July 31, 2024 • 38 mins
Douglas W. Lundy, MD, MBA, FAOA, interviewed Jim Barber, MD who is an accomplished orthopaedic surgeon who practices in Douglas, Georgia. Dr. Barber shares his compelling journey, the various leadership roles he has embraced, and his experiences enriching a close-knit community despite the geographical limitations of a small town. His story illuminates the challenges and rewards of rural healthcare, showing how one dedicated individual can make a significant impact both locally and nationally.
Drs. Lundy and Barber tackle the evolving landscape of rural solo private practice, touching on the mounting pressures from insurance companies, the complexities of electronic medical records, and the growing need for larger teams. Dr. Barber offers his thoughts on state support programs, value-based care, and the pressures of consolidation, while reflecting on the changing dynamics of physician collegiality and scope of practice. Through innovative collaboration with local hospitals and Medicare shared savings programs, various pathways are explored for sustainability and the importance of staying positive and proactive in this challenging environment.
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Episode Transcript
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Dr. Lundy (00:21):
Welcome to the AOA Future in Orthopaedic Surgery
podcast series.
This AOA podcast series willfocus on the future in
orthopaedic surgery and theimpact on leaders in our
profession.
These podcasts will focus onthe vast spectrum of change that
will occur as the futurereveals itself.
We will consider changes asthey occur in the domains of
(00:42):
culture, employment, technology,scope of practice, compensation
and other areas.
My name is Doug Lundy, host forthe podcast series.
Joining us today is Dr.
Jim Barber.
Dr.
Barber is an orthopedic surgeonpracticing in a rural setting
in Douglas, Georgia.
He graduated with hisbachelor's degree from the
(01:03):
Georgia Institute of Technology,his medical degree from the
Medical College of Georgia andhe completed his residency at
the Georgia Baptist OrthopaedicProgram.
He completed the AOS LeadershipFellows Program and ascended to
become president of the GeorgiaOrthopedic Society.
He has faithfully served as amember of the AOS Board of
Counselors and now sits on theAOS Board of Directors as the
(01:26):
Secretary of the BOC.
He also serves as Speaker ofthe House of the Medical
Association of Georgia,president of the Georgia Society
of Ambulatory Surgery Centers,chair of the Georgia Board of
Healthcare Workforce appointedby Governor Kemp and Vice Chair
of the Board of Trustees of theOkefenokee Swamp Park.
(01:47):
Dr Barber, welcome to thepodcast.
Dr. Barber (01:50):
Thank you Doug.
Dr. Lundy (01:51):
Great to talk to you.
So, jim, before we get started,how far is Douglas Georgia from
Hartsfield InternationalAirport in Atlanta?
Dr. Barber (02:01):
Infinity.
It's about three hours south ofAtlanta, Georgia.
Dr. Lundy (02:10):
It just staggers me, brother, that you've been able
to do all these things living sofar from a major hub airport.
Dr. Barber (02:17):
It's just it staggers me that my wife has let
me do all these things.
Dr. Lundy (02:21):
There you go.
Well, jim, in this series youknow we're discussing the
changes that we will believethat occurs in the future of
orthopedic surgery, and today Iwould love to discuss the future
of a small rural privatepractice which, my friend, you
have been in for quite a longtime.
Can you tell the listenersabout your practice?
Dr. Barber (02:41):
Love to Doug Douglas .
Georgia is a town of 13,000.
It's about three hours south ofAtlanta, about two hours north
of Jacksonville and about twoand a half hours west of
Savannah and those would be thenearest what we'd call cities.
There's about 45,000 people inthe county.
The nearest trauma center isprobably Savannah and when you
(03:03):
count loading time by helicopterit's about two hours to get to
the trauma center there, aboutfour hours by ambulance or so.
My first ER patient 25 years agowas a farmer whose hog had
bitten off his finger and I wentto the ER to see him and he was
(03:24):
adamant that he could go getthat finger if I was able to put
it back on, and I assured himthat no, we just need to shorten
his finger.
They're very hardworking inthis area and it's rare to meet
a patient that I don't know oris a stranger.
I get a lot of feedback.
Some of that is positive andsome of that's negative, but in
a small town you just can'tescape it.
(03:44):
It's a great place to raise afamily.
I've got a wife and threedaughters and it's just.
I really enjoy living here.
Dr. Lundy (03:52):
But you're not a small town guy.
I mean, you grew up in ATL.
You, like I said, you went totech, you went to high school in
Atlanta.
Dr. Barber (04:03):
I mean, that's quite a shift, isn't it?
You know, they say that God hasa funny sense of humor, and
when I was in Atlanta, I livedin Atlanta for 20 years and I
swore I would never live in asmall town ever.
And I used to visit mygrandparents in a small town in
South Georgia and I just thoughtit was terrible.
I could never live there, neverbe happy.
But my best friend in residencycame to Douglas the year before
(04:27):
.
He was a year ahead of me inresidency and he just insisted
that I needed to come down andjoin him and I thought it'd be
great to work with him.
So I ended up coming straightto Douglas from residency and
I'm so glad I did.
It's just been a greatexperience and I'm really
thankful that I'm here.
I wouldn't want to be anywhereelse.
Dr. Lundy (04:49):
So, jim, this is not a small thing.
You have elevated, all on yourown and in the setting that you
practice in, up to becoming thesecretary of the board of
counselors, which is a prettybig deal.
Dr. Barber (05:01):
Well, thank you, Doug.
I do want to make it clear thatI'm speaking on my own behalf
and not on behalf of the AOSboard of directors, of course,
and that's fair.
Dr. Lundy (05:09):
Thank you Now, before I go too far.
I mean you are also the posterchild for all the people who
just can't seem to get involvedbecause of fill in the blank.
I mean you are all by yourself,way down there, far from the
airport.
When you go out of town, youhave a PA right.
Dr. Barber (05:29):
I do.
Dr. Lundy (05:30):
So your PA then is covering your patients, but
somehow you've been able tobecome very involved, obviously
extensively there in Georgia,but also on a national level.
Dr. Barber (05:50):
Well, the reality is around here.
Most people spend a lot oftheir time hunting or fishing,
and I just don't enjoy eitherone of those.
So I have a lot of free timeand I have a very understanding
family and I just really enjoyserving in organized medicine.
It's just a passion and a funthing for me to do and I feel
really rewarded in giving backthat way and I feel really
rewarded in giving back that way, but I also am able to keep my
head above water by beingengaged and involved, and I can
(06:10):
see what changes are coming downthe pike, so to speak.
Dr. Lundy (06:17):
And so it's just something I really enjoy doing.
Based on your experience, bothin the state of Georgia,
regionally in the southeast, andthen your experience in the in
the country, being involved inthe BOC and the AOS, how many
folks do you know out there havesimilar rural, small town solo
private practices like you?
Dr. Barber (06:36):
You know, I think there's a lot more than we think
.
I think we're just not verywell organized.
But I think that it's we, weall.
We know about the big groupsand everything, but we just
don't know about the solo guysin rural.
But I don't know a number.
Honestly, I, I, I would justsuspect that it's more than we
think.
Dr. Lundy (06:52):
Well, my point is when you go to the meeting and
you're, when you meet somebody,it's not, it's not a total
rarity.
You meet folks that you go.
Hey, I do the same thing andit's.
It doesn't seem that uncommonto you.
Dr. Barber (07:03):
That's right.
Is that fair?
That's fair.
Dr. Lundy (07:06):
Yeah, so over the past 25, 26 years you and I
finished residency at the sametime.
So we're dating ourselves Trueand in full disclosure.
You and I finished residencytogether since we were
co-residents.
Hey, jim, over the past 25years I'm sure you've seen a
(07:26):
market change in the developmentof your practice.
Certainly that goes along withthe development of your skillset
and your comfort and takingcare of complex patients and
routine patients and to yourpoint, by now a lot of these
folks are your neighbors andyour friends, which puts a
certain twist on it that a lotof the rest of us like.
When I was practicing inAtlanta, most of the folks I saw
I never would run into againoutside the clinical setting and
you see them all the time atthe grocery store and at church
(07:49):
and at Friday night footballgames and all that Over the
period of time.
How has your practice changed?
How have you seen, specifically, this fellow private practice
in rural America change?
Dr. Barber (08:03):
Well, one thing that hasn't changed is my income.
