I was greatly saddened to hear of the death of Dr. Chenicheri Balakrishnan, plastic surgeon, friend and mentor to generations of residents in both the plastic and general surgery training programs at the Detroit Medical Center/Wayne State University.
Dr. Bala, as he preferred to be called, was the major figure in the program when I had the good fortune to train there several years ago. At that time he was the primary plastic surgeon for three hospitals; Detroit Receiving, the Veteran’s Affairs hospital and Sinai-Grace.
Working with him was special in many ways. Surgery training is very personal – no two individuals ever have quite the same training experience. Just as a human body is made up of trillions of different cells, surgical training consists of thousands of interactions, large and small, with other people as one progresses from neophyte beginner to fully-trained (but still inexperienced) surgeon.
During this process, I had the benefit of working with many excellent surgeons, but he was one of the most significant. Dr. Bala was a major part of my plastic surgery training, as he was for my classmates and those who came before and after our time with him.
“In plastic surgery, experience matters a lot.” He told me. “We sometimes have to come up with a new operation right there, because every time things are different.” He wasn’t kidding. And he delivered that experience.
He had a huge repertoire of operations he had mastered. He would find a way to make sure we got experience doing as many different sorts of flap techniques, grafts, and other methods of reconstruction as possible. He kept track of which residents had done which types of reconstructions. If you needed a certain type of case and were not currently on his service, he would coordinate with your service so you could participate and get the required experience. He was that sort of surgeon.
His team handled all kinds of injuries, burns, facial fractures, severe hand trauma, you name it. He had a wide practice variety and drew on substantial background training in India, England, Scotland and Ireland. Like many great surgeons trained in international programs, he had a no-nonsense approach to operating and elevated his resident-trainees to new levels, giving them as much challenge as he felt they could handle, and sometimes more.
His operating ability and speed were legendary. Suffice it to say, he could fix just about anything.
He would move his team through cases rapidly and without skipping important details. An elective daily schedule might run more than ten cases, with emergencies worked in as needed. Somehow he had everything running so smoothly between rooms that no matter how packed the schedule, the team would finish and be home before too late. He cherished his own family and wanted to get his residents home to theirs as well.
A typical Monday morning would see us reviewing digital images of trauma cases – many the second-place finishers in that weekend’s Detroit-area bar brawls – planning who would get what operation, and when. It seemed no matter how severely someone’s face was broken, he could get us through the repair in two hours or less, and with a minimal rate of complications.
It was the same thing with hand surgery. Despite some terrible injuries, everything would be washed, pinned, plated, sewed and splinted in what seemed like no time, and with good results. I would not truly appreciate the full range of his skill until later, when I would find myself greatly challenged to try to produce the same outcomes in my own early practice experience.
He loved teaching the general surgery residents rotating on his service, who would enjoy getting plenty of operating experience.
Though he did some cosmetic surgery, his main interest was in reconstructive plastic surgery and burns. Many thousands of patients benefited from his service to the institution during his career, and many more would have had he been able to be with us longer.
Dozens of plastic surgery and general surgery residents also benefited from their exposure to such a talented surgeon and gentle, friendly man. He published many scientific papers and book chapters, frequently collaborating with his residents, contributing to the fund of surgical knowledge. I am proud to have contributed with him, showcasing some truly interesting and memorable cases.
May whoever follows in his footsteps at that fine institution keep his spirit alive. I also wish the Detroit Medical Center will memorialize Dr. Bala in a manner worthy of his remarkable service to the facility and the community.
The Detroit Medical Center and its patients have lost a great surgeon. The residents who were fortunate enough to have trained with Dr. Bala have lost a wonderful mentor and friend.
A recent case from Dayton, OH highlights the tangled mess of emergency department specialty coverage, federal law, and out-of-network insurance benefits. When these interact, patients, doctors, insurers and hospitals can be left frustrated and perplexed.
Here’s a brief summary:
A 6 yr old boy suffered a fingertip injury and the emergency staff called the covering plastic surgeon, who repaired the injury. The surgeon, who does not participate with insurance, submitted a bill for approximately $8000. The insurance company paid 80% of what it determined to be usual and customary charges, leaving the family the remainder, approximately $6000. They were unaware the surgeon was out-of-network. The hospital later changed call coverage, contracting with another group that accepts all insurances.
This case illustrates how current on-call realities can fail all four parties: patients, hospitals, insurers, and on-call doctors.
First, a few preliminary facts:
- The Emergency Medical Treatment and Active Labor Act (EMTALA) applies to hospitals accepting federal funds. It does not allow for a discussion of financial considerations prior to rendering care. (It is less clear whether this applies to independent physicians or just the hospital).
- Doctors in private practice are not required to participate with insurance, and do not work for the hospital.
- Hospitals often do not pay for on-call coverage. Some hospitals may have other sources of funding for serving the uninsured, but such arrangements may not apply to the covering doctors.
