D (3:24)

Yeah, yeah.

E (3:26)

I think the big issue is again doing some medical legal work is the potential income, which in a college athlete you can think about if they go professional, but now they're actually getting money. So before it was argumentable. Theoretically they may not be recruited. So you can argue a little bit, but there's no guarantee of that. But now they're getting a million, $2 million, $500,000. They now have the ability to claim that that money clearly would have shown they would make X amount later and you're shockingly liable. I was in a case for high school. The numbers were in the 20 million dollar range. High school, this is nonsense in my opinion. So I think for those of us that treat athletes, I'm lucky I'm at Northwestern, which is self insured, so that I don't worry about it. But if you're in private practice, it is something that is a real issue talking to one of our colleagues that does professional athletes, that the burden is getting higher and higher. And you think just for professional, but for college, you gotta think about it too. And you gotta think about it for high school now. And you know the question, is there value in us putting our neck on the line to treat these athletes? It's like worker's comp now, like this, this patient that you said is cleared to play, they can come after you. Like I'm not clear, but you get into A huge fight. Like it actually now holds this person because usually they're cleared to play. Like a worker's comp, like work is complex. I'm not ready for work. And you're like, I think you're like, I'm not ready for work. Well then if you say they're ready for work, they don't want to go back to work. Now the anger comes towards you. And so it's, it's, it's different than college athletes were fun because you just want, they won't want to go back to play. That situation now totally changed. Yeah. And so it's, you know, I think for a lot of people that do athletes like, there's a lot of risk. We really have to start calculating reward a lot more. Yeah. It's not put. The burden is only on us.

D (5:07)

Yeah. What we've done is we co scrub with another surgeon for those cases. And so. And you know, does it help, does it, does it mitigate your risk?

E (5:19)

I don't know.

D (5:19)

But you know, having another person there that can document that you make sure that what you're doing is, you know, backed up and verified, I think in some realm protects you a little bit. Probably not perfectly, though.

C (5:33)

I think the hard part is what about when the surgery is done? Like the example Ben gave. What if the surgery is done perfectly? Everything looks right, but they just, you know, having that extra person in the room still doesn't tell you that this person isn't still having pain. Right. That they can still click, click. I don't even want to say claim they may still be having pain. None of our surgeries are perfect and we may be moving into this phase where now they're going to attribute their inability to get that next transfer contract based on their fifth metatarsal that didn't fully heal, for example.

B (6:12)

Yeah. I worry that ultimately or not it's going to lead to the same thing that we're going to roll into, which is an access to care problem. Because I think once there are enough lawsuits, people are not going to want to take the headache of it because for the most part that there's a lot of extra burden that comes either with time or family or emotions of taking care of high level teams. And then it's the. For what? And so I think that in my institution, because I'm a state institution in the state of South Carolina, like I get dismissed from every lawsuit and there's a million dollar cap, you know, so it'd be interesting so I could take care of a lot of athletes and there's a maximum that they could potentially sue me for. So I see a lot of people only at some of these institutions like what I'm talking about. And maybe you aneesh that those are going to who's going to be taking care of all those folks? Because there's some medical liability cap to it. But I do worry about the access to care for these folks, which is also not great if you don't ability to get them. They don't have the resources. I mean, talk about some high school kid. Well, they can't drive maybe four hours to go have some person that does have medical liability cap that's going to take care of them versus not take care of them. And I do worry about that, you know.

C (7:12)

And also we're in a landscape now where a lot of our mentors are close to the end of their careers who have managed many, many of these professional athletes for their entire time and practice. And so that's, that's a new reality.

E (7:24)

Right?

C (7:24)

There's who are the. Who do you trust? Who's the go to authority on turf toe or Achilles rupture?

