons, including my husband, can't find any in Canada. He's looking to start working this summer and is having no luck. 11 years of studying and sacrifice and over 170k of debt to become an OR assist... The struggle is real, yo. Thats tough, though I'm surprised only 170k debt! at least the fellowship pay(I assume it is at a level greater than or equal to r5 wages?) benefits from the U.S.:CAD conversion! Link to comment Share on other sites More sharing options...
GrouchoMarx Posted December 31, 2015 Report Share Posted December 31, 2015 My husband is doing his second surgical fellowship in the US. The patients are at the mercy of their insurance companies and the docs need to word their dictations and prescriptions properly so that their meds/procedure/hospital stay gets covered. The insurance companies are always looking for a way out of paying for things. Re: finding OR time. A lot of new surgeons, including my husband, can't find any in Canada. He's looking to start working this summer and is having no luck. 11 years of studying and sacrifice and over 170k of debt to become an OR assist... The struggle is real, yo. having the option to work in the usa is always a bonus for most specialties, including surgery and its subspecialties. pathology does not have this option due to the american oversupply. Link to comment Share on other sites More sharing options...
NLengr Posted December 31, 2015 Report Share Posted December 31, 2015 Re: finding OR time. A lot of new surgeons, including my husband, can't find any in Canada. He's looking to start working this summer and is having no luck. 11 years of studying and sacrifice and over 170k of debt to become an OR assist... The struggle is real, yo. Ortho? Sounds like ortho. Link to comment Share on other sites More sharing options...
FeministKilljoy Posted December 31, 2015 Report Share Posted December 31, 2015 Thats tough, though I'm surprised only 170k debt! at least the fellowship pay(I assume it is at a level greater than or equal to r5 wages?) benefits from the U.S.:CAD conversion! He's making about what he was making during his first fellowship in Canada. The major downside to being in the US is that I'm unable to work (also in health care) so we're forced to survive off of one pay check. Our big splurge is Chipotle once a week... Link to comment Share on other sites More sharing options...
JohnGrisham Posted December 31, 2015 Report Share Posted December 31, 2015 He's making about what he was making during his first fellowship in Canada. The major downside to being in the US is that I'm unable to work (also in health care) so we're forced to survive off of one pay check. Our big splurge is Chipotle once a week... I guess the silver lining is that he still probably makes more than the 80% of the patients he serves even as a fellow but definitely debt load is tough compounded with only 1 earner. Is he on h1b? If he went on a j1, you should be able to get the employment authorization(though I guess if you have a licensed/regulated job then you can't) Link to comment Share on other sites More sharing options...
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