- Insurers may send payment directly to patients for out-of-network care. When this happens, doctors try to recover from the patient, often receiving nothing.
- On-call doctors summoned by the Emergency Department cannot refuse, and as noted above can’t discuss financial considerations, such as their insurance participation status.
- In specialties such as plastic surgery, on-call doctors are sometimes called in for non-emergencies.
When these factors intersect as in this case, there can be confusion and finger-pointing. The doctor may be upset at being inappropriately called (not so in this case), or not paid. Patients may be surprised by a large bill despite having insurance. Hospitals risk a public-relations problem if patients complain. Insurers limit their out-of-network liabilities or risk being overcharged. All of these positions have some validity.
The essence of the problem is not the Emergency Department’s behavior, the out-of-network status of the doctor, or the insurance company’s payment policy.
The problem is that under EMTALA, care is mandated but payment is not, and no cost discussions are permitted. Hospitals and doctors know this, but all too often nothing is done to plan for the inevitable misunderstandings.
The solution lies with hospital executives meeting with each specialty, and figuring out how get patients the emergency care they need, that specialists are available and billing surprises do not occur. There are many options, such as paying for call, providing for payment if patients are uninsured, or an agreement that there will be a limiting charge in emergency situations. Some hospitals may decide that hiring specialists meets their needs. Plenty of options are possible though they need vetting for legal correctness.
As the healthcare delivery system evolves, creative on-call solutions may be required. What works in one community may not be optimal for another. But with an open approach, and all stakeholders working together, collaborative solutions are possible.
- ER overcrowding hurts minorities in California (eurekalert.org)
- Children’s Hospital Boston testing three innovative telemedicine pilots (medcitynews.com)
- Health Insurance Definitions: What the Terms Mean (health.usnews.com)
The American Board of Plastic Surgery’s February 2011 newsletter discusses ethical practice, noting that a surgeon reportedly billed $50,000 for a 1 cm laceration, which was paid as an out-of-network charge. This vignette presents several avenues for discussion. It seems clear that such a charge is flagrantly excessive. Consider a surgeon who repaired six similar injuries each day. Given a five-day week and 4 weeks of vacation per year, total payment would be $72,000,000. Wound healing physiology being what it is, even a $72 million surgeon has to leave a scar!
But the newsletter does not explore the issues behind the problems illustrated by this example. Notably, that there is no price transparency in healthcare services, and that leads to market failures that do not serve patients, doctors or insurance companies. The concept that “in healthcare, nobody pays sticker price” is hardly untrue. There is no problem with insurers or patients paying sticker price, as long as that price reflects reasonably accurate value for services provided. It seems odd that the insurer had no safeguard or review procedure for extreme claim amounts. Health insurance policies could contain out-of-network benefit limits that would limit extreme claim amounts. Would the surgeon realistically expect a patient to pay $50,000 for a 1 cm laceration?
In defense of the surgeon, there are abuses on the other side as well. Out-of-network doctors covering emergency patients often are not paid, or see payments disbursed to the patients directly, then are forced to try to collect from them. Reimbursement of the patient for out-of-network services works well for elective care, but is not feasible for emergency situations. My guess is that the surgeon was trying to “make back” many past losses.
Insurers have bitten back on out-of-network overcharging, as noted here. I don’t agree with the charges noted in the article (over $56,000 for a 25 minute consultation?) because they are clearly disjointed from value provided. These instances are too often portrayed as vast overcharging and price-gouging, but they really should serve as a primer to discuss the return of value-based pricing to the system. This is best done by allowing market forces to act far more than they can at present.
Yesterday, the President caught an elbow during a basketball game and suffered a lip injury. News reports stated that he had 12 stitches applied under local. Does that mean anything? Sort of, but not really. Everyone is always fascinated by the number of stitches needed to fix a cut. You will get this question almost every time you sew somebody up in the emergency room (if you do that sort of thing).
Of course it is important for reporters to determine what the injury is, how serious it is, and so forth. Stitch counts are not going to go away, but they are not that meaningful. Here’s why: the number of sutures required for a cut can vary widely, and are largely arbitrary. Some surgeons put them in very close together, others farther apart. This depends on the surgeon’s background, experience, habits, suturing technique, and so forth. So a “12 stitch” cut isn’t necessarily bigger than a 6 stitch cut, or smaller than a 20 stitch cut. (I am guessing that being the President will get you about 20% more stitches. That doesn’t mean a better outcome).
So how should the cut be described? I suggest length and location. Those are better and more informative. You can also give the depth, but that is getting overly technical. “The President suffered a two-inch cut to his upper lip that was fixed with stitches.” Or, “a one inch scrape to his cheek that did not need stitches.” Note I did not use the metric centimeters (preferred in actual medical discussions but not suited to news articles).
