© Shao-chun Wang | Dreamstime T and notnecessarilythoseofPM. The opinionshereinaretheauthor’s, lar surgicalmethodsororganizations. publication does not endorse particu- Readers shouldbeawarethatour topics ofinteresttotheprofession. offer theirpersonalperspectiveson podiatrists withtheopportunityto occasional PMfeaturethatprovides www.podiatrym.com The field ofpodiatry, weneedDPMswho think; butnow morethaneverinthe terintuitive tohowtoday’sresidents cols. Doing surgery in-office is coun - ternate methodsoftreatment proto- today, wemightwanttolook atal- current economicsofhealthcare pitals inthecountry,butdue tothe idencies atsomeofthefinesthos- have theadvantageofthree-yearres- to come. the pastwhopavedwayforyears forever grateful to the foot doctors of podiatry residentsoftodayshouldbe by necessity performed in-office. The majority ofpodiatrysurgerieswere for granted.Thusyearsago,thevast hospital privilegesthatwenowtake podiatrists ofthepasttoobtain how difficultthepathwaywasfor will (thankfully) never experience podiatry intomainstreammedicine. Glamry haveguidedthespecialtyof Guido LaPorta,andE.DaltonMc- MIS Editor’s Note: The youngpodiatristoftoday Now, youngpodiatryresidents

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63 THE FORUM

In-Office Surgeries (from page 63) ASC from your office, pre-op the pa- in an society that wants and expects tient, have anesthesia put the patient to heal immediately. Relatively few ed toes, and hammertoes are cor- under, perform the surgery, transfer doctors perform in-office surgery, so rected by this technique and patients the patient back to recovery, perform MIS could be a new niche market in a remain ambulatory. We now have dictations, fill out post-op orders and practitioner’s market area. state-of-the-art, in-office surgical pro- complete after-care, there is little to MACRA With deductibles and healthcare With today’s affordable technology, cost-effective, costs expected to increase in the fu- ture, podiatrists need to look for cost minimal invasive foot surgery is now a reality. savings for the patient, the govern- ment, and insurance companies.The AAPPM expert panels at healthcare cedure rooms. With today’s afford- no profit to be made because of wast- reform meetings have stated that able technology, cost-effective, min- ed time. Building an in-office surgery in-office surgical procedures should imal invasive foot surgery is now a suite could be one of the best things meet the new requirements for the reality. you can do to build your practice. Medicare Access and CHIP Re-authori- zation Act (MACRA) and Merit-based Medical Economics Marketing In-Office Surgery to the Incentive Payment System (MIPS) to There is so much wasted time Public set physician reimbursement. traveling to the hospital or ambulato- Patients today, particularly with ry surgical center (ASC). You might the high cost of deductibles, are high- Other Specialties Starting to ask yourself: “Is it worth my time to ly sensitive to price. And they are so Perform In-Office Surgery 64 perform small procedures like correct- much more educated than in the past, Over the last five years, a number ing hammertoes and neuromas at the with surgical procedures seen on You- of other healthcare specialties have ASC?” By the time you travel to the Tube and doctors’ websites. We live Continued on page 65

OCTOBER 2017 | PODIATRY MANAGEMENT www.podiatrym.com THE FORUM

In-Office Surgeries (from page 64) is performed in an office or an outpatient surgical center under local anesthesia. A small incision is made on the increased the number of in-office surgeries they perform. patient’s skin, and a specially designed instrument is These include dermatology, plastic surgery, eye surgery, inserted into this opening. The entire procedure is per- and hand orthopedic surgery. Dentists, of course, have formed through this tiny opening. At the conclusion of been performing in-office surgeries for years. the surgery, a few stitches may be used to close the open- ing and a small bandage protects the area. The patient Safety generally leaves the office walking, and in many instanc- The use of mini C-arms in the office setting can in- es in his or her own shoes! The condition has been cor- crease positive outcomes and reduce surgical risks. Lido- rected and the patient remains ambulatory with minimal caine 1% without epinephrine is one of the safest drugs discomfort. The prolonged disability has been avoided. If around today. There is much less risk with local anesthe- the patient is kept comfortable, there is no need for seda- sia performed in the office. tion or general anesthesia for in-office surgery.

