Skin In The Game


Leonard Zwelling

         In a critically important article in the NY Times on Sunday, January 10 called
“Defying the Medical Machine,” Noam Schreiber describes efforts by a group of
hospitalists in Oregon to organize in a union, not to protect their incomes,
but to protect their patients.

         Hospital administrators are off-loading management costs as
well as the costs of acquiring needed quality data to large physician
management companies with which the hospital contracts for the hospitals services rather than hire its own in-house physicians. A singular telling
paragraph late in the article explains the entire problem of American medicine,
the different ways administrators and doctors see the world.

         “The hospitalists (this was the in-house physician group) assured the
administrators that their concern had nothing to do with money—that none of
this was about money. They preferred to work less and make less to avoid
burnout (these docs were working 7 days on and 7 off for a total of 173 shifts per
year and were being asked by the administration to work 182 shifts, but for
more money)…Burnout was bad for them and bad for their patients. At which point
the administration responded that money was always the issue.”

         Now doesn’t THAT sound familiar.

         Over 80% of the revenue that runs MD Anderson comes from
patient care. Philanthropy, income from intellectual property and the dividends
from investments are small potatoes comparatively. So wouldn’t it make sense to
have a leadership team capable of grasping the importance of the quality of
that care, support that quality at all costs with investment and infrastructure,
while preserving the unique aspects of that care that provide the institution
with its competitive advantage.

         But No!

         The President isn’t even an oncologist. His chief doc isn’t
a surgeon or a medical oncologist or a pediatric oncologist and his chief
academic officer is not a patient care specialist either. Who the heck is
running the place? Obviously, the money guys!

         The real battle in American medicine is not about making
fewer errors, although that would be helpful. It is about the big three of
which errors are part of one: Access, Cost and Quality. Let’s focus on quality
the part that is in part about errors.

         The Error Era, which began with To Err is Human in 1999 when
the IOM convinced us that 98,000 deaths each year were due to hospital errors,
is only part of the quality movement. The real quality movement is based on
improving the systems by which care is delivered and has manifested itself in
armbands, Magic Markers on limbs and skull hemispheres that are to be operated
upon, and electronic health records that putatively prevent us from ordering
the wrong meds. We shall see how that all turns out.

         Another part of the “quality movement” has to do with how
doctors interact with patients and the administrators still think this is open
to bribery. It is not. Each physician has his or her own style of interacting
with patients. Some do it quickly, some do not. I was dazzled how differently
the doctors caring for me approached me when I was recently hospitalized. None
had a bad bedside manner. But they all were different at gleaning information
they needed to care for me including the fact that I was wondering whether my
shortness of breath was due to a pulmonary embolus. (It was!)

         But none of these men and women were anything but
professional and I seriously doubt that any of them were motivated by money.
That’s not why I went to medical school and it is not why they did either.

         Once and for all, money guys, we are not like you, or at
least the best of us aren’t. There are more important things in our lives than
money. As far as needing to work on contingency (bonuses for every extra
patient seen) to have “skin in the game,” this is just plain false for doctors.
And if it isn’t, shame on those doctors who have prostrated themselves on the
examining table of mammon.

         If the physicians of MD Anderson need to organize to
adequately convey to the leadership what medicine is all about, they should be
neither surprised nor reluctant to do so. You can’t expect a bunch of lab
jockeys and out-patient doctors to understand high powered surgery or cell

         I believe that our colleagues in Oregon have the right
answer. To quote Benjamin Franklin:

“We must, indeed, all hang together or, most
assuredly, we shall all hang separately.”

And speaking of Revolutionary figures, this
just in from those who would have us be a colony over 200 years ago (thanks
to a blog reader for the tip):

Leonard Zwelling