Al's Musings

I have not written an article for quite some time due to a combination of ennui and not knowing what to write about. I have decided to share some ramblings on three different aspects in the healthcare arena.  First I will look at health care attorneys.  Then I will turn my attention to physicians and lastly to physician hospital relations.  If I offend anybody with this, so be it.

 It seems to me that in the legal community there is so much focus on the law and the doomsday scenario that common sense is lost.  In the medical community I sense a loss of caring as to what happens to them.  In the hospital community I sense the "we know better than them" attitude.

I belong to a significant number of listservs in the healthcare law arena.  I continue to see the attorneys, most of which represent hospitals or systems, with a true sense of fear.  They are focused on the law and how to keep their clients from getting any risk or at least from the attorneys having any risk in their advice to their clients.  They are more focused on avoiding risk than finding solutions to the issue.

This does a major disservice to their clients and to their own reputations. A solution does not necessarily always fit into the lines.  Occasionally one must take chances, with the client's blessing.  In the last month some attorneys have grasped the ring by asking and receiving permission by the feds for gainsharing deals between hospitals and physicians.  This is truly unusual from the conservative institutional Bar.  

I continue to be involved in the medical field by virtue of my contract and peer review work with the physicians, my continued medical friendships as well as the weekly visits to the hospital for medical meetings.  I still need to get CME.  I see and feel a sense of defeatism that permeates the California medical community where I live and practiced.  Remember, this is California where the medical community does not have to deal in the med mal arena and the neglect of the legislature, as in Illinois or Pennsylvania. The doctors are tired of being beaten on by the hospital administration to do this or that and of having no input into the direction and services of the hospitals, of whom they, along with the patients, are the customers.  They are tired of the insurers stating that they will not pay for what the physician and patient believes are medically necessary.  The physicians are resentful of the hospitals and their agents (lawyers) disrespecting them by using the word Docs.  These men and women spent four years of college, four years of medical school and anywhere from one to seven years post medical school.  They did not do this to be called Docs.  They have earned the right to be called physicians or doctors.  I don't believe the hospital people enjoy being called The Suits, another derogatory term.  I don't believe the attorneys enjoy being called shysters or being the butt of all the jokes.  The next time an attorney or administrator calls the physicians Docs, tell them they are being disrespectful.  If they are not told, they have no way of knowing.

The hospital administrators seem to believe they are smarter than the physicians and nurses working in the institution.  Newsflash: they aren't.  If the administrators would look, they would see that among the ranks of the medical professionals are people that have financial, managerial and leadership abilities.  This may scare them as they read that there has been an increase in physician CEOs of hospitals in the country.  

There is no one that knows the inefficiencies of the hospital as well as the physicians that utilize the brick and mortar.  This is one of the main reasons why specialty hospitals and ambulatory surgical centers have grown away from the community hospital. Is there a hope that some money will be generated in these ventures? Of course.  Is that the main reason?  No.  It is to get away from the hospital inefficiencies and the poor productivity of the union worker.  

When I helped start a surgical center next to a hospital it was to get away from the unionized nurses who could not be forced into speeding up between cases and/or not having the correct instruments present for a case.  In the new facility productivity was markedly increased but it made no money since this was in the early 1980s and some physicians still believed the hospital was the only place to do surgery.  Eventually we sold the center to the hospital with the proviso they could not use union personnel.  They still ran it into the ground and it is now owned again by a private party. In another hospital the ambulatory surgical center was within the hospital but owned by a separate entity made up of both physicians and the hospital. This continues to be doing well for all the investors.  

How can these three diverse groups come together for the betterment of patient care.  The answer is fairly simple.  Cooperation and mutual respect. The changing economics of practice has had a major impact on the physicians. There is no more of the idea of my hospital is my friend.  They may be competitors for the insurance dollar.  Things that physicians used to do for free such as emergency room care and working to help the hospital in their utilization management are now being compensated. The hospital has to be mindful of this and begin to treat the physician as an economic partner and not just expect the physician to do that which eats into their economical time.  The physician now expects to be paid for their services.

If physicians are not respectful of their fellow workers at all levels and that disrespect goes to the quality of the care the patient receives, they should be counseled and then disciplined.  However, those that do the discipline should truly listen to what the physician is saying and not just call them disruptive.  The physician may be correct and instead of physician needing discipline it is the hospital that needs changing.  Several examples of this are the Ventura Community Hospital fiasco and a hospital in Pennsylvania that is going against state law by putting a non physician in charge of a medical department. The attorneys for these hospitals only care about what their clients want and not about settling the issue.  They are the catalysts that allow the fire to flare and then to keep burning.  The attorneys forget that another name for them is a counselor.  This entails looking at all sides of an issue and advising their clients what is best, not for them but for the issue or in medicine, the patients. 

The March 15, 2005, edition of Hospitals and Health Networks had a superb article by Dan Beckham, a consultant.  He recommended the CEO get out of the executive suite to visit the floors during morning rounds and talk to the nurses and physicians, visit the physicians in their offices instead of always making them come to the hospital for meetings, eat with the physicians and carry on a dialogue regarding problems and programs of the hospital and the physician, bring the physician into the planning for the hospital and lose the halo of being a non profit.  

When I was a physician I had a CEO that came to the Doctor's Lounge at least once a week.  He did listen and gave the impression he cared about the physician's aspect of the hospital.  This helped him when the Board fired him.  The medical staff fought for him and he was rehired.  When I was a medical director I had a CEO who made rounds every week and also ate lunch in the physician's dining room.  Some of the physicians took umbrage at the CEO invading their space.  However, at that time it truly made no difference since the CEO had already, in the previous years, made brutal enemies of the medical staff and that ended up costing him his job.  An idea Mr. Beckham  did not specifically state but implied  was to bring the ideas of the physicians and nurses back to the executive suite, see if the ideas have merit and if so how to implement them into the hospital culture.

I am done with my musings for now.  I hope I have made some of you angry or ashamed.  Anger and shame are good if they lead to discussion and discussion leads to positive change. Please remember the old legal adage "Doing a job RIGHT the first time gets the job done.  Doing the job WRONG fourteen times gives you job security".

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DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.