B (7:32)

The other thing I want to get Yalls thoughts on this was brought up by our unsports medicine department about six months ago. Was obviously there are a ton of transfers, right? I mean there's some teams that basically have their team or transfers every year. So what about your examination of them, your kind of medical screening examination? So there's been questions. Okay, the guy had a surgery. You don't think it's done very well. They have let's say a fifth metatarsal non union. We'll just use that as an example. Fifth metatarsal union. You document their fifth metartal union. Now all of a sudden your team doesn't want to pick them up now that it's in their medical record. Now 12 other teams don't want to pick them up. Now they don't get their contract. Now they're going to sue you for I don't know what. Because lawsuits are easy to do and a lawyer might take it because that could be millions of dollars of loss of income. Because you said that a fifth metatarsal nonunion when maybe they were asymptomatic. And people have seen that before too. So how is your institution handling these transfers? Is it basically an IME and is there a fee for that IME and does it go into the medical record or is it just a. There's a sort of a courtesy exam that only goes to our coaching staff how are you guys handling that?

E (8:35)

Our team docs, of which I'm not the official, like, overall team document. Our team docs will do all the entry exams. If they have a footnote injury, they'll ask us. But I actually fundamentally have stepped down from Northwestern athletics for most of. Unless it's really weird for that reason. It was a lot of extra liability. These are not amateurs anymore. So fundamentally now you're treating a slew of theoretically potential professionals with that. I'm like, I don't need this in my life. And so, like, I'll do the professionals. I still do professional athletes and stuff like that. Cubs in the Blackhawks that show up. But I give it to my junior partners. You guys can deal with this now you're on your own. And they'll get sick of it, too. But it's because I got threatened. And that's part of the reason why I was like, I'm done. I don't. I don't need this in my life. Athletics don't pay my bills, rather do. And people just show up for real problems. So it's a real concern. It's a huge headache. And the burden, again is only on the physician. So our team docs still take that burden, but the pain is all on them.

C (9:35)

I think it's especially tricky these high school, like, very, very elite athletes that you see. I think that's the same thing as transfers. But I think you have to be very cautious. And like the example you gave, like, if you think someone had a poorly performed surgery, you know, I would just really focus on saying, well, if you have continued issues, here's the revision or next step. I try not to comment on what's already taken.

E (10:00)

The question is, can you play? So somebody comes in. X rays showed like 3/4 healing pressure was to let them play. I'm like, I don't think they should play season, etc. They have to play. Okay, if you play, there's risk. Blah, blah, blah. I did all the documentation as I am good at this. Reebrook, let me tell you who was at fault. It wasn't the trainer, wasn't the coaches, wasn't the patient. There was only one person whose fault this was mine. They got an opinion that they got another opinion. And the question was, did Dr. Khadakia do a bad job? It was not anything else. Despite everything I told him, the only question was, did he do a bad job? And this is why it failed. And on that day, I was like, I revised it. They ended up, whoever they saw, luckily Said no, I didn't think I did a bad job. Revised it heals, went back to play fine. This is insane. Question of what do you. Do you have a three quarter union, solid CD with a little bit of that plantar lateral. Right. We see it all the time. They're three months out. The protocol, I think not the standard because we never want to use that word. But on average three months out. Post op CT show 80% union, no pain. Now transfer from the university to you. Joe park, right? University of Virginia. Yo, Joe, can they, can they play?

C (11:13)

Yeah, I mean I deal with this problem every week almost, you know, every, at least several times a month. I think it has to. Do you. I always say I have to trust the training staff and follow their performance. But I tell them some people are able to play with a partial or non union but there is the risk of in season refracture and it would require a longer revision recovery time and that they would likely miss that whole next season. And so I just, I try to spell it out that way. I don't know if it's the right answer. But I, but I leave it up to them and I say things like if you were my son or daughter, I would not allow them to play on this. But you're an adult and you can make this decision with the coaching staff.

E (11:57)

Would you, if they were a professional athlete, would your decision change?

C (12:00)

But that, but that's what our colleagues do every around the country. You know who's who they're getting, they're retiring. Right? Right.

