The Twenty-First Century Hospital

It is now undoubtedly obvious to all physicians that the hospital environment and the role of the physician have changed. Our government’s attempt to fix our “broken” health care system has dramatically disrupted the way in which we practice the art and science of medicine and surgery. Laws have been passed mandating the implementation of electronic medical records and universal health care, limiting resident work hours, and improving patient safety. Although these changes were well intended and thought to be advantageous, some have been more negative than positive. The expected and unexpected challenges of our new workplace have made me wonder whether our once enviable system of health care is now truly broken. With all the disruption that has occurred in the hospital environment, I often wonder whether there is a benchmark for comparison. How do we measure whether a disruption has been positive or negative? For example, with the implementation of electronic medical records, the positives are that medical documentation is now legible, retrievable, and accessible for research, billing, and review. The negatives are that it has significantly retarded the consultation process, generated redundant documentation, and depersonalized the patient-physician interaction. Rather than focusing on the patient and engaging in a meaningful dialogue, many physicians are focused on their computer screens as they check various buttons to create an electronic note that resembles a verbal dictation. Eye contact is continuously interrupted, the consultation is awkward, but the end-all electronic note is complete and we are in compliance. Despite the many naysayers, some advocate the benefits of electronic medical records and have actually stated that patients do not mind if the doctor is typing on a computer while obtaining a history. Given that we now live in an era of evidence-based medicine, I requested a level I or II study demonstrating that this was indeed true. I am still waiting for such a document and seriously doubt that it exists. Having seen thousands of patients over the past 20 years, I cannot imagine that patients would rather have me focus on a computer screen rather than on them. The other negative disruption about electronic medical records is that there is no standardized or universally accepted system. At one institution in which I work, there are four different and unrelated electronic medical records systems: one for hospital orders, one for operative notes, one for clinic notes, and one for hospital laboratory tests and radiographs. The irony is that none of them communicate with each other. There are separate passwords that have to be remembered for each. This is further complicated by the fact that different hospitals cannot agree on which electronic medical records system is best. Like most physicians, I consider myself fairly computer savvy, and maybe it is because I am old school and struggling with a negative disruption, but I have not yet met anyone, old or new school, who thinks that we have now perfected medical documentation. I am not recommending that we abandon electronic medical records, but I do believe