Medical Justice provides free consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. We also provide counsel specific to COVID-19. If you are navigating a medico-legal obstacle, visit our booking page to schedule a free consultation – or use the tool shared below.

Many surgeons are entrepreneurial. They are driven to succeed. Sometimes that means adding new services. Or adding capacity to serve additional volume. Sometimes it means expanding into a new community.

What could go wrong?

Well, the first question is whether you are bringing a new service to an underserved community. If so, you will likely see a red carpet, welcoming you to Podunk^[1]. Of course, you need to use good judgment as to what types of procedures you can and should do in Podunk. For example, would it be wise to start a transplant program in Podunk, where the surgery is performed in Podunk? No. Would it be wise to have a satellite office to screen/see patients in Podunk, but have the surgery performed in the metro area? Perhaps.

What if your satellite surgery center is actually in a major metro area with loads of perceived competitors? What if you actually live two hours away? Any concerns?

The issue is known as “itinerant surgery.” Addressing this does not yield a perfect black/white answer. It’s a more gray zone. Nonetheless, the triggers are regulatory, legal, and ethical issues.

Regulatory: The first issue is what the state Board of Medicine mandates if anything. Some state Boards may have much to say on the topic. Other states may be silent. The issue may be addressed tangentially with a delegation of duties to mid-level providers. For example, a physician who delegates the performance of a nonsurgical medical cosmetic procedure to a midlevel provider (PA or APRN) in one state must be “available” for an emergency consultation or appointment in the event of an adverse outcome. Do they have to be onsite? No. Just available. Is available defined? No. So, in that model, living two hours away is not explicitly foreclosed.

Legal: What happens IF a patient has a complication? Well, before it gets to that point, the operating surgeon needs to educate/instruct the patient on what might be considered a complication, and give the patient written instructions on how to mitigate – or what to do. I’m a fan of giving the patient your mobile number. That way you can directly hear what the problem is, and allow the patient even to share photos.  Next, do you have privileges at the remote hospital? If so, great. If not, consider obtaining them. In the event of an emergency, you will likely tell the patient to dial 911 or go to the closest hospital ER. If you are on staff, this patient will be stabilized and then you can see the patient. If you are not on staff, a perceived competitor will take over. Such a competitor might have an ax to grind. They will not be happy about getting out of bed at 1 AM to address your complication. They could file a complaint to the Board, instigate a lawsuit, or just rile your patient up. If you prefer not to get staff privileges at the remote hospital, can you develop a relationship with a surgeon who lives locally? That surgeon can be the admitting surgeon in the event of a complication.

Ethical: Many surgeons are members of the American College of Surgeons (ACS). If so, the ACS frowns on itinerant surgery. A recent article was published in Annals of Thoracic Surgery on the pros and cons of itinerant surgery.

Here are snippets from the article.

In regard to the topic of continuity of care, the College establishes that an ethical surgeon should not perform elective surgery at a distance from the usual location where he or she operates without personal determination of the diagnosis and of the adequacy of preoperative preparation. Postoperative care should be rendered by the operating surgeon unless it is delegated to another physician who is equivalently qualified to continue this essential aspect of total surgical care.

These rules have been challenged. For example, Dr. Robert Koefoot and a group of surgeons from Nebraska challenged the rules in 1982, but the College was awarded a favorable ruling. In the legal proceedings, the College was clear in stating that:

• the surgeon has a moral, ethical and legal obligation to give patients upon whom he has operated his personal attention and to attend his patients postoperatively;
• if Dr. Koefoot chooses not to drive the required distance to see his patients if Dr. Koefoot disagrees with the College policy, or if Dr. Koefoot chooses to spend his time on pursuits other than surgery, that is certainly his choice, but
• then he may not call himself a Fellow of the American College of Surgeons.

In the illustration, the itinerant surgeon lived 75 miles away.

In sum, is itinerant surgery done? Yep. Can problems be anticipated? Yes. The more such anticipated problems can be managed, the less likely there will be blowback. Ideally, having a local surgeon available to manage emergencies is best. The next best would be obtaining staff privileges at the remote hospital and being able to show up within a reasonable time frame. Even for someone living one mile from the hospital, what happens if he is in the operating room when a fresh post-op patient shows up in the ER in extremis? That surgeon can’t be in two places at one time. Still, having a plan anticipates such problems. The patient goes to the ER, and the ER can assist in buying time by stabilizing the situation. Then the operating surgeon shows up in a reasonable time frame.

Finally, most problems with itinerant surgery are complaint driven. If you anticipate patient problems with actionable solutions, the risk goes down.

Sometimes when you show up in a new community, you’re greeted with flowers. Sometimes with knives. Plan accordingly.

What do you think? Let us know your thoughts below.

[1] Podunk is of Algonquin origin. It denoted both the Podunk people and marshy locations, particularly the people’s winter village site on the border of present-day East Hartford and South Windsor, Connecticut. Podunk was first defined in an American national dictionary in 1934, as an imaginary small town considered typical of placid dullness and lack of contact with the progress of the world. https://en.wikipedia.org/wiki/Podunk

Medical Justice provides free consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. We also provide counsel specific to COVID-19. If you are navigating a medico-legal obstacle, visit our booking page to schedule a free consultation – or use the tool shared below.

Jeffrey Segal, MD, JD

Chief Executive Officer and Founder

Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.

Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2021 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.