Bridge over troubled waters

May 25, 2007
Surgical Rounds, September 2006, Volume 0, Issue 0

Bernard M. Jaffe, Professor of Surgery, Tulane University School of Medicine, New Orleans, LA

Bernard M. Jaffe, MD

Professor of Surgery

Department of Surgery

Tulane University

School of Medicine

New Orleans, LA

Nine months after Hurricane Katrina, the bridge over Tulane Avenue, between the Tulane University School of Medicine and the Tulane University Hospital, reopened. Once you have lived through a disaster, as we in New Orleans have, you realize how important tiny changes?even amoebic motions toward normalcy?become. The reopening of the bridge wasn't a major step on the road to convenience. The second floor entrance to the hospital was still under repair, which meant that from the bridge, we had to cross over to the parking lot, go down to the ground floor near the elevator, walk across LaSalle Street, and enter the hospital via the emergency department. Yet it was progress. I smiled as I first crossed the bridge and soon realized I was unconsciously whistling the great Simon and Garfunkel song "Bridge Over Troubled Waters."

Or perhaps it wasn't really that unconsciously. The title of the song is quite pertinent. The passageway across Tulane Avenue certainly is a bridge. Built to withstand 90-mph winds, it was remarkable that the covered structure had remained intact despite being buffeted by winds as strong as 137 mph. In addition, there was plenty of water. At one point, the flooding was 3 feet deep, drowning the newspaper stands and submerging the large trash receptacles. The lobbies of both the medical school and the hospital experienced serious flooding, and, despite having concrete floors, both have had to be totally redone.

As you might imagine, the critical word in Simon and Garfunkel's lyrics is "troubled." Historically, even under the best circumstances, the relationship between medical schools and teaching hospitals has been difficult. In many cases, each side stakes a claim of primacy and, in turn, each feels slighted. Since the boards on both sides of the street are comprised of financial wizards and important (or, in some cases, self-important) individuals, egos run large and competition rather than cooperation prevails. While there are many productive marriages, there are a lot of divorces; because the financial stakes are so high, the latter are often vitriolic, public, and just plain ugly.

I might be criticized for saying so, but until recently, the relationship between Tulane University School of Medicine and Tulane University Hospital was less than ideal. When I was recruited, the university owned the hospital and had academic as well as financial interest in its success. The CEO at that time was a genius, and I don't use that description lightly. As a result, despite some problems, the hospital functioned marvelously. Beds were full, nursing care was excellent, and the staff had a real esprit de corps.

The Tulane faculty was quite surprised when Columbia HCA, the for-profit health care giant, expressed interest in purchasing Tulane University Hospital and alarmed that the university was so interested in seeing it acquired. We were told that the hospital couldn't continue to exist long-term with such a small market share and that the Columbia regional network would markedly increase tertiary referrals. The medical school faculty were also told that Columbia would buy the practices of a large number of primary care physicians who would support the hospital. We were correct to be skeptical of these forecasts. What we weren't told was that the university was anxious to offload the financial responsibility for the hospital; in the wake of Katrina, they were absolutely right.

The contract between Tulane and Columbia HCA transitioning an 80% interest in the hospital to the for-profit chain is very complex. It provides funding for resident education and the establishment of several clinical centers of excellence. As far as we know, Columbia has met these obligations, and then some. The hospital was also provided with options to recruit critical new faculty members, whom the university could not have hired without the additional support. In many ways, Columbia has been an excellent partner.

On the other hand, there have been several problems. As could have been projected, education has taken a backseat. Columbia is interested in making money, not providing service. Nursing care has been far from ideal, and nurse-to-patient ratios have fallen as has the quality of ancillary caregivers. New programs are initiated only if they are likely to be financially successful. Tulane has clearly lost control of its hospital, a fact we all grapple with on a daily basis.

Several other medical schools have sold their hospitals to for-profit chains, and the results have been much the same. A marriage of two unequals is intrinsically problematic.

Before Katrina, the Tulane University Hospital environment was very busy yet not totally happy. Many practitioners felt like grown children watching their parents try to work through a troubled relationship, which included two other dependents: Charity Hospital and the New Orleans Veterans Administration Medical Center.

All that changed with Katrina. Columbia HCA, with its deep pockets and apparent commitment, has been the savior of the medical school. The hospital has filled critical faculty positions terminated by Tulane for fiscal exigency. Columbia HCA pushed very hard and spent millions to reopen Tulane University Hospital, the critical source of faculty private practice funds. As you must realize, practice income is as much the lifeblood of all clinical medical school departments as it is for the community.

The world of academic medicine has changed. It is no longer sustained by research, as important as such investigation is. The new technologies and faculty with super-specialized skills are incredibly expensive. Even wealthy universities have to dig deep to locate the necessary funding to run first-class medical schools and teaching hospitals. My initial assessment of the appropriateness of selling 80% of Tulane University Hospital was totally wrong. The relationship between Tulane and Columbia HCA isn't perfect, but few relationships are. It can, however, serve as a role model, particularly for other medical schools that are feuding with their for-profit partners. It has become fashionable to establish public-private partnerships. It is important for institutions not to overlook the possibilities of private-private partnerships as well. Tulane has been blessed to have Columbia as its bridge over troubled waters.

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