I've made about the same everyyear for the last 25 years, but
I certainly have worked harder.
I'm sure that all of thelisteners would feel the same
way about that, but I know for afact that I'm seeing twice as
many patients now as when Istarted.
I think that in many ways theburdens have gotten more
difficult with dealing withinsurance companies and the
(08:26):
bureaucracy of practicingmedicine.
I think maybe in some ways it'sgotten a little bit better.
I think I really am not a verybig fan of the EMR, but I have
to admit in some ways that'smade it easier to practice.
I think the biggest problem isjust it seems like it takes a
larger and larger team to getthrough the practice of medicine
(08:49):
now and we just don't havethose type of teams in my area.
Dr. Lundy (08:54):
Specifically, how do you think that impacts you more
than if you had had like, if youhave like a half a dozen
partners with you?
Dr. Barber (09:05):
half a dozen partners with you.
I'm really jealous of thoseguys.
I think you know I would loveto have a CEO and a CFO and a
CAO and an HR department andmarketing department.
I'd love to have all of thosethings working with me.
And those are the things Idon't have and I just have to do
more jobs, wear more hats.
I put more responsibility on myoffice manager and others, and
so that's just gotten harderover the years with the
(09:27):
increasing complexity ofpracticing.
How many staff do you have?
I have 13 staff.
Okay.
Dr. Lundy (09:36):
So I'm sure with the past 25 years you have a
trajectory.
I mean you can see where thisis heading.
What's your, what is yourpredictions of where solo rural
private practice is headed inthe next pick it brother, five,
10, whatever, whatever you'recomfortable with.
Dr. Barber (09:53):
Honestly, I am not.
I'm not sure I, I really don'tknow for certain.
I'm optimistic that at least inGeorgia I don't know about the
other states, but in Georgia thelegislature has put a real
tremendous emphasis on ruralhealth care and there are really
good state programs in Georgiathat have support for
(10:17):
undergraduate medical educationtied to rural health care and
residency slots tied to ruralhealth care and a lot of loan
forgiveness programs for ruralphysicians and others.
I'm optimistic about ourcommunity here.
We have a tight community withthe hospital and we have really
(10:38):
embraced value-based care.
So we've had a greatinvolvement with a risk-based
ACO for several years now.
Last three years we've actuallyearned shared savings and we've
started a direct-to-employercollaboration between the
hospital and the privatepractice physicians, which is
(11:01):
right along the lines ofvalue-based care.
All that I'm really excitedabout.
I think that it's surprisingthat a small town could do so
much with value-based care, butthat's been really encouraging.
I've been a little bitpessimistic about the whole
concept of consolidation.
I'm a little bit worried aboutwhat am I going to do.
(11:21):
Am I going to join the hospitaland get employed or am I going
to look into private equity orventure capital?
But the reality is the power ofthe insurance companies just
continues to grow.
If you think about priorauthorization, that's just a
great example.
But I feel like I need a largerteam with me to navigate all of
(11:43):
that.
So I'm a little bit pessimisticabout that and I think the
collegiality has been tougherover the last 25 years.
It seems to be getting tougher.
I think the physicians tend tobe more siloed as they're more
employed and less likely to hangout and talk, and there's just
more apathy in general.
(12:04):
I think At least I see moreapathy in general and I remember
a talk you gave that I stoleabout 15 years ago about famous
excuses for not getting involved.
They were politics are dirty,contributions are bribery.
Only big industry corporationshave influence.
Politicians should do the rightthing without influence and I
(12:27):
can't give much.
It won't make a difference.
And that was 10 or 15 years agoand it's gotten worse since
then.
Doug, I was so a little worriedabout scope of practice.
I think that has eaten into ourfiduciary responsibility with
patients.
That seems to be getting worse.
Ultimately, one of my biggestconcerns is complacency.
(12:53):
I think we are at the top ofthe medical specialties as far
as advocacy, as far as solvingproblems for our patients.
As far as demonstrating thatfiduciary responsibility to our
patients, we are at the top.
But I think we might be gettinga little bit complacent on that
and I don't want to polarizeany of the listeners, but I do
(13:15):
want to quote coach Nick Saban,who was reflecting on his
disappointment and successesover the years and said for us
to have the kind of team we needto have, there's got to be an
element of being hungry.
We've had to deal withcomplacency at times because of
the success that we've had and Ithink that creates a blatant
(13:37):
disregard for doing what's right.
So, a little concerned aboutcomplacency in our profession so
mixed picture and ourprofession so mixed picture.
I'm optimistic, I want to staypositive and I think that if we,
if I, if we, if I, look forsolutions, they're out there,
we'll find them.
I just don't know if that'sgoing to be staying in private
(13:58):
practice solo, or if that'sgoing to be getting employed or
private equity or whatnot.
Dr. Lundy (14:06):
Well, before we go on , if you're going to quote Saban
, I got to drop a War Eagle GoAuburn in there, so I knew you
would back to a more holypresence here.
Dr. Barber (14:14):
That's why I quoted him.
I needed a reaction.
Dr. Lundy (14:17):
There you go.
So it's fascinating to me thatyou were able to work a lot.
So you're in pure privatepractice.
You don't have any formalrelationship with the hospital,
right, I don't?
Ok, so you're able to work withthe hospital in a Medicare
share savings program throughthe accountable care
organization that y'all have setup.
Clearly, that is asustainability factor that other
(14:42):
folks in your situation couldengage with, because one
advantage I would say if I couldgo out on this limb that y'all
have is that the hospital hasgot to play with you because
there's it's not like they cango cross street and get the
other group with a dozenorthopedic surgeons and get them
to play.
So they're going to work withy'all because you're engaged in
(15:03):
the system, engaged in thecommunity.
Am I on par with this?
Dr. Barber (15:06):
You're on track.
It's just think of us as anoasis.
You know there's a.
We don't have an interstatewithin 50 miles, so we're a bit
isolated, so to speak, and so weare responsible for the
outcomes of our care in thiscommunity.
And so it is imperative thatthe hospital work with the
(15:28):
physicians and vice versa, thatthe hospital work with the
physicians and vice versa, andthat gives us a little bit of an
advantage as far as being ableto I don't want to say control
outcomes, but to monitoroutcomes.
Let's say monitor outcomes, andif someone has an idea on
improving quality of care.
we can implement that prettyquickly and it is local, so
(15:48):
there is some advantage to that.
Dr. Lundy (15:52):
Okay, have you noticed other collaboration?
I guess there's a bunch ofother solo private practice
doctors outside of orthopedicsin your community, right?
Dr. Barber (15:59):
Yes, and we all work well together.
That is one of the things I'mencouraged by.
Dr. Lundy (16:04):
Do you feel like they have a bullish or a bearish
approach to the future in termsof how they think this is going
to go?
Dr. Barber (16:11):
I think people are kind of sitting their ways at
this point.
Most that are employed and theones that are in private
practice are comfortable ridingit out.
The things are going okay, youknow, I think people are kind of
sitting their ways.
Dr. Lundy (16:24):
So what would you recommend?
So a kid comes up through the,a guy or a girl comes up through
the Coffey County school system, goes off to Georgia Tech, goes
off to the Medical College ofGeorgia, goes off and becomes an
orthopedic surgeon and wants tocome back.
What would your recommendationbe if they wanted to move down
to Coffey County and work there?
Would you recommend to go intoprivate practice?
(16:47):
Would you recommend joining thegroup in one of the big mega
groups around the area or workfor the hospital?
What would you say?
Dr. Barber (16:54):
You know, that's a great question and I think that
you basically have to knowyourself and what conditions you
work best in.
I think there are people thatare well-equipped and ready to
be an employee, you know, andthey need an employed scenario
and I don't think they wouldwork well in a private practice
(17:15):
type practice.
Are there others that reallywant to be able to control the
way that they treat patients interms of how they interact with
patients, the types of patientsthey see and the services that
they offer, and I think to havethat level of control you really
need to be in private practice.
That is one, and the servicesthat they offer, and I think to
have that level of control youreally need to be in private
practice.
That is one of the things thatkeeps me going is, if I see a
(17:37):
deficit in how we're treatingpatients, I can fix that that
day or that week pretty easilyand basically, you know, solve
problems very quickly when wesee them and that is something
that's been really nice as faras being in private practice.
