The medical staff is a choice

Earlier this week, I had the opportunity to observe a medical staff meeting of a long-term client of mine. The CEO told the staff that volumes at the hospital were “soft” and that the hospital was breaking even. He thanked the medical staff for their continued support of the hospital. A member of the staff then announced that the largest integrated hospital group in the state had just bought a hospital similar in size to their own and now had a presence in over one-third of the state’s counties.

The medical director of the emergency department then presented an interesting case for the medical staff to review and discuss. A 35-year-old woman presented to the emergency department with severe right hip pain and swelling, a fever of 103 degrees, a pulse of 135, a blood pressure of 90/60, and a white blood cell count of 22,500 with a left shift. She had hip surgery one month earlier. She was in obvious distress and had swelling, redness, and tenderness over the right lateral hip with limited motion. Blood cultures were pending, and a CT of the right hip demonstrated a subcutaneous loculated fluid collection (4cmX4cmX24 cm) indicative of a probable abscess.

The patient’s personal attending physician was called to admit the patient and stated that he did not feel comfortable managing a surgical emergency. An orthopedic surgeon was called and he asked that the patient be transferred to his office for evaluation. When the emergency physician on duty stated that the patient was much too sick to be transferred, the orthopedic surgeon suggested that the patient be transferred to another hospital’s emergency department for evaluation. When the emergency physician stated that he still did not feel comfortable transferring the patient, the treating orthopedist stated that he could not see the patient at the moment because he was “tied up.” The emergency physician, out of his frustration, told the patient that he attempted to admit her to her primary care and treating orthopedist but that they had declined. He asked her if she would be willing to be transferred, but she refused stating that she wanted to be cared by her local hospital and did not wish to be transferred out of town. She also stated that she did not have the additional funds for an ambulance ride and had a young child at home that she wanted to be near.

The emergency physician then contacted the chief of staff and vice president of the hospital asking what he should do. They suggested contacting the patient’s primary physician again and this time calling the orthopedic surgeon’s partner to admit the patient. The orthopedic surgeon’s partner admitted the patient and drained the abscess the next day. The patient was discharged two days later with IV antibiotics and a peripherally inserted central catheter (PICC).

After a thoughtful discussion by the staff, I asked if they saw a link between this peer review case and their colleague’s announcement about the buy out of the small hospital by the large hospital chain. They became very quiet for a while, and then one physician stated that larger hospitals were taking over hospitals throughout the state due to the economics of healthcare and how difficult it is for stand-alone hospitals to “make it.” I then asked him if he thought that this was inevitable or if it was a choice, and the room became very quiet.

I didn’t answer the question for them because I felt that they needed to do that on their own. Epiphany is a personal and private experience and cannot be drawn out. What I wanted to tell them was that one’s destiny is the result of large external forces and small internal ones. If they want to remain a stand-alone organization with a community identity and mission, it does not come without some personal sacrifice. When individuals stop contributing to their patients and their colleagues and begin focusing on their own needs, the volumes become “soft,” and the hospital flounders. The medical staff has a personal and collective choice to either support a “buy out” by a larger organization or the sustenance of a hospital with the dedicated mission to care for its own community.

There are many powerful economic forces today causing physicians to retreat into their private spheres and drive high volumes in order to combat waning reimbursements, ever climbing costs, and public expectations. Hospitals are always being driven by the same forces; they, too, are struggling to maintain their operating margins at a time of significant investment pressures.

The choice at the end of the day is whether hospitals and physicians can and will work together toward a shared mission or focus only on their own needs. Once a larger organization purchases a smaller one, the mission is no longer the same. The community is only part of its consideration, and the medical staff becomes absorbed into a larger corporate culture.

The medical staff that I addressed earlier this week has a choice: It can unite behind a shared mission and make personal sacrifices so that its community hospital can survive and its community can receive the care it deserves. Or, each member of the medical staff can choose to focus on his or her individual practice and let the chips fall where they may.

There are many small choices that we make as physicians and collectively as a medical staff every day. The choices we make define who we are, what we represent, and what happens around us and to the organizations we serve. The medical staff is a choice.

Wishing you continued success.

Jonathan H. Burroughs, MD, MBA, FACPE, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.