It seems that I’m always getting involved with my kid’s friend’s injury. I saw one yesterday that I was fairly convinced had a mid shaft metatarsal fracture and told them it could wait until morning for treatment. My daughter tells me today she is going to have it plated. She is in the high school band and although I have no direct knowledge, I wondered if a decision may have hinged in part on whether she would have to miss the season (which plating would allow her to return to activity sooner). It got me to thinking about whether the “system” is fixable.

Let’s say you live in Canada, which has limited numbers of  orthopedists. I suspect some decisions are made based on availability. You may not be willing to travel into another province (or country) for a 4 week advantage in healing. The physician may not be willing to take you to the OR for that advantage, either. You and your priamry care doctor may, however, be able to negotiate that cost if the benefit is percieved to be high enough.

Let’s say you live in America, work as a waitress and have no insurance. You will likely not get offered surgery which brings with it a 4 week advantage in healing, regardless of how many orthopedists are around. You will be out of work for 6 weeks but the cost to the healthcare system is negligible. Unless you have a lot of money, few orthopedists will take you to the OR on credit for a self-limited ailment (somewhat differnt for plastic surgery).

If you live in America under the current system, the orthopedist can either take care of the fracture with casting or with surgery. It pays better (at least under Blue Cross/ Blue Shield of Alabama) to go to the OR. In addition, if the physician owns the OR as a part of a free standing practice, he or she can now pay the OR personel, the rent on the OR space, and other fixed costs which are associated with the practice.

For those with insurance, most of America has an infrastructure where access to outpatient orthopedic operative care for is almost instantaneous. This infrastructure is expensive to maintain but it means jobs for scrub techs, nurses, x-ray techs, and other personnel. We also have patients who are accustomed to getting the same treatment as professional athletes almost immediately and for little to no out of pocket expense. For those without insurance, giving them this level of care might just increase expenses more than we think.

Do we need for the genie to go back into the bottle on her own? Do we need to create a different type of care for those to whom the genie has yet to come?

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