Physicians need to deal with complex issues that encompass the whole of human experience, but business people live in a more narrowly defined world.
By Ted Mitchell
Published February 14, 2008
The Hamilton Health Sciences (HHS), the corporation that manages Hamilton's five hospitals and one medical centre, recently announced a plan to close the emergency room and adult general medicine care at McMaster University Medical Centre (MUMC), moving these functions to other sites which would then clump subspecialties together to function as "Centres of Excellence".
McMaster University Medical Centre (Image Credit: Your Canadian Connection)
This decision was made the way large corporations make decisions - that is, by administrators with little knowledge of, or input from, the public or frontline physicians most affected by the proposed changes.
HHS calls this "Access to the Best Care". Notice that the HHS plan contains only generalizations and no details as to how it will be accomplished. Neither is there any acknowledgement of negative consequences, because for administrators, if you don't ask the people affected, there are none.
I will identify several problems with this proposal.
Health care in Canada is not just a business and cannot be run like one without tremendous fallout.
Hamilton already has a high degree of specialization where it is appropriate, and championing more leads to diminishing returns.
Excessive emphasis on sub-specialization leads to marginalization of basic, meat and potatoes general health care and ignores creative solutions.
Geographic effects are ignored.
McMaster University students and interdisciplinary research suffer.
Other problems in health care management are marginalized.
Finally, I will ponder possible administrative motivations for these proposed changes and barriers to sober second thought from the public and physicians.
Public health care in Canada is part of our identity. Our system is built to put the patient first, with physicians obliged to represent what is in their patients' best interest.
When hospitals are run on the business model, there is reduced creativity in treatment options. Physicians need to deal with complex issues that encompass the whole of human experience. Business people live in a more narrowly defined world. When you use the rules of the latter to govern the former, things tend to hit the fan.
The key interaction in health care is between doctor and patient; oddly, the most complexity and expertise is required at the lowest level of the top-down business model. If you were to compare education of hospital employees, it is the frontline physicians who will rank highest, well above the more powerful and higher paid administrators.
In today's business-oriented hospitals, various levels of administration exist which have ever-decreasing relevance to patient care. If HHS loses a doctor, patients suffer.
The same can't be said about its administration. When you run a hospital on the business model, it places frontline doctors in the position of assembly-line worker, with about as much power. Oddly, the only doctors with some power are the ones who forgo direct patient care to do part-time administration. In terms of optimizing patient care, is that smart?
In the HHS plan, there is still no opportunity for community and physician input, either to debate or modify this top-down decision. Some of the information is downright untrue, for example this excerpt from the self-reverential "Murray Minute":
This plan was created during months of careful review with advice and guidance from a variety of experts including our own staff, physicians, members of the Hamilton Health Sciences Board of Directors, our partners in the health care system and academic leaders.
My wife is a general internal medicine specialist and educator working full time at McMaster. Neither she nor any of her colleagues were informed or consulted about this plan, and in fact the only awareness of it was from rumours passed between hospital staff. How is that compatible with the administrative rhetoric?
When you fail to ask for or listen to input from the community and frontline health care workers on a major restructuring of hospital services, you are going to get a lot of things wrong.
Medical care in Hamilton has arranged itself into specialized centres where it is appropriate. McMaster already hosts a children's hospital and a high volume pediatric emergency room. If you convert this to a "dedicated" site, not much changes. Specifically, most of the same physicians will provide care, and the marginal efficiency benefits are minimal.
Some services do benefit from dedicated locations. Hamilton has already done this with the Trauma unit at Hamilton General ER, and Oncology (Juravanski) at the Henderson. In both cases, it makes sense to cluster the expert physicians, support staff, diagnostic technology and subspecialty backup because the scale is appropriate for the size of our city.
Conversely, many specialties do not benefit from moving to a single centre. Two examples are outpatient psychiatry and dermatology. Here, the expertise resides almost solely in individual physicians; there is little dependence on other expert staff and expensive high tech diagnostics, so there is little benefit from forcing them into larger groups.
Other specialties reside somewhere in between these extremes, balancing efficiencies of scale with patient access. Each specialty presents a unique case and the optimal degree of clustering should be considered individually.
We need specialists, and as time goes on, there will be greater need for new sub-specialists. But it can, and is, getting out of hand. When it comes to health care, I believe we have too much emphasis on excellence and not enough on basic medical services.
Most patients will tell you that the problem today is getting into the system, that is having a family doctor, being seen in the emergency room in a timely fashion, and if needed, getting admitted to a bed, not a hallway. Once you get into the system, things tend to go very smoothly.
These are not sexy, flauntable things like having a world class cardiology centre, but in the big picture are more important to the average Canadian's health.
For several years, enrolment in family medicine residencies has been declining in favour of specialties. In 2007, only 29 percent of MD graduates chose family medicine, compared to about half before 1990.
There are several reasons for this; lifestyle, income, and prestige among them. Add to this the changing patterns of more women in medical school and fewer young grads willing to sacrifice themselves with long hours at the clinic.
Finally, add the changing demographic of a growing elderly population with complex multi-system problems, and the result is predictable: not enough family doctors to meet the need. Not to get too sidetracked, but acknowledging this as possibly the major problem in health care helps to put the HHS proposal, which at best ignores this, in perspective.
