Hospital emergency departments across the United States are increasingly unable to find specialists to help treat seriously injured and ill patients, according to medical experts. A nationwide survey by the American College of Emergency Physicians in 2005, the most recent available, found that 73 percent said they had a problem with inadequate on-call coverage by specialists.
It's the season for giving so I thought I'd share with you some of the feedback that readers have so generously e-mailed the past few months. You've had a lot to say--on everything from blogs to infectious disease to firing people. Most of it nice, some of it not, but all of it thought-provoking.
Last month, I addressed hospital-acquired infections in MRSA, MRSA Me by describing my personal experience and urging leaders to consider more rigorous screening protocols. I didn't intend to become a poster child for infectious disease but the e-mail I received in response to this post was overwhelming. I read countless stories of patient safety breakdowns and received numerous invitations to join "survivor" networks and write about my story. For an event that's supposed to be rare and unusual, there sure are a lot of medical error survivors out there.
"I had a post op infection after an ankle replacement. . .and guess what, MRSA. You and I are some of the lucky ones. I only spent three and half months at home not able to work and needed to keep my foot elevated, two extra hospital admissions and another surgery. My first week back to work, I met a woman who lost her leg due to a hospital acquired infection--MRSA. The following day, I was at a meeting at the Joint Commission in Chicago and met a woman whose 24-year-old son survived a horrific parachuting accident only to die a couple of months later of a hospital-acquired infection," wrote Linda Kenney, President and Executive Director of Medically Induced Trauma Support Services (MITSS), an organization formed to support patients, families and clinicians affected by medical errors.
On the flip side, I was surprised by how many readers e-mailed asking what MRSA was. I can only hope these readers aren't too deeply imbedded in healthcare (but now I'll be sure to link to the definition).
Believe it or not, I always appreciate readers who take the time to criticize me--especially those who write not just to be nitpicky but in a way that is truly beneficial to readers. For example, Jeanine Thomas, president of the MRSA Survivors Network, pointed out that I was inaccurate in saying that Illinois hospitals are required to screen only ICU patients. "The law mandates (I wrote the bill and initiated it) that all ICU and at-risk patients must be screened upon admission," Thomas wrote. Suzanne Henry, Campaign Organizer for the Stop Hospital Infections Campaign at Consumers Union, provided this link to a compilation of all states' hospital infection reporting laws.
Bad Press in late November discussed the long-term impact of medical errors on disease management and patient-driven care. One of my favorite responses to this column came through our new user-friendly Web site.
"The public appears convinced that physicians and hospitals are incompetent and dangerous, so I have a proposition in the form of an experiment. Every physician and hospital will shut down for three weeks, after which time the public can decide whether they were better off with us or without us. If they decide they are better off without us, we will admit our shortcomings and find other ways to make a living. If they decide they are better off with us, we will come back to work on the condition that they pay us what we're worth and show a little respect."
This is one of my favorites not because it is particularly informative but because it highlights far better than I ever could some of the challenges leaders face when trying to implement change and overcome tired thinking. I can only hope this view is the exception rather than the rule.
Another reader wrote: "Why in the world would you take your parents to a hospital for a mammogram or a colonoscopy? People who are not sick should not take up space in a place for sick people. The risks for infection make it a poor choice when there are adequate outpatient facilities available." He makes a point, of course, but not everyone in America has access to a multitude of outpatient specialty clinics. In rural Maine where my parents live, the local hospital is a one-stop shop for all services--both inpatient and out.
Fire Away, my column on weeding out underperformers, wasn't quite as infectious a topic as medical errors but it did elicit some good feedback.
Healthcare consultant Mary Malone wrote: "I have been working with healthcare organizations for more than 20 years--mostly in the area of improving patient experiences and leadership. Without fail, the organizations that most quickly embrace the idea that low-performers (however defined) must either improve or leave are the ones that have greatest success. However, the number of leaders (at all levels) who don't deal with this issue in a timely manner is astonishing to me."
And, last but not least, a healthcare leader in Texas summed up the importance of effective employee evaluations far better than I could: "I too have been in multiple leadership positions ranging from inpatient and ambulatory nursing management settings, COO/Risk Manager of a large multi-specialty clinic, to hospital CEO. Disciplinary action is never easy, but unfortunately, as your article highlights, is sometimes necessary for the good of other employees and the organization, not to mention the patients served by these staff members or organizations. If a low performer sucks the life out of those with whom he or she works, it can have a negative impact on the patients cared for by other staff members. Low employee morale, indifference, absenteeism, and turnover may be symptoms that this is happening, as well as lowered patient satisfaction ratings or evidence of patients seeking care elsewhere."
