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Robert A. Berenson, Paul B. Ginsburg, and Jessica H. May, Hospital-Physician Relations: Cooperation, Competition, Or Separation?, Health Affairs Web Exclusive, December 5, 2006 [Abstract] [PDF] [Full Text][Table of Contents] [Reprints & Permissions]

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Electronic letters published:

Hospital-Physician Relations: Mission Control -- We Have A Problem

Nancy E. Ness   ( 6 December 2006 )

Facility/Physician Relations: Positive Results from Ambulatory Surgery Centers

Craig Jeffries   ( 11 December 2006 )

Hospital-Physician Relations: Mission Control -- We Have A Problem 6 December 2006
Nancy E. Ness, Medical Director Mile Bluff Clinic LLP Send letter to journal: Re: Hospital-Physician Relations: Mission Control -- We Have A Problem nness{at}milebluff.com Nancy E. Ness	"The physician’s mission is to serve the health care needs of the patient. The hospital’s mission is to serve the physician in providing care to the patient." For hundreds if not thousands of years, the primary therapeutic relationship has always been between the physician and the patient, the healer and the sick - a personal, one-to-one relationship of trust - the physician’s mission is to serve the health care needs of the patient. Being a “servant” of the patient requires humility and commitment. That “service” is a burden on a physician that, once assumed, is a 24/7 burden. Although specific services can be delegated to others, the service obligation cannot - it remains effective until either the physician or patient terminates it. To a patient, “my doctor” defines an ongoing semi-permanent relationship that is constantly active, even if he has not seen “my doctor” in a year or more. Most medical students enter school with a desire to pursue that mission, no matter what their specialty interest. A hospital is an organization. An organization cannot have a one-to-one relationship with a person – only another person can. A hospital is an aggregation of individuals working different shifts, performing various duties, whose responsibilities are defined by their job descriptions, not by an continuous 24/7 direct individual relationship. Hospitals’ services have broadened from the acute care setting to include other locations and aspects of care, but always services “as ordered by the physician” - the hospital’s mission is to serve the physician in providing care to the patient. As long as the physician behaves as a committed “servant” of the patient, the hospital’s mission is clear. When physicians' demands from nursing and other staff are motivated by patient needs, not their own, hospital employees readily recognize that degree of commitment, and readily provide support without debates over being a “servant” of the physician. We have a problem: That mission has eroded for several reasons: many physicians have been pompous asses (the “god complex”) who have not viewed themselves humbly as servants of patients, but do treat hospital staff as servants. Medical schools have tried to recruit students who will be future cutting-edge researchers, rather than requiring all to be, first of all, kind and compassionate people. The proliferation of specialization has made it easier for physicians to distance themselves from one-to-one relationships with patients, particularly if they have poor interpersonal skills. Primary care has been reimbursed poorly, encouraging physicians to pursue subspecialty training that makes them, in essence, “limited practitioners” both in scope of practice and in commitment to patients. Those physicians who did embrace service to patients as a mission did not pursue their own, or collective, economic self-interest to the degree pursued by others, and have been economically devastated in consequence, while hospitals and profit-oriented subspecialists thrived. Nursing education has renounced service to physicians as a mission, and has focused on an “equal but different” care plan strategy that fragments care, in order to increase nurse self-esteem and support feminist goals. Hospitals are overwhelmingly not physician-directed, but led by lawyers and accountants, who have vigorously pursued all avenues to accumulate power and profit. As a result, the current medical system has become hospital-centric, and has tried to change the mission statement to be: "the hospital’s mission is to 'service' the patient; the physician’s mission is to serve the hospital." Loss of Mission Control: When this distortion in mission control occurs, it creates increasingly lethal problems with the health care system affecting practitioners, patients, hospitals and hospital employees. Physicians: If physicians serve the hospital, not the patient, they become “cogs” and behave like employees - they are only willing to “serve” patients during specified hours, and will avoid responsibility and commitment. They place their own convenience and schedule ahead of patients, and become selfish. They are unhappy with many aspects of work, and readily complain. The ubiquitous problems with surgical ER coverage, particularly in large urban areas, is a direct outgrowth. If the hospital’s mission to the patient is the primary one, they reason, then the hospital is responsible for call and coverage, not the physician. The physicians and other providers will, like any other employee, take care of themselves first - and will do what is required by the hospital - but no more. Leaving work as soon as the last patient has been seen, being “picky” about hours, vacations, and meetings, and being willing to meet performance requirements but not go beyond are all practitioner symptoms of a distorted mission. Patients: The hospital is an organization, and cannot relate to patients with the one-to-one closeness of a person. Patients’ perception has increasingly been that hospitals are just greedy for money, and that neither hospitals nor physicians care about them, and they turn to lawyers when anything unfortunate happens. With erosion of the trust relationship, patients demand many unnecessary services, and then complain as the costs of health care accelerate. Fragmentation of physician care leads to errors and duplication, and decreasing opportunities to address lifestyle and other patient behavior issues. As the health care team becomes hospital-centered, not physician-centered, the communication and coordination of care deteriorates, and patients become more confused about medications and treatment. Patients are clamoring for physicians who care, and the health care system is fumbling with managing chronic disease. Hospitals: The hospital