The Upper Hand: Chuck & Chris Talk Hand Surgery
The Upper Hand: Chuck & Chris Talk Hand Surgery
Ray Resections and Clinical Practice Management
Chuck and Chris begin this episode with a discussion of ray resection and then pivot to discuss practice management and payer mix in our practices as well as the benefits and challenges of workers compensation.
Subscribe to our newsletter: https://bit.ly/3iHGFpD
See www.practicelink.com/theupperhand for more information from our partner on job search and career opportunities.
See https://checkpointsurgical.com or www.nervemaster.com for information about the company and its products as well as good general information about nerve pathology.
Please complete our Survey: bit.ly/3X0Gq89
As always, thanks to @iampetermartin for the amazing introduction and conclusion music.
Complete podcast catalog at theupperhandpodcast.wustl.edu.
Welcome to the upper hand podcast where Chuck and Chris talk hand surgery.
Chris Dy:We are two hand surgeons at Washington University in St. Louis here to talk about all things hand surgery related from technical to personal.
Charles Goldfarb:Please subscribe, wherever you get your podcasts
Chris Dy:Thank you in advance for leaving a review and rating that helps us get the word out. You can email us at Handpodcast@gmail.com. So let's get to the episode.
Charles Goldfarb:Oh, hey, Chris.
Chris Dy:Hey, Chuck, how are you?
Charles Goldfarb:Good. We're recording it a little bit of a different time. Yeah,
Chris Dy:Its actually daylight outside. It's nice. Well, of course, we're both inside and both in the office.
Charles Goldfarb:In the office. Yeah. St. Louis weather I hope it's turning for the better. So yeah,
Chris Dy:I think it's been a nice day, I usually get my weather reports from patients in clinic and when I'm in the car all day, I have no idea what it's like outside. And I sometimes I think it's better if I don't know what the weather's like when I have to be inside.
Charles Goldfarb:Oh, for sure. You know, we we may have mentioned before, in one of our surgical locations, we have windows. And for those of you who have the opportunity to operate at a site with Windows, I recommended highlight because you kind of do keep a little bit in touch with the outside world. And when I'm in clinic, I just have a big window and it's it can be really hard to look outside. But it's a beautiful day.
Chris Dy:I still remember being at the at one at that particular site and being in Dr. Gelberman's clinic and just feeling like I needed a refresh. Sometimes I would just watch cars go by thinking to myself to give myself some Zen. Yep
Charles Goldfarb:no, it does the trick. It can do the trick for sure. But yeah, the kind of just being in the car and being oblivious. I guess there's something to that too. Yeah,
Chris Dy:you know, there you never know what's gonna like, what what could be unfolding in the world. Once you emerge from a long case, things change I remember. Well, I mean, I guess we won't delve too much into the details. But I remember hearing about the details of January 6, unfolding as I was leaving the O R and other what just happened in the world. And, and I also remember, I was visiting Chang Hospital in Taiwan, as the November 20 2016 election results were coming in, which was also super interesting. It's
Charles Goldfarb:funny, I as you started that whole conversation piece, the first thing that came to mind was where was I? When, and the immediate one that comes to mind when I was in the ER was September 11. I was a fellow in Cincinnati and I was in the O R and we kind of all walked into the waiting room to watch the television there is a different era a different generation that was right, you know with
Chris Dy:one to one TV if you probably had no remote you had to get up and change the channel. And you know what little
Charles Goldfarb:rabbit here? Yeah, yeah, exactly. Oh, and
Chris Dy:the other the other Where were you when thing that I some sermons always remember is that the day that Michael Jackson died, I was on call, I was a junior resident on call at one of the hospitals and I was just a run of distal radius fractures, patients with this race fractures that came in and actually had them all kind of set up in an assembly line, like classic residents style, just like ready for reduction. And I'm just going down my assembly line and patients start talking to each other about how Michael Jackson just died. I always remember that. That
Charles Goldfarb:is so interesting. Yeah. I don't know when Michael Jackson died.
Chris Dy:All right. Well, you know, we have an interesting episode today, I think we have a case that I wanted to ask you about how you would approach and then, you know, I think we're gonna get into a practice management topic about approach to the Worker's Compensation Program.
