It used to be so simple. The relationship between doctors and hospitals was a straightforward quid pro quo.
Hospitals granted privileges to physicians to admit and treat their patients, and the physicians returned the favor by assuming unpaid responsibilities like taking call, providing care to uninsured or emergency patients, and serving on administrative committees.
The hospital was like a friendly club whose members exchanged benefits for duties—a win-win situation. No more.
“You used to be part of a fraternity,” explains Win Whitcomb, MD, director of performance improvement at Mercy Medical Center in Springfield, Mass., and a co-founder of SHM. “There were social rewards. There was opportunity for collegial interchange.”
Economic pressure has taken that all away. “The pace of care has greatly intensified, and the financial reward system has deteriorated significantly,” Dr. Whitcomb continues. “We treat larger numbers of uninsured patients with chronic unmanaged illnesses that require intervention. The reward system for physicians to take call and fulfill their obligation to the hospital no longer matches the responsibility.”
To illustrate the change, Dr. Whitcomb offers an example: “We have some days of the month where the call roster for general surgeries has vacancies. A month ago we had to send a patient to another hospital for an appendectomy.”
It is not an isolated instance. “Every hospital is struggling with the fact that many physicians don’t view unassigned call as a part of membership on the staff; they want to be paid for it,” says SHM President Patrick Cawley, MD, executive medical director of the Medical University of South Carolina (MUSC). And extra “pay” for services that used to be rendered gratis is one thing today’s strapped hospitals can little afford.
Committee staffing is another area undergoing change. Attending physicians are simply declining the duty. Neal Axon, MD, a hospitalist and assistant professor of medicine and pediatrics at MUSC, has seen the transformation firsthand. At one hospital his service covered, he saw the following: “At the first staff meeting there were 50 people; there was food, liquor. It was social and attendance was mandatory. You had to make three or four meetings a year to be on medical staff at this hospital.” But then, he says, attendance waned, and in the last year “dropped off precipitously.”
The old ways don’t work so what will replace them? “The point is that both physicians and hospitals need to put something on the table to collaborate,” Dr. Cawley says. “Many are saying that the hospital-physician relationship needs to change, but everyone is still feeling their way through it. What does it mean?”
SHM’s CEO Larry Wellikson, MD, sees a layered structure ahead. “Clearly the system is evolving into three kinds of physicians who use the hospital,” he says. “We are not advocating for it—just saying what it is. This is what is evolving, and hospital staffs need to see this is coming.” His three kinds of physicians are categorized by their relationship to the hospital.
The home team: “The first group is those physicians who work only at the hospital,” he says. “Their professional life is with the hospital as an institution: hospitalists, ER doctors, critical care physicians, and sometimes the anesthesiologists and radiologists. The hospital is the location of their work and provides the tools to do their job. If the hospital works well, they can do their job well. If hospital is dysfunctional, they can’t work well.”
He describes their relationship to the hospital with an anecdote: “When I was regular physician who came to the hospital just to see my patient, if they couldn’t find the chart I would scream and yell about that one patient.” Every physician faced with a missing chart thinks of it as an individual problem. “But now as a hospitalist, I try to fix the system, because all my patients are affected,” he says. “Hospitalists are on the inside trying to make it work.”