Differences: Quality vs. Volume



       I was fired yesterday—again.

       Wow! This guy can’t keep a job!

       As I related in the past, I let go of the
one job I loved, heading the infrastructure for clinical research at MD
Anderson, in June of 2004. Three years later my job was eliminated when the log
of functions I had kept after 2004 had been whittled to toothpick size by
others and I was VP of Bupkis (not on your org chart). Dr. Dubois and Dan
Fontaine put me out of my misery on July 2, 2007 and a year later I was on my
way to DC. What a blessing!

       When I came back to Anderson from DC in
August of 2009, I was drafted into ad interim leadership of the Department of
Carcinogenesis in Smithville when the then department chair was fired (a lot of
that going around, eh?). I did that for 6 months, living three nights a week in
an apartment in Bastrop and driving back and forth to and from Smithville on Monday
morning and Thursday night.

Beginning in March of 2010, I ran the Pharmaceutical Development
Center for 18 months for Dr. Powis. Then Dr. DePinho came, Dr. Powis left, and
I was permanently out. I took the job at Legacy a mere 9 months ago and I am
out again. Can’t this guy hold a job? Oh, I said that already.

       Not any more in medicine apparently.

       I believe in medicine. I believe in the
innate goodness of what doctors do both from the point of view of someone who
cared for some very sick people in my life with all the energy I could muster
and for being on the other side of the stethoscope more than I wish was the
case in the past 12 years and receiving truly empathetic, humane care from some
wonderfully attentive and intelligent physicians. Unfortunately, that is not
what medicine is about any longer.

       Medicine used to be about doctors and
patients. Now it is about money and no amount of energy is going to change
that. I don’t care whether it is the drive to see more and more patients at
Anderson, a place where quality was the essence of its clinical care characterized
by time taken by the docs and nurses, freedom to consult without fear of losing
financial credit for a patient visit, and the brilliance of all the caregivers
down to the volunteers. It never used to be about flow charts, income
statements, RBRVUs or departmental productivity metrics. Or at my immediate
past employer where I heard many times, as I had heard at Anderson, no margin,
no mission and this from the leadership of two non-profits. Once you realize
that non-profit is a tax status not a description of a business strategy you
understand the drivers in health care today.

Patient care quality is not on the priority list despite the lip
service being paid to it with the patient-centered medical home concept because
no one is yet paid for delivering a quality product. It will likely occur, but
not tomorrow. The ACA guarantees fee-for-service is here for the near term at

       In attempting to emphasize the new
perception of reality and anticipate the need to morph from a high throughput
to a high quality system of care, but not too quickly, medicine has run into a
non-perceiving host of financial and administrative leadership teams that claim
to understand clinical care but do not. They haven’t been trained to. Physician
leaders are being hammered between the docs who want to deliver high quality care
and the finance and strategy folks who run hospitals and clinics who want to
push the assembly line harder at all costs. The infrastructure has not been
constructed for either speed or accuracy and is usually inadequate to optimize
either for we are all learning about this together. Staffing is often by lowest
common denominator support personnel. As a physician with corporate
responsibility, one tries to find a middle ground, but it is hard for a
physician to get his or her heart into finding a middle ground or negotiating
when it comes to care quality. In business there is always a balance between
quality and volume. In medicine, no one wants to hear about that choice. And I
made that choice badly as a corporate chief medical officer, because I refused
to compromise care. This is not an excuse or a rationalization. It is an
explanation for why I don’t fit in any longer. Heck, I probably never did. I am
a lousy team player as so many doctors are.

       Not sure what’s next for me. After all, I
am almost 66 and there really doesn’t have to be a next. But I want a next
because I do believe in medicine. I do believe medicine is really about doctors
and patients not insurers, payers and “providers.”

       I still believe what I believed in May of
1973 when I first took the Hippocratic Oath. I believe in life and the fact
that doctors are trying to help people through life. As my first analyst Dr.
Belinda Straight taught me over 30 years ago:

       “Doctors bring people into this world, and
doctors help them out. Doctors can handle most of what happens in between.”

Leonard Zwelling