Charles Goldfarb:Yeah, it's a super interesting. First of all, I think that we briefly discussed the case so we could prepare the, the, the management topic, I think, will be really fun to discuss. It's certainly something that we both think about a lot. And I think it's really important to, you know, future hand surgeons everywhere.
Chris Dy:Right. And I think that initially work comp I think, you know, elicits some kind of like visceral reaction, and a lot of people just groans and oh, my gosh, why would I do that? Et cetera, so painful. I don't think it's as bad as people make it out to be, but we'll get to those details. Before we talk about our case. Why don't we thank our friends over at practice link.
Charles Goldfarb:The upper hand is sponsored by Practice Link.com the most widely used position, job search and career advancement resource.
Chris Dy:Becomcing a physician is hard finding the right job doesn't have to be joined, practicing for free today at www.practicelink.com/theupper hand
Charles Goldfarb:All right, tell me about your case.
Chris Dy:So it's, I mean, it's something that comes up, you know, probably a couple of times a year. So, you know, how do you think about patients who know technically how to do how to approach indications how to counsel patients who need a re resection? So I'm not talking about in the context of any sort of oncologic issue You but I think that's completely different. But I had a patient who is, you know, an older woman in her 70s, who had a very challenging recovery after a complex flexor tendon surgery, and essentially has ended up with a finger that is flex down in, it's the middle finger, it's flex down at the tip joint, the posture is about 40 degrees of flexion really does not get any improvement with passive has really no tendon glide, you know, those things we talked about with Macy and one of the prior episodes about tendon gliding than any of that the MP joint just feels stiff and your fingers just in the way. And it's not a useful hand. And she has difficulty gripping and grabbing things because she can't initiate flexion with her middle finger, it stays flexed or stay stays flex, and she can't straighten it out. So she's about a year out from her flexor tendon surgery, and is just not happy. How do you approach that situation?
Charles Goldfarb:Yeah, I think that's an that's an interesting lead in to the topic of kind of just challenging finger status. Certainly there are other potential legions one would be, you know, bony trauma or partial amputation, something like that. Lots of congenital tie ins which I could bore you with for many hours. And, you know, I think when you feel as though you have maximize therapy, when you feel as though your surgical strategies to help the patient improve, have reached their limit, then you have to have the difficult discussion about whether that finger can ever be useful for the patient. And it's a discussion that in my mind shouldn't be held at one sitting is something that you have to plant the seed for and revisit.
Chris Dy:Yeah, I think absolutely. I remember you teaching me that. You know, Ryan Calfee is very good at teaching about how to broach this topic with patients. Remember that when I was a fellow in this patient was not just known and not to minimize that it wasn't just a flexor tendon repair, it was much more than that, in involved trauma and pulley issues. And, you know, there was not great adherence to post operative recommendations, both in general and specifically with regards to therapy. So, you know, it's a challenging situation overall, I think, you know, all parties are frustrated. And I, you know, kind of talk through different options, I feel like we had exhausted our non operative treatments that we've had available to us. And, you know, I did spell out kind of the things that we would need to do if we were to try to salvage the finger and including, you know, your stiff finger surgeries, followed by to get full passive, and then followed by Tina, lysis, etc, to get some gliding after you've, if you've been able to maintain the passive. So we talked about the multiple steps that would take and that just, you know, after multiple visits, was not appealing to her.
Charles Goldfarb:Right, so it sounds like at this point, you're sort of you're It was the middle finger, I'm not sure if a dominant hand or non dominant hand and I don't know that it matters. So your options really are leave it as it is. amputate at the level, the MCP joint or, you know, somewhere about there or consider an amputation or with a re resection plus minus transposition of the index finger. Is that kind of where you were and what you had discussed with the patient?
Chris Dy:Yeah, basically, that's it, I really honestly did not give much of an option for you know, an MCP level disarticulation. And I'd love to know, your thoughts as to you know, whether you think that's a surgery that provides meaningful improvement or whether you think that that's, you know, is there? Is there anything aside from array resection?
Charles Goldfarb:I think for certain patients, an MCP level, amputation is an option, that will be the patient that just needs to get back to work very quickly, and doesn't want to think about extensive rehab, and is not overly concerned about that. cosmesis and the functional challenges that that gap can create?
Chris Dy:Yeah, so tell me about those functional challenges about the gap.
