Sunday, January 10, 2016

Medicine and Metrics Don’t Mix
Real life is all about the narrative. 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.
Rajeev Alexander, MD, hospitalist, on why he and other hospitalists formed a union,  in“Defying the Medical Machine,” New York Times,  January 10, 2015
Ah, yes, metrics. In God we trust,  all others use data.   If you can’t measure it, you can’t measure it. If you can’t express it in numbers,  you don’t understand it.   And all that jazz.
And so the logic goes if you are a hospital administrator  seeking  to become more efficient by asking hospitalists  to see more patients and to use metrics to judge if hospitalists have cut patients ‘ hospital stays,  hospital-acquired infections,  hospital readmission rates,  and enhanced  patient satisfaction.
Hospitalists,  those doctors who see patients only in the hospital,  are themselves creatures created by the search for efficiency.    Hospitalists did not exist before the 1990s,  when Doctor Robert Wachter, among others, created the hospitalist movement to make doctors more efficient.   Doctors wanted to be more efficient.   They complained there wasn't enough  time in the day to see patients in the office and tend to the needs of hospital patients . 
Voila!   Have a subset of doctors practicing full-time in the hospital was  the answer.  Doctors could stay in their offices while hospitalists care for their patients in the hospital.   By 2003 there were 11.000 hospitalists and today there are 50,000.
But alas!  Costs kept rising, Medicare and Medicaid rates kept falling ,  government kept punishing hospital financially for readmission and infection rates,    and hospitalists started complaining  about their rising patient loads and the metrics required to judge their performance  to keep the hospital’s profit from falling.
Hospitals  faced a dilemma.   They needed hospitalists, but they did not want to antagonize  hospitalists  by asking them  to see more patients per shift and spend more time documenting  their own performance, at the expense of using their clinical judgment and spending more time with patients.
Doctors had their own dilemmas. Taking orders from hospital  administrators who  lacked clinical judgment and who were not at the bedside.  Besides administrators  had no “skin in the game,” i.e., they didn't have to cope directly with sick patients and their complicated needs.
The answer in the Sacred Heart hospital system in Oregon in 2014  was to farm out the work of its 36  hospitalists to a management firm who would become the doctors’ employers.    These firms had the expertise with metrics, and they could take the heat from the doctors.   
The doctors  didn’t like and didn't  accept the outsourcing solution. The feared they would be asked to see more patients and would be fired if they resisted.   About one-third of the hospitals left, and the rest formed a union. 
Sacred Heart backed down from the outsourcing idea, but the hospitalists' skepticism remains.   Negotiation  is still  going on. The hospitals had proposed an increase in pay from $223.000 for 173 shifts to $260,000 for 182 shifts with a $20,000 bonus for meeting performance metrics.  The doctors responded it was not about money, it was about the metrics  and  avoiding burnout and compromising  patient safety.  And there the matter stands.

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