"While some may feel that employee termination is a failure of leadership to adequately mentor or develop staff members, not every employee is a model of decorum. The '20/80 rule' (20 percent of your staff take up 80 percent of your time) sometimes rings true more often than leaders would like to see. For employees falling into this category, you may well alienate other productive employees by focusing attention, time and money in the wrong direction. This does not mean these folks are a lost cause, however, and sometimes a termination of employment or disciplinary action can turn someone around. I have seen members move on (either by their own volition or by being fired), or disciplined, who have become highly productive members in a new organization or in a different setting. Leaders should keep this in mind when dealing with less productive employees."
Thanks for all your feedback this year. HealthLeaders Media Corner Office won't publish next Friday, but I look forward to hearing from more of you in 2008. Happy holidays!
Molly Rowe is leadership editor with HealthLeaders magazine. She can be reached at mrowe@healthleadersmedia.com.
Thomas Zenty, who joined the Cleveland-based University Hospitals system as president and chief executive in 2003, has agreed to stay on through December 2012.
Moody's Investors Service has upgraded Dallas-based Baylor Health System's debt rating, in part because of the hospital chain's expansion into Tarrant County has boosted its financial performance.
The departure of two executives from the West Penn Allegheny Health System in 2007 resulted in severance payouts of $2 million, weighing down the system's financial results for the first quarter of fiscal 2008.
Allegheny General Hospital in Pittsburgh has announced that it plans to open a lung transplant program. The hospital performed lung transplants from 1992 through 1995, but the program was discontinued due to an organ allocation policy at the time that was based on a patient's time on the waiting list. Hospital officials said the policy favored larger transplant centers.
Part-time physicians haven't presented a major compensation challenge for groups in the past--a physician or two may have occasionally requested part-time work options, but it wasn't enough to destabilize the entire group. However, a convergence of several market pressures will make part-time work commonplace in the near future, and practices would be wise to integrate a transition compensation policy into their overarching plan, said Deborah Walker Keegan, PhD, president of Medical Practice Dimensions, Inc., a healthcare consulting company based in Arden, NC, who spoke about transition physician compensation plans at the MGMA annual conference in October.
In addition to the "graying" of the physician work force, younger physicians' desires for work-life balance and the increasing rejection of traditional call-coverage duties make requests for part-time work more common, says Peg L. Stone, principal with PLS Professional Associates, LLC, a Cumming, GA-based firm that specializes in developing and evaluating physician compensation plans.
Whether it's an older physician looking for a semiretirement option, a Generation X physician seeking work-life balance, or a committed specialist who no longer wants to take call, practices should anticipate the effects of part-timers on their bottom line and work to develop part-time compensation plans if they want to retain these physicians.
"It's going to be a fact of life--we will have part-time physicians, and it's not going to be the one or two per practice we've had in the past," Stone says. "Groups are going to have to step out of the box and plan for those events as a normal everyday operational factor."
Older doctors dissatisfied Although a part-time request can come from any physician, the primary source is older physicians looking to scale back their practice rather than completely retire. early half of all physicians in the United States are 50 years or older, making scale-downs an important issue already, and one that will have a greater effect on healthcare in the next decade.
For example, a recent Merritt, Hawkins & Associates (MHA)--a physician search and consulting firm in Irving, TX--survey of physicians 50-65 years old found that only half plan to continue practicing as they currently are in the next three years. Twenty-four percent said they plan on working part-time, reducing their workload, or switching to locum tenens, and 14% will completely retire. Others are turning to jobs in a nonclinical setting or even in a field other than medicine. It's not just that physicians are getting older; they are more dissatisfied with the practice of medicine than in the past, and many would rather retire early than deal with the hassles of running a business when reimbursement is stagnant and costs are rising. When asked how many hours they spent on administrative duties such as billing and compliance in their first three years of practicing medicine, the vast majority of respondents said fewer than four hours per week. Contrast that with the more than half who said today they spend between five and 10 hours on administration, and the roughly 12% who dedicate more than 14 hours to administration weekly.