Charles Goldfarb:You know, I think the benefit of that surgery is you maintain the width or the breadth of the hand which, which has been shown to be correlated with strength. The negative is very simply they failed the m&m test, right? If they're holding a bunch of m&ms, you're gonna lose some through the gap. And I think that is that is true. We don't worry about pocket change much anymore, since none of us have it. But the m&ms We still have them. Right.
Chris Dy:I'm trying to think of, I think my daughter would love that. She just go and pick up all the m&ms and eat them anyway. But so, yeah, and I tend to think that that procedure, at least from what I've seen, doesn't Don't necessarily provide the earlier recovery benefit. And I think the, you know, objects slipping out of the hand, you know, the m&m testing, I think that's a real issue. But you know, I think I get what you're saying in terms of the breath. Do you purchase any differently if it's the ring finger?
Charles Goldfarb:No, I don't think so. I mean, certainly. So the, you know, again, as we've discussed, ring fingers going to provide a little more contribution to strength, and a little less contribution to fine motor, although I think both can contribute in both directions. But now I don't I don't think the ring finger fundamentally changes because in my mind, in my mind, the ideal procedure, no matter if it's middle, or ring, is re resection with a transposition of the adjacent digit. And I'm not sure if you immediately think about the transposition. And we can talk about pros and cons of transposition, versus trying to close down the space. But I've been very happy with transposition.
Chris Dy:For sure. And before, I think that would be a great topic to discuss. And before we pivot to that, I mean, how do you approach this if it's an index or a small finger?
Charles Goldfarb:Yeah, so actually, in the last couple of months, I think I've done a couple of each of those. I think they're much more straightforward, in the sense that I do array resection. And I don't necessarily feel as though I want to take out the entire array. Because there's negatives, right, we have tendons inserting onto the base of most of our metacarpals. And I want to maintain those if at all possible. So my goal if it's an index finger, is an amputation, mid metacarpal, with an oblique cut in the in the metacarpal. So the liquidy is from distal and ulnar to proximal and radial and flipped for a small finger amputation. What about you? Pretty
Chris Dy:much the same. I like that you're not trying to close a gap or anything like that. I don't have to worry about transposition. And I think the aesthetics of it are much nicer for the index and for the small. But ya know, I think that, you know, for me getting back to this case, I don't necessarily always think about the going to a transposition. Because I have found that in my limit, somewhat limited experience with this, that I have been able to really use those deep transverse inner metacarpal ligaments to close the space in a way where I don't feel like I'm missing a whole lot. I mean, have you what's been your experience with patients who have had the transposition those who haven't, and what the classic teachings were?
Charles Goldfarb:Yeah, I think I think you can close the space down. I think it never looks exactly right. But it can look good enough for some people. I have had patients and I don't do that really anymore. My go to is a transposition. But I have had people where it stretches out with time. But I think many people will be satisfied with that. And it certainly is a quicker recovery, although I would say not dramatically quicker than the transposition. Because you do have to give time for soft tissue healing, which you know, can be less predictable. Right?
Chris Dy:Of course, when you do your transposition, how are you? I guess, maybe explain what a transposition is for those that may not be familiar with that. And then we'll have what's your bony fixation like? Yeah, and
Charles Goldfarb:I should preface it by saying the reason I like the procedure is in part because I've done it a lot, because I do it in the congenital population, with cleft hand, commonly, and an injured worker, you know, less commonly, but sometimes, and so, essentially, what you're doing, let's use the middle finger as the example, if your middle finger is either absent or traumatize, especially if you have a good third metacarpal, then the goal is to cut your index metacarpal removed part of the, the so cut that second metacarpal and then cut out the distal part of the third metacarpal. And then you're bringing your entire index array, you're placing it on the on the proximal aspect of the cut third, metacarpal, and then plate and screws to fixate the finger. And that widens your first webspace, which theoretically gives you a functional advantage, or certainly not a disadvantage. You can try to preserve the origin of the ad Dr. Policies and done correctly, the aesthetics are amazing. Function is great. The hands a little narrower, but you warn patients about that beforehand. Right.
Chris Dy:Right. I think I think that's those are all really good points in terms of, you know, I think the counseling is key about what to expect. How long do you think it takes for that transposition bone work to heal standard kind of orthopedic unit of six weeks?
