Dr. Melos is a gastroenterologist in solo practice in a medium-sized Midwestern city. One day she hears a knock on her door. When she answers, she finds two representatives of Athenian Health System, who request a few minutes of her time. She invites them to take a seat in her office.
After exchanging pleasantries, the visitors get down to business. They extend Dr. Melos an offer to join the ranks of Athenian’s employed physicians. If she declines, they say, they will hire their own gastroenterologist, whose practice will grow rapidly on referrals from their large network.
The representatives of the health system are remarkably candid. “We will not take up your time with arguments about the appropriateness of what we are doing. What we have here is a large imbalance of power, and as a business matter, you really have no choice.”
Dr. Melos replies that she has always worked amicably with Athenian Health, using many of its diagnostic testing services and admitting her patients to its facilities, so the health system has no need to deliver such an ultimatum.
The representatives respond that, if they allowed Dr. Melos to maintain her practice in the form she is accustomed to, it would make Athenian Health, which is seeking to consolidate its market position in the area, look weak.
Americans tend to like fast things: instant coffee, sports cars, and speed dating. Many share a fascination with record holders, such as the world’s fastest runner or texter. And increasingly, the same goes for medicine. The number of minute clinics is exploding. Some emergency rooms now post their current wait times on roadside billboards. And increasingly, physicians and other health professionals are under pressure to increase the speed at which they see patients.
A friend of mine, a family physician, was recently advised by the new manager of his practice that he will be penalized if he doesn’t increase the number of patients he sees each day in clinic. A thorough and compassionate physician who is known for the quality of the relationships he builds, he asked the man, “How am I supposed to work faster and still provide good care?” The practice manager thought for a moment and responded, “Why don’t you stop asking open-ended questions?”Continue reading…
Rube Goldberg was an American cartoonist and inventor, perhaps best known for the extremely complicated contraptions he devised for performing the simplest tasks. Each year, a national Rube Goldberg Machine Contest is held, challenging competitors to devise bizarre contrivances that can shine a shoe or zip a zipper. One day while watching a group of children marvel at such a machine in a museum, a thought occurred to one of us: As healthcare becomes more complex, the interactions between patients, physicians, hospitals, payers, and communities increasingly resemble a Rube Goldberg machine.
Consider a recent case. Ms. Jones was a 50-something year old African American woman with type I diabetes, high blood pressure and end-stage kidney disease requiring peritoneal dialysis, a form of dialysis performed nightly at home. She was recently admitted to the hospital because of an apartment fire that destroyed everything she owned, including her home dialysis equipment and medications. Once she was hospitalized, the medical team restarted her dialysis, restored her blood chemistries to normal, corrected her blood sugar, and began to make plans for her discharge. There was just one problem. They had no place to send her.
Ms. Jones could not return to her apartment, which had essentially burnt to the ground. She did not qualify for admission to a nursing home. And she couldn’t afford to rent a new apartment, at a cost of about $1,500 per month. She had paid for insurance on the apartment for years, but had recently let the insurance lapse to help finance the purchase of an $8,000 living room suite. The medical team had heard that social service agencies would provide one month’s rent, but it turned out that she could get only one-time distributions of $100 from the Red Cross and $200 from the Salvation Army – not nearly enough.
As the days rolled by, the medical team caring for Ms. Jones began feeling escalating pressure from hospital administration to discharge her. Her medical problems had been taken care of, and there was no medical need for her to remain in a hospital bed at a cost of $1,500 per day. The team arranged to get her dialysis supplies delivered to her sister’s house, hoping that she could stay there until she found a place of her own. But it turned out that too many people were already living there. Attempts to find temporary housing through friends and her church dead-ended. Hotels she contacted were all too expensive. Going to a homeless shelter was not a viable option; it would give her a place to sleep, but she couldn’t perform her dialysis there. She volunteered that she could live out of her car, for which she reportedly used some of the $300 to buy gas, but it later turned out that she did not have one.
As pressure to discharge Ms. Jones mounted, team members became increasingly frustrated. Each new hope was thwarted by an opposing reality. The team had provided their patient with the best available medical care, marshaling the impressive resources of a major academic medical center to solve her acute medical problems as effectively and efficiently as possible. But now they had run up against a barrier for which they lacked the necessary training and resources – not a medical problem so much as a social one. Treating acute illness was doable, but looking out for their patient as a whole person with a real life outside the hospital was proving quite another matter.