JOHNSON CITY, Tenn. (WJHL) — A dispute over a seemingly innocuous part of medicine — who’s taking call — has flared up between Ballad Health, the region’s hospital system, and a large orthopedics practice.
Ballad Health says its decision to limit orthopedic call at Johnson City Medical Center (JCMC) to primarily its expanded stable of orthopedic trauma doctors is a win for the community and will improve care in the most serious ortho cases that come into JCMC’s Level 1 Trauma Center.
Watauga Orthopaedics, a prominent practice that has been on JCMC’s call schedule but won’t be come February, sharply disagrees.
The kerfuffle entered the public eye Wednesday when Watauga released a statement on social media criticizing the decision, which was made in mid-December. The practice said the change would interfere with patients’ rights to choose their healthcare providers, labeling it a “blatant attempt to prevent us from treating our valued and loyal patients presenting to the (emergency department).”
Ballad denied that when it fired back in its own defense, also on social media, several hours later. Leaders from both systems talked to News Channel 11 Thursday.
Ballad CEO Alan Levine and Ballad trauma doctors say this is part of a move toward gaining American College of Surgeons (ACS) certification for the Level 1 Trauma Center. They also say the change will improve the level and care of safety for the most critically injured orthopedic cases that present at the emergency room.
Ballad’s Trauma Program Director, Dr. Bracken Burns, said the changes come after hard work by Ballad to increase availability of traumatologists at JCMC once it became the region’s only Level I center following Ballad’s lowering of Holston Valley Medical Center’s trauma center status in late 2019. The system now has four of them all centered at one trauma center.
“Being fellowship trained…it’s a specialization within orthopedics and have that oversight brings expertise in the management of certain skeletal injuries,” Burns said.
Recruiting more fellowship-trained orthopedists (it’s an additional one-year program) “was to have them provide oversight on the injured patient so that we are assuring the best quality of care that we can for patients in the region,” he added.
By December, the system was ready to introduce a two-tiered on-call system. It left an option for the doctors at Watauga, but the traumatologists are by far the primary gatekeepers. Other orthopedists could “continue to participate in orthopedic surgery call” at JCMC in limited cases, and without reimbursement.
Watauga Orthopaedics partner Dr. Richard Duncan said the group’s CEO, Dr. Greg Stewart, went before JCMC’s Medical Executive Committee to lobby against the change. Watauga Orthopedics surgeons have been part of call rotation at JCMC for years and shared call with other non-hospital practices along with hospital-based traumatologists.
“We worked with the orthopedic trauma surgeons, we would stabilize the patient, and then the next day we would refer patients to them that were appropriate,” Duncan said of the times when Watauga doctors encountered high-level skeletal traumas. “That’s the way that’s worked for a number of years, and that’s the way it works at most (trauma) centers that I’m aware of.”
He said other Level 1 centers — he mentioned Erlanger in Chattanooga and Memphis among them — don’t use a “two-tier” system that limits call on certain cases to fellowship-trained traumatologists.
“They do have to have a fellowship-trained orthopedic trauma surgeon that’s with the program, so they oversee the program,” Duncan said. “That is part of the guidelines with ACS as I understand it. But to take 24-7 365 days a year call is not. That’s not what’s done in the state.”
Asked whether ACS mandates a two-tier system that puts call in the hands of traumatologists in order to receive accreditation, Burns said it doesn’t. His answer was similar to Duncan’s.
“The mandate from the ACS is that you have oversight of that process, that you have oversight of your quality of care, and that that is all driven by an ortho fellowship-trained traumatologist,” Burns said.
He did add that JCMC has implemented a required performance improvement program run by a traumatologist since increasing its numbers.
“When you look at the facts, it is clear that JCMC is doing exactly the right thing to elevate the level of trauma care, and to achieve ACS verification of the region’s Level 1 Trauma Center for the first time in history,” Levine said in an email.
News Channel 11 asked Watauga Orthopaedics for verification that other Level 1 trauma centers in Tennessee used non-traumatologists in their call rotation. Answers came back to them from centers at Erlanger in Chattanooga, UT-Knoxville and Memphis’s center and were shared with News Channel 11.