Combine the shifting demographics with an increasing administrative burden, and practices face a large cohort of discontented doctors: Fifty-two percent of respondents to the MHA survey say practicing medicine has become less satisfying in the past five years, and 56% say they wouldn't choose medicine as a career if starting today.
Being near the end of their careers, these physicians have an out--retirement--that their younger dissatisfied counterparts don't, and practices may have to show some flexibility in order to keep these doctors happy and in the practice, Stone says.
Allocate overhead fairly Aside from an obvious loss of revenue and a drop in patient access, a physician going part-time can put additional strain on practice operations and other physicians' compensation levels, said Keegan. The effect will depend on whether the group allocates revenue and expenses based on productivity--in an eat-what-you-kill manner--or divides them equally. Revenue allocation is relatively easy to handle: If a group divides revenue based on productivity, then a physician working part-time will produce less and see a natural drop in compensation, and if a physician receives an equal share of revenue, then that share can simply be adjusted if he or she scales back. For example, a physician working as a 0.75 full-time equivalent (FTE) physician will see a 25% reduction in revenue. It is dividing overhead that becomes tricky, because typically 60%-80% of a group's costs are fixed--for example, building and equipment leases and staff salaries don't vary based on how much one physician works, said Keegan, who is also the coauthor of Physician Compensation Plans: State-of-the-Art Strategies, an MGMA book. That means overall costs usually don't decline as significantly as revenue when a physician goes part-time.
Prepare ahead of time Practices should keep an eye on culture and demographics to anticipate waves of retirements or unhappiness with call duties, Keegan said. "Graph physician ages today, five years from today, 10 years from today" to assess when it might be an issue and avoid a precedent-setting case. Practice leaders will need to answer questions such as:
What will be the eligibility criteria for scaling back?
Should part-time physicians still have a vote about governance issues?
Should part-time physicians still have a stake in expanded revenue from ancillaries and other ventures?
How will the group define an FTE?
"Develop a plan now--hopefully before it is needed--so that a precedent-setting decision based on any one individual physician's circumstances is not made that will be detrimental to other physicians in the practice or the future health of the medical practice itself," Keegan said.
Phil Pin, senior vice president for administration and CFO of ProHealth Physicians, Inc., discusses the financial decision-making process for adding a sleep apnea service line to his 200-physician primary care practice. Phil is a panelist on the HealthLeaders webcast, Service Line ROI: Financial decision-making to grow your physician practice.
She sees the loss of life and limb firsthand. Some of the cases that stand out in Lisa Zacher's mind involve amputees. Despite their battle wounds, many of these soldiers want to return quickly to duty with their comrades. And they are crestfallen when told they cannot.
"There is an unspoken closeness [among soldiers] that you sense but cannot truly understand," she says.
Col. Zacher is an intensivist and chief of critical care services deployed with the 28th and 86th Combat Support Hospitals (CHS) in Baghdad, Iraq. She's run the intensive care units there since August 8, 2007.
"We have definitely noticed a decrease in the overall number of casualties recently," says the 18-year Army veteran. "But the acuity still remains high--and we have to ensure that we maintain constant readiness for the mass casualty event."
Frequently I include my discussions with industry insiders in this space, but as we approach the holiday season, I decided that it is fitting to share with you some thoughts from a physician leader who is serving our country in Operation Iraqi Freedom. Below are the highlights of an e-mail conversation I had with Zacher.
RJ: Tell me a little about the mission of your assignment?
LZ: My main role is to be the physician in charge of the ICUs, but I work closely with nursing, patient administration and other ancillary services to optimize care and disposition of our patients. For the surgical patients, I work very closely with the surgeons and serve as the primary physician for patients with medical emergencies. It is a nice partnership with the surgeons--especially in mass casualty situations. Often the initial surgery is called "damage control" where the surgeons stop the bleeding and do life saving resuscitation in the emergency room and operating room. The patients are then brought to the ICU for further resuscitation which usually includes lots of blood products and warming the patient. Once the patient is more stable they go back to the OR for more definitive surgery. A study done at Ibn Sina comparing patient outcomes before using intensivists with [outcomes] after using these specialists showed a definite survival benefit. I believe in part this is because it becomes a focused, priority mission for the intensivist, who interfaces on a daily basis with the ICU team of nurses and respiratory therapists with resultant improved communication and multidisciplinary care.
