Surgical Society’s Rules Put Country Doctor in a Dilemma

Once a week at 3 a.m., Dr. Robert Koefoot opens his office, makes a pot of coffee, reads the morning newspaper and then drives off into the darkness--a medical renegade.

The moon and an infrequent passing car provide the only light, an occasional deer or raccoon the only sign of life on the flat central Nebraska farmland as Koefoot drives north to St. Paul, population 2,000.

By 4 a.m. he is performing his first operation of the day--in defiance of the American College of Surgeons.

Koefoot, a third-generation physician, is an itinerant surgeon. His are the only general surgical services available to the 35-bed Howard County Community Hospital, which serves the St. Paul area 22 miles north of Grand Island.

He has traveled the lonely Nebraska blacktops from Grand Island to nearby towns for decades now--fixing hernias, removing appendixes, amputating limbs--but he leaves post-operative care in the hands of the family physicians who live in the towns--the doctors who referred the surgical cases to him in the first place.

Referrals Violate Rules

That arrangement violates the bylaws of the American College of Surgeons, the only major professional medical organization that prohibits so-called itinerant practice. It requires its members to follow up cases personally or to delegate postoperative care to other qualified surgeons.

For 10 years, Koefoot has waged a one-man crusade against this restriction. He challenged the College of Surgeons as a member and, after he was expelled from the prestigious organization, from a federal courtroom in Chicago. So far, he has been unable to get the rule changed, but the legal fight is continuing and so is his practice of itinerant surgery.

“They picked on the wrong fellow,” said Koefoot, who has been joined in his fight by the Kansas City-based American Academy of Family Physicians.

The dispute between Koefoot and the 47,000-member surgeons’ organization is as much a matter of Koefoot’s ego as of medical principle, but it underscores the difficulties of providing specialized medical services in rural areas that have a chronic shortage of doctors, particularly specialists.

Critics of the surgeons’ group’s prohibition say that the economic well-being of country hospitals, already suffering from cuts in federal programs, shrinking populations and competition from regional medical centers, is further hurt by such a policy.

Position of College

The College of Surgeons contends that patients are better served by surgeons who provide postoperative care or delegate it to other qualified surgeons who will be nearby in case complications develop.

The issue, the group’s lawyers say, is assurance of quality care. “ ‘Itinerancy’ is not going back and seeing the patient, no matter where he is. Elements of time and distance are irrelevant,” said Paul G. Gebhard, attorney for the College of Surgeons. “It isn’t traveling . . . . There are fellows in Nebraska who travel some distance, and who see their patients regularly (after surgery).”

Koefoot said: “People in rural areas should have surgical problems solved by a competent, trained surgeon (and) they should also have the opportunity to have their surgery (near their) home, in the rural hospital. Without (income from) surgery these hospitals would not remain open.”

“The surgeon is more than a ‘hewer of flesh,’ ” the surgeons’ association argues in court documents. “The college believes that the surgeon has a moral, ethical and legal obligation to give patients upon whom he has operated his personal attention, and to attend his patients postoperatively.”

‘Happening More Now’

“Itinerant medicine is essential,” insists Robert T. Van Hook, executive director of the National Rural Health Assn. “Radiology, pathology, ophthalmology, cardiology--almost all the sub-specialties in internal medicine are out there and being practiced on an itinerant basis. It’s happening now more than it was 10 years ago.”

Because he refused to stop practicing itinerant surgery, Koefoot was suspended from the College of Surgeons in 1979 and expelled two years later. He filed suit, claiming his right to due process was violated by the disciplinary procedures. That claim is being considered by a federal judge in Chicago who presided over a seven-week trial earlier this year.

Koefoot and the family practitioners who attend to his patients also contended that the ban on itinerant surgical practices was anti-competitive, restrained trade and violated federal antitrust law. On that issue, a jury ruled against Koefoot and in favor of the College of Surgeons.

A surgeon does not have to join the American College of Surgeons. In fact, many do not belong, but membership is considered important in the medical profession.

Excluded From Directory

“The prestige of being a member of the American College of Surgeons is tremendous,” Koefoot said. “That is the one surgical organization that, to me, is the most outstanding in the country. They have their yearbook, and that book is used for patient referrals. I think I have lost a tremendous amount of income because of (absence from the yearbook).”

“Certainly, within the medical community itself, physicians look at other physicians’ certifications--whether they are board-certified or not--as to whether they’d want to refer a patient to them,” said R. Michael Miller, vice president and general counsel of the 59,000-member American Academy of Family Physicians.

