The Most Commonsensical And Hopeless Reform Idea Ever (Guest Opinion)

Jun 28, 2011

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The way that Michael Long and Sandeep Green Vaswami want to change hospital care may well rank as both the most commonsensical and most hopeless health reform proposal ever. The real question is whether they can show the same tenacity in pursuing their goal as an elderly Jewish woman from Munster, Ind., who has invested nearly two decades in a similar effort.

What the two men are advocating is simple: hospitals should offer the same level of professional staffing and patient care on weekends as during the rest of the week. They should do this, the two men write in the Health Affairs blog, because trying to cram seven days of care into five leads to a cascade of problems that harm and even kill patients. It also costs a lot of money.

That's the commonsense part. The hopeless part is that Long and Vaswami, both affiliated with the Institute for Healthcare Optimization, seem to believe that doctors, nurses and hospital execs will read their article and then spontaneously volunteer to work the weekend shift.

American hospitals are complex entities, but at heart they remain the doctor's workshop, dependent upon the goodwill of physicians who admit and care for patients. Maintaining that goodwill requires treading carefully. For instance, telling a neurosurgeon, "You're working Wednesday through Sunday this week" would rank high on the list of what a friend of mine calls a "career-limiting event."

Long and Vaswami are aware they're tampering with long-standing tradition, but as justification they offer a disturbing catalog of the effect of care controlled by the calendar.

To begin with, bunching scheduled admissions in midweek often overwhelms the staff, leading to "significant" increased risk of patient death or admission to the Intensive Care Unit. Filled beds force emergency rooms to discharge patients to "inappropriate care locations," with the hospital relying on specialized teams to ride to the rescue "when patients deteriorate because of inadequate care." At the same time, "medically appropriate transfers … may also be delayed or rejected."

And that's when hospitals are operating normally. Patients admitted over the weekend face an increased risk "because critical diagnostic or therapeutic modalities are not available," while patients staying over the weekend experience "delays at best and deterioration in clinical condition at worst."

Finally, peak-and-valley scheduling is inefficient, causing hospitals to build expensive new facilities instead of efficiently using existing capacity. With an aging population and new access to health insurance, that approach will cost "billions of dollars."

For all their indignation, however, Long and Vaswami pull their punches on both causation and remediation. So, for instance, in a 1,000-word essay backed by citations from The New England Journal of Medicine and similar sources, they never once use the words "doctor" or "physician" when referring to those whose behavior needs to change. Indeed, Long, an anesthesiologist, and Vaswami, an MBA, seem to run away from the implications of their own words. Avoiding either practical recommendations or moral outrage, they conclude: "Health care professionals have no choice but to carefully consider [emphasis added] whether weekends off are more important to us than the quality and cost of care we provide to our patients."

I'm surprised they didn't just write, "Take a few days off to think about it."

Of course, the two men understand they are opening a Pandora's box. The kind of compromises hospitals make to keep the medical staff happy is not a topic anyone wants to openly discuss. Let's look at a few examples.

In a just-released survey by the American Association of Critical Care Nurses nearly nine of 10 nurses said they've seen doctors make mistakes or take dangerous shortcuts. Yet only four in 10 nurses felt empowered to speak up. In a similar vein, 3 to 5 percent of hospital physicians are estimated to be outright disruptive, with a strong correlation between their misbehavior and problems ranging from nurse turnover to outright errors. Researchers bemoan the unwillingness of doctors to discipline colleagues or hospitals to risk alienating big admitters.

In that kind of environment, it takes a special person to question who the hospital is really set up to serve. Myra Rosenbloom, the elderly lady I mentioned earlier, is that kind of person.

Myra first called me back in 1993. Jack Rosenbloom, her husband of 45 years and her partner in a kosher catering business, had been admitted to a local hospital the previous September after suffering a heart attack. Jack was in stable condition when Myra visited him on Saturday evening but then started suffering chest pains. The hospital declared a code-blue emergency, but on a weekend night no doctor was available. Jack died that night in the ICU.

That's when Myra discovered that in Indiana, as elsewhere, no law required a doctor to be on duty, only that one be available within a certain time. (Typically, that's 15 to 30 minutes.)

Myra initiated a one-woman crusade to require hospitals over 100 beds to have a doctor other than the one in the emergency room on duty at all times. During Indiana's 1994 legislative session, she slept for five cold nights on a hard wooden bench inside the Capitol before the legislature passed a watered-down bill requiring a doctor, but letting an ER doc count towards the requirement. An ER physician was on duty at the hospital where Jack died, but he’d been too busy with other patients to answer the code-blue call.

Facing tenacious opposition from hospital groups that said her idea would cause them economic hardship, Myra has since then failed to win approval of a tougher law in Indiana, failed to pass a law in Illinois and failed to win even a hearing on similar federal legislation called the Physician Availability Act. It was first introduced in Congress in 1976, was reintroduced for a few years, vanished and then resurfaced in 2009 with the backing of Rep. Jan Schakowsky, a Democrat from suburban Chicago. At the time, Myra was 85 years old.

I called Myra the other day, and she said Schakowsky wants her to find some Republican co-sponsors so Schakowsky can reintroduce the bill. "I won't give up till the day I die," Myra told me with the same spirit as when we first spoke 18 years ago.

Perhaps if the nascent specialty called "nocturnists" had existed back in the early 1990s, there would have been someone to save Jack Rosenbloom that Saturday night. But the larger point made by Long and Vaswami remains. The distortions caused by giving provider convenience a greater priority than clinical necessity is exacting a fearful and avoidable toll of deaths, injuries and expense that far outweighs the cost of addressing the problem.

If Long, Vaswami and colleagues are serious about how hospitals operate, they would do well to act seriously. They could start by showing even a smattering of Myra Rosenbloom's persistence and courage.