But I also know plenty ofcolleagues that are very
(17:59):
comfortable in a more of anemployed role and that suits
them well and I don't think theywould really like the
management type role that isrequired in a small private
practice.
Let's say that I don't reallythink there's a tremendous
difference, honestly, doug,between rural and metro.
As far as the employment style,whether that's employed or
(18:22):
academic or private practice, Ithink that those scenarios are
the same, at least in my limitedviewpoint.
I think those scenarios are allthe same throughout.
I think people need to knowwhat style they want to work in
and where they want to live.
I think that's the two bigissues there.
Dr. Lundy (18:42):
I think it's important to point out that your
viewpoint is not limited.
You know a lot of folks andyou've done a lot of things.
Well okay, maybe now aninteresting aside here is you
and your own surgery center,right, I sure do so to some
degree.
That does put you at odds with.
Is it coffee regional?
Is that what?
Dr. Barber (19:01):
that's right yeah.
Dr. Lundy (19:02):
So that does put you at odds with the hospital, since
you're supposedly cherrypicking and lemon dropping and
we both know I'm being sarcastichere- but, if you're, if you're
pulling revenue off thehospital, how does that?
Does that help or drive a wedgeinto the sustainability of your
, of your ability to practice inthe, in the methodology that
(19:23):
you've been doing as you goforward?
Dr. Barber (19:25):
That's a great question and complex, and I
would say that I didn't want tobuild a surgery center, but I
felt like I had to becausepatients needed a more
economical option for gettingthings done.
And so my surgery center isvery good at efficiency and you
(19:48):
may believe it or not, but it'struth at efficiency, and you may
believe it or not, but it'struth, we operate one day every
two weeks and we are incrediblyefficient and I don't make much
money off it, but it just feelsgood to offer that surgical
option to the patient.
That's a lot easier to swallow.
But it does cause some strifewith the hospital.
(20:09):
It's nothing major and we'veworked through it and I don't
think it really affects theirbottom line too much.
Honestly, there are so manyrestrictions on who we can
operate on in my surgery centerthat we're not really pulling a
lot from the hospital, honestly,and I don't think it's been too
harmful to the hospital.
Let's put it that way.
Dr. Lundy (20:29):
Another big thing that's often touted as damaging
the folks the men and women inyour type of practice setting is
the ability to comply with thecomplexities that Centers for
Medicare and Medicaid Servicescontinue to spew out at us.
Yet it seems that you found asweet spot with working
(20:52):
alongside Coffee Regional inorder to get this done, through
the Accountable CareOrganization and other things.
Do you feel that your abilityto comply and be compliant with
federal and state mandates hasbeen made easier because of,
even though you're remainingsolo and private practice?
The collaboration with thehospital is enabling you to get
by and sustain that further.
Dr. Barber (21:13):
Honestly, I wouldn't say it had much to do with the
hospital.
I would tell you, though, doug,that the key there has been
getting involved withorganizations like my state ASC
organization, like my stateorthopedic society, even my
state medical association,obviously AAOS and through BOC
(21:35):
and whatnot.
I think being involved withthose things has really given me
so much more than I put into itin terms of knowing what's
coming, what we need to complywith, how do we do it.
It's just so nice to go tomeetings like that and find
someone who's already solved theproblem that I have, so that I
(21:55):
don't have to recreate the wheel.
So I think it's more beinginvolved.
That's really been the key toto keeping my head above water
with the regulations.
Dr. Lundy (22:05):
And how difficult is contracting with the insurance
carriers been for you?
Dr. Barber (22:09):
Is impossible a word I could use here.
It's just very difficult.
As you can imagine, I pay topdollar for implants.
There's probably nobody thatpays more than me and that
really impacts the cases I cando.
I'm just low volume, I'm a lowvolume guy.
So that's an example of anegative of being solo, and the
(22:34):
same goes with contracting.
Thankfully there is a veryvibrant and active independent
physicians association, IPA,that I'm a member of.
That helps so much with thecontracting and so we come
together.
We've got about 600 physiciansin the IPA and that does help a
(22:55):
lot with dealing with insurancecompanies.
But we have the same nightmaresthat I'm sure everybody has
with denials and recoupments andthings that just make me just
really upset.
So I know the insurancecommissioner on a first name
basis and I do not hesitate togive the insurance commission
(23:20):
phone number to patients.
We have a problem.
We have it printed out on apiece of paper.
Here's the insurancecommissioner's office.
Give them a call, Tell themwhat's going on.
So it's been a challenge, but Isuspect that's been a challenge
everywhere.
Dr. Lundy (23:35):
Honestly, Administration of your group.
I mean, you've got said youhave 13 FTE staff right, correct
, right and these folks live inSouth Georgia, probably were
born and raised in south georgiaand have family connections and
social connections throughoutthe area there.
Yep, I would think, if I had toguess, that you could really
(23:59):
leverage that to make yourselfpretty valuable in the community
, especially if you gain the,the loyalty and the vision of
the staff you cast the visionthat they could buy into of what
your practice could be.
That's got to go a long way interms of maintaining the
sustainability of your practiceand you know, in many ways I
(24:21):
think many of us want you andyour people, your colleagues, to
survive this.
We kind of love the idea of thesolo person out there.
What are your thoughts?
Dr. Barber (24:32):
Well, first of all, I appreciate that.
So you know, I think I don't doa good enough job with exactly
what you're describing and Ithink that, frankly, I don't
think any of us do a good enoughjob.
I think the reality is, if youlook at teachers, they teach
students.
They have a very powerfuladvocacy source with students
and parents when they have aproblem.
(24:54):
You know, and we have an equal,maybe even greater, advocacy
source our patients.
If we were able to communicatewith them better about our
problems and why it's a problemfor the patient and the doctor,
those patients could be suchpowerful advocates for things
like prior authorization andwhatnot.
But I just don't do that.
(25:15):
I don't know why I don't do it.
I just feel a little bitawkward about spending time
during an E&M talking aboutpolitical things, but I do think
that we could do better withmotivating our patients to be
our advocates with insuranceissues, with bureaucracy issues,
all of those things.
Dr. Lundy (25:35):
I'm a little surprised at your EMR
discussions.
I mean, you did go to GeorgiaTech.
Let me remind you of that.
That is one of the bestengineering schools around.
Yet you say you struggle withthe EMR and you just recently
got it.
I'm surprised you haven't madeyour own EMR.
But obviously this is a pointof the sustainability of your
practice into the future.
(25:56):
So how has the EMR affectedyour practice?
How do you think it will changethings going on?
Will it help you sustain thisor will this be one of the nails
that destroys solo ruralprivate?
Dr. Barber (26:10):
practice search.
That's a good question too,doug.
So my my, you know, myundergraduate degree was
computer science and that kindof tainted me for 20 years or so
.
I just couldn't find an EMRthat I could live with, you know
, just because they all sucked,you know.
So it took me a long, long timeand eventually I got my arm
(26:31):
twisted so hard.
Hey, you got to have an EMR,we've got to integrate your EMR
with our ACO, et cetera.
So I did a little shopping andI found one, and I'm not going
to tell you which one it is.
I like it, I don't like it.
It's a love hate thing.
I'll tell you one thing thatrecently I remember it used to
be Doug, did you ever have papercharts ever?
Dr. Lundy (26:52):
Oh yeah, when I first started in Colorado, we had
them, yeah, all right.
Dr. Barber (26:56):
So you remember, if you forgot to dictate a paper
chart, that could be a nightmare.
You know you've got to find achart and someone else had it
and it was just.
You know nothing worse than astack of charts to have to
dictate at the end of the day oron a weekend or whatever.
And the one thing for sure thatthe EMR has done for me is I
get all my, all my stuff donewhile the patient's there and
(27:18):
many times I can I immediatelyprint the note out for him.
Here's your note for today andthat that truly is a benefit.
And I realized that I'm thelast orthopedic surgeon on the
planet to acknowledge this, butI'm just telling you it took a
lot of therapy.
After, after all those yearsand seeing how awful the EMRs
(27:40):
are, the simple fact is theyneed to allow a lot more
customization of the userinterface and the EMR that's the
number one problem is I knowhow, what I want to see on that
screen and they should let mechoose what I want to see on
that screen and nobody can dothat for me.
But that's, that's the biggestproblem as far as you know.
(28:00):
Bigger question overall is EMRspecifically a negative or
positive.