Charles Goldfarb:I think it's a little longer. I don't know if you've had experienced or what's your experience? I would say I tell people eight to 10 weeks. We work on motion right away. That's the other beauty to therapy you know very quick Do you have good bony rigid fixation? I think it just takes a little bit longer. There's a little bit of federal factor intraoperatively. And maybe I do more stripping than I would like to admit of the bones which may delay healing to some degree. But I think it's it's, it's it's a little longer than typical. But patients are happy. They're in removable brace. They're working on motion, and hopefully healings on eventful
Chris Dy:and how do you orient your bone cuts? So that, you know, you get the to decrease the fiddle factor? Or do you get the bones and then figure it out later?
Charles Goldfarb:I, well, you sort of want enough tension. So you're getting kind of automatic compression. And so I sort of either try to cut them at equal levels, that is the index metacarpal and the third in the in the in the middle finger metacarpal. Or else try to cut the index finger metacarpal, a little shorter, so a little bit of a longer residual stump, and then I kind of tilted in and pop it over before I put my plate on.
Chris Dy:Fancy fancy. And I think for those listening, it's important to note that we are preserving our insertions of our ecrl and B respectively. So our bone work is distal to that on those metacarpals. Yeah, and
Charles Goldfarb:this is one again, there, you know, you do a lot of work that that generates high patient satisfaction. And I like to think that I do as well. There's nothing like this, when you have a patient with a really difficult problem. Typically, one that's been a problem for a long time after a trauma. That patient satisfaction for this surgery is amazing. And you know, it just it takes a very difficult situation waiting provides a really good outcome.
Chris Dy:Yeah, absolutely. I have a former patient of mine who has had this done and some pork steaks often show up in the office. I don't know, what's your what's your take on on consuming things that patients bring in for you?
Charles Goldfarb:I don't hesitate unless it's a weird situation where you're not sure if the patient likes you know, I you know, it's interesting. I occasionally am gifted food, I would say more often it's beverages.
Chris Dy:Right. Okay, well, yeah, those are safer, I guess. Yeah, I guess the last thing I want to ask you about the rate resection is how do you design your incisions, you have a lot of experience with kind of incision and web space management from your PT and adolescent practice. So how do you design these incisions?
Charles Goldfarb:Yes, sort of, I think there's a lot of different ways to do it, what you really have to be careful of is creating the interval between your explicit if you're taking out your middle finger, once you excise the middle array, you have to create a web space between the index and the ring. And so there's different ways to do that I sort of tried to make a racket incision. But I create, I tried to do it in a way that I use the web space that exists between the index and middle finger and sort of just shifted over. So you're not you're not sewing in the apex of the web, if that makes sense. You're sort of taking skin. For those on YouTube, you're taking skin off the index finger and leaving this whole web space. And then it becomes your new web space between your index and ring finger. So is there good technique descriptions, but I think that's the important part of how you access everything else less important, but it's the webspace, which is critical. Yeah,
Chris Dy:no, I think that's, that's well said, I remember I was telling our resident who was working with me, Dr. Jesse, who, at the time, that when I was at the VA, as a resident, they were getting rid of a bunch of books. And the one book that I took from that was a book called Atlas of amputations, which has been an incredible book for the rare occasion where you're doing, you know, kind of more major non digital amputation all over the body, just all the incision designs was definitely a wartime book, but very cool. Very interesting.
Charles Goldfarb:Yeah. What's your the another tangent? I'm looking at my bookshelf here in my office. How often do you access books, real books?
Chris Dy:Ah, you know, earlier on in practice, I would go to books pretty frequently. I actually have two copies of Dr. Goldman's nerve repair Blue Book, which for anybody listening is a fantastic book that is timeless to volumes you can oftentimes find it on Amazon if you find it yet because it is an awesome resource. But I used to have I used to use it pretty frequently so I should keep a copy here in this office and one at home. Because I was able to pick up a couple of different copies Wow,
Charles Goldfarb:that's something Yeah, i i You know, I still expect if I write a chapter I want a physical textbook doesn't always happen anymore, which is really frustrating to me because the ebooks I personally, and I know I'm old ebooks don't resonate with me. Well,
Chris Dy:I mean, honestly, if you had the chapter like, would you actually read the textbook as I've got some editions that I've written recently? I don't think I've ever actually opened it to be honest with you. No,
Charles Goldfarb:I don't open it. I've started to give them away to residents and fellows. know I'd still open them, but I just want it
Chris Dy:right. If you put in all that volunteer work to do it, I still remember bringing you a copy of my acsh elite athlete book and seriously asking you to sign it during fellowship and you've rejected and just laughed in my face.
