One of the issues that leaders of private practice orthopaedic groups regularly contend with is the scope of practice. Specifically, leaders have to manage the delicate balance of deciding whether a patient should be treated by a subspecialty surgeon or one who is competent but has a more-general orthopaedic practice. This issue can become extremely contentious within a practice group, and many practice leaders fervently hope that it will just work itself out without outside intervention. But hope is not an effective management strategy.
One common example is straightforward TKA; this procedure is professionally rewarding, and when it goes well, it is especially personally satisfying to surgeons. Many general orthopaedic and sports medicine surgeons perform TKA, and they reject the notion that TKAs should be performed only by fellowship-trained joint surgeons.
But high surgical volume is associated with a lower risk of postoperative complications, including death, after TKA . Since that study quantified complications as a function of surgical volume, practices could opt to determine whether surgeons may perform TKA based on whether those surgeons’ practices exceed certain TKA volume thresholds. Such an approach would appear well-supported by high-quality evidence . Certainly, some could say that this practice is just using volume as a surrogate for quality. Volume is much more easily quantified than many quality measures (like patient-reported outcome measures), and complications data are often unreliable and difficult to collect. As a result, I believe that volume criteria is a great metric to use when starting this effort.
For purposes of fairness, it would seem important that any standards on topics like this be set by a group of surgeons in the practice that reviews the best-available evidence together; ideally, the surgeons making the decision should not also be affected by it. That is, if a practice is setting standards for who should or shouldn’t perform TKA, the individuals charged with setting those standards should not themselves perform TKAs as part of their practices. Even though this removes conflicted surgeons from the decision-making process, it may be safe to assume that subtleties in studies on TKA may not be evident to the surgeons making the decision. So while the nonconflicted group may be more objective in their threshold decision, the group runs the risk of making decisions based on a potentially less-enlightened position.
There are potential deleterious effects to limiting the scope of practice based on volume criteria. What about surgeons who have had a change in their career or are fresh out of training? Certainly, a practice could designate “volume and/or fellowship training” as a criterion to perform TKA. Many times, it can take years for a new surgeon to generate the volume required to be above certain thresholds.
I can imagine several scenarios where competent surgeons would be inappropriately limited from doing these procedures if the criteria were solely based on volume metrics. Certainly, there are very high-quality surgeons who have more-general practices, and TKA is just one of the many things they do. There are many other metrics that could be used as well—patient-reported outcome tools, patient satisfaction scores, or gait metrics—to stratify which surgeons are eligible to perform TKA, but these are not all readily available and can be difficult to interpret. The situation gets more complicated when there is a high-volume surgeon with poor patient-reported outcomes. Low-volume surgeons with exceptional patient-reported outcomes could well argue that they should be on the “total knee doctor list.” All of this must be based on an even playing field such that patients are risk-adjusted as much as possible. For that reason, patients undergoing revision TKA or complex TKA should be excluded from the calculations.
So if I were starting this initiative, I would do it this way. The initial criteria would be based on volume (based on previous studies) and/or fellowship training. There would be a second rung of criteria that would enable lower-volume surgeons to meet the bar, but also to cull out high-volume surgeons who don’t produce the outcomes they should. This second tier would be based on patient-reported outcome measures (such as the Hip Disability and Osteoarthritis Outcome Score or Knee Disability and Osteoarthritis Outcome Score), timed walking, or other objective criteria. If the practice believed that they had an accurate grasp on complications data (whether it be reoperation, readmission, infection, or revision), then those criteria could also serve as a second tier. As a result, the best surgeons would be performing TKA at the end of the process.
A very reasonable question could be “would surgeons who are excluded by the private practice group from having TKA in their scope of practice have a legitimate legal action against the company”? Surgeons could argue age discrimination or make other claims that they are being treated with unfair bias. The bottom line is that if the criteria were selected objectively and if the standard were equally applied across the practice, then a legal claim is not very strong. Certainly, basing the volume criteria on well-designed published studies would strengthen the policy the practice adopts.
Indeed, the entire flow of patients through the system could be altered substantially, but as a personal proponent of disruptive change, I feel this is not necessarily a bad thing. Disruptive change, although sometime painful, can usher in massive improvements in quality, efficiency, and patient satisfaction. In certain situations, “blowing up” the way we do things can in fact be a very helpful exercise.
Other issues should be considered. Referring physicians who have been sending patients to Dr. “X” for decades may not appreciate the sudden message that he is not doing TKAs anymore. Clearly, there are political issues that make these decisions extremely difficult. The bottom line remains that it is our responsibility to do what is best for our patients, and we should endeavor to hold that principle paramount above all others. Disruptive change should always be in the patient’s best interests.
The best way to handle these issues is always from the perspective of our patients. We need to consider the issues of access and quality. Volume criteria may be a good starting point, but we should be willing to make exceptions when a surgeon can demonstrate superior results. Regardless of what is best for us individually, let’s do what’s best for our patients.
1. Wilson S, Marx RG, Pan TJ, Lyman S. Meaningful thresholds for the volume-outcome relationship in total knee arthroplasty. J Bone Joint Surg Am 2016:98:1683–1690.