It's a positive.
I mean it's positive for ourbilling.
It's positive for our billing,it's positive for my notes, it's
positive for the patient.
It's a pain in the butt to dealwith and you know, it just
makes me frustrated when I can'tfix the clickies.
(28:20):
Why do I have to click so manytimes?
This should be on the page thatI'm looking at, et cetera.
But overall it's a positive andI don't think the EMR is
necessarily going to cause me tochange my practice style or
give up private practice.
It is expensive though, doug.
I mean the EMR is pricey whenyou're solo and you're paying
full freight for the EMR andyou're not distributing that
(28:42):
over a bunch of partners.
There is a lot of expense tothat and at the end of the day,
thank goodness, money is notthat important and I don't mind,
you know, necessarily making alittle less if life is easier,
but there is a large cost to it.
Dr. Lundy (28:59):
I understand the hospital couldn't work with you
in terms of.
Dr. Barber (29:03):
Sure, if I would just get employed, all I had to
do is sign the contract and allthat would be no problem.
And honestly, I don't know whatI'm going to do.
I'm being honest with you, I'vethought about it, I've actually
talked to him a little bit andI've also started reaching out
to some PE people, and I'mnowhere close to making a
(29:26):
decision or anything.
But that is one of theadvantages of getting employed,
or PE is a lot of that stuff istaken care of for you.
But I have employed colleaguesthat just love to gripe about
their particular EMR and theyhave no control over it.
And you know, if tomorrow Idecided that I hated my EMR, I
(29:48):
could change it tomorrow.
That would not be a big deal,other than the cost, of course.
Right, right, yeah.
Dr. Lundy (29:54):
All right then.
So, with all we've talked about, what else is impacting the
future of the solo privatepractice role?
Orthopedic surgeon.
Dr. Barber (30:04):
I would say the number one thing that I would
like to see, which I'm justdreaming here.
I realize this is unrealistic,but I think we should work on it
anyway.
But we need better coordinationbetween rural and urban, rural
metro, whatnot, and I don'tthink any urban metro
orthopedist wants a delayedpresentation of something that
(30:24):
should have been there long ago.
We just don't have greatcoordination when it comes to
arranging that.
I want to brag on you just alittle bit, if I could.
Uh-oh.
(30:45):
Uh-oh, I think it was about 20years ago, doug Lundy came down
to Coffey County.
You were paid.
We did pay you to come toCoffey County, but my partner
and I went out of town and youtook over the practice for a
week.
And you took the call and youwent to the OR and you handled a
(31:05):
week's worth of Coffey Countyorthopedics.
Ironically, when we got back wewere considered terrible
surgeons because you had justshown them how to do it.
We didn't know what we weredoing.
So the downside was we lookedpretty bad when we got back into
town.
But the fact that you spent aweek in Coffey County, I think
that and now I'm speaking foryou and correct me if I'm wrong,
(31:28):
but I think that that reallygave you an understanding of
some of the limitations, thelimitations to subspecialty care
, you know, etc.
So, as you recall, for the lastI don't know, 15 years before
you left atlanta, you you recallthat I would frequently call
(31:49):
you or text you or email youwith a tough case.
Right, yeah, and you gave megreat advice.
You know you would say, hey,put a plate on that, hey, put a
rod on it, whatever.
You know, you would give megood advice on the case.
And then other times you wouldsay, oh Jim, you just need to
send that to me and it was great.
(32:11):
I mean, it's exactly what Ineed more of even now is the
ability to collaborate like that.
But there's just no paymentmechanism for that.
Really, you were just beingnice, you were just being a
friend, you know.
So that kind of ties in with thesecond thing I'd like to see,
and that is the dreadedtelemedicine which is so
(32:33):
overhyped.
Again, computer science, I'mjust a Luddite with all that.
But telemedicine has a lot ofpotential.
But the huge mistake is itshould never have been or should
be.
Doctor to patient.
Telemedicine should be doctorto doctor, doctor to mid-level
specialist to generalist,whatever.
(32:54):
But in terms of a forcemultiplier, in terms of, in your
case, you educating me or yougiving me advice, it's very
quick for you to say, hey, youneed to send that to Atlanta or
oh, you can do that, just put aplate on it, you know.
And that we need, we needtelemedicine, doc to doc, and we
(33:17):
need a funding mechanism sothat it's it's sustainable.
You know, it's not that we'renot asking favors for that.
That would really really helprural orthopedics.
I think we could really work ona better coordination in
telemedicine.
There's an interesting companythat exhibited at the last AAOS
meeting that I've talked to verybriefly.
I don't know much about them, Ican't vouch for them, but the
(33:38):
company is called InHealth andthey do locums in rural areas
and that's another interestingconcept of guys bringing in
orthopedic surgeons to a ruralarea for a period of time and
kind of fulfilling the needsthere for that time.
So interesting.
I'm going to look more intothat and I don't know a lot
about them but that's anotherinteresting solution.
(34:01):
But you know, I do think thefact that you spent a week in
Coffey County was amazing and Iwould love to force every AOS
member to have to do one week ayear something like that, almost
like a missions project, youknow, in a rural area.
I think that would be amazing.
Dr. Lundy (34:20):
In true fairness, I was a trauma fellow at the time
I went down there.
I was in the middle of myfellowship.
Dr. Barber (34:26):
So I appreciate your kind words my fellowship.
So I appreciate your kind words.
Dr. Lundy (34:32):
Well, thank you, and to your point, though it was a
very interesting andenlightening experience that you
were, you are out on your ownIsland.
There You're.
There was nobody else to callif you, if you needed help or if
you got in trouble, andanything else that you would say
.
That is impacting the future ofthe folks in your setting.
Dr. Barber (34:55):
I don't think so.
I think we share a lot.
I think we just have.
I know everyone loves to saythey have the sickest patients,
but we do have really sickpatients.
You know, we have the numberone group of smokers is rural
males, you know.
And we have a lot of diabetes, alot of obesity, a lot of
hypertension, a lot of thingsthat lead to worse outcomes.
(35:16):
We have a real, a real problemis the social determinants of
health, sdoh, the things liketransportation, for instance.
You know, don't have a car,don't have gas for the car,
can't go to Atlanta or Savannah,and then we're stuck with it,
you know.
So there's a lot of things likethat that I think are general
(35:38):
problems, but I think everyonefeels like they have tough cases
.
Dr. Lundy (35:43):
So, overall, if you had to assess the future in
terms of your setting, is itpositive, is it negative?
How much?
How much?
I'm not going to let you stayon the midline.
You got to go one way or theother.
Dr. Barber (35:56):
I was going to ask you do I have to?
Dr. Lundy (35:57):
commit.
You could stay on midline ifyou want.
Where do you think it is?
Well, you're the one living it.
Dr. Barber (36:02):
I think that I saw a recent study that showed that
rural orthopedic surgeons aremuch older in general, on
average, than metro ortho, andthat's a worry.
The trend is toward lessorthopedic surgeons in rural
areas.
It was 77% metro in 2000 and93% metro in 2019.
(36:27):
Wow, and there are 93% of UScounties have no orthopedic
surgeon 93% 93%.
That's from JAOS 2022.
So I think that's fairlyalarming.
That's worrisome to me.
I think that's not a good sign.
I think it seems like it seemslike it's getting worse, but I
(36:49):
again, I'm I'm optimistic.
It seems like there are a lotof people.
I mean, look at, you're doingthis podcast about rural ortho
and that's I'm thrilled.
You know, it seems like there'sa lot of groups in our state
legislature and AOS.
I think a lot of people areconcerned about rural ortho and
(37:13):
that's encouraging.
So I think things are going toget better because of that.
I always like to remind my citycolleagues that you will be
driving through a rural area atsome point, probably with your
family, and the death rate ismuch, much higher if you have a
car wreck in a rural area.
So we all need to work on thisproblem together, all right.
Dr. Lundy (37:35):
Anything else you'd like to add?
My friend.
Dr. Barber (37:37):
I've really enjoyed talking to you and I've enjoyed
your friendship and yourleadership, and thank you for
paying attention to rural ortho.
Dr. Lundy (37:46):
Yeah, man, all right.
It's been my pleasure to spendthis time discussing the future
of orthopedic surgery in termsof the solo practice rural
orthopedic surgeon with Dr JimBarber.
