Hospital Administration Attempts to Cut Costs and Increase Quality at Expense of Physicians

A nonprofit hospital care system in Oregon with 450 beds has been in an acrimonious negotiation with its staff hospitalists for the past 2 years. The mounting economic pressures on this small, community oriented institution have had the expected consequences of hiring new administrators to implement the latest trends to rein in the budget and effect efficiencies of healthcare delivery-- as if that has been so successful in the rest of the country. The battle has really centered over the physicians losing control of their work time allocation, individual decision-making for diagnostic and treatment plans, as well as bristling at bonuses based on the administration’s definition of quality.

The parry and thrust shows both sides being intransigent as the physicians avoid confronting the economic exigencies facing the survival of the institution and the administrators demanding they have “skin in the game” for reaching cost saving metrics, as though putting your name on the chart and taking professional and legal responsibility for patient outcomes is not skin enough. Now the hospitalists want to unionize, thinking that solidarity will preclude mass firing and may allow leveraging their negotiating power by allying with hospitalists at other institutions.

When I was still clinically active, I never could understand the value added of the rapidly breeding throng of administrative FTE’s that complicated, not expedited, patient care. But in the Oregon case I was taken aback by one stalled issue. These hospitalists work 7 days on then 7 days off. They are base paid $223,000/year for 173 8-12 hour shifts per year. They are balking at an offer of $260,000 for 182 similar shifts per year, as it may infringe upon sick leave and vacation time. There are many practitioners working full time whose hourly rate is far less than that.

The United States is not the only country with a potential union-led labor dispute. Last week, hospital doctors in England began a 24-hour strike that disrupted treatment for thousands of patients in the National Health Service. Although a beloved institution of ole Albion, the health service has had chronic financial strains that have recently been exacerbated by an aging population and the current political mandate for stiff budget cuts. The British Medical Association represents 37,000 of these “registrars” in training (our residents), who are disputing a new contract that would increase base pay, but pare back weekend compensation. The government says more staffing is needed to create true 24/7 coverage. Ninety-eight percent of doctors voted to strike because they said the proposal would create excessive working hours that would negatively impact patient safety.

Officially, the house staff works a 48-hour week, but that is calculated over 26 weeks. The new schedule may have them work longer stretches than at present, particularly over weekends. I reiterate, the house staff (doctors in training), have a 48-hour work week, as opposed to our mandatory 80-hour limit that has impacted most surgical programs, if not non-surgical specialties.

I do not subscribe to the myth and nostalgia about the “good old days” when I trained when men were men and giants walked the wards. Postgraduate education has changed and is meeting new challenges, the autocratic system of yore swept under the table. However, I think both stories speak to a need that certain physicians, either in training or in practice, have to answer to a higher standard of professional dedication when negotiating work contracts. Patient safety is sacrosanct, therefore, do not wave it bogusly as a bloodied shirt of labor’s extortion by capitalistic greed.

By Norman Silverman, MD, with Ryan McKennon, DO and Ren Carlton


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