All three said their trauma center orthopedic call included a mix of fellowship-trained traumatologists and other surgeons who are certified by the American Board of Orthopaedic Surgery but don’t have fellowship training.
Jon-David Deeson, the CEO for OrthoTennessee, wrote that UT Medical Center in Knoxville has 11 call surgeons and five of those aren’t fellowship trained. OrthoTennessee is an independent, physician-owned group not affiliated with the hospital or UT.
Duncan said the point is that non-traumatologists are capable of being part of a well-run call rotation and that half of orthopedic surgeons’ five-year training involves trauma of some level.
“Every orthopedic surgeon takes care of trauma,” Duncan said. “It’s what we do, it’s our day-to-day. So we have done it for years and we will continue to do it and we’re practicing that at the other two hospitals in the region (Holston Valley and Bristol Regional Medical Center, both facilities where Ballad isn’t changing the call protocols.)”
Dr. Matt Graves is a traumatologist who directs the University of Mississippi’s Orthopaedic Surgery Residency Program. He said in his personal professional opinion, including non fellowship-trained ortho surgeons in a trauma center’s call rotation can be a successful coverage method for trauma patient care with respect to quality and safety.
Similar to Duncan’s description of the current JCMC status quo, “the definitive care of complex cases commonly occurs outside of overnight call time,” Graves said. What he called “judicious temporizing measures” are common and said when their services are deemed necessary, “in-hospital consults or outpatient referrals to fellowship trained providers then occur.”
Graves said success in those cases is all about doctors recognizing when someone with more trauma experience is warranted and passing the cases along in a timely way. He said protocols can be developed for this, but surgeons must be introspective because training volume and experience varies.
“There need to be systems in place where you are monitoring quality and safety in patient care regardless of the system in place,” he said. “Changes logically follow the data.”
Duncan said he and his partners are concerned the change could easily result in people who are already Watauga patients getting assigned to other doctors for procedures after they present at the emergency room.
He said those types of situations often aren’t the Level 1 and 2 scenarios that should and already do get directed to the traumatologists.
“Many times we get a call from the emergency room physician, saying that this patient has particular injury and the decision is to splint it and we follow it up in office that’s very common,” Duncan said. “So we will no longer be seeing those patients either I’m assuming because we were not on call.”
Duncan also said what he interprets as a mandate that traumatologists treat hip fractures in geriatric patients is unnecessary and unfair.
“It seems to me that Ballad right now with these actions is inhibiting our ability to care for the community and our patients,” Duncan said. He said the practice went public with its complaints “because we want to be able to take care of our patients. We felt very, very strongly about that. And this is preventing us from doing that.”
Asked whether he believes the lack of call by Watauga doctors could impact flow of referrals when an “unattached” patient comes in, he said “I think it could, yes.”
Dr. Daniel Krenk, one of Ballad’s traumatologists, said he believes such fears are overblown. He said Ballad has a policy in which patients must be asked whether in the last certain number of years they’ve seen any orthopedic surgeon.
“Most patients can say, ‘I broke my toe, I broke my finger, I want to go see X, Y and Z group,’ and that’s usually how it happens,” Krenk said. “And so it’s the rarity that actually somebody wouldn’t know.”
Even in those cases, Krenk said, the Epic electronic medical records system would likely catch a fact like that.
“Their entire history is visible and usually it doesn’t even come to an (on-call) orthopedist seeing them,” he said. “Usually the ER doctor already has that information and says, ‘this is Bob Smith’s patient, will you please call Bob,’ or call the trauma team and say ‘who do they need to have their care taken with?”
Krenk said he believes the angst is rooted mostly in the natural difficulty that comes with change. He expects Watauga to realize at some point it’s business as usual with the added community benefit of better care for true high-level orthopedic emergencies now that JCMC more traumatologists than it ever has.
“The sooner that we can get them and get them stabilized or get them and actually fix their broken bones, it’s less stress on their heart and lungs,” Krenk said.
“There’s literature out that says orthopedic traumatologists can reduce the length of stay of all critically injured patients. And so if we can fix them and take the stress off the rest of their systems in their body and get them discharged from the hospital sooner, they have better outcomes.”