The Academy, whose members often take over the postoperative care of itinerant surgeons’ patients, is helping to underwrite Koefoot’s legal battle with the American College of Surgeons. The family physicians’ group decided to support Koefoot because “we felt this rule regarding itinerant surgery challenged the competency of family physicians to provide competent postoperative care,” Miller said.

While the controversy can be viewed as a dispute between a strong-willed country doctor and an equally strong-willed professional organization, it also highlights the growing problem of health care in rural America. In areas far from the nation’s population concentrations there continues to be a shortage of doctors, particularly specialists, and hospitals are closing at an accelerated pace.

Rural Doctors Scarce

“Rural areas are losing doctors at a more rapid rate than before and replacing them at a slower rate, despite the increasing supply of doctors nationally,” said Roger D. Tracy, director of community programs at the University of Iowa’s College of Medicine.

“We’re not Los Angeles or the Gold Coast of Chicago or Fort Lauderdale,” Tracy said. “Certain things lead doctors to locate in nice climates and healthy health-market places. That makes it difficult to attract doctors to lesser-performing economies and more rural areas.”

“Rural residents tend to be disproportionately elderly and disproportionately uninsured or under-insured,” said Jan Shulman of the American Hospital Assn., explaining some of the realities that doctors and hospitals in the country face.

“You have a population which was largely self-employed, or small business people. They do not have the opportunity to get group health insurance the way many of us do as part of our jobs. If you’re in a mining area or a farming area, probably the economics of your region are devastated at this point, and the chances are real good that if it’s a choice between staying on your farm or buying insurance, you’re going to stay on your farm. So a lot of people in rural areas have the bare minimum of insurance or have let their insurance lapse.”

Lower Medicare Coverage

Medicare pays rural hospitals less than it pays city hospitals for the same services, according to the American Hospital Assn., and this is a contributing factor in the closing of an increasing number of rural hospitals, Shulman said.

In the last two years, country hospitals have been closing at a faster rate than urban hospitals. According to American Hospital Assn. figures, 38 of the 72 hospitals that have closed since the beginning of 1986 served rural areas.

Surgery is one way to keep these facilities alive economically, many medical authorities say. And, according to some, the only way to provide surgery is through itinerant practitioners.

“Hospitals need to fill their beds,” said National Rural Health Assn. executive director Van Hook. “Itinerant medicine is essential to the rural hospitals . . . . Bringing in additional specialists helps improve the utilization of their facilities. It is critical to them.”

He added: “Itinerant surgery is happening in every rural state, which probably means 35 of the states. It happens everywhere. It is not an unusual thing (but) most hospitals would be reluctant to admit they use itinerant surgeons. Even behind closed doors, they like to talk in kind of hushed tones about it, because you don’t want to jeopardize your service and your surgeon has signed this little card that the college (of surgeons) puts out that says ‘no, I don’t practice itinerant surgery.’ But they do.”

“(Hospitals) could really make a contribution by acknowledging that it’s happening and by trying to find ways in which it makes sense.”

‘Same Level of Care’

“The college has no interest in putting rural hospitals out of business or bringing surgical patients into big cities,” said Douglas J. Polk, a lawyer for the surgeons group. “What the college insists upon is that rural patients receive the same level of care that city patients receive.”

“The college simply doesn’t want people wearing the label of the college, which insists on a certain level of care, and then not delivering that level of care,” added College of Surgeons lawyer Gebhard.

St. Paul, where Koefoot still openly practices itinerant surgery, is like many rural communities. Once a flourishing agricultural area, its economy has gone from good to poor. There is no industry. Three banks in Howard County have been forced to close in the last two years, and the region’s population has declined an estimated 25%. The little one-story hospital, built in 1955, replaced an old house as the community’s medical center. Its surgical suite replaced a kitchen table that was used for operations.

“This hospital is the biggest industry in town. It’s the biggest employer, along with the rest home, and we won’t keep going without itinerant surgery,” said Dr. Richard Hanisch, a general practitioner who works with Koefoot and says that “he brings in a lot of business.”

“I don’t understand why they think he’s doing wrong,” said Margaret Zocholl, a retired nurse whose husband was having a leg amputated by Koefoot. “If we can have (surgery) done here, why go to Grand Island?”

“It’s quality. It’s not unethical. It’s not immoral,” said Koefoot, “and our patients know it and their relatives know it.”

Researcher Wendy Leopold contributed to this story from Chicago.