Charles Goldfarb:I've learned since that I've grown I think it was a very briefly I was recently on a business school trip to DC and we had a lot of policy experts come to the Brookings Institute, and talk to us about different policy things and there was a really, really good speaker and I bought his book and asked him to sign it and he didn't bat an eye. Clearly he makes a lot more than I have. Right,
Chris Dy:right. Exactly. Yeah. Okay, fine. So before we talk about our worker's compensation topic, we should thank checkpoint. The upper hand is sponsored by checkpoint surgical, a provider of innovative solutions for peripheral nerve surgery. Checkpoint surgical is always striving to elevate the clinical practice of peripheral nerve surgery by providing surgeons with new techniques to help improve patient outcomes.
Charles Goldfarb:Checkpoints surgical is newest intraoperative nerve stimulator. The Gemini bipolar nerve stimulator does just that. With a bipolar stimulation probe Gemini provides finely controlled stimulation even at that particular level, allowing surgeons to take actions based on the most precise information available. To learn more visit www.checkpointsurgical.com Checkpoint surgical driving innovation in hand surgery Oh, nerves surgery driving innovation in nerve surgery, Chris not hand surgery
Chris Dy:your fire your fire Chuck, you're fired. The purple stimulator is what I also call the Gemini because that's the bikecad Keep the can't keep it straight between the Guardian and Gemini and his major faux pas on the alliteration in terms of like making them both G's, because it's really confusing. So it just ends up being I want the blue and I want the purple one.
Charles Goldfarb:Yeah, which is more than I could ask for. Dr. D, you and I are an academic medicine. Do you have any idea what your payer mix is?
Chris Dy:I actually do. I can't. I don't know, I know what my collection rate is.
Charles Goldfarb:Asking for specifics. But right
Chris Dy:now I'm trying to think like I have a general sense of what my payer mix is because you know, we do get our dashboard every month and I try to look at it. I can tell you what I feel like the biggest ones are and what the smallest ones are. But I mean, how do you Did you always keep tabs on that when you were in my stage? Well,
Charles Goldfarb:part of the question is simply, academic medicine in 2024, is very different at most academic institutions than it was, I don't know, 1020 30 years ago, in the sense that you're not hiding in a very controlled environment. You're not salaried without any knowledge of what's going on. I think most academic practices are like ours, where we are certainly aware of every aspect of the financial part of our practice.
Chris Dy:Yeah, no, I think that, you know, you could just kind of put your head in the sand and you know, you know, get paid what you get paid. But I do think we're all at least the people that lay in here tend to be the type where you're pretty type A and you're motivated, and you kind of you know, everybody likes to know what's going on. You know, it's particularly if you're in a position where sometimes, you know, you are incentivized to, to know what's going on in terms of how you can improve your efficiencies, etc.
Charles Goldfarb:Yeah, and I may be giving too much credit, I don't think I am and if listeners, you know, correct me, that would be great. I really think Dr. Gelberman, who was our chair from 1995, to 2014, here at Wash U was really the one who helped to change sort of the orthopedic perspective on what academic practice meant, and evolved to more like a private practice where we wanted to and needed to know sort of the financial parameters of our practice, and didn't just like I said, bury our head in the sand.
Chris Dy:So I mean, obviously, I owe a lot to a doctor gelderman And a huge mentor to me. Why do you say that though? I guess you know more about kind of how he came and changed or, you know, started things here.
Charles Goldfarb:Yeah, I just My sense is that 30 years ago, there wasn't a lot of attention paid in academic practice, about our views about how an academic orthopedic surgeon could generate more revenue Who, and there really wasn't a sense of kind of shared financial benefit in the sense that if I worked harder, I made more money. And the people that doctor government attracted here, even back in the day, that model appealed to them. And we kind of developed a practice based on that, obviously, I didn't know what every other practice, I don't know what every other practice and academic practice was doing. But my sense was, he was the kind of really one of the first if not the first to really push that model, I
Chris Dy:think is people, you know, who either were here and took leadership positions elsewhere, or came and kind of understood what, what he was doing here. There's a lot of things that he initiated here that seemed to have permeated to other places in terms of, you know, you know, incentive programs for academic productivity, you know, making sure that that you knew that there were opportunities to, to earn more, if you were more productive, I remember asking him to have an extra research day, which the standard for here was to have one admin slash Research Day, and then for active clinical days, and I told him that I ultimately wanted to have an NIH K award, which meant having 50% research time, you know, for a surgeon, and I said, Alright, welcome. When I start, can I just have to research days? He's like, Yeah, you could do it. But he made sure and my agreement is very clearly stated that it is potentially at the an opportunity cost at the my own personal incentive may be compromised if I'm spending all that time on research.
