“Just business, nothing personal” is an oft-quoted apology in godfather-type movies justifying an unemotional action usually with a negative result. Recently, as I was visiting my patient at Henry Mayo Hospital, I overheard a disturbing conversation with a family in the adjacent bed telling them their loved one had to be discharged that day. His wife was pleading with staff the limited home care they would be provided was not adequate for her elderly spouse, and the impact would affect her physical and mental health also. Other family members at bedside also pleaded to no avail, as the patient was discharged home. “Just business, nothing personal”. The next week I noticed his return...to the ICU.
No one is able to predict how well a patient will do after discharge, and many times I know there are risks we take. Quite often, when I’m asked to predict outcome, I tell my patients and their families “My initials are GRD, not GOD!”
The hospital is paid by insurance companies and Medicare based on the diagnosis: four days for pneumonia, five days for heart attack, etc. Beyond that predetermined length of stay, the hospital will push for discharge. “Just business” These standards are set to shrink costs and whether you like it or not, we all must deal with this ongoing problem.
How does one put a dollar sign in front of adequate health care? Basing a pneumonia discharge solely on a chest x-ray or blood test is wrought with danger. Again, dealing with risk, physician experience and advocacy allows better and secure “reading of the tea leaves” than standardized care.
As a physician for 30 years, my expertise folds into the picture not only the patient’s health, but also family, living situation, physical and mental capabilities, finances, and legal aspects of the total problem. Understanding this “full picture” improves the chance of surviving discharge, achieving their previous quality of life, and not returning to the hospital...and yes, saving money.
What if though physicians were taken out of their patient advocacy position, which is being perpetrated by our hospital? In a local newspaper editorial, CEO Roger Seaver analogized hospital leadership as a “three-legged stool” including Medical Staff, Administration, and Board of Directors. With financial conflicted control of the Board of Directors by Administration, we have a “two-legged stool”. Together they are personally attacking doctors through insults, deprecating remarks, “Resolutions”, veiled “code of conduct” and “corrective actions” threats, and annihilation of their independent voice which has outraged physicians into a “Vote of No Confidence” against them. I for one have no confidence in sitting on a “one-legged stool”!
All physicians who admit patients are not employed by Henry Mayo. The intention of the hospital is to hire and control your doctor, thus removing the main advocate for you or your loved one’s health care. What will be the impact on patient care? Out-rightly, physicians will be told when to discharge patients by Administration regardless of how your doctor might feel...and most importantly, how you feel. More subtly, concerns over medication errors, screening of new physician applicants, “sentinel events”, and standards and criteria for ancillary caregivers will be compromised. “Just business, nothing personal.”
There are some who don’t regard the doctor-patient relationship important in their health care. When you become an elder senior though, it becomes a prerequisite to have someone be an advocate, accountable, reliable, and aware of your medical and personal problems. This trusted, caring, and confidential doctor relationship has always set the basis for health and well-being, and goes to the deepest part of our spirit.
After serving as a healthcare advocate for this community for years, Dr. John Cocco was contentiously suspended by the Board of Directors on January 5, 2011, leaving many physicians to take over care of his hospitalized patients. Moving from “Just business” to something “More personal”, I lastly present to you a pertinent dedication I wrote and distributed to Medical Staff and my friends in the community earlier this year:
As a hospice doctor, I was asked by Dr. Terrazzino to see a patient for end-stage respiratory disease on Friday evening. She had been hospitalized just after New Years, but the reality of three futile weeks attempting improvement convinced the family end-of-life care was appropriate.
Her medical record indicated this 88 year-old women was a smoker and had a history of Alzheimer’s dementia. Noting an artistic background, she had worked as an animator for Hanna-Barbera for many years, reminding me of fond days watching The Flintstones and The Jetsons.
Entering the hospital room, I greeted her and introduced myself. Not in distress, but clearly uninvolved, she acknowledged my presence. Knowing the underlying problems, yet wanting to access her mental capabilities, I asked my usual sequence of mental status questions.
Where were you born? “Vienna.” Ah, I thought...a good start. How old were you when you moved to the United States? “Four.” A thread of hope that mentally she was better than the record depicted. Where did you move to...and grow up? “I can’t remember.” Were you married? “I think so.” Is your husband alive? With a sad and withdrawn look she responded, “I don’t know for sure.”
Midway through, I realized her memory was seriously deficient, but despite this reality, I discussed her medical problems and my role in assuring comfort and minimal pain. It was difficult to understand whether this fragile soul truly could comprehend our conversation.