E (12:08)

And if you talk to them, it's a headache. There's no question. So professional athletes, same thing. Do you tell them the same thing or you're like, you know what, you're not playing for four and a half, three months because they're getting paid. Right. They're on the deal, it's no big deal. You say, look, you're not going back for three months, three more months, six months. Because we know you got a contract. You know, you're on the dls, you know, you got. Do we treat them differently then? Because a college athlete needs to show off to get to the pros and there's the pressure. Before they had nothing, so it wasn't a big deal. But now there's a difference between a college athlete, professional. I have lower stress on professional athletes and I don't stress about much in life. But the college ones because the professional just do whatever you say.

C (12:48)

Yeah, Professional, I think also depends if they have a guaranteed contract.

E (12:51)

Yes, for sure.

C (12:52)

Right. If they're not getting paid or they're, let's say they're a free agent or something. I think it's, again, it's a high risk. All these things are just. We talk about it, oh, we may have to revise it. Well, it's a big deal to revise a fifth metatarsal.

E (13:05)

You can say it right. It's easy to rebrace or revise it. Like that's not.

C (13:08)

It's a big deal.

D (13:09)

Big deal, absolutely. And I think, you know, you bring up a good point. The thing that's clear is it's like a fracture in the midst of the season versus where they're at in their contract. It's a little bit of the same discussion. And you have to. It takes extra time to go through that with them, as you pointed out. I mean, it's usually phone calls with them, the agent, coaches, training staff. And your point, I think is well made, Joe, that, you know, in that setting there may not be one right answer. It's going to be dependent on where they're at in their season in that particular scenario. And a lot of those. Now you get something else that's a little riskier, like medial mal fracture or navicular, navicular or anterior tibial stress fracture. And those start to get a little bit, you know, that maybe changes things a little bit.

B (13:56)

But yeah, I think challenge the way the way I've handled it, which I think has changed. And like y' all saw the way you handle it and the way I explained to residents, there's sort of three groups. There's your high school athletes, essentially those are minors. And I sort of treat it like I'm your dad and this is just what you should do. And this is my recommendation. I care about more about 40 year old you than 16 year old you. And you should do this. In college it was always sort of a little bit more shared decision making, right? Like, hey, where are you in the depth chart, the season, can you redshirt all these things? And then professionals, I'd say, listen, if I get paid a million dollars to play on Sunday, I could play through a lot of pain, I promise you. And so I feel like it was my job to say, okay, here's what you have. You have this fifth metatarsal. It's partially healed. You could have no pain, you could play well. You could have a risk of a re injury. If you re injure, it's going to be bone graft and a longer recovery and you can make it worse. But you may not I'll leave the decision up to you. So it's my job. Tell them sort of risk benefits, and then they've got to make decision about where they are in their contract, the timing, all that stuff. Because again, if you gave me an 80% fifth metatarsal fracture and I got paid a million dollars to play on Sunday, I would absolutely play on that every day of the week and twice on Sunday, I'd make 2 million. And so, but that's different. But I mean, I think if in high school, I probably would not. I would let the thing heal because I'm young and healthy and I want the rest of my career and I never want to have to worry about refracturing ever again. So that's how I've handled it. But now that the college athlete is the pro athlete, I can't decide should that now be my same discussion and decision making process with the college athlete? How do you all think about that?

D (15:24)

I mean, it's a tough one. And I still, I mean, we're still figuring out what the best way to approach it is. But, you know, I like what you're saying is that's, it's a good way to think about it. The funny thing is, who's most likely to play through that? The high school kid.

C (15:38)

Right?

D (15:39)

I mean, they're the ones that are like, it's okay, you know, that's, that's the person that's not compliant. Whereas professional athletes, like, I'm getting paid, I'm okay. I can more likely be like, I can take the time off and let it heal.

