Sunday, April 21, 2013

HMNMH Physicians Practice in a Hostile Work Environment

Over the past twenty years, Wall Street business has covertly taken over the medical profession while doctors have been distracted by a deluge of procedural, financial, and legal paperwork. A strategic plan was launched to extract exorbitant profit benefitting business, and is now mainstream without challenge from our profession nor the public.

Legal boardrooms were abuzz in the 1990s as a blueprint assault was made against organized medicine, redirecting a profession into a commodity. Symposiums templated this game plan for hospital administrators, while lobbyists strengthened their legal foothold. Despite recognition of this onslaught in medical journals, the anemic response from physician leadership allowed it to sweep from east to west coast. Now occurring in California, I wish to shed light on this evolution using my experience at our small community non-profit hospital.

Ten years ago, Henry Mayo Hospital went into bankruptcy. We were mismanaged, but business professionals were brought in keeping the hospital from closing. At this point, the template commenced.

Not being involved in hospital politics for 22 years, my election to the Medical Executive Committee (MEC) three years ago probably rose from whistleblowing writings in The SCV Beacon. Within months, I was falsely accused of “Code of Conduct” charges, and “Corrective Action” was taken against me. Renewal of my admitting privileges were withheld forcing me to hire lawyers to prevent the Board of Directors from removing me from the Medical Staff. Many of my colleagues faced similar problems, some of whom are no longer on staff. To my surprise, when I told my east coast friends of this problem, they said it had already happened in their hospitals.

California law allowing Medical Staff “self-governance” was interfered with and trampled upon by the Administration. I found staff meetings with Administrators verbally abusive, prompting physicians to videotape these interactions. Not surprisingly, lack of communication at our hospital amongst the Administration, Board of Directors, and MEC was sanctioned by a national oversight agency.

Medical reputations in the community were sullied by mudslinging, and we were marginalized by the undertones of spurious propaganda. There are some business people adept at this, while physicians are not. Anger by local doctors was temporized though as many have contracts with the hospital and must “keep a low profile,” especially since this Administration was notorious for financially “twisting arms” and “dangling the carrot” to silence their voices.

The use of similar tactics to influence votes skewed the Board of Directors and created dubious conflicts of interest. One member had lucrative hospital building contracts, two had hospital money in their bank, and another did secondary real estate transactions on the hospital’s behalf. Four CEO appointed physicians had profitable medical contracts with the hospital. One can see how easy a vote might be swayed. The Administration used this influence to not only ramrod changes in hospital policies and procedures, but to persecute and prosecute any physician in their way. These tactics continue today.

The only voting member elected from the Medical Staff to the 15-member Board is the Chief of Staff, and up until a year ago the Deputy Chief of Staff could vote, but this was changed by the Board at the behest of the Administration.

Has this aggressive template business takeover made any improvement in quality patient care? Not at all, as Henry Mayo Hospital still does poorly on national surveys. Then why pursue this onslaught? Profit. We have seen the salaries of all Administrators continually increase, with augmented bonuses and concomitant contribution to their retirement plans. Voila!

Humanity has been replaced by the fiscal bottom line. Physician decision-making relative to patient care is threatened, and doctor advocates have been subjected to Administrative crosshairs. At our hospital, physicians practice in a hostile working environment.

Ignorance is no excuse for not seeing this tsunami takeover of a worthy profession. If being a commodity must be the sacrifice of having excellent patient care, doctors would acquiesce. But with profit being the business motive, igniting the fire of public opinion against this clandestine assault of the medical profession must begin.

Reaching the west coast, we are now on the edge of the cliff.
Gene Uzawa Dorio, M.D. – Guest Commentary
Gene Dorio, M.D., is a local physician. His guest 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 SCV Beacon.