Charles Goldfarb:Yeah, that that that certainly is correct. And I would say that not only So, again, if you understand one compensation plan of the many that exist, you understand one compensation plan, and we're not here today to discuss our compensation plan. It, you know, again, if listeners are interested, we can certainly dive deeper into this topic. But not only were we incentivized to think about our clinical productivity, we are also sort of responsible for controlling our own expenses. And sometimes practices have part of that equation and not the other. But we had to think about both. And I think maybe that's what made it more unique at the time is that not only should I think about how can I boost revenue, but I also needed to think about how I could control my own cost who I hire to help me all those kinds of things. Right.
Chris Dy:So I mean, to your to the to the former about boosting revenue. And I think the intensive your question, I remember, I think her learning from you that you know, probably work comp is the one thing accepting work comp is one thing you can do to really shift your payer mix. I mean, I guess, in some systems, you could choose whether or not and then how much to see patients with Medicaid. You know, I personally have an open door for that. But and, you know, I know that taking workers compensation does allow me to really shift that part of my payer mix in a way that you typically will, will reimburse at a higher rate than the other payers.
Charles Goldfarb:I think that's well said. And that's exactly how I think about it in the sense that I have a large number of pediatric patients, but I don't I have a completely open door policy to any patient. Without any restrictions whatsoever. That is not universally the case. I'm talking across the country across different practice types. And for good reason, to be honest, I mean, that, you know, Medicaid, for example, and it's vary state by state, right states generate their own rates for Medicaid, and so certain pay states better than others, you will lose money every time you care for a Medicaid patient. Now, as a physician, I still think it's important to care for all those patients. But how do you balance it? I don't think taking commercial insurance balances. Commercial insurance can typically help pay your bills. But if you really want to sort of balance the low payers, you need the high revenue of work comp, which again, not true for every state, but for many states, it is financially advantageous to care for work comp patients. Yeah,
Chris Dy:absolutely. I mean, I think when I was starting out, you know, I still do a fair bit of health disparities research. But my one of the big things I was doing early on was looking at policy changes, such as the Affordable Care Act or otherwise known as Obamacare, and how that may have shifted, you know, delivery of care. And because Medicaid is a state by state based program, and the thrust of the Affordable Care Act was to increase Medicaid enrollment, we were super interested in seeing if you know, Medicaid, expansion plans actually moved the needle in terms of, you know, increasing the care that was delivered, because maybe people were just getting insurance and name and, you know, one of the papers that we wrote was actually looking at variability state by state in what Medicaid will reimburse for certain procedures. And, you know, it was fascinating paper. You know, it shows it's all over the map. And it totally depends, you know, if you're in Alaska, Medicaid is great payer. But if you're in Missouri, not so much.
Charles Goldfarb:Yep, that's exactly right. And so Oh, you know, it. Again, this is a huge topic. So maybe we'll just, we can revisit it, I think. But if we talk about work comp, for those listeners who aren't familiar with it, so essentially work comp is caring for the injured worker. And every state has its own guidelines about what that means. So I think every state, if, if a worker has a finger amputation working on a on a industrial line, that's work comp, but certain states make compensation for repetitive use activities. Carpal Tunnel is very different state by state, we happen to live on the border of Illinois and Missouri. And so the two states are very different, how they think about it, but you have to learn the rules of the game. It's a different kind of patient care than everything else we do.