Dr Barber has obviously beenquite successful in his career,
both organizationally and in hislocal practice and setting
(38:07):
there, and, jim, thank you somuch for spending this time with
us.
Dr. Barber (38:10):
Doug, I loved it.
Miss seeing you.
Thank you very much.
Dr. Lundy (38:19):
I miss you too, buddy .
All right, and so y'all stay intouch as we continue through
this podcast series with thedifferent settings and the
different aspects in terms ofhow is the future going to be
defined in orthopedic surgery.
Stay tuned.
Welcome to the AOA Future in Orthopaedic Surgery
podcast series.
This AOA podcast series willfocus on the future in
orthopaedic surgery and theimpact on leaders in our
profession.
These podcasts will focus onthe vast spectrum of change that
will occur as the futurereveals itself.
We will consider changes asthey occur in the domains of
(00:42):
culture, employment, technology,scope of practice, compensation
and other areas.
My name is Doug Lundy, host forthe podcast series.
Joining us today is Dr.
Jim Barber.
Dr.
Barber is an orthopedic surgeonpracticing in a rural setting
in Douglas, Georgia.
He graduated with hisbachelor's degree from the
(01:03):
Georgia Institute of Technology,his medical degree from the
Medical College of Georgia andhe completed his residency at
the Georgia Baptist OrthopaedicProgram.
He completed the AOS LeadershipFellows Program and ascended to
become president of the GeorgiaOrthopedic Society.
He has faithfully served as amember of the AOS Board of
Counselors and now sits on theAOS Board of Directors as the
(01:26):
Secretary of the BOC.
He also serves as Speaker ofthe House of the Medical
Association of Georgia,president of the Georgia Society
of Ambulatory Surgery Centers,chair of the Georgia Board of
Healthcare Workforce appointedby Governor Kemp and Vice Chair
of the Board of Trustees of theOkefenokee Swamp Park.
(01:47):
Dr Barber, welcome to thepodcast.
Dr. Barber (01:50):
Thank you Doug.
Dr. Lundy (01:51):
Great to talk to you.
So, jim, before we get started,how far is Douglas Georgia from
Hartsfield InternationalAirport in Atlanta?
Dr. Barber (02:01):
Infinity.
It's about three hours south ofAtlanta, Georgia.
Dr. Lundy (02:10):
It just staggers me, brother, that you've been able
to do all these things living sofar from a major hub airport.
Dr. Barber (02:17):
It's just it staggers me that my wife has let
me do all these things.
Dr. Lundy (02:21):
There you go.
Well, jim, in this series youknow we're discussing the
changes that we will believethat occurs in the future of
orthopedic surgery, and today Iwould love to discuss the future
of a small rural privatepractice which, my friend, you
have been in for quite a longtime.
Can you tell the listenersabout your practice?
Dr. Barber (02:41):
Love to Doug Douglas .
Georgia is a town of 13,000.
It's about three hours south ofAtlanta, about two hours north
of Jacksonville and about twoand a half hours west of
Savannah and those would be thenearest what we'd call cities.
There's about 45,000 people inthe county.
The nearest trauma center isprobably Savannah and when you
(03:03):
count loading time by helicopterit's about two hours to get to
the trauma center there, aboutfour hours by ambulance or so.
My first ER patient 25 years agowas a farmer whose hog had
bitten off his finger and I wentto the ER to see him and he was
(03:24):
adamant that he could go getthat finger if I was able to put
it back on, and I assured himthat no, we just need to shorten
his finger.
They're very hardworking inthis area and it's rare to meet
a patient that I don't know oris a stranger.
I get a lot of feedback.
Some of that is positive andsome of that's negative, but in
a small town you just can'tescape it.
(03:44):
It's a great place to raise afamily.
I've got a wife and threedaughters and it's just.
I really enjoy living here.
Dr. Lundy (03:52):
But you're not a small town guy.
I mean, you grew up in ATL.
You, like I said, you went totech, you went to high school in
Atlanta.
Dr. Barber (04:03):
I mean, that's quite a shift, isn't it?
You know, they say that God hasa funny sense of humor, and
when I was in Atlanta, I livedin Atlanta for 20 years and I
swore I would never live in asmall town ever.
And I used to visit mygrandparents in a small town in
South Georgia and I just thoughtit was terrible.
I could never live there, neverbe happy.
But my best friend in residencycame to Douglas the year before
(04:27):
.
He was a year ahead of me inresidency and he just insisted
that I needed to come down andjoin him and I thought it'd be
great to work with him.
So I ended up coming straightto Douglas from residency and
I'm so glad I did.
It's just been a greatexperience and I'm really
thankful that I'm here.
I wouldn't want to be anywhereelse.
Dr. Lundy (04:49):
So, jim, this is not a small thing.
You have elevated, all on yourown and in the setting that you
practice in, up to becoming thesecretary of the board of
counselors, which is a prettybig deal.
Dr. Barber (05:01):
Well, thank you, Doug.
I do want to make it clear thatI'm speaking on my own behalf
and not on behalf of the AOSboard of directors, of course,
and that's fair.
Dr. Lundy (05:09):
Thank you Now, before I go too far.
I mean you are also the posterchild for all the people who
just can't seem to get involvedbecause of fill in the blank.
I mean you are all by yourself,way down there, far from the
airport.
When you go out of town, youhave a PA right.
Dr. Barber (05:29):
I do.
Dr. Lundy (05:30):
So your PA then is covering your patients, but
somehow you've been able tobecome very involved, obviously
extensively there in Georgia,but also on a national level.
Dr. Barber (05:50):
Well, the reality is around here.
Most people spend a lot oftheir time hunting or fishing,
and I just don't enjoy eitherone of those.
So I have a lot of free timeand I have a very understanding
family and I just really enjoyserving in organized medicine.
It's just a passion and a funthing for me to do and I feel
really rewarded in giving backthat way and I feel really
rewarded in giving back that way, but I also am able to keep my
head above water by beingengaged and involved, and I can
(06:10):
see what changes are coming downthe pike, so to speak.
Dr. Lundy (06:17):
And so it's just something I really enjoy doing.
Based on your experience, bothin the state of Georgia,
regionally in the southeast, andthen your experience in the in
the country, being involved inthe BOC and the AOS, how many
folks do you know out there havesimilar rural, small town solo
private practices like you?
Dr. Barber (06:36):
You know, I think there's a lot more than we think
.
I think we're just not verywell organized.
But I think that it's we, weall.
We know about the big groupsand everything, but we just
don't know about the solo guysin rural.
But I don't know a number.
Honestly, I, I, I would justsuspect that it's more than we
think.
Dr. Lundy (06:52):
Well, my point is when you go to the meeting and
you're, when you meet somebody,it's not, it's not a total
rarity.
You meet folks that you go.
Hey, I do the same thing andit's.
It doesn't seem that uncommonto you.
Dr. Barber (07:03):
That's right.
Is that fair?
That's fair.
Dr. Lundy (07:06):
Yeah, so over the past 25, 26 years you and I
finished residency at the sametime.
So we're dating ourselves Trueand in full disclosure.
You and I finished residencytogether since we were
co-residents.
Hey, jim, over the past 25years I'm sure you've seen a
(07:26):
market change in the developmentof your practice.
Certainly that goes along withthe development of your skillset
and your comfort and takingcare of complex patients and
routine patients and to yourpoint, by now a lot of these
folks are your neighbors andyour friends, which puts a
certain twist on it that a lotof the rest of us like.
When I was practicing inAtlanta, most of the folks I saw
I never would run into againoutside the clinical setting and
you see them all the time atthe grocery store and at church
(07:49):
and at Friday night footballgames and all that Over the
period of time.
How has your practice changed?
How have you seen, specifically, this fellow private practice
in rural America change?
Dr. Barber (08:03):
Well, one thing that hasn't changed is my income.
I've made about the same everyyear for the last 25 years, but
I certainly have worked harder.
I'm sure that all of thelisteners would feel the same
way about that, but I know for afact that I'm seeing twice as
many patients now as when Istarted.
I think that in many ways theburdens have gotten more
difficult with dealing withinsurance companies and the
(08:26):
bureaucracy of practicingmedicine.
I think maybe in some ways it'sgotten a little bit better.
I think I really am not a verybig fan of the EMR, but I have
to admit in some ways that'smade it easier to practice.
