Collegiality in an Adversarial Economic Environment

Internal Medicine World ReportNovember 2005

Collegiality in an Adversarial Economic Environment

By Philip R. Alper, MD

Like most physicians I know who practice primary care, regular attendance at the hospital has become a thing of the past. This does not always sit well with other physicians for whom the hospital represents both an opportunity and a source of continuing obligation. This was made unmistakably clear when I stopped by the surgical lounge the other day.

“Here for a free lunch?” one of my surgical “colleagues” wisecracked, referring to the casseroles and sandwiches on the far wall.

Not to be outdone, I answered (ironically), “Actually, I’m mainly here for the pleasure of seeing you.”

Just the usual banter one might think, but behind the personal digs lay a lot that went unsaid. I probed a bit and quickly found that many specialists miss the presence of primary care physicians. Nor have hospitalists been entirely satisfactory substitutes.

“When you came to the hospital, we got to know how you do things, when you’d be around, and where to find you,” said one physician. Another pointed out that hospitalists rotate so often that it’s hard to know how to relate to them—and how far to trust them. That’s in addition to losing the historical knowledge of the patient and the added measure of trust that primary care physicians typically bring to shared care.

In a way, it is nice to be missed and to hear it said. It made me realize that I too miss the encounters with other physicians in many specialties that the hospital facilitates so well. Meeting socially does not entirely make up for the camaraderie of sharing in the care of patients, but enjoying a free lunch with colleagues does remind me a little of the old days.

That weekend, during lunch before a Giants/Cardinals baseball game, the conversational theme continued. I asked an old friend, an orthopedist, for his take on the situation. Even though managed care and the resulting negative economic forces are understood to be the cause, there is resentment at what is perceived as primary care physicians’ defection and choice of an easier lifestyle. The most recent irritant was a vote taken by the hospital staff that resulted in orthopedists with hospital privileges having to continue covering the emergency department. Other hospitals make calls voluntary. And some pay full market rates for coverage. We do pay, but not enough to satisfy the majority of our orthopedists.

“That vote would never have passed if it weren’t for most of the primaries voting for mandatory emergency department calls for us…and they don’t come to the hospital at all themselves,” my friend grumbled. “It doesn’t make sense that they can vote on this kind of question.”

The last comment hinted at what turned out to be a wish for a 2-class system of hospital staff privileges. And apparently that feeling is widely shared locally among other specialists, who so far have said little about it. I suspect the feeling is widely shared across the country.

That silence may change. And it may blow the lid off one of the biggest fictions in American medicine: that as years pass without admitting inpatients, the competence that is implicit in being awarded full staff privileges is deserved. Privileges are normally required by preferred provider organizations (PPOs), however. Hospital credentialing provides an element of quality control over physicians and assures covered patients of access to a hospital. The dislocations that a revolution in credentialing would cause are probably the biggest reason why nobody wants to even touch the issue. A “don’t ask, don’t tell” policy has resulted and the issue is still in the closet.

This is not only a local problem. Most of the nation’s major hospitals already employ hospitalists. While their substitution for primary care physicians as inpatient care providers is usually voluntary, it is sometimes mandatory. Ironically, managed care plans that prescribe mandatory use of hospitalists may nevertheless require primary physicians to maintain active hospital privileges. Meanwhile, the number of hospitalists in practice nationally has doubled from 6000 in 2002 to 12,000 in 2005, according to the Society of Hospital Medicine.

Although more than 80% of hospitalists are internists, “hospital medicine” is emerging as a new specialty that is likely to devalue internal medicine as a comprehensive specialty. I do not expect an honest discussion of the issues surrounding the flash point of credentialing to come anytime soon, though, because the House of Medicine no longer has the privacy to work things out on our own, and because in the broader public arena, deceptiveness and grandstanding are all too prevalent.

I am continuously shocked by the degree to which marketing departments have taken control of hospital policy—much reminiscent of what occurred in the pharmaceutical industry when Eli Lilly and Co, long a leading “ethical drug manufacturer,” unwisely launched the short-lived drug Oraflex in 1982 to the accompaniment of the first nationwide direct-to-consumer advertising blitz. The over-promotion that has nevertheless become standard in the drug industry has subsequently moved into the nation’s finest hospitals; in one study, 16 of the 17 queried acknowledged using advertising to attract patients.

An article entitled “Advertising in Academic Medical Centers” (Arch Intern Med. 2005;165:645-651) reports that appeals to emotion, highlighting institutional prestige and mentioning a disease or symptom, occurred in the majority of instances and that the use of come-ons for “mostly unproven” specific interventions was widespread. None of the 127 ads examined quantified benefits and only 1 mentioned potential harm. The authors concluded: “Many of the ads seemedto place the interests of the medical center before the interestsof the patients.”

Given this kind of cover, the floodgates are open to emulation by community hospitals. That is exactly what my own local hospital did with an advertising campaign promoting “state-of-the-art” orthopedic surgery, including minimally invasive procedures that some orthopedists feel are far more prone to complications than standard approaches. To be sure, free advertising on behalf of competitors did not sit well with members of the department who were not hyped either individually or by the kind of surgery they offer (such as less lucrative reconstructive procedures for crippled children).

But the invasion of “money talks” thinking means hospitals’ operating rooms, the highest margin service, will dominate policy. Favoritism will flourish as a consequence and since surgeons are dependent on the hospital’s goodwill for their livelihood, protest will be muted. The opportunity to divide and conquer will not be lost on hospital management.

How far is this from “traditional values” in medicine? It is of a piece with billing and then chasing the uninsured, no matter how poor, for multiples of insured patients’ contracted rates and waiting until whistleblowers and the media expose the practice before pulling back somewhat. Nor is the departure from the restraints of the past confined to hospitals.

Professional courtesy and generosity are fading. Where managed care is dominant, copays from physicians and their families are often expected in a kind of “it’s just routine for everyone” fashion. Goodwill among colleagues takes a backseat. In fact, in a personal example of senseless economics, I myself am pondering what to do with a precollection notice for an unpaid $15 copayment sent by a surgical specialist (to whom I’ve previously referred patients). He’s already been very well compensated by my top-flight PPO insurance, but whether by design or inadvertence, his office wants the entire fee. I’m quite unhappy with the quality of the consultation, let alone any question of courtesy. So the battleground has become the last $15.

That is a minor irritant that exposes a far larger problem. Fracture lines are evident throughout medicine. The next big upheaval to erupt will probably involve not only conflicting economic interests but also personal and interspecialty resentments. Hospital staff privileges for primary care physicians will not be overlooked in the eventual clash.

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