I read with genuine fascination a report published in Saturday’s New York Times, entitled “Doctors Unionize to Resist the Medical Machine,” with a deck that stated that “An Oregon medical center’s plan to increase efficiency by outsourcing doctors drove a group of its hospitalists to fight back by banding together.” I would urge readers to read the entire article, which can be found here.
The article, by Noam Scheiber, tells the rather complicated story of developments in the past couple of years at PeaceHealth Sacred Heart Medical Center in Springfield, Oregon. The story is rather involved, and has numerous elements. But what particularly interested me was how the Times report framed the situation as a set of conflicts over hospitalist productivity and patient throughput, versus the quality of patient care outcomes and patient and physician satisfaction. The binary conceptual framing of the issues is far from new in healthcare: indeed, many in the industry still seem to believe that one can have either lower costs based on high clinician productivity and “assembly line” types of approaches to delivering patient care, or one can have high outcomes quality and patient and especially physician satisfaction, but never (or at least rarely) both. And that perception really is a problem.
Certainly, it is the perception of physicians like Rajeev Alexander, M.D., one of the PeaceHealth Sacred Heart hospitals who became so upset by Sacred Heart administrators’ attempts to prod hospitalists into higher productivity via the proxy measure of higher volume per day of patient consults by hospitalists, that he helped organize his fellow hospitalists there into forming a union, one of the first hospitalist unions in the country.
Here’s how Dr. Alexander frames what has become a conflict between the hospitalists and the hospital administrators at PeaceHealth Sacred Heart over how many patients hospitals should be seeing per day: “Real life is all about the narrative,” he told the Times reporter. It’s sitting down and talking about bowel movements with a 79-year-old woman for 45 minutes. It’s not that interesting, but that’s where it happens.”
Now, here’s the part of the story where things get really interesting: “It was the idea that they could end up seeing more patients that prompted outrage among the hospitalists at Sacred Heart, which has two facilities in the area, with a total of nearly 450 beds,” the Times’ Scheiber noted in his article. “We’re doctors, we’re professionals,” Dr. Alexander told the Times. “Giving me a bonus for seeing two more patients — I’m not sure I should be doing that. It’s not safe.” Yet a hospital spokesperson told the Times that patient safety was “inviolate.” Meanwhile, as the Times reported, “Some Sacred Heart hospitalists left for other jobs, and the rest formed a union, one of the first of its kind in the country. To everyone’s surprise, Sacred Heart’s administration agreed to junk its outsourcing plan, but this retreat did not usher in a love fest. Instead, there has been a long, grinding negotiation with the administration over the proper role of the hospital doctor, which continues to this day.”
The Times report goes on to say that “Dr. Alexander and his colleagues say they are in favor of efficiency gains. It’s the particular way the hospital has interpreted this mandate that has left them feeling demoralized. If you talk to them for long enough, you get the distinct feeling it is not just their jobs that hang in the balance, but the loss of something much less tangible — the ability of doctors everywhere to exercise their professional judgment.”
Of course, blogging about this is tricky, in that I am relying on reporting by a mainstream media reporter, and on how that reporter has understood and framed what a number of interviewees have told him about a very controverted situation. But, based on what I read today in the Times, I will say this: it is deeply unfortunate that the dialogue between that hospital’s senior non-clinician administrators and its hospitalists ended up getting bollixed up to this extent, in that a binary comparison-contrast was set up between “productivity/efficiency” and “quality,” when in fact, so often in the new healthcare, those concepts are not in conflict at a deeper level. Often, it really is about how things are framed—and by whom, and to whom.
In other words, why were the hospitalists at this hospital organization not consulted from the beginning, and not brought into discussions around hospitalist productivity and hospital operating margins, from the beginning, as key stakeholders who could work together with other physicians and with non-clinician administrators, to come up with solutions that could prove ultimately to be satisfactory to everyone?
At the absolute nexus of this, too, is the data. I would love to know where the hospital’s CMIO and chief of staff/VPMA were in all of this. There are a million possibilities here, but it seems clear to me that data can truly be the friend of all parties concerned, as long as it is used correctly and well and in a consensus-driven way.