I think the biggest problem isjust it seems like it takes a
larger and larger team to getthrough the practice of medicine
(08:49):
now and we just don't havethose type of teams in my area.
Dr. Lundy (08:54):
Specifically, how do you think that impacts you more
than if you had had like, if youhave like a half a dozen
partners with you?
Dr. Barber (09:05):
half a dozen partners with you.
I'm really jealous of thoseguys.
I think you know I would loveto have a CEO and a CFO and a
CAO and an HR department andmarketing department.
I'd love to have all of thosethings working with me.
And those are the things Idon't have and I just have to do
more jobs, wear more hats.
I put more responsibility on myoffice manager and others, and
so that's just gotten harderover the years with the
(09:27):
increasing complexity ofpracticing.
How many staff do you have?
I have 13 staff.
Okay.
Dr. Lundy (09:36):
So I'm sure with the past 25 years you have a
trajectory.
I mean you can see where thisis heading.
What's your, what is yourpredictions of where solo rural
private practice is headed inthe next pick it brother, five,
10, whatever, whatever you'recomfortable with.
Dr. Barber (09:53):
Honestly, I am not.
I'm not sure I, I really don'tknow for certain.
I'm optimistic that at least inGeorgia I don't know about the
other states, but in Georgia thelegislature has put a real
tremendous emphasis on ruralhealth care and there are really
good state programs in Georgiathat have support for
(10:17):
undergraduate medical educationtied to rural health care and
residency slots tied to ruralhealth care and a lot of loan
forgiveness programs for ruralphysicians and others.
I'm optimistic about ourcommunity here.
We have a tight community withthe hospital and we have really
(10:38):
embraced value-based care.
So we've had a greatinvolvement with a risk-based
ACO for several years now.
Last three years we've actuallyearned shared savings and we've
started a direct-to-employercollaboration between the
hospital and the privatepractice physicians, which is
(11:01):
right along the lines ofvalue-based care.
All that I'm really excitedabout.
I think that it's surprisingthat a small town could do so
much with value-based care, butthat's been really encouraging.
I've been a little bitpessimistic about the whole
concept of consolidation.
I'm a little bit worried aboutwhat am I going to do.
(11:21):
Am I going to join the hospitaland get employed or am I going
to look into private equity orventure capital?
But the reality is the power ofthe insurance companies just
continues to grow.
If you think about priorauthorization, that's just a
great example.
But I feel like I need a largerteam with me to navigate all of
(11:43):
that.
So I'm a little bit pessimisticabout that and I think the
collegiality has been tougherover the last 25 years.
It seems to be getting tougher.
I think the physicians tend tobe more siloed as they're more
employed and less likely to hangout and talk, and there's just
more apathy in general.
(12:04):
I think At least I see moreapathy in general and I remember
a talk you gave that I stoleabout 15 years ago about famous
excuses for not getting involved.
They were politics are dirty,contributions are bribery.
Only big industry corporationshave influence.
Politicians should do the rightthing without influence and I
(12:27):
can't give much.
It won't make a difference.
And that was 10 or 15 years agoand it's gotten worse since
then.
Doug, I was so a little worriedabout scope of practice.
I think that has eaten into ourfiduciary responsibility with
patients.
That seems to be getting worse.
Ultimately, one of my biggestconcerns is complacency.
(12:53):
I think we are at the top ofthe medical specialties as far
as advocacy, as far as solvingproblems for our patients.
As far as demonstrating thatfiduciary responsibility to our
patients, we are at the top.
But I think we might be gettinga little bit complacent on that
and I don't want to polarizeany of the listeners, but I do
(13:15):
want to quote coach Nick Saban,who was reflecting on his
disappointment and successesover the years and said for us
to have the kind of team we needto have, there's got to be an
element of being hungry.
We've had to deal withcomplacency at times because of
the success that we've had and Ithink that creates a blatant
(13:37):
disregard for doing what's right.
So, a little concerned aboutcomplacency in our profession so
mixed picture and ourprofession so mixed picture.
I'm optimistic, I want to staypositive and I think that if we,
if I, if we, if I, look forsolutions, they're out there,
we'll find them.
I just don't know if that'sgoing to be staying in private
(13:58):
practice solo, or if that'sgoing to be getting employed or
private equity or whatnot.
Dr. Lundy (14:06):
Well, before we go on , if you're going to quote Saban
, I got to drop a War Eagle GoAuburn in there, so I knew you
would back to a more holypresence here.
Dr. Barber (14:14):
That's why I quoted him.
I needed a reaction.
Dr. Lundy (14:17):
There you go.
So it's fascinating to me thatyou were able to work a lot.
So you're in pure privatepractice.
You don't have any formalrelationship with the hospital,
right, I don't?
Ok, so you're able to work withthe hospital in a Medicare
share savings program throughthe accountable care
organization that y'all have setup.
Clearly, that is asustainability factor that other
(14:42):
folks in your situation couldengage with, because one
advantage I would say if I couldgo out on this limb that y'all
have is that the hospital hasgot to play with you because
there's it's not like they cango cross street and get the
other group with a dozenorthopedic surgeons and get them
to play.
So they're going to work withy'all because you're engaged in
(15:03):
the system, engaged in thecommunity.
Am I on par with this?
Dr. Barber (15:06):
You're on track.
It's just think of us as anoasis.
You know there's a.
We don't have an interstatewithin 50 miles, so we're a bit
isolated, so to speak, and so weare responsible for the
outcomes of our care in thiscommunity.
And so it is imperative thatthe hospital work with the
(15:28):
physicians and vice versa, thatthe hospital work with the
physicians and vice versa, andthat gives us a little bit of an
advantage as far as being ableto I don't want to say control
outcomes, but to monitoroutcomes.
Let's say monitor outcomes, andif someone has an idea on
improving quality of care.
we can implement that prettyquickly and it is local, so
(15:48):
there is some advantage to that.
Dr. Lundy (15:52):
Okay, have you noticed other collaboration?
I guess there's a bunch ofother solo private practice
doctors outside of orthopedicsin your community, right?
Dr. Barber (15:59):
Yes, and we all work well together.
That is one of the things I'mencouraged by.
Dr. Lundy (16:04):
Do you feel like they have a bullish or a bearish
approach to the future in termsof how they think this is going
to go?
Dr. Barber (16:11):
I think people are kind of sitting their ways at
this point.
Most that are employed and theones that are in private
practice are comfortable ridingit out.
The things are going okay, youknow, I think people are kind of
sitting their ways.
Dr. Lundy (16:24):
So what would you recommend?
So a kid comes up through the,a guy or a girl comes up through
the Coffey County school system, goes off to Georgia Tech, goes
off to the Medical College ofGeorgia, goes off and becomes an
orthopedic surgeon and wants tocome back.
What would your recommendationbe if they wanted to move down
to Coffey County and work there?
Would you recommend to go intoprivate practice?
(16:47):
Would you recommend joining thegroup in one of the big mega
groups around the area or workfor the hospital?
What would you say?
Dr. Barber (16:54):
You know, that's a great question and I think that
you basically have to knowyourself and what conditions you
work best in.
I think there are people thatare well-equipped and ready to
be an employee, you know, andthey need an employed scenario
and I don't think they wouldwork well in a private practice
(17:15):
type practice.
Are there others that reallywant to be able to control the
way that they treat patients interms of how they interact with
patients, the types of patientsthey see and the services that
they offer, and I think to havethat level of control you really
need to be in private practice.
That is one, and the servicesthat they offer, and I think to
have that level of control youreally need to be in private
practice.
That is one of the things thatkeeps me going is, if I see a
(17:37):
deficit in how we're treatingpatients, I can fix that that
day or that week pretty easilyand basically, you know, solve
problems very quickly when wesee them and that is something
that's been really nice as faras being in private practice.
But I also know plenty ofcolleagues that are very
(17:59):
comfortable in a more of anemployed role and that suits
them well and I don't think theywould really like the
management type role that isrequired in a small private
practice.
Let's say that I don't reallythink there's a tremendous
difference, honestly, doug,between rural and metro.
As far as the employment style,whether that's employed or
(18:22):
academic or private practice, Ithink that those scenarios are
the same, at least in my limitedviewpoint.
I think those scenarios are allthe same throughout.
I think people need to knowwhat style they want to work in
and where they want to live.
I think that's the two bigissues there.
