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A trauma surgeon's busy life on the edge

August 11, 2002

For a guy who'd had only one hour's sleep the night before, Dr. Andrew Pollak seemed remarkably alert when we sat down to talk this past week.

That's because he's used to the routine. The 38-year-old orthopedic trauma surgeon has been at this for eight years, spending 80 to 100 hours a week at the University of Maryland Shock-Trauma Unit in Baltimore and in his private practice.

Hagerstown's own trauma surgeons haven't been talking to the press since their differences with Washington County Hospital led to a shutdown of the trauma center here, so I turned to Pollak for some insight into what trauma doctors face on a weekly basis.

Did you have a bad week at work? Maybe, but you probably didn't have to stay there overnight, as Pollak does twice each week. I had hoped to tag along with him on medical rounds, but arrived way too late for that. He starts them at 6:30 a.m., at the beginning of a day that doesn't end until he arrives home to see his wife and three children at 7:30 or 8 p.m.

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It's busier in the summer and fall, Pollak said, because "people are outside now, putting themselves more at risk."

Pollak and surgeons like him are not only expected to be medical miracle workers, but also to be businesspeople and advocates for patients trying to get reimbursed by worker's comp or insurance companies.

He may have another 10 years to do this, if he's lucky. He speaks of a colleague who "hung on" until he was 52, when he could no longer handle the pace.

So why does he do it? Part of it is the challenge of handling difficult cases. With the pride of a master craftsman he described what was involved in repairing a body after a motorcycle accident in which a key segment of a man's bone was shattered, and the fragments lost, requiring a difficult graft.

The other reason he keeps going is that people he's treated for their injuries at Shock-Trauma need specialized care for some time afterward, and they want it from the doctor who first worked on them.

"These are people with complex injuries, patients who want continuity of care. They expect you to continue to take care of them," he said.

But although there's pride in accomplishing what he does, Pollak is concerned that the obstacles he and others in trauma surgery face may make it difficult to recruit the next generation.

First comes the challenge of facing the unknown, financially and medically. Should he stop scheduling elective surgeries on the days he's on call? If he does, and no trauma cases come in, then he hasn't brought in any income to support the overhead costs of his office.

Trauma cases take a great deal more time than elective-surgery patients, because their injuries are more severe. And because they're unexpected, victims and their families need more face-to-face contact - and more phone conversations - with the doctor to reassure them about what's to come.

With elective surgery, Pollak said, there are routines established for different procedures that make them easier to handle.

"You know what a total hip (replacement) is going to take, you know the pain-management profile. The amount of work is much greater in trauma," he said.

As Pollak describes it, it's a job in which it's easy to take on too much. Too many elective surgeries followed by a rash of trauma patients and it's easy for doctors to exhaust themselves.

"When it gets that busy, you get (doctors) who drive off the road on their way home and end up in a ditch," Pollak said.

Another challenge: The federal Emergency Treatment and Active Labor Act, which prohibits hospitals from turning away emergency patients with no insurance coverage.

Over time, Pollak said, the definition of emergency has expanded so much that someone with a non-life-threatening injury like a ligament tear may be eligible for surgery for which there's no reimbursement.

"Are you obligated to treat that patient without insurance? There's only so much free care you can afford to provide," Pollak said.

The problem is, Pollak said, is that while the hospital sees some relief for its costs in the rate-setting procedures, doctors get no such help. And Medicare and Medicaid reimbursements have been dropping since 1993, he said.

At the same time, the work involved in helping patients get insurance reimbursements or settlements has become more complicated, Pollak said, but added that if doctors don't help the patient with that work, then they don't get paid.

How many hours can society expect doctors to work? It seems clear that trauma centers could not pay surgeons what they do now if the doctors didn't also have private practices. But as Pollak told me, because people now value their time with home and family more than they once did, "that macho, working-100-hours-a-week thing is not as attractive as it used to be."

Asked what the solution is, Pollak hesitated, saying his opinion was his alone, and not that of the shock-trauma system or the Maryland Orthopedists Association, which he serves as legislative committee chair.

Pollak said that all involved need to work on getting more money into the system, because Hagerstown's problems are not unique.

"The EMS system or the ground and the helicopters in the air are only as good as the institutions caring for the patients," Pollak said.

What's the prospect for a legislative solution? That's a topic I hope to explore in the next few weeks.

Bob Maginnis is editorial page editor of The Herald-Mail newspapers.

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