From the AP:
The medical unit that treated Obama used a smaller filament than typically used, which increases the number of stitches but makes a tighter stitch and results in a smaller scar
Sounds reasonable, but you don’t really want the closure “tight”, and the length of the scar will be affected only minimally. Its possible a running subcuticular (under the skin) suture was used to keep the closure short.
No word yet on what happened to the guy who elbowed him!
- Barack Obama Gets STITCHES After Basketball Injury (PICTURES) (huffingtonpost.com)
- Obama Gets 12 Stitches After Being Injured in Basketball Game (businessweek.com)
Discussing on-call issues with other specialists is always fun. I am part of an email group of several plastic surgeons from around the country, and one issue that always brings a lively exchange is EMTALA.
For those unfamiliar with medical alphabet soup, EMTALA is the Emergency Medical Treatment and Active Labor Act of 1986. Sometimes it is called “the anti-patient dumping law”.
What it is supposed to do (and generally does pretty well), is to make sure that hospitals do not turn away emergency patients or those in active labor. They must provide a screening exam and stabilizing treatment, regardless of ability to pay.
There are many nuances involved with specialists taking emergency call, and the law can be ambiguous in terms of what is and what is not acceptable. Each type of specialty has its own particular difficulties which arise when they are on-call. Plastic and hand surgery seem to frequently involve EMTALA concerns.
One common situation is the patient with a fracture or cut tendon, something which needs to be definitively fixed, but can be treated first by the E.R. staff and then sent to the specialist’s office where definitive treatment can be arranged. In some cases, specialists refuse to see these patients if they are uninsured. Ethical concerns aside, such a situation likely violates EMTALA, and the E.R. can be cited for failing to require the specialist to come in for the “unstable” tendon.
There are plenty more examples, but it seems that private specialists are reducing their on-call exposure. As margins tighten for private practices, losses from taking call need to be reduced. More hospitals are paying for specialists to be on-call, which is itself another hotly debated topic.
E.R. specialist staffing may become less of a problem in the future, if the trend towards clinical integration continues. For now, with a patchwork of coverage from various private specialists, the EMTALA questions will continue.
Read more about EMTALA:
I want to talk a bit about disruptive innovation, which is an important player in the reshaping of industries. Disruptive innovation generally requires three elements, which I am going to define below.
- A new technology which allows something complex to be done more simply
- A business model which emerges to take advantage of the new technology
- A network of suppliers/enablers which supports this model
For further reading, specifically concerning D.I. in healthcare, I will refer you to Professor Clayton Christensen’s superb book, The Innovator’s Prescription.
Considering Proxiderm, the wound closure device I discussed previously, some elements of the disruptive process can be seen. The device allows wounds to be closed in a simpler manner than skin grafts, or regional/distant flaps. Some may argue that a multistage Proxiderm procedure is not “simpler” than a single stage graft or flap, and that may be true, depending upon the wound in question. With Proxiderm, elements #1 and #3 are at least partly true. It’s not a perfect example of the disruptive innovation concept, since the device supports, but does not redefine reconstructive surgery.
The disruptive element is that Proxiderm can be easily handled by a general or specialty surgeon with reasonable skill. In other words, many wounds which might have required the services of a Reconstructive Plastic Surgeon can be handled by the patient’s primary surgeon.
Rural centers using Proxiderm may avoid transfers to tertiary centers for definitive wound closure in some cases.
Although this example is a minor one, healthcare is poised for numerous disruptive innovations. As these take hold, they will continue to transform the field in ways that would have seemed impossible just a few short years ago.
I wanted to talk about a method of wound closure that deserves to be in the toolkit of any trauma or reconstructive surgeon who faces difficult wounds. I have no commercial involvment with Progressive Surgical, which is the company that makes the Proxiderm external tissue expansion device.
Each Proxiderm device has two opposing tissue hooks which are separated on tension and inserted away from the wound edges. The device applies a specific amount of tension on the tissue (460g) which causes steady expansion of the tissue without pressure necrosis. Technically, a similar procedure is possible using a serial-suturing technique with rubber bolsters, but the disadvantage of this is the variability of the tension being applied. With Proxiderm, it is designed to provide the right amount of force every time.
By placing these devices every 2-3 cm along the wound edges, and changing them every 2-3 days, wounds can be gradually closed with good skin, not needing grafting or flap procedures. Wounds need to be well debrided prior to beginning the procedure, and are generally recleaned with each stage, when new Proxiderms are applied and the old ones discarded. The following photos (from the company website at www.proxiderm.com) show a tough lower extremity wound closed at 16 days without the need for grafts or flaps.
The procedure can be done as an outpatient, and it is necessary to secure each device with a suture across the wound and tied over the top. A well-padded, bulky dressing is also a must.
For more information, head to www.proxiderm.com, which is filled with detailed information and many more case photos.