Chris Dy:You know, and I actually want to push back on that a little bit, is it? I think it's not necessarily that different, I think the rules are a little bit different. You know, in terms of, actually, you know, most people, I think a lot of people their first blush, when they think about work comp is, you know, it's so painful, so much paperwork, it's, you know, I just want to take care of the patient, I feel like, you know, I started, I decided I was going to take it just as honestly, starting in practice, I think he told me, I should take it, so I took it. And I was like, Alright, I'm gonna do this. And at the end of the day, it does help, you know, support my ability to take care of any patient with a nerve injury, regardless of their ability to pay. So that's super important to me. So it keeps my part of the practice solvent, you know, so that I can you know, kind of, I feel like I can deliver that level of care to whoever needs it for nerve injury. So you told me to take it makes sense for me to help with my nerve program. And then I didn't find it to be that painful to be honest with you. You know, I remember watching you and being in your, in your clinic is a fellow and kind of seeing the steps and getting some advice from you and Ryan Calfee early on about kind of how to handle it. And it's seemed okay, so far, we are very fortunate to have an excellent work comp team that helps kind of keep things organized for us. But how, why do you think it's so different in terms of patient care?
Charles Goldfarb:Essentially, in my for, first of all, I, I guess I do agree with you, you know, once you have jumped through the hoops, and understand the rules of the game, then you take care of the patient. And that's the goal. But it's the hoops you have to jump through and understanding the rules. And once you have that down, then you just do what you do. And the other thing that's that's hard, I think, is we as physicians, most of us are not experienced or necessarily comfortable with hard conversations with patients, telling them that you're going back to work. Because if it's a non work comp patient, it's sort of up to the patient to a certain degree, I don't really push non work comp patients. And if they they have time and are able to take more time off, I don't push them that hard. But for comp, you have to send them back to work in a you know, with restrictions, perhaps but you send it back to work early. As one example of one of the hoops.
Chris Dy:Yeah, and I think I'd love your thoughts on this. You know, I'm very clear with patients before surgery, I think this is where expectation setting is super important in the context of work comp, saying most patients after the surgery are back to doing these things by this time, after this surgery, I expect for you to return to work with some restrictions on this date. And as we go every month or six weeks, I'm going to relax those restrictions gradually until I feel like you're at the point where you can get back without any restrictions.
Charles Goldfarb:Yeah, I think that's exactly how one should do it. And almost all one has to do it. It doesn't always mean it's well accepted. And it's sometimes it's not even the worker is the family member. And there's all kinds of questions and and that's the other part, you have to be willing to spend more time talking to the patient and the family about what to expect, you often have to talk to a nurse case manager or an insurance adjuster to seek approval or get, you know, testing done. Those are just some of the hoops you have to jump through. But in many states, the jumping through the hoops is financially worth it.
Chris Dy:Yeah, I think so. And you know, I think you mentioned the nurse case manager, I don't know how you feel about this. I mean, I feel like you know, we often talk about how, you know, physical therapists and therapists, OTs can be a very valuable, you know, informal source of referrals. I feel like some of the nurse case managers see some of the stuff that we do and how we take care of patients. And I think that helps, you know, build additional referrals to our work comp program. As word gets out of, oh, you know, Dr. Goldfarb can do this, that and the other and you know, Dr. D is pretty good at the nerve stuff, that kind of thing. I feel like I've seen some of the same nurse case managers because they've, you know, they've been happy with how not necessarily, they don't know what we do in ER, but they've seen how people do and also how we handle those situations. So
Charles Goldfarb:relationship building is everything in this field, and we probably don't do enough of it, but I can say unequivocally that when a nurse case manager is with a patient in our clinic, it is good for the reasons you stated, right? It can help us build a bigger work comp practice, and it helps communicate with the patient, I get frustrated when a patient does not allow the nurse case manager in the room. And that happens sometimes. And that's always under the instruction of attorney who I know means well for their client, but nurse case manager have helped the process a good nurse case manager helps the process and so it for me, they are they are always an asset, but I look at it like that, not as someone that I have to explain things to, but that I do explain things to and then they can spend additional time if necessary, talking to the patient. Yeah,
Chris Dy:and I think that once you know, they, they they're in the room, and you know, the points that you need to hit to make sure that they get the information they need. I love it, when they're happy that I have addressed, you know, kind of the things they need to write the report, I've said, I'm going to do this note for you, we're going to get therapy prescription for you. And, you know, just make sure everything's tidy. And I think you know, for the people that are listening, and if you're starting out just know what they expect of you and deliver it. And it does end up being a pretty reasonable relationship. I mean, how do you as we start to wrap up? I mean, how do you talk to new faculty about you know, whether, you know, to take to become part of the work comp program, and have kind of pearls about how to how to approach organization and that kind of thing.
