When the business of medicine trumps appropriate care

I almost fell off my chair.  It was bad enough that he showed up to the ER.  But what happened next really blew my mind.  He fell and bruised a rib.  The pain in his left chest had obvious enough origins.  But triage had put in for an electrocardiogram and the interpretation apparently scared the resident.  The attending took a look, and shook his head.

“Left bundle branch block.  Better call the Mecca.”

A few minutes later a cardiologist and nurse manager were videoconferencing in and interviewing the patient.  Next came an order for thrombolytics and transfer to the big medical center ninety minutes away by ambulance (the same medical center that owned the emergency department as well as the local hospital the ambulance bypassed).

Rules are rules.  And the bylaws state that all patients given thrombolytics have to be transferred to the brand new multi-billion dollar cardiovascular institute no matter how far a distance.  It didn’t hurt that said institute was having trouble filling it’s beds and apparently the administrative folks were starting to lean on the clinical staff.

The cardiac cath was mostly clean.  Was it an overcall, or did the medicine really just do a great job? He was never given a clear answer.  He left the hospital with more questions then answers, and a prescription for a baby aspirin and a statin. He came to my office to try to figure out what had just happened to him.

This sort of thing seems to be occurring more and more often.  The business aspects of medicine are starting to trump appropriate care.  While no one is saying that more is better, aggressive management has become the rule and not the exception.

Healthcare reformers, politicians, and policy wonks wag their fingers at physicians and place the blame squarely on our shoulders.  They say that only the doctor has the power of the pen.  They completely ignore the bullying, administrative pressure, and the automatic rules and regulations forced on clinicians by the nonclinical (or no longer clinical) c-suite.

A recent article in American Medical News brings to light a radically different view point:

When the federal government sorted through the first round of clinical information it was using to reward hospitals for providing higher-quality care in December 2012, the No. 1 hospital on the list was physician-owned Treasure Valley Hospital in Boise, Idaho. Nine of the top 10 performing hospitals were physician-owned, as were 48 of the top 100.

This news comes three years after the Affordable Care Act effectively prohibited the expansion of such existing facilities and severely limited the creation of new ones.

As Obamacare pushes more and more physicians out of decision making positions and herds them into large academic and nonacademic hospital systems, one would expect one thing and one thing only: spiraling costs.  Business exists in order to make money.  Businessman go to school to learn about profit.  Physicians who leave clinical practice to become administrators aspire to similar ends.

Physicians are the only ones who have made a covenant.  We are the only ones who have taken an oath.  We are smart, well educated, and innovative.  And we have to look each and every patient in the eye before making decisions.

Yet time and time again, we are asked to move out of the way so the smart guys with the business degrees can come in, and make the tough decisions.

(This story is an amalgam of a number of experiences gleaned over years of practice in a number of different hospital systems.  The details of the actual medical story are fiction.  Neither the patient mentioned or the medical center are meant to be reflective of any specific patient or hospital.)

Jordan Grumet is an internal medicine physician and founder, CrisisMD.  He blogs at In My Humble Opinion.

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