RJ: Give me a sense of how many cases your team attends.
LZ: On a daily basis our census fluctuates from three to 12 patients, with an average of about five or six. The numbers might be a little misleading because the patients have such a short length of stay. If they are Americans, we are stabilizing and moving them rapidly forward in the theatre of operation. If they are host nation, we are stabilizing and returning them to the Iraqi healthcare system.
RJ: Contrast what it's like to serve in a combat support hospital with challenges at a U.S. facility?
LZ: Probably the biggest difference is the unit cohesiveness since we live, eat, and breathe together. We are very dependent upon each other and the individual skill sets that each one of us brings to the theatre. "Turf" battles go away and mission takes precedence over everything else. Our mission in the CSH is first and foremost trauma care, which means that we are in constant triage mode. It is not uncommon for the surgeons to do elective surgeries in the middle of the night to facilitate discharge the following day or to ensure that the ORs are available for incoming traumas. Even when our census is low, we have to concentrate on stabilizing patients for evacuation forward in the theatre.
RJ: What do you feel is the role of a physician leader for the CSH?
LZ: Ensuring that with turnover of personnel and fluctuations in casualty numbers that we stay focused on our primary mission, which is world class trauma care. In the months of June and July, this little hospital was one of the busiest trauma centers in the world. More recently, our daily census has decreased compared to the previous year; however, it becomes even more important not to become complacent and lose focus. Keeping in mind this mission refocuses our entire physician group on the truly important features of our day. The physician leaders have also prioritized working with the Iraqi physicians in Baghdad that are on the receiving end of many of the host nation patients that we stabilize and in boosting the training and capabilities of the healthcare available to Iraqis in the International Zone. Enhanced communication with our Iraqi colleagues have also given us a greater understanding of the significant challenges that these dedicated clinicians face on a daily basis in taking care of their patients. They are constantly struggling with shortages of supplies and medications. Additionally, they have a huge shortage of trained nurses and other ancillary support staff. The physicians themselves are very knowledgeable and most have trained in the British system. It really makes you appreciate the support (logistics and trained personnel) that we receive as Army physicians--even in a combat zone.
RJ: Is the hospital performing as effectively and efficiently as it could?
LZ: Yes in regards to trauma care--especially of our soldiers and coalition forces which is our primary mission. We don't perform some of the more sophisticated procedures, such as heart catheterizations and hemodialysis, or elective procedures due to the complex nature of the intervention.
RJ: How do you keep the clinical staff motivated?
LZ: Our physician staff is very close, and we keep close tabs on each other. We break the monotony with real exercise and the occasional wiffleball game in the motor pool area. A 180-day rotation is very doable. The bigger concerns are the 15-month deployers, who deal with more stress related to being away from home and family--but still manage to perform admirably. I believe that trying to keep rounds academic, acknowledging and also expanding and challenging the expertise of our nurses, is also key. Hopefully they will come out of this deployment with an expanded skill set that will serve them well professionally.
RJ: What's one thing that you're most proud of about the CSH? What's one thing you'd change?
LZ: I'm proud of the quality of care that we deliver on a daily basis and the teamwork and mission focus that it takes to pull it all off. There [are fewer] turf battles than back in the U.S. because we have a common goal and we have to live and work with each other on a daily basis. What would I change? I worry about the effect of compassion fatigue that has been well documented in ICU literature back in the States, not only on current mission but [also] in our future dealings as healthcare providers. There is also the potential for skill degradation for very specialized professionals and the need for retraining.
Prior to serving in Bagdad, Zacher's most recent position was chief of the Department of Medicine at Brooke Army Medical Center in San Antonio, TX. She attended medical school at the University of South Dakota and completed her residency at William Beaumont Army Medical Center, El Paso, TX. She followed that up with a pulmonary/critical care fellowship at Madigan Army Medical Center, Tacoma, WA. Zacher says that her family has been very supportive of her deployment and it is a rare day that she doesn't receive a care package or letter.
As I plan to take some needed time off to be with my family this Christmas, I will be sure to pause and give thanks to the healthcare professionals who sacrifice much to lend their special talents to those in need. Because people like Col. Lisa Zacher are the real physician leaders.
In a response to the state's medical malpractice insurance crisis, some New York City doctors are airing televised messages in their waiting rooms that warn patients of a looming physician shortage.