Charles Goldfarb:I think it's really important that a new partner understands what they're getting into. Because for you and I, if someone says, Yeah, I want to take work comp, and they do a lousy job, they don't get their notes dictated in a timely fashion, they don't get the patients back to work, they don't communicate well, it actually ends up being a negative for all of us. And so I want to make sure they understand what they're getting into. And it's just it really boils down to communication, verbal communication in the office, understanding of why it matters, to get patients back to work, why it matters to close a case, as soon as one is able what it means to watch a patient plateau. And then ultimately say that they're at maximum medical improvement, other tools we have at our disposal. So it's, it's to everyone's advantage that if we're going to take care of the injured worker, we do it well. Because then it's good for our entire practice. Right.
Chris Dy:And then I guess there are two things I want to ask you. One, how do you utilize the functional capacity evaluation as patients are kind of wrapping, you know, towards the tail end of their care, but still have some issues? And then you've seen them plateau? And what was I can't even remember the last Oh, yeah, ratings, how do you handle the ratings? Because I think that was one thing where I was not like, initially enthused about doing but as I've done more of them, like, Oh, this is actually not that huge deal. Not big of a deal.
Charles Goldfarb:Yeah, ratings are a huge discussion. They're done differently state by state. Some states require us the AMA Guides, and they'll mandate which edition of The American Medical Association guides, I use the AMA guide, to kind of give me a general sense when I was starting out in Missouri, you're not supposed to. And I try to just give an honest assessment, because what often happens is I'll give my best honest assessment. And I'm not saying other people aren't answering honestly. But they may get sent by an attorney or by work to a different physician who may lean on the employee side who are or who may lean on the employer side. And one can see ratings, there are carpal tunnel, permanent disability ratings of you know, 40%, I mean, just crazy stuff. And so I think our best asset is being sort of the neutral arbitrator who just says what we think, as honestly as we possibly can, I think that's appreciated both by the worker, I hope, by work comp, and all and the next step is the administrative judge, the attorney, the you know, the judge who's going to ultimately arbitrate whether settlement looks like,
Chris Dy:right right now. So I think the the FCE is, is helpful, because I think it gives me some numbers and some objectivity around, you know, to base my or final rating on. You know, I think the ultimate test of people's feelings about work comp will be if they've made it to the end of this episode. And when we look at our download stats to see maybe don't put work comp in the title, Chuck, if they actually kept listening. Well,
Charles Goldfarb:you know, it's funny when I look at my patient reviews, like when people take the time these days to fill out a Google review. I know we talked about this, I know who all the negative comments are, they're all were calm. I know that and I know exactly who each patient was and why they were mad at me. But the flip side of that is we don't always see the patients who are appreciative of the care. And you know, I think most people People want to get back to work, want to do it as soon and as safely as they possibly can, which of course is our goal to
Chris Dy:write of course. And I guess one thing that's not necessarily just work completed, but I feel like I need to be better about handing patients the cards that say, please leave an online review. Because you know, it's the happy patients who want to do something that thank you. I still love cookies, I will take them any day a week for steaks, you know, beverages as well, but an online review probably helps more than anything else, because there's so much bias with you guys to leave a review.
Charles Goldfarb:I need to do more of it as well. I just don't I think there's something about me that doesn't feel 100% comfortable. We're
Chris Dy:too we're too old school. Like I'm the same way but I mean, you know, it's the new generation. You just got to get after it. It
Charles Goldfarb:matters and there's there's data out there that says it matters. Hey, if you did make it to the end and you want to hear more work, cop, well, maybe we'll avoid Yeah,
Chris Dy:good. Oh Goldfarb with all the the fan favorites congenital and work comp. All right, have a good one.
Charles Goldfarb:Hey, Chris, that was fun. Let's do it again real soon. Sounds
Chris Dy:good. Well, be sure to email us with topic suggestions and feedback, you can reach us at hand podcast@gmail.com.
Charles Goldfarb:And remember, please subscribe wherever you get your podcast.
Chris Dy:And be sure to leave a review that helps us get the word out.
Charles Goldfarb:Special thanks to Peter Martin for the amazing music. And
Chris Dy:remember, keep the upper hand them back next time.