Staff Education Calculate Your Happiness and Freedom There are many ways to educate your staff on in-of- What is your happiness worth? Performing in-office fice surgery. One helpful tool is the book Assisting in surgeries can give doctors tremendous flexibility in their Podiatric Surgery by Telford Thomson. It is designed for personal lives. It seems more than ever that doctors have podiatric medical assistants to learn minor surgical pro- less free time. An in-office surgery suite can allow you to cedures. Encourage your staff to read books like this and have more free time. watch videos to understand the protocols for an in-office surgery suite. Practitioners need to look at quality vs. After-Care and Pain affordability. More expensive does not always equate to Many doctors have performed both traditional hospital higher quality. Your staff should be educated on this sub- and minimally invasive surgery (MIS) in-office for Ha- 65 ject and be looking for ways to reduce costs and increase glund’s deformities over the last couple of years. Both have quality. Continued on page 66

The Cost of a Surgical Procedure Suite The cost of a minor procedure room in a clinic is relatively inexpensive to set up with an Osada bone drill, electric ankle tourniquet, and sterile prep/drapes/gowns. A mini C-arm can also be purchased at a reasonable price. The AAFAS website at www.aafas.org is a great resource for advice on how to set up a small procedure room in-office.

Complications Are Few Podiatrists have performed thousands of minor in-of- fice surgeries. If protocols have been taken to decrease the risk, complications post-operatively should be very low. Patient education on post-surgical protocol can also reduce this risk dramatically.

Conditions Treated Bunions, common nail problems, hammertoes, heel pain surgery, laser surgery, neuromas, and warts can easily be performed in the office setting. Statistically, this is about 80% of what most clinics treat surgically. Most podiatrists feel that in-office surgeries should be limited to minor procedures only to decrease the chance of seri- ous complications, but remember that most surgeries that podiatrists perform are considered to be minor.

Local vs. General Anesthesia Many surgical procedures performed in a hospital require large incisions and, many times, general anesthe- sia. A major factor in recovery time and discomfort is the amount of tissue that has been involved via the incision. The risk of surgery is multiplied by the use of general anesthesia. Ambulatory foot surgery, in most instances, www.podiatrym.com OCTOBER 2017 | PODIATRY MANAGEMENT THE FORUM

In-Office Surgeries (from page 65) have surgery if performed in the of- from transmetatarsal amputations to fice. In addition, if a vision block total ankle replacements, but a large obvious advantages and disadvantag- is placed in front of the patient, percentage of procedures can easily es, but the big advantage for (MIS) the anxiety greatly decreases. And be performed in the office setting. in-office is decreased recovery time. having patients wear headphones And it is vital that we look at what Most in-office surgeries do not create while watching TV or a movie play- the patient can afford as well as qual- ity of care—both of these concerns should go hand in hand. All podia- Surgical suites can be trists care deeply about their patients’ success, but it is important that we made to feel like a dental procedure room rather keep an open mind as doctors, partic- ularly as we are learning to navigate than a hospital operating room. through the newest versions of val- ue-based healthcare. PM

the post-op pain and need for medica- er during a procedure can decrease Dr. James Kent is tions that hospital surgeries frequently stress. Patients can listen to their fa- in private practice at require. vorite music or radio and may not East Texas Foot and even hear the electric bone saw or Ankle Centers in Tyler, Decreasing Anxiety drill. A surgical suite can be made Texas. He completed his surgical residency at The psychological barrier of sur- to feel more like a dental procedure Lourdes Hospital under gery can greatly decrease by doing room than a hospital operating room. Dr. Guido LaPorta. surgeries in the office. Patients will 66 Dr. Kent is a member think, “If this can be done in the of- Conclusion of both AAPPM and fice, it must be pretty easy and less There will always be a need for AAFAS, and has a special interest in healthcare expensive.” They are more likely to hospital-based podiatric surgery, practice management.

OCTOBER 2017 | PODIATRY MANAGEMENT www.podiatrym.com