E (15:51)

But it has a really weird layer. And I think it'll. I think the key thing for us is to, you know, as we treat these people, you have to think about it, because college athletes are a curious deal. They have potential for massive income. They don't have any guarantees. And now they're getting paid certain weird amounts of money that have potentially, they're in their own unique bucket. They're not professional. If they are like free agents and mid season maybe getting traded or professionality, that's different. But a lot of those that we treat are, you know, they're doing okay and they'll cover it. And so, but college, you know, they have that tiny window and now they have a lot of money attached to that time, which is a different animal than before. It's gonna pan out. I hope none of our colleagues face some terrible lawsuits because that's literally how everything changes. Right? I think the axis is an issue. Who really wants to do this in Our generation, I mean, as we're at aops today, who wants to be the doctor for the athletic people with the risk involved. The numbers aren't as high as you think.

B (16:49)

It's smaller than it used to be. Yes, I think the job has gotten dramatically less glamorous and dramatically more liability to it. And I think people have seen it takes a significant personal commitment to be able to do this. Because I mean you really do have to be good in a lot of aspects. You have to be a good surgeon, you have to be a good, a good communicator. And you got to be willing to take the personal sacrifice, take time to communicate with all those folks. So I think each one of those sort of aspects to that is really important. And last thing I'll mention before we maybe transition is I've got a problem and maybe a solution. I think it's fascinating. You do a surgery that you get paid $2,000 for. Let's just make a number get paid good. Just you get paid $2,000 for some surgery to you do, yet you can be on the hook for 30 million. I can't think of many other area in life that you could have so little reward for so much liability. Right. And so the thing I've said and why I think a solution this in the future is basically just like agents do and other things like that. It is a. I will do your surgery for 1% of all your, all your future earnings. Just like imagine because, because that way we're both into success here. I mean, you'll have it. But why not? Like why would I be liable? I mean I know people who are sports agents. I mean one guy is a baseball agent. If One guy makes $8 million a year and they get, they get whatever it is, I think 4%. I mean, how would you like to make $320,000 because you had a guy sign a contract three years ago. That's a pretty good deal. But like that person may not be able to return to sports without a really good surgeon doing a really good job to fix what their injury is. Why should you be liable for $20 million for a high school athlete, yet you get the one time surgery fee. Just a question, what are your thoughts on that? It's a very different model.

E (18:29)

I think the world has decided for now that doctors are supposed to be doing right for the people without any gain for themselves. And any gain you get is already more than enough because you're helping people. And I have many, many wealthy patients. And it's funny, when you talk to them, they're good people, but nobody is looking to help you make a dollar. Your job is to make sure that they have a perfect life.

A (18:52)

Right?

E (18:52)

And I find it fascinating. And I used to be angry about it, I'm not anymore. But it's. If you look at medicine, they're like the players. Like, that's your job. It's your job to help people. You're not supposed to be doing this for the money. I obviously would agree with you in some ways that makes a lot of sense. But it becomes then now the last thing we have as doctors is, and it's probably dying anyways, is the sense that we do things for the right reason. That goes right out the door.

B (19:19)

Aren't we on the same page? I mean, isn't their agent's job to get the best contract they can? My job is get the best outcome so you can get another contract. Now we're on the same page.

E (19:28)

I'm with you. And maybe you throw all the doctors off. Society has a problem and our job we decided to do, and I think a lot of us started this way, was to help people. And yes, you make a good living, but your fundamental ethos is to help people. Agents fundamental ethos is to make money

B (19:47)

and get paid for it.

E (19:48)

And so that's their job. Like financial people, they're like, yeah, all we do is make money.

B (19:52)

We don't help people.

E (19:54)

They make a boatload of money. And I'm like, yeah, so I'm, you know, paying off debt. Like, wow. Yeah, but you really help people. And if you start talking about making money, what we do, they lose trust in us.

