A medical center is not a hospital: Reflections of a department chair still in the game

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Dr. Thomas Lansdale’s commentary in the September issue (Cleve Clin J Med 2008; 75:618–622) resonated with many physicians because he so eloquently captured the increasing frustration many physicians feel:

  • Frustration at the loss of a hospital culture that many of us loved;
  • Frustration at the increasing challenges of providing effective medical care;
  • Frustration with the increasing difficulty of providing outstanding education to future generations of physicians;
  • Frustration at the escalating pressure to increase productivity and efficiency, shorten length of stay, reduce cost, improve quality, and enhance patient safety and satisfaction, all at the same time;
  • Frustration at the nursing shortage and the need for more and more paperwork that takes physicians and nurses away from the bedside;
  • Frustration with the ascendancy of third-party payers who dictate reimbursement and deny payment for care that is often necessary; and
  • Frustration with hospital administrators who themselves are struggling to maintain the viability of our institutions at a time of escalating financial stress in health care.

Not all change has been for the worse

I trained in the same era as Dr. Lansdale and Dr. Brian Mandell (editor of CCJM), though at a different institution. Dr. Lansdale perfectly captured the ethos of the hospitals where I worked. Those were the days when house officers and nurses were in it together and bonded, when “everybody knew everybody,” when house staff and nurses ran patient care, and when we kept patients in the hospital for as long as we deemed necessary and got reimbursed for it. Those were also the days (before Libby Zion) when attending oversight was sometimes marginal (attending rounds happened on the wards three times a week for 45–60 minutes), when 36-hour shifts without sleep were common, when hospital-acquired infections were felt to be the cost of doing business and were not tracked (let alone prevented), when quality and patient safety were not articulated as drivers, when medication errors weren’t on the radar screen, when professionalism was not a core competency and we jokingly referred to some patients as “gomers,” when patient satisfaction didn’t matter, and when answering a question that came up on rounds required a trip to the library to sort through textbooks and journals in the stacks, rather than a few minutes on the computer. A lot has changed in hospitals and health care over the last 30 years, and not all of it for the worse.

I have been in medical leadership positions for the past 16 years, as a division chief for 10 and as a chair of medicine for the past 6. Maybe I’ve been lucky, but I have worked at institutions where there has been a commitment to medical education and to quality and patient safety. My current institution has quality as the dominant strategic goal, and we have tried to put our money where our mouth is. Hospital administrators and physician leaders are remarkably aligned in support of this goal, and we have won numerous national awards for the quality of our care. Educational innovation is another institutional strategic goal, which we have supported with hard money to fund teaching time for our faculty. Despite these commitments, physicians in our community share many of the frustrations articulated by Dr. Lansdale. Even at institutions with physician and hospital leadership aligned around goals of importance to doctors, these are tough times.

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