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October 1997
Volume 61 |
Number 10
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PRESIDENT'S PAGE
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| What's in a Name? |
Phillip O. Bridenbaugh, M.D., President
When we were children, many of us had one or more nicknames,
some not very flattering. With time and maturity, none deterred
us from pursuing our goals and principles, but rather served as
distractions to our acquaintances and obligated us to live them
down or sometimes to live up to those more flattering.
Over the past few years, physicians have been called more names
than any of us ever had as children. Initially the names were
"descriptors," i.e., to better describe the specifics
of our practice of medicine and levels of advanced training. More
recently, we have been referred to as "distracters,"
i.e., names such as providers, health care workers, perioperative
managers and now "hospitalists." These names certainly
imply to the public that health care is homogenized into particles
(tasks) that can be "provided" by an army of health
care workers and, oh yes, physicians too. Even physicians are
becoming more and more distracted from their specific practice
of medicine for which they are trained, certified, credentialed
and, hopefully, reimbursed!
How has this affected anesthesiologists?
As briefly as possible, I would like to review a narrow and more
recent evolution of the ambiguity in the anesthesia nomenclature
just in the past three years of my senior "officership."
I have been guilty of using generic names for anesthesiologists
by referring to us as physician providers and the others as "nonphysician"
providers. I do believe all physicians should provide the best
science and medical knowledge they can to their patients. I also
believe physicians are not required to complete every act of patient
care themselves and should lead (direct?) by example and advanced
training the nonphysician health care providers who assist in
the care of their patients.
Last year, the May
issue of our NEWSLETTER was devoted to defining the
new anesthesiologist as a "perioperative physician."
This is a name that should be unique to anesthesiologists and
their training. I did offer a personal concern in my "President's
Page" in the June 1997 issue of our NEWSLETTER1
that I hoped our focus was medicine and not "management"
as an unreimbursed service to the hospital not essentially or
exclusively performed by an anesthesiologist. Unbeknownst to me
and I suspect many of you, back in August 1996, The New England
Journal of Medicine2 published
an article in its "Sounding Board" feature titled "The
Emerging Role of 'Hospitalists' in the American Health Care System."
This article (opinion?) was authored by two internists from the
University of California, San Francisco, and presented academic
and medical orientation. Needless to say, the article generated
a number of letters to that editor.
Some 11 months later, an editorial by Erwin Lear, M.D., in our
July
NEWSLETTER 3
commented on his concerns about the new "hospitalist"
practitioner of medicine. Coincidentally, Paul Ebert, M.D., Executive
Vice President of the American College of Surgeons, wrote his
editorial that same month in the Bulletin of the American College
of Surgeons4 on the same topic,
as seen through the eyes of a surgeon. I cannot possibly provide
an in-depth background of whom or what a "hospitalist"
is or does. I do urge all who want to learn about it to read the
original article in The New England Journal of Medicine
and any subsequent published material you choose, and then make
up your own mind. For purposes of this discussion, however, let
me offer a few points from the original article:
The authors start by noting that managed care has created an
increased role for general internists, who "have perennially
been undervalued." They note that, "Ideally, the primary
care physician would provide all aspects of care ... which would
result in medical care that was more holistic, less fragmented
and less expensive." They go on to note that such practice
"collides with the realities of managed care and its emphasis
on efficiency." As a result, they anticipate the rapid growth
of a new breed of physicians called "hospitalists" who
are "specialists in inpatient medicine," responsible
for managing the care of hospitalized patients in the same way
that primary care physicians are responsible for managing the
care of outpatients.
The objections to the hospitalist model, initially at least,
come from both generalists and specialists. Some primary care
physicians clearly prefer to manage their patients' care during
hospitalization, even if there is no economic incentive to do
so. Specialists fear that skilled hospitalists may order fewer
consultations than primary care physicians.
A feature article on this "new specialty" (?) appeared
in the September 1 issue of American Medical News, noting
that 2,000 physicians nationwide belong to this new practice.
The spokesperson for the American Academy of Family Physicians
noted his organization is neither ready to applaud nor condemn
arrangements between primary care physicians and hospital-based
physicians. John Eisenberg, M.D., Administrator of the Federal
Agency for Health Care Policy and Research (himself an internist)
said in AM News, he believed widespread reliance on hospitalists
would create significant problems. His agency is soliciting research
proposals to generate hard evidence about how hospitalists impact
the health care system.
Are they highly paid, permanent house staff?
As one looks at the national trend of reducing residency training
positions to 110 percent of American medical school graduates
and as more and more students choose primary care, who will provide
hospital care except those physicians (medical specialists especially)
who have been squeezed out of large managed care panels and young
graduates looking for employment?
Dr. Ebert, in his comments to the American College of Surgeons,
noted that "if hospitals do become more specialized, the
hospitalist may replace the resident in providing routine care.