A (20:04)

Well, there's a perception that most doctors still make a lot more money. They have no idea about the every year decrease in Medicare reimbursement where it doesn't even keep up with your cola. You know, if you described medicine to anybody else without telling them that it was medicine, you'd go into a job that you would just lose money, like get less every year. You'd have to see and do more work just again the same. You tell them about the hours, you tell them about not seeing their family. How many people would change the years of training, right?

B (20:35)

And most people are in 250 to $500,000 worth of debt that's been accruing interest. And by the way, you have Nothing in your 401k, right?

A (20:43)

And then you say that to a person and they're like, would you take that job? No, I don't think anybody would. And the only Time, they'll say it is. Oh, wouldn't you say it's for a doctor. Oh, but you're helping people. But this whole entitlement of that, I think our society, whereas they think they're entitled to get the care, to not have to wait to ask you all these questions, to be the first one that you answer, to answer the emails, answer the questions. And I think that contributes to a lot of, as we've talked about before our physician burnout, they didn't pay me anything.

B (21:12)

So if they didn't get back, they paid me nothing.

E (21:16)

We'll transition to that at the end.

B (21:17)

Yeah, I think Joe has an answer and then I want to transition to Pam's patient vignette here. Do you have thoughts on that?

C (21:22)

Oh, I was just going to say, I think if you tie your reimbursement for a surgery based on their performance, I think it's really dangerous because like we just talked about, I think there are cases where you think you did a perfect job, but they are not able to go back to that level. And then they might say, well, you, Dr. Jackson, you are responsible for me not having this.

E (21:44)

They didn't pay me anything.

B (21:46)

They paid me nothing.

E (21:47)

That's it. In the end, for the young physicians, when you listen to a podcast like this is that just understand what you're getting into. When you start taking on high profile people. Everybody wants to be in the news, everyone wants to be on the platform podium, everybody wants all that fame and whatever it is, but just, you know, understand the risks, understand your liability so that you don't get into trouble. And I will promise you nobody will come to your aid. So just be careful and know what you're getting into. And it's still a lot of fun to treat athletes, don't get me wrong. Even I, who don't care about athletics, like treating them, those are fun people. But just know what you're getting into.

D (22:24)

Yeah.

E (22:25)

And that's the biggest, biggest advice we have.

D (22:28)

So one of the other things that we were talking about when we were thinking about this topic was Pam was talking about some challenges you were facing a little bit different.

A (22:37)

Right. I could contribute about taking care of college athletes and professional athletes, but kind of being in LA and just kind of the current milieu, it's been a little bit difficult and it's, I mean, I like this forum because I get to bring it up and talk about it with you guys because it's hard to know things on a national level. There's so much fake news things. But in My neck of the woods. It's been difficult just for especially our Hispanic population, with the recent federal agents being in the city kind of taking it over. And for my patient population, I deal a lot with the Medicaid patients, not the PPOs, not the medicares, but just me having to question and really see my place and kind of be grateful for where I'm at, but not being able to take care of patients or patients not being able to come in because they're fearing for their lives, about being deported or being separated from their family. And I think it's not even the people who are here potentially undocumented, but even people who are here of that background, that culture. I think there's been a lot of just racial profiling. And, you know, I've had patients who. I've had a higher cancellation rate, for sure, no show. And definitely seeing the results of that. And so, yeah, when we were talking about challenges, new challenges now in our patient population, that came to mind for me.

B (23:50)

How's your medical center handling that? Are they. Is there any support from them? Because I would think it's not just you.

E (23:55)

Right?

A (23:56)

I mean, I work in a very small practice, so it's only. It's like a four orthopedic surgeon practice. It's a very small practice, so there's not much we can do about it. We understand. I mean, we've always had, like, a policy for, like, you know, no show, you charge A$25. But in this, we kind of, like, wave a lot. We understand, and we know their background. We understand the situation. There's, of course, people who are still willing to come in and willing to be taken care of, willing to take that chance. But I've had patients come in, and it's stressful. I mean, ever since COVID you know, us working through all this. But it adds a whole other layer of stress because, like, I had a patient tell me that he was coming. His wife always came with him, but she was just so, like, mentally distraught about, you know, potentially being caught that she didn't want to come. And I had another family where their son was with them. And it wasn't a. Like a school holiday. And he was of, you know, high school age. And I was like, oh, is there a new holiday that I'm not familiar with? And the dad was just saying, no, we just want to keep him at home right now. Like, we're not sending him to school.

