How Carilion Clinic's Dr. T.K. Miller plans to grow his practice + best advice for new surgeons

Thomas K. Miller, MD, is the sports medicine section chief at Carilion Clinic in Roanoke, Va.

In addition to his clinical practice, which focuses on knee and shoulder reconstruction as well as nonoperative sports medicine, Dr. Miller is a professor of orthopedic surgery at Roanoke-based Virginia Tech Carilion School of Medicine an assistant professor of medical specialties orthopedics at Blacksburg-based Virginia College of Osteopathic Medicine.

Dr. Miller is a featured speaker at the Becker's 17th Annual Future of Spine + The Spine, Orthopedic and Pain Management-Driven ASC Conference, June 13-15 in Chicago. Click here to learn more and register. For more information about exhibitor and sponsor opportunities, contact Maura Jodoin at

Here, Dr. Miller discusses his goals for the next few years and best advice for young surgeons entering the field.

Question: What are your top one or two goals for your practice over the next three to five years? How do you see it growing and developing?

Dr. T.K. Miller: The challenge for any practice and healthcare system is associated with directing patients and services required to the most appropriate facility for the entire "package" of care. The concept of who really needs a traditional hospital environment continues to evolve.

Matching and appropriately allocating the limited resources of time/OR access, overhead, materials and staffing to the patient and procedure needs to be approached outside the longstanding models of care. This includes:

● Rigorous [preoperative] screening of comorbidities and assignment to a site of care based on anticipated perioperative needs (not just the procedure to be performed)
● Assessment and optimization of postoperative support services
● Patient (and family) education and training
● Supply of durable goods to enhance recovery
● Development of efficiencies based on large volumes and reliably reproducible protocols and continuous monitoring of outcomes and adjustment of care models based on objective evidence from this monitoring

As more complex procedures are shifted to nontraditional sites of care, we expect to see a narrower focus of service for sites of ambulatory care. Just as surgical specialties have become more subspecialized, we can expect ambulatory centers to become more specialized to improve efficiencies and quality of care. We expect to see not just specialty specific ASC sites but narrow focus procedure centric facilities.

Q: What advice do you have for new orthopedic surgeons just entering the field?

TM: As surgeons, we have traditionally been shielded or isolated from costs associated with providing care. This may be even more of an issue during residency or fellowship where volumes and complexity of care take precedence over attention to fiscal issues. I would encourage any new surgeon to ask what everything costs. What is the cost of the implants used, how do they compare to other alternatives, what do grafts, biologics, etc., cost, is there a primary vendor arrangement (usually associated with volumes) and is there a cost differential when using one-off implants/systems.

The concept of case costing is essential for the fiscal viability of any facility, especially in a freestanding ASC environment so a proactive approach should be taken to how these costs relate to facility/institutional reimbursement. While new providers are often hired to bring new techniques and improve options in patient care, asking these questions in advance and adjusting to processes in place smooths the process for a provider integrating in to the system and may build a level of acceptance when a truly new/expensive system or implant is required.

While training may lead [physicians to form perceptions] of the best/ only implant or technique, repetitive supply/implant costs in excess of reimbursement cannot be viewed as sustainable and some flexibility and recognition of fiscal realities is required when working in a new environment.

Be realistic about case posting, both in regard to time duration and accuracy of the components of the procedure that should be noted in the posting order. Training with an established, high volume, efficient, well supported mentor does not translate to the real world as a new provider. Do not expect the same efficiencies at the start of practice.

New providers who recognize all factors involved in the time required for "in room to out" and post accordingly typically find facilities more accommodating to adding cases to the schedule or allowing for revised case posting than those who routinely under post (and then complain that "they can’t get cases on the schedule"). A provider who "posts long and finishes early" and accurately posts the procedure is usually accommodated better than one who "always runs long" or adds "unexpected" additional procedures to cases.

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