Dr. Lundy (18:42):
I think it's important to point out that your
viewpoint is not limited.
You know a lot of folks andyou've done a lot of things.
Well okay, maybe now aninteresting aside here is you
and your own surgery center,right, I sure do so to some
degree.
That does put you at odds with.
Is it coffee regional?
Is that what?
Dr. Barber (19:01):
that's right yeah.
Dr. Lundy (19:02):
So that does put you at odds with the hospital, since
you're supposedly cherrypicking and lemon dropping and
we both know I'm being sarcastichere- but, if you're, if you're
pulling revenue off thehospital, how does that?
Does that help or drive a wedgeinto the sustainability of your
, of your ability to practice inthe, in the methodology that
(19:23):
you've been doing as you goforward?
Dr. Barber (19:25):
That's a great question and complex, and I
would say that I didn't want tobuild a surgery center, but I
felt like I had to becausepatients needed a more
economical option for gettingthings done.
And so my surgery center isvery good at efficiency and you
(19:48):
may believe it or not, but it'struth at efficiency, and you may
believe it or not, but it'struth, we operate one day every
two weeks and we are incrediblyefficient and I don't make much
money off it, but it just feelsgood to offer that surgical
option to the patient.
That's a lot easier to swallow.
But it does cause some strifewith the hospital.
(20:09):
It's nothing major and we'veworked through it and I don't
think it really affects theirbottom line too much.
Honestly, there are so manyrestrictions on who we can
operate on in my surgery centerthat we're not really pulling a
lot from the hospital, honestly,and I don't think it's been too
harmful to the hospital.
Let's put it that way.
Dr. Lundy (20:29):
Another big thing that's often touted as damaging
the folks the men and women inyour type of practice setting is
the ability to comply with thecomplexities that Centers for
Medicare and Medicaid Servicescontinue to spew out at us.
Yet it seems that you found asweet spot with working
(20:52):
alongside Coffee Regional inorder to get this done, through
the Accountable CareOrganization and other things.
Do you feel that your abilityto comply and be compliant with
federal and state mandates hasbeen made easier because of,
even though you're remainingsolo and private practice?
The collaboration with thehospital is enabling you to get
by and sustain that further.
Dr. Barber (21:13):
Honestly, I wouldn't say it had much to do with the
hospital.
I would tell you, though, doug,that the key there has been
getting involved withorganizations like my state ASC
organization, like my stateorthopedic society, even my
state medical association,obviously AAOS and through BOC
(21:35):
and whatnot.
I think being involved withthose things has really given me
so much more than I put into itin terms of knowing what's
coming, what we need to complywith, how do we do it.
It's just so nice to go tomeetings like that and find
someone who's already solved theproblem that I have, so that I
(21:55):
don't have to recreate the wheel.
So I think it's more beinginvolved.
That's really been the key toto keeping my head above water
with the regulations.
Dr. Lundy (22:05):
And how difficult is contracting with the insurance
carriers been for you?
Dr. Barber (22:09):
Is impossible a word I could use here.
It's just very difficult.
As you can imagine, I pay topdollar for implants.
There's probably nobody thatpays more than me and that
really impacts the cases I cando.
I'm just low volume, I'm a lowvolume guy.
So that's an example of anegative of being solo, and the
(22:34):
same goes with contracting.
Thankfully there is a veryvibrant and active independent
physicians association, IPA,that I'm a member of.
That helps so much with thecontracting and so we come
together.
We've got about 600 physiciansin the IPA and that does help a
(22:55):
lot with dealing with insurancecompanies.
But we have the same nightmaresthat I'm sure everybody has
with denials and recoupments andthings that just make me just
really upset.
So I know the insurancecommissioner on a first name
basis and I do not hesitate togive the insurance commission
(23:20):
phone number to patients.
We have a problem.
We have it printed out on apiece of paper.
Here's the insurancecommissioner's office.
Give them a call, Tell themwhat's going on.
So it's been a challenge, but Isuspect that's been a challenge
everywhere.
Dr. Lundy (23:35):
Honestly, Administration of your group.
I mean, you've got said youhave 13 FTE staff right, correct
, right and these folks live inSouth Georgia, probably were
born and raised in south georgiaand have family connections and
social connections throughoutthe area there.
Yep, I would think, if I had toguess, that you could really
(23:59):
leverage that to make yourselfpretty valuable in the community
, especially if you gain the,the loyalty and the vision of
the staff you cast the visionthat they could buy into of what
your practice could be.
That's got to go a long way interms of maintaining the
sustainability of your practiceand you know, in many ways I
(24:21):
think many of us want you andyour people, your colleagues, to
survive this.
We kind of love the idea of thesolo person out there.
What are your thoughts?
Dr. Barber (24:32):
Well, first of all, I appreciate that.
So you know, I think I don't doa good enough job with exactly
what you're describing and Ithink that, frankly, I don't
think any of us do a good enoughjob.
I think the reality is, if youlook at teachers, they teach
students.
They have a very powerfuladvocacy source with students
and parents when they have aproblem.
(24:54):
You know, and we have an equal,maybe even greater, advocacy
source our patients.
If we were able to communicatewith them better about our
problems and why it's a problemfor the patient and the doctor,
those patients could be suchpowerful advocates for things
like prior authorization andwhatnot.
But I just don't do that.
(25:15):
I don't know why I don't do it.
I just feel a little bitawkward about spending time
during an E&M talking aboutpolitical things, but I do think
that we could do better withmotivating our patients to be
our advocates with insuranceissues, with bureaucracy issues,
all of those things.
Dr. Lundy (25:35):
I'm a little surprised at your EMR
discussions.
I mean, you did go to GeorgiaTech.
Let me remind you of that.
That is one of the bestengineering schools around.
Yet you say you struggle withthe EMR and you just recently
got it.
I'm surprised you haven't madeyour own EMR.
But obviously this is a pointof the sustainability of your
practice into the future.
(25:56):
So how has the EMR affectedyour practice?
How do you think it will changethings going on?
Will it help you sustain thisor will this be one of the nails
that destroys solo ruralprivate?
Dr. Barber (26:10):
practice search.
That's a good question too,doug.
So my my, you know, myundergraduate degree was
computer science and that kindof tainted me for 20 years or so
.
I just couldn't find an EMRthat I could live with, you know
, just because they all sucked,you know.
So it took me a long, long timeand eventually I got my arm
(26:31):
twisted so hard.
Hey, you got to have an EMR,we've got to integrate your EMR
with our ACO, et cetera.
So I did a little shopping andI found one, and I'm not going
to tell you which one it is.
I like it, I don't like it.
It's a love hate thing.
I'll tell you one thing thatrecently I remember it used to
be Doug, did you ever have papercharts ever?
Dr. Lundy (26:52):
Oh yeah, when I first started in Colorado, we had
them, yeah, all right.
Dr. Barber (26:56):
So you remember, if you forgot to dictate a paper
chart, that could be a nightmare.
You know you've got to find achart and someone else had it
and it was just.
You know nothing worse than astack of charts to have to
dictate at the end of the day oron a weekend or whatever.
And the one thing for sure thatthe EMR has done for me is I
get all my, all my stuff donewhile the patient's there and
(27:18):
many times I can I immediatelyprint the note out for him.
Here's your note for today andthat that truly is a benefit.
And I realized that I'm thelast orthopedic surgeon on the
planet to acknowledge this, butI'm just telling you it took a
lot of therapy.
After, after all those yearsand seeing how awful the EMRs
(27:40):
are, the simple fact is theyneed to allow a lot more
customization of the userinterface and the EMR that's the
number one problem is I knowhow, what I want to see on that
screen and they should let mechoose what I want to see on
that screen and nobody can dothat for me.
But that's, that's the biggestproblem as far as you know.
(28:00):
Bigger question overall is EMRspecifically a negative or
positive.
It's a positive.
I mean it's positive for ourbilling.
It's positive for our billing,it's positive for my notes, it's
positive for the patient.
It's a pain in the butt to dealwith and you know, it just
makes me frustrated when I can'tfix the clickies.
(28:20):
Why do I have to click so manytimes?
This should be on the page thatI'm looking at, et cetera.
But overall it's a positive andI don't think the EMR is
necessarily going to cause me tochange my practice style or
give up private practice.
It is expensive though, doug.
