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.
By towngownguy (anonymous) | Posted February 15, 2008 at 09:18:49
The HHS plan is the classic vote for the centralized "silo" organizational model vs. the more decentralized community based model.
There are advantages and disadvantages to each model, and typically organizations swing back and forth from these two extreme vsions, depending what is " in vogue" at the time.
Current community models trumpeted by many urban planners call for smaller community based resources to be developed. The implication in this type of structure is more local access points for services which address the vast majority of the community needs.The HHS plan seems to be moving in the opposite direction, influenced by the current popular medical model of service consolidation.
I look forward to the upcoming public sessions.
As a west end resident, I see the removal of a community service (adult emergency services)replaced by a "silo" service. If Mac womens and childrens clinic needs more space, perhaps HHS should think more outside the box in coming up with alternatives that actually improve west end residents community access to emergency services that address the vast majority of issues that arise.
Giving family physicians more afterhour tools to address patient issues could be one area to explore further.
By Ted Mitchell (registered) | Posted February 15, 2008 at 12:43:07
Today's spec carries an opinion piece by Dr. Krizmanich, chief of HHS emergency medicine. http://www.thespec.com/Opinions/article/...
I'll leave it to readers to assess the content of his article, and my own, on the basis of cheerleading versus argument.
I think the point most blatantly missing from the Krizmanich article is the heavy reliance that emergency docs place on consulting what I call frontline physicians, ignored by the HHS plan, like general internal medicine. Ask anyone who works in an emerg, that is the leading specialty in terms of number of consults, and willingness to do work.
For an ER doc, getting subspecialists to even see a patient, nevermind take responsibility as the MRP, is often like pulling teeth. Unless the clustering plan has an unspoken agenda for micromanaging what specialsts do (which is a possibility, who knows?), that problem is unaddressed.
By Ted Mitchell (registered) | Posted February 24, 2008 at 20:21:12
anonymous, your concern is in the right place but you are considerably overestimating the benefit of a dedicated paeds emerg / hospital and underestimating the harm done to adult medicine in west hamilton.
Children who cannot be cared for at Mac are very rare, and fall into two categories: 1.really complicated ones who need to go to Sick Kids anyway , and 2.children who can be treated locally but lack enough resources as in beds, staff.
wrt 1, why try to compete with a world class children's hospital that is so close to Hamilton, it's a losing concept. as for 2, there are much easier and less harmful ways to accomplish this than wiping out adult medicine at Mac. Mac is already an excellent children's hospital, and referral support, rather than physical infrastructure,is the critical need. Mac will always need to respond to referrals from small peripheral hospitals, such as the one I work in , and from family docs all over the city, so why not also a few more from other ERs in Hamilton? This is a problem of facilitating consults and it is the primary problem as far as quality of care is concerned, independent of anything they do to the physical infrastructure. I fear this problem will not be addressed as admin will be too mixed up in vacuous rhetoric about centres of excellence while they ignore real problems.
The proposed "emerg" in west hamilton is really a walk-in clinic with some testing capability. Triaging is a nightmare in such facilities, and there will be considerable obstruction to necessary transfer to bigger centres. The more capability this facility has, the greater these referral problems. I'd like to do this kind of work, but it is medicolegally risky, not to mention unpleasant wrt begging consultants to see someone, which also means physical transfer, and by what mode? Can of worms...
By pauline (registered) | Posted February 28, 2008 at 22:58:29
I agree with Ted Mitchell. Also, I do not know how the private/public partnership is panning out and what the hidden financial considerations are at the HHSC. For example, all psychiatric services have been removed from the hospital - outpatient and inpatient. I would like to know what the FINANCIAL considerations are - I suspect that there is a less than ethical financial issue here - hospitals are not paid equally for inpatient beds and if you have an emergency department that takes all patients, it seems to me HHSC is descriminating against the old and the medically ill ( who might take up chronic beds and cost more in terms of labour costs) in favour of quick admissions - usually the case for children and women in ob/gyne. It is NOT true that access to good care is important even if it means driving across the city - any emergency department can conduct a cardiac arrest or treat shock - there are few major life-threatening emergencies and time to the ER is CRUCIAL and any modern ER knows what to do for these people. Finally, the ER's are already crowded - I fail to see how closing one will help the new catch phrase - 'wait times'. I feel that it is inconsciencable for a large public funded hospital that is going to treat adults to close its emergency doors. This has NOTHING to do with patient care. Pauline Pytka M.D.
By towngownguy (anonymous) | Posted February 29, 2008 at 17:56:12
I have been doing some research into this topic, and have come up with the following concerns/comments.
1. There seems to have been little done in the way of consultation with other key medical caregivers in the community. The recent letter to the editor in the Spectator from the Chair of the Canadian Association of Emergency Physicians points out that there is no clear agreement with the underlying justifications for this restructuring. As a resident, I would feel more comfortable if the experts in the health field were all on side with this idea.
2. There is a large and growing senior’s population in Dundas as a number of new condo developments have been constructed. This growing demographic will be asked to travel further for their emergency needs.
3. I have seen no mention by the students association of the loss of an on-campus emergency department for its students. Currently, the on - campus emergency first response team (EFRT) transfers students needing attention directly to the Mac emergency department, in many cases travelling with them on Mac campus vehicles. This service will no longer be available, and as a result many more emergency vehicles will be visiting campus to shuttle students from campus. It may be worthwhile to look at how many visits to the McMaster emergency department are made by students.
I am not comfortable with how the information has been presented so far. The official releases from the HHS have a large amount of spin to them, and the lack of unanimous agreement from key health provider groups makes me very nervous.
By Neil (registered) | Posted June 01, 2008 at 20:21:23
I live no where near Mac. I live in Guelph and the citizens of Guelph are slowly learning that if we want any decent chance of living through a medical emergency, McMaster is the only place to go.
I have to thank McMaster for saving my life. If the E/R was not there, I would not have made it, as I required gastro surgery. If I had to go to another E/R and then been "shipped" to McMaster for surgery, I probably would not have made it. I was rushed from the CAT scan to the OR. I only had minutes to live.
I thank McMaster and the doctors, nurses and friendly admin staff. PLEASE DON'T BREAK THE BEST THING GOING THIS SIDE OF BUFFALO!!! PLEASE!!!!
By Adnan (anonymous) | Posted December 06, 2011 at 00:24:02
i have done BE from pakistan, but i belong to very poor family in pakistan...its my dream that i would do master from mcmaster....
can anyone help me out, if there is any scholership or loan available for master degree program
By Adnan (anonymous) | Posted December 06, 2011 at 00:26:04
i will be very happy if any one reply me on my email : firstname.lastname@example.org
if i would get job in canada, then i will go master on my own.
thnx and regard
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