E (24:56)

I think you're a good person. I know this is a very politically charged climate, and so we Try to keep this as nice as possible. I think our job as surgeons, I think what's going to happen is just like it was back in the day when there was no Obamacare per se. When I was at Michigan, we would just see them late, end game. The people will start coming now, only when they have no choice, right? They're desperate, legs falling off, sideways, whatever. But I think as a physician, it's bad for society. But I, that's what I saw back in the day, which is not that it's like 20 years ago, but it's what I saw when they had no money, it would only come when it was a nightmare. Show up to the ER and we would just bang it out. But like the elective stuff that we would see because you don't see it, right? They don't show up. So you don't know what you don't know.

A (25:46)

But even for like the fractures that come in, like, I know those are going to be that way. It's like, why did you come in this late? And things. And it opens my eyes because I'm like, we're at this meeting, I'm seeing all the technological advances, I'm seeing all these things and yet I know I'm not alone in this. And so it's really hard to put together these very opposite end things. We have all this capability, we have all these things that we can offer. But there is such a discrepancy of patient care and access to care.

B (26:16)

It's kind of sort of like the moral injury thing. So you've got these people that are getting, we bring CT scans and personalized custom 3D guides for their total ankle. And you got this other person that can't get their basic Weber BE ankle fracture fixed. They don't get ankle arthritis. They go back to their job and work. Right. And it's that whole thing like again, I would agree with initially, like you're a good person, you just want to take care of people, you want to take the best care of people. And when you see somebody with a six week old ankle fracture, you know they're not going to have as good outcome as had they come to you a week after and fix it early or whatever. And that's just super. It's frustrating. It's frustrating for sure. And unfortunately largely outside of your control. Right.

D (26:53)

And I think.

B (26:54)

But it just sucks. You know they're going to work out,

E (26:57)

it's outside of our control when they show up.

A (27:00)

Just do the best you can.

E (27:01)

Best you can. My practice is a lot of that, most of it's atrogenic, but you do the best you can. It takes you double the time for the same or less pay. That is what it is. And as we're going to see it more and more, so it's a huge problem for which unfortunately there's no answer. So when they show up, I think we just got to do our best, not get frustrated. And we're going to see a lot more late competition medications in six months, in a year, like during COVID Right. That's all sorts of lunatic stuff. What the hell is this? Like, this is crazy. It's going to happen all over again now. And that's just us. Like, imagine like real medical doctors, cancer, like the real doctors. Imagine the stuff they're gonna deal with. Yeah, it's gonna be. It's terrible for society. It actually gonna cost our medical system way more to do it on the back end, which is, you know, even crazier. I don't know what we're going to do. Buckle down and I guess do what we're born to do.

C (27:55)

Fix this stuff.

E (27:56)

It's not good for anybody.

B (27:58)

But no, I appreciate you sharing that. I think it's a problem that everybody deals with and the, the moral side of it and the ethical side of it is tough because I think we. When you care about patients, you hate that when they don't have as good outcome as what you wish they would have had. So, yeah, I think we all agree on that. I think an issue's point is when the patient comes, take the best care of the patient that you can. And that's what we all want to do. So on that note, I appreciate you guys listening, appreciate the panel's thoughtful discussion about a lot of these topics and look forward to maybe discussing them more.

A (28:27)

Thank you for listening to the AOFAS Ortho Podcast, a Convey Med production. To learn more about joining our dynamic community of highly skilled orthopedic specialists, visit aofas.org.