I mean the EMR is pricey whenyou're solo and you're paying
full freight for the EMR andyou're not distributing that
(28:42):
over a bunch of partners.
There is a lot of expense tothat and at the end of the day,
thank goodness, money is notthat important and I don't mind,
you know, necessarily making alittle less if life is easier,
but there is a large cost to it.
Dr. Lundy (28:59):
I understand the hospital couldn't work with you
in terms of.
Dr. Barber (29:03):
Sure, if I would just get employed, all I had to
do is sign the contract and allthat would be no problem.
And honestly, I don't know whatI'm going to do.
I'm being honest with you, I'vethought about it, I've actually
talked to him a little bit andI've also started reaching out
to some PE people, and I'mnowhere close to making a
(29:26):
decision or anything.
But that is one of theadvantages of getting employed,
or PE is a lot of that stuff istaken care of for you.
But I have employed colleaguesthat just love to gripe about
their particular EMR and theyhave no control over it.
And you know, if tomorrow Idecided that I hated my EMR, I
(29:48):
could change it tomorrow.
That would not be a big deal,other than the cost, of course.
Right, right, yeah.
Dr. Lundy (29:54):
All right then.
So, with all we've talked about, what else is impacting the
future of the solo privatepractice role?
Orthopedic surgeon.
Dr. Barber (30:04):
I would say the number one thing that I would
like to see, which I'm justdreaming here.
I realize this is unrealistic,but I think we should work on it
anyway.
But we need better coordinationbetween rural and urban, rural
metro, whatnot, and I don'tthink any urban metro
orthopedist wants a delayedpresentation of something that
(30:24):
should have been there long ago.
We just don't have greatcoordination when it comes to
arranging that.
I want to brag on you just alittle bit, if I could.
Uh-oh.
(30:45):
Uh-oh, I think it was about 20years ago, doug Lundy came down
to Coffey County.
You were paid.
We did pay you to come toCoffey County, but my partner
and I went out of town and youtook over the practice for a
week.
And you took the call and youwent to the OR and you handled a
(31:05):
week's worth of Coffey Countyorthopedics.
Ironically, when we got back wewere considered terrible
surgeons because you had justshown them how to do it.
We didn't know what we weredoing.
So the downside was we lookedpretty bad when we got back into
town.
But the fact that you spent aweek in Coffey County, I think
that and now I'm speaking foryou and correct me if I'm wrong,
(31:28):
but I think that that reallygave you an understanding of
some of the limitations, thelimitations to subspecialty care
, you know, etc.
So, as you recall, for the lastI don't know, 15 years before
you left atlanta, you you recallthat I would frequently call
(31:49):
you or text you or email youwith a tough case.
Right, yeah, and you gave megreat advice.
You know you would say, hey,put a plate on that, hey, put a
rod on it, whatever.
You know, you would give megood advice on the case.
And then other times you wouldsay, oh Jim, you just need to
send that to me and it was great.
(32:11):
I mean, it's exactly what Ineed more of even now is the
ability to collaborate like that.
But there's just no paymentmechanism for that.
Really, you were just beingnice, you were just being a
friend, you know.
So that kind of ties in with thesecond thing I'd like to see,
and that is the dreadedtelemedicine which is so
(32:33):
overhyped.
Again, computer science, I'mjust a Luddite with all that.
But telemedicine has a lot ofpotential.
But the huge mistake is itshould never have been or should
be.
Doctor to patient.
Telemedicine should be doctorto doctor, doctor to mid-level
specialist to generalist,whatever.
(32:54):
But in terms of a forcemultiplier, in terms of, in your
case, you educating me or yougiving me advice, it's very
quick for you to say, hey, youneed to send that to Atlanta or
oh, you can do that, just put aplate on it, you know.
And that we need, we needtelemedicine, doc to doc, and we
(33:17):
need a funding mechanism sothat it's it's sustainable.
You know, it's not that we'renot asking favors for that.
That would really really helprural orthopedics.
I think we could really work ona better coordination in
telemedicine.
There's an interesting companythat exhibited at the last AAOS
meeting that I've talked to verybriefly.
I don't know much about them, Ican't vouch for them, but the
(33:38):
company is called InHealth andthey do locums in rural areas
and that's another interestingconcept of guys bringing in
orthopedic surgeons to a ruralarea for a period of time and
kind of fulfilling the needsthere for that time.
So interesting.
I'm going to look more intothat and I don't know a lot
about them but that's anotherinteresting solution.
(34:01):
But you know, I do think thefact that you spent a week in
Coffey County was amazing and Iwould love to force every AOS
member to have to do one week ayear something like that, almost
like a missions project, youknow, in a rural area.
I think that would be amazing.
Dr. Lundy (34:20):
In true fairness, I was a trauma fellow at the time
I went down there.
I was in the middle of myfellowship.
Dr. Barber (34:26):
So I appreciate your kind words my fellowship.
So I appreciate your kind words.
Dr. Lundy (34:32):
Well, thank you, and to your point, though it was a
very interesting andenlightening experience that you
were, you are out on your ownIsland.
There You're.
There was nobody else to callif you, if you needed help or if
you got in trouble, andanything else that you would say
.
That is impacting the future ofthe folks in your setting.
Dr. Barber (34:55):
I don't think so.
I think we share a lot.
I think we just have.
I know everyone loves to saythey have the sickest patients,
but we do have really sickpatients.
You know, we have the numberone group of smokers is rural
males, you know.
And we have a lot of diabetes, alot of obesity, a lot of
hypertension, a lot of thingsthat lead to worse outcomes.
(35:16):
We have a real, a real problemis the social determinants of
health, sdoh, the things liketransportation, for instance.
You know, don't have a car,don't have gas for the car,
can't go to Atlanta or Savannah,and then we're stuck with it,
you know.
So there's a lot of things likethat that I think are general
(35:38):
problems, but I think everyonefeels like they have tough cases
.
Dr. Lundy (35:43):
So, overall, if you had to assess the future in
terms of your setting, is itpositive, is it negative?
How much?
How much?
I'm not going to let you stayon the midline.
You got to go one way or theother.
Dr. Barber (35:56):
I was going to ask you do I have to?
Dr. Lundy (35:57):
commit.
You could stay on midline ifyou want.
Where do you think it is?
Well, you're the one living it.
Dr. Barber (36:02):
I think that I saw a recent study that showed that
rural orthopedic surgeons aremuch older in general, on
average, than metro ortho, andthat's a worry.
The trend is toward lessorthopedic surgeons in rural
areas.
It was 77% metro in 2000 and93% metro in 2019.
(36:27):
Wow, and there are 93% of UScounties have no orthopedic
surgeon 93% 93%.
That's from JAOS 2022.
So I think that's fairlyalarming.
That's worrisome to me.
I think that's not a good sign.
I think it seems like it seemslike it's getting worse, but I
(36:49):
again, I'm I'm optimistic.
It seems like there are a lotof people.
I mean, look at, you're doingthis podcast about rural ortho
and that's I'm thrilled.
You know, it seems like there'sa lot of groups in our state
legislature and AOS.
I think a lot of people areconcerned about rural ortho and
(37:13):
that's encouraging.
So I think things are going toget better because of that.
I always like to remind my citycolleagues that you will be
driving through a rural area atsome point, probably with your
family, and the death rate ismuch, much higher if you have a
car wreck in a rural area.
So we all need to work on thisproblem together, all right.
Dr. Lundy (37:35):
Anything else you'd like to add?
My friend.
Dr. Barber (37:37):
I've really enjoyed talking to you and I've enjoyed
your friendship and yourleadership, and thank you for
paying attention to rural ortho.
Dr. Lundy (37:46):
Yeah, man, all right.
It's been my pleasure to spendthis time discussing the future
of orthopedic surgery in termsof the solo practice rural
orthopedic surgeon with Dr JimBarber.
Dr Barber has obviously beenquite successful in his career,
both organizationally and in hislocal practice and setting
(38:07):
there, and, jim, thank you somuch for spending this time with
us.
Dr. Barber (38:10):
Doug, I loved it.
Miss seeing you.
Thank you very much.
Dr. Lundy (38:19):
I miss you too, buddy .
All right, and so y'all stay intouch as we continue through
this podcast series with thedifferent settings and the
different aspects in terms ofhow is the future going to be
defined in orthopedic surgery.
Stay tuned.
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