My last question to her was “who is your doctor?” As I peered into her eyes, you could see them widen with her face growing into a smile...”Why doctor Cocco, of course!” For a moment, I saw the animation she had put into her cartoons as the memories flowed...and then drawing back and looking to either side of me she asked...”Where is he?”
From the depths of our senses and understandings come profound memories even when there is underlying illness. For four decades, John Cocco has taken care of patients in this community and has had heartfelt effects on them. Indeed, he has had heartfelt effects on us all.
Something to think about.
Yabba dabba doo!
Gene Dorio, M.D.- Guest Commentary
Gene Dorio, M.D., is a local physician. His commentary represents his own opinions and not necessarily the views of any organization he may be affiliated with including the Medical Executive Committee and Medical Staff of Henry Mayo Hospital, or those of the West Ranch Beacon.
# Missy clark Says:
ReplyDeleteMay 7th, 2011 at 12:17 pm e
I am an RN at HMNMH and find a few problems with this recent blog. While I understand Dr Dorio’s comments, people who read this also need to know that the hospital does not discharge patients the DOCTORS do. If that patient was discharged home it was because the doctor wrote the discharge order not the hospital or it’s administration. This hospital cannot do anything unless the doctor writes the final discharge order so please do not be misled into thinking that the hospital pushed this patient out of the hospital because that is not the case. The doctors at HMNMH do whatever they want, when they want and nothing the hospital administration says will change that.
I understand peoples frustration with sick loved one but the bottom line is that Henry Mayo is an acute care facility and not a skilled long term facility. A long term skilled facility is where a sick elderly person can go if their family is unable to care for them, but many people here in Valencia find this option below their standards and expect to stay at HMNMH like it is a hotel and that they have the right to stay here regardless the fact that the patient no longer has criteria for an acute care hospital.
I applaud Dr Dorio for standing up for his patients but he also knows the reality of medicine and is willing to write a check that he has no responsibility for and that is one that keeps this hospital open and running. If Dr Dorio had his way all of his elderly patients would stay in the hospital till THEY wanted to go home and this is not how ANY hospital is run, so please read between the lines and realize that this hospital does it’s best in taking care of it community members regardless of what Dr Dorio writes. .
# Gene Dorio, M.D. Says:
ReplyDeleteMay 8th, 2011 at 6:18 am e
Missy Clark is correct that ultimately the final decision to discharge a patient from Henry Mayo is dependent on an order from the doctor, but to make it seem our hospital does not play a role in this discharge is disingenuous.
It is in the best financial interest of the hospital to assure the “movement” of patients into and out of Henry Mayo is “cost effective”, and as I alluded to is “Just business”. But the Administration does have a team of “Discharge Planners” whose function is to monitor all inpatients for continual admission. Other than those who directly care for patients (RNs, LVNs, and CNAs), it is probably the most difficult job in the hospital. Why? Because they are stuck between “a rock and a hard place” appeasing Administration who pays their salary, and being diplomatic with doctors who are trying to determine during the healing process when the patient will be ready to go home.
Discharge planners are very helpful to physicians making arrangements once that decision is made. Prior to that though, doctors are receiving phone calls and notes on the chart, and sometimes even threats of reporting them to upper echelon agencies if the patient is not sent home. Families are aware, and doctors are use to this daily arm-twisting, and I look at it as a part of the Discharge Planner’s job to again, “keep the patients moving”.
Importantly though, from my article, considerations of discharge should not just be criteria taken from a standardized book, as there are many factors involved trying to make sure that the patient is headed to a recovery that will not result in relapse or readmission. This is not easy and a balancing act for all of us.
We sadly know of a few patients who do indeed treat their hospital stay as if they are in a hotel. As Missy Clark states, Henry Mayo is an acute care facility, and should not function as a Skilled Nursing Facility (SNF-nursing home). The financial decision to close our Transitional Care Unit (TCU) was detrimental to our elder seniors as it removed a stepping-stone option of getting them out of the acute hospital faster, yet allowing them more time to recover from their illness. Loss of the TCU made the Discharge Planner’s job much more difficult.
When a patient is discharged, discussion is made with the patient and the family with all surrounding circumstances considered, but as doctors, we accept the other side of the coin that consideration must be made for the financial viability of the hospital as well. Physicians and discharge planners are just a part of the balancing act allowing our community to maintain Henry Mayo. The point of the article should not be missed, Missy, hiring and controlling physicians by the hospital and disrupting the doctor-patient relationship will have impact on this balance.