organization has often traded any semblance of patient-centeredness for cost-centeredness, and for-profit and specialty hospitals have proliferated. Additional service lines are viewed primarily from the perspective of revenue, not need. Since the function of the hospital is no longer “to serve the physician”, hospitals and physicians often battle over medical staff membership, privileges, surgicenters, and ancillary revenue. Hospitals may cease supporting education if it doesn’t generate revenue. Information systems and technology proliferate, but primarily serve to meet the demands of third parties (lawyers and regulators), not the needs of physicians. The relationship with physicians changes to primarily stress physicians’ obligations in terms of record-keeping and the requirements of regulatory agencies, not physicians’ needs in terms of patient care. The imposition of enormous numbers of burdensome requirements upon physicians and hospitals is also a symptom of the distorted mission, nation-wide, since physicians are viewed as servants of the third party regulators. Hospital staff: The hospital, as an organization, may be able to staff some departments 24/7, but no individual in those departments will have the same commitment to an individual patient that “my doctor” has, and most staff will not be motivated to “go the extra mile” for patients. The older nursing staff become frustrated with the attitude of the young, and neither is encouraged to make physicians’ work more efficient - rather, physicians are berated for anything that requires additional staff time or effort, and physician-nurse conflicts increase, both open and covert. “The Administration” is viewed by both as an adversary. Conflicts between departments increase, since each has a different perspective on what is important, and service to physicians is only an adjunct, not the principal goal. Mission Control Repair: We cannot change the entire health care system easily, but we can repair these problems at the local level, by returning to working according to the original Mission Control: "The physician’s mission is to serve the health care needs of the patient. The hospital’s mission is to serve the physician in providing care to the patient." Where physicians or other providers are not “serving” patients, but being self-serving, or treating staff as “servants”, we (physicians) must reform their behavior, or dismiss them from the organization. Physicians entered medical school with this mission - most remember it, but may have become distracted. Physicians will clean up their own act. Where hospitals have lost sight of their mission, we will remind them, and demand that, as we accept our burden, they accept theirs. Service to physicians is more mission-critical than service to JCAHO or other entities. Every employee needs to be re-educated and reminded, and decision-making needs to incorporate this mission at every level. By so doing, we will once again align our missions in a way that benefits and satisfies patients. Where there is conflict between departments, individuals, or between patient care and regulations, we will insist that hospitals restate the conflict in terms of this mission: what best serves the physician in providing care to the patient? The health care system is rapidly approaching a crisis point due to the imbalance between costs and demands. What form the post-meltdown system will take is anybody’s guess, but any hospital and medical staff that restores Mission Control will probably survive the voyage.
Facility/Physician Relations: Positive Results from Ambulatory Surgery Centers 11 December 2006
Craig Jeffries, Executive Director AAASC - American Association of Ambulatory Surgery Centers Send letter to journal: Re: Facility/Physician Relations: Positive Results from Ambulatory Surgery Centers CraigJeffries{at}AAASC.org Craig Jeffries	As noted by Berenson and colleagues in their analysis of CTS communities, ambulatory surgery centers (ASCs) have grown increasingly important as a source of surgical care. This growth can be attributed to the patient-centered, high-quality model of efficient care ASCs deliver at lower cost to health care consumers. Despite the expansion of the ASC industry, there are communities across the country where patients encounter waiting lists for important services like screening colonoscopies. Physicians and ASCs have responded to increased demand for these services by stepping up their capacity and opening new facilities at a fraction of what it costs patients and payors to seek the same service in a hospital. It is unfortunate that the debate over the setting of outpatient surgery is posited as financial competition between hospitals and ASCs. Efforts to thwart through legislation and regulation what is identified by the authors as competition for financial gain reduce physicians’ ability to provide services to populations that need care. Physicians continue to provide the impetus for the development of new ASCs. By operating in ASCs instead of hospitals, physicians gain the opportunity to have more direct control over their surgical practices.[1] In the ASC setting, physicians are able to schedule procedures more conveniently, assemble teams of specially trained and highly skilled staff, ensure the equipment and supplies being used are best suited to their techniques, and design facilities tailored to their specialties. Simply stated, physicians are striving for, and have found in ASCs, the professional autonomy over their work environment and over the quality of care that has not been available to them in hospitals. These benefits explain why physicians who do not have ownership interest in ASCs (and therefore do not benefit financially from performing procedures in one) choose to work in ASCs in such high numbers. ASCs are a positive trend in health care and a progressive model for surgical services. Given the history of their involvement with making ASCs a reality, it is not surprising physicians continue to have ownership in virtually all (90%) ASCs. But what is more interesting to note is how many ASCs are jointly owned by local hospitals. According to 2004 data, hospitals have ownership interest in 21% – or almost 1,000 – of all ASCs; 3% are owned entirely by hospitals.[2] This growing trend of hospital ownership in the ASC model contrasts sharply with the public policy initiatives of hospital associations seeking to use the political process to curb or curtail ASC growth. Notes 1. “Ambulatory Surgery Centers.” Encyclopedia of Surgery. Ed. Anthony J. Senagore. Thomson Gale, 2004. 2. 2004 ASC Salary and Benefits Survey, Federated Ambulatory Surgery Association, 2004.