Tuesday, November 12, 2013

How Many Doctors Does It Take?

I had not realized that the Annals had posted my thoughts on this article a few years back, though only on the web site comments which probably did not get much read.  In any case, I think this is still relevant though perhaps too "insider" for many.

Click HERE to go to the article sample and my comment at the bottom.  Or just read my comments below.

Doctors as Bed Managers Inappropriate Use of Resources

Posted on March 7, 2009
Paul D Bunge

In the December 2 Annals, Howell et al present their case for "active bed management." In the intervention, they had hospitalists take turns doing twelve-hour shifts as bed manager, a position usually filled by a senior nurse (1). The bed manager typically coordinates the placement of the new patients from the emergency room and clinics onto the appropriate available ward. This person also tracks patients as they go in and out of the ICU and other units. The bed manager must keep track of all available beds, and negotiate as needed when beds, patients, and staff must be shuffled around to make room. Note that in the intervention, the hospitalists did not do any patient care while they filled this role.

I am not surprised at the result reported: The patients moved around the hospital more efficiently. The time that the patient remained waiting in the ER was shortened (a quality and hospital efficiency goal). The major problem with this intervention is not the result, but the cost: Whatever the possible short-term cost savings to the hospital and short-term benefit to patient comfort, the overall cost to the health care system must be factored in, which is essentially the huge cost of pulling 1/4 of the hospitalist staff out of direct patient care.

I am afraid that I must regard this intervention as both unethical and ridiculous. Unethical because "pressure from administration" lead to inappropriately removing doctors from patient care to achieve a financially-motivated efficiency goal. It is the doctor's responsibility to call foul when the administrator crosses a line and refuses the patient appropriate care. Yet in this intervention, the patients were left to the mid-level providers and others while the doctor was making phone calls.
This intervention is ridiculous in that it is already a waste that so much senior nursing time goes to administrative duties, including the role of bed manager. Are we to have the doctors do this job that would more appropriately be performed by a clerk? When the movement of patients around the hospital is dysfunctional, that is a leadership problem, not a clinical problem.

This article is an unfortunate illustration of some very important points:

1. We have strayed far away from our job, our profession, our calling: patient care. We have left it to a few weary, brave soles who we now call "primary care managers." The rest of us, with no apparent limit, gather specialty or hospitalist status, and make as clean a break as we can from the whole mess. Shame on us! And shame on us for blaming others (the government, the economy, the payment system).

2. We need to question the current band-wagon thinking that there is a shortage of physicians in this country. When our highest levels of medical learning can advocate using doctors as bed managers, we may actually have the opposite problem: an illness of too much. (see Shannon Brownlee's article for a look at this topic: http://www.theatlantic.com/doc/200712/health-care )

3. Common sense needs to find its way back into the hospital. In the days of Oryx measures and JCAHO rules and sub-rules, the doctors of the world must be the ones to bring some wisdom to the table to question quality measures that may actually decrease quality, the multiplication of pointless paperwork, and other like challenges.

Once as a young physician on the way to work, I stopped my car at the scene of an accident. I told the ambulance crew my credentials and asked if they needed my help. One wise EMT told me quite simply: "sir, it probably would be more helpful if you made your way to the hospital where you are needed and see the patients there. We can handle this part." I did just that. Perhaps more of us should do the same.

1. Eric Howell, Edward Bessman, Steven Kravet, Ken Kolodner, Robert Marshall, and Scott Wright Active Bed Management by Hospitalists and Emergency Department Throughput Ann Intern Med 2008; 149: 804-810

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