Thursday, April 4, 2013

Your Hospital Care May Be Compromised

We are fortunate in our country to have the best medical technology in the world. Unfortunately, delivery of this technology, reflected in a worldwide healthcare ranking of 37th, is a disservice to the American people and must be rectified especially when Cuba is ranked 39th.
As provisions of the Affordable Care Act are put in place, a daunting factor is the shortage of doctors who will be needed to provide this healthcare. Statistics from the Association of American Medical Colleges predicts by 2015, we will lack 62,900 physicians nationwide, and this will grow to 130,000 by 2025. This is a dilemma that cannot be quickly nor easily remedied, as it will take decades to catch up. What can be done until then?
We must harness present available resources including Nurse Practitioners (NP) and Physician Assistants (PA) to bridge the healthcare gap. Integrating NP and PA expertise is imperative, but this must be done while assuring quality patient care and not bring the American healthcare ranking even lower.
As a member of the Medical Executive Committee (MEC) and Chairman of the Department of Medicine at our small community hospital, Henry Mayo, I have studied these details and would like to convey to you my findings. Our hospital is not presently considering PAs for staff membership; therefore I will restrict this discussion to NPs.
A Nurse Practitioner is a registered nurse (RN) who has completed graduate-level education 1-2 years beyond their degree, with some even specializing in fields like pediatrics. Typically, they provide primary care in an outpatient setting like a clinic or medical office under the supervision of a doctor. For years, qualified RNs have moved forward attaining an advanced degree as a NP allowing better and complete care to our patients. So what is the problem?
Hospital Administrators now want NPs to take care of inpatients, but obviously, these patients are much sicker than those who are outpatient. NPs rarely get training in a hospital setting, and prior to their post-graduate degree, RNs are taught to follow and implement physician orders, not to develop nor manage a medical care plan.
I trained in a hospital starting my first year in medical school, and this continued through surgical and medicine programs for the ensuing 10 years. My recognition and ability to treat acutely ill inpatients allows strategy development from the initial history and physical resulting in a treatment plan, and then management of that patient during their hospital stay. NPs are fully capable of this intellectually, but it must be rigorously taught in a hospital setting to assure quality and perfection. They do not have these initial qualifications, but should they be restricted from a hospital inpatient setting? I do not believe so, as long as adequate training and oversight is maintained.
The State of California regulates the “scope of practice” for NPs as legislation is not at the federal level. Some of these rules though sit in a “gray zone” and hence there is tugging by special interest for doctors from the California Medical Association, nurses from the Board of Registered Nursing, and Administrators from the California Hospital Association.
In order to allow NPs to provide patient care in a hospital, by State law, a Committee on Interdisciplinary Practice (CIDP) must be established. Henry Mayo did this, but the hospital Administration asserted control over this committee by recently having the Board of Directors change a Hospital wide Policy removing it from the auspices of doctors. Consequently, the physician chairperson was replaced by an Administrator, and this has been surreptitiously done at other hospitals as well.
With the CIDP no longer a physician committee, I must be careful not to divulge confidential information. Suffice it to say, problems faced by other similarly changed outside hospital committees are: oversight credentialing and proctoring of NPs is not by the Medical Staff but instead by the Administration CIDP; there is no physician committee peer review of NPs; and NPs are hospital employees.
This last problem is fearfully disturbing as NPs might be financially coerced into discharging patients too early at the behest of the Administration. No doubt this will especially effect our elder senior patients.
Wherever you live, your local hospital may now be implementing programs using personnel not scrutinized by physicians. The healthcare rendered to you or your loved one might therefore be substandard and lead to undesirable complications. As Americans, this should be where we start tugging our special interest.
The doctor shortage will have a profound effect on every community attempting to receive adequate medical care. Using existing resources like NPs will bridge the healthcare gap, but this must be done wisely and carefully to assure patient care is not compromised.
California and other state legislators must be made aware of this problem and strictly define the rules between outpatient and inpatient care, as there is clearly a difference in acuity and intensity of illness. Ultimately, any legislation concerning acutely ill patients cared for by NPs must lean toward scrutiny by well-trained medical doctors, and not hospital Administrators.
Should we see this happen, you might expect our worldwide healthcare ranking to improve.
Gene Uzawa Dorio, M.D.

Gene Dorio, M.D., is a local physician. His guest 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 SCV Beacon.