Commentary - June 2010
Tex Med . 2010;106(6):61-62.
By John Pettigrove, MD
After one-and-a-half years as the vice president for medical affairs in a large metropolitan hospital, I have learned a lot about how health care is managed today. Some of what I have learned has been very hopeful, but much of it has vexed me.
Some form of metric evaluation of performance in our health care system has been around for more than a century. A hundred years ago, Abraham Flexner issued his now famous report on the state of medical education in this country that led to widespread reform and helped create the education system as it is today. Dr. William Osler at the University of Pennsylvania, Johns Hopkins, and later at Cambridge in England, began a movement toward evidence-based medical practice and application of the scientific method.
Modern business principles presumably based on the scientific method are part of everyday management of hospitals across the country. Measurements of quality in health care most recently by government and other third-party payers have centered on performance by hospitals and physicians on certain practices. This policy presumes that if a hospital does well on these "core measures," it is an indication of the quality of care delivered by the providers scrutinized in that way. Government and other third-party payers use these measurements to ensure that they are getting what they pay for.
All sorts of measurements commonly referred to as "metrics" are used today to evaluate performance of hospital staffs - both employees and medical staffs. Hospital budgets have become dependent upon many of these measurements. Hospital lengths of stay are compared with geometric mean lengths of stay calculated from data gathered from across the country, and hospitals are paid case rates according to these data. Hospitals live or die by the diagnosis-determined lengths of stay and case mix ratios that drive their reimbursement.
Data-driven best practices are now used nationwide to determine staffing and budgets. Consulting firms that pander to institutional fears and inadequacies thrive by showing hospitals how to improve their performance on these metrics.
A Personal Story
Let me now tell you about my own family's experience in this brave new world. My 97-year-old father-in-law, a dairy farmer, fell and fractured his femur. At the time of his injury, he was still driving and living in his own home alone. He had worked cattle the day he slipped in his den and fell.
A very competent rural EMS team came to his home and transported him to the hospital emergency department where he was seen, evaluated, and admitted to the hospital. An outstanding orthopedic surgeon pinned his hip the next day. So far so good, but possibly from age, fat emboli, or whatever, he became delirious. During his delirium, he was combative and developed atrial fibrillation, heart failure, and renal insufficiency. We were unprepared in the intensive care unit (ICU) to manage him. In spite of an abundance of physicians consulting on the case, there seemed to be no one in charge. For about three days, he foundered about almost on his own in spite of being in a critical care unit and having around-the-clock care.
On his best day, my father-in-law is a tough man to deal with. He is independent and seldom sees a doctor. He has worked every day since he was at least 11. He has never learned to depend on anyone other than himself.
The system failed him. His advanced age and injury all were against him. Some providers discounted him because of those factors. The physical design of the ICU made the metrics-driven staffing ratios inadequate for him. To my family, no doctor seemed to feel responsible to take charge of his care and if they felt empowered, the nurses seemed reluctant or afraid to call them or even notify them of his condition. I am not saying that was exactly the way it was. I am saying that is the way it appeared to the family.
Therefore, after a few days of this and against what I consider the ethical thing to do, I stepped in against all my own advice and expectations and took temporary control of the situation. No family member should have to do that, even if he is a physician, and no physician should do as I did. Out of shame, I changed some of his doctors and asked colleagues I knew would make responsible decisions to assume his care. His surgical care was and is outstanding. His medical care started out pathetic but thanks to my friends and colleagues, it improved dramatically. The nursing care was dependent on the staffing of the units he was on and varied from wonderful to pitiful.
In my father-in-law's case, none of this as far as his outcome is concerned probably really matters. He is very old and his fate, aside from good surgery and postoperative care, is probably out of the reach of medical science. The most shocking realization is that if I had not been a physician and had not had good friends on the medical staff, things would have probably been much worse.
I strongly believe everyone should receive the same standard of care - the best we can do. I strongly believe it is in the best interest of the patient for a family member who is a physician to stay out of the way of the caregivers. I strongly believe all those things. My experience with case management and dealing with families every day makes me realize that if I hadn't been there, things would have been very different.
As health care professionals, our behavior often fuels the notions like "death panels" and other ridiculous beliefs. Further, the loss of physician autonomy and the rise of unbridled management by metrics are disastrous for health care. The idea of giving antibiotics in a timely fashion for pneumonia is a good one. Being consumed by metrics-driven performance standards at the cost of all else is nonsense.
Is there a doctor in the house? Sometimes there is not when there should be.
Dr. Pettigrove is an internal medicine specialist in Corpus Christi and member of the Texas Medicine Editorial Board.
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