In addition, many hospitals are considering reducing or phasing
out residency training because of cost and the lack of patients
with various subspecialty disease processes." He comments
that "with the changing trends in surgical practice and also
of the activity moving toward ambulatory surgery, the emergence
of the hospitalist at this point is predominantly for the purpose
of assisting medical physicians and surgeons who find running
between office to hospitals several times a day very ineffective."
Who pays?
Just in case you might be attracted to the change, it is worth
trying to determine who pays the bill. What appears in the various
articles is a variety of arrangements apparently based on perceived
need. Some contract with primary care physicians to allow them
to focus exclusively on their office practice. Others sign on
with large medical groups. ("A group of 400 physicians decided
to hire several doctors to cover their hospitalized patients.")
Managed care companies are said to see potential cost savings
in the arrangements. According to the co-founder of the National
Association of Inpatient Physicians, pay levels now range between
$130,000 and $200,000. Others are full-time hospital employees.
If you doubt that "someone" thinks this is a developing,
lucrative market, you can consult your World Wide Web where a
(nameless) company advertises, "The hospital that delivers
the highest quality of care at the lowest cost wins the
managed care contract. Our hospitalists specialize in delivering
the highest quality care in the inpatient setting." Their
motto: "For the benefit of the hospital, for the good of
the patient." (Did anyone see anything about what's in it
for the physician?)
Should we as anesthesiologists care?
Dr. Ebert concluded his remarks by wisely commenting, "...
Although technological advances are often most impressive and
very important insofar as they alter patient results and outcomes,
changes in health care staffing and in how health care is structured
and actively delivered will also take place. It is most important
that we not be influenced entirely by our emotions and that we
analyze those modifications in the most objective way possible
in order to determine if they truly improve the delivery of health
care services at a reduced cost."
It would seem to me that anesthesiologists are at "a fork
in the road and we should take it!" As I indicated in my
comments in the June
1997 ASA NEWSLETTER, I believe we can and should exploit
every opportunity for perioperative medicine. I worry about "the
hospital strings" that might be attached to perioperative
management. I have received a few calls from our members already
suggesting that hospitals want to put the entire anesthesiology
department on salary. The July/August issue of the California
Society of Anesthesiologists Bulletin5 republished
an article from the May 2, 1997 Wall Street Journal titled
"M.D. vs. M.B.A." In brief, the issue between the Columbia/HCA
hospital administrator and his hospital-based specialists was
"practice exclusively in our hospital or leave." Although
many anesthesiologists may think that is okay, it puts one at
the mercy of that administrator. The article noted that the argument,
although ultimately about money, was more immediately about power
and control.
"I am offended that a businessman is trying to tell me where
and with whom I can be a doctor," says Dr. "X."
"No one likes change, and here is a new guy nobody knew wanting
to institute change," says the administrator. In these arguments,
there is a collision of culture as well. Dr. "X" is
a 49-year-old physician who calls the people he treats "patients."
The administrator is a 51-year-old M.B.A. who calls them "customers."
Do hospitals really want to put physicians on salaries and pay
benefits and malpractice? We hear more about hospitals reducing
their nonphysician employee ranks (especially those in unions)
and contracting with independent providers for patient services.
Physicians doing management or patient services for hospitals
might consider contracts rather than employment.
The other part of the fork in our road worthy of keeping may
be viewed more as an escape route. If we want to practice in freestanding
pain centers, ambulatory surgery centers or multiple hospitals,
we need to protect ourselves from the aforementioned scenario
of a major hospital or hospital chain saying, "Restrict your
practice exclusively with us or leave." This has to be the
ultimate in economic blackmail! John Randolph in 1829 said, "Change
is not reform." We have, over the past five years, seen lots
of health care change for the economic benefit of the payers,
but little true health care reform. Cardinal Gibbons in 1909 stated,
"Reform must come from within, not from without. You cannot
legislate virtue."
Anesthesiologists, along with all other specialty practices of
medicine, must become more united and active in health care reform.
Quality of patient care should be our goal, not just
customers' satisfaction. President Jimmy Carter attributes
to his high school teacher my final quote: "We must adjust
to changing times and still hold to unchanging principles."
Without regard to what name physicians choose, they must not abandon
their principles. That includes all of us.
References:
- Bridenbaugh PO. Perioperative Medicine
or Perioperative Management? American Society of Anesthesiologists
NEWSLETTER. June 1997; 61(6):2.
- Wachter RM, Goldman L. The Emerging Role
of "Hospitalists" in the American Health Care System.
N Engl J Med. 1996; 335:514-517.
- Lear E. Shifting Dullness. American
Society of Anesthesiologists NEWSLETTER. July 1997; 61(7):1.
- Ebert PA. As I See It. Bulletin of The
American College of Surgeons July 1997; 82:7.
- Langley M. M.D. vs. M.B.A. California Society of Anesthesiologists
Bulletin. July/August 1997; reprinted from Wall Street
Journal. May 2, 1997.
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