Years ago, the situation was simple: general practitioner or specialist. Today, specialists are divided further.
There are those in frontline care who provide consultation but also follow patients closely for an extensive period as outpatients or as their most responsible physician (MRP) in hospital. Examples of such specialties are general internal medicine, pediatrics, general surgery (sometimes), and oncology.
Others, who I will call "sub-specialists", tend to have much less contact with the patient. For example, they will have a consultation, possibly surgery and a follow up visit, but rarely whole-person care.
These are not black and white categories, but suffice to say there has been an increase in sub-specialty emphasis in recent years, with an accompanying commoditization of health care and multiplication of specialists required for the complex, multi-system problem patient. A typical chronically ill elderly patient who was once treated by a single general internist might now need a cardiologist, respirologist, and endocrinologist, and the list could be much longer.
In some ways care is better, but a price is exacted in the human side of medicine, and this can have a strong influence on patient satisfaction and even health. In my view, the excess cost of the multi-specialist route overwhelms the efficiencies of scale gained from clustering and emphasizing sub-specialty care.
By championing sub-specialties, HHS is seen to be evolving as a regional referral centre. But what actually happens is that patients that are too sick to be treated in community hospitals only rarely have single-system illnesses (in any case sub-specialists generally hate being the MRP) and will still require a lot of generalist hospital care (e.g. general surgeon, general internist) before they can be stabilized and, in the lingo, repatriated to their community hospital.
There is no plan to grow generalist hospital care at all, simply to move the same number of beds and physicians from McMaster to fewer centralized sites. Both demographic and referral pressures tell me this is a shortsighted approach that will quickly need to be modified, probably at great and "unforeseen" cost.
In the 1990s, the small, crumbling Henderson was on a course for closure. Public pressure reversed this, as East Mountain folks made a case for easy access to care. West Hamilton, Dundas and Ancaster so far have not shown the same cojones to protect the larger and newer McMaster.
Adding minutes of ambulance transport time for points west of 403 is of significant concern. Moving adult medicine and the adult emergency from McMaster to the three central locations also increases car traffic and parking requirements in several ways: for staff, patients and visiting family members.
The proposed children's hospital at McMaster requires much more travel from the east end, but is a triumphant post-hoc justification to Red Hill cheerleaders.
There is a surprising sense of ownership and community surrounding local hospitals. Even if there is not a lot of vocal opposition from these west end communities, the price paid for McMaster's loss will be very real.
To those who are not familiar with the architecture of the McMaster University Medical Centre (MUMC), it is an impressively efficient layout. I have seen several other university hospitals and none are as well integrated with their university. The geographic layout of the hospital in close approximation to the campus and especially health-care oriented buildings is the product of considerable effort.
In addition, the integrated design of clinical medicine, clinical research, basic science research, and education, all under one roof leads to a tremendously productive environment. Ripping out adult medical care, the cornerstone of this organization, disrupts the benefits of integration.
Ironically, the much touted design of Diamond and Schmitt for the McMaster Innovation Park aims to duplicate for engineering what is already present for medicine at MUMC and slated for the chopping block. The bright minds behind McMaster's medical school must be rolling in their graves.
Have you ever heard of problem doctors, the kind who can't get along with anyone and disrupt the system? Have you ever seen a doctor get frustrated from wasting time waiting for the phone or making repeated, unnecessary calls? Have you ever come across arbitrary rules that don't make any sense impeding patient care?
These are the kinds of frustrating things that make my work difficult, and by extension, detract from the quality of patient care. It is nearly impossible for individual physicians to do anything to change this. However, doctors working together with administration on topics like this can have a huge impact on improving patient care.
With HHS' new vision, administration will have its hands full. They won't have the time or inclination to address these things.
From my perspective, talking to the appropriate specialist in a timely manner and getting helpful advice or patient transfer is vastly more useful to a patient than ensuring they go to a "centre of excellence". This sounds so basic, but in practice it is very difficult.
It should be no surprise that like many practical people, I dislike the elitism, inefficiency, self-perpetuation, inaction and/or misguided action of administrators everywhere. So with that declaration of bias, I maintain that there is a complex web of motivations for the HHS plan.
Some administrators may be simply justifying their jobs. Others are caught up in the sexy appearance of progress that accompanies the project. When you can use adjectives like bold, excellence, and progressive, it is far more exciting than tackling systemic barriers to good care. It is also an easier task.
Personally, I cannot imagine that people want to spend their days in boardrooms surrounded by power suits, coffee and donuts rather than talking to patients. But maybe that's just me. The bigger question is: do you want to fund medical care or administration with your tax dollars?
The public also has an affinity for glitter and buying into things the experts tell them should be done. It is unfortunate that few will get to read this, as the mainstream local media swallowed the administrative bait without any fight.
Physicians also can be misled, or beaten down by the system such that they are not up for a struggle. The real letdown comes from those ambitious, part-time administrator physicians who are enablers for what they must know is an unfair, inadequately discussed proposal.
I end with a disclosure that I have nothing to gain or lose from opposing the administrative plan. My wife will be affected neutrally. I want to be clear that there are benefits to this plan of centralizing specialties.
But for the patients of the west end, and all taxpayers, this is a misguided, losing proposal that has been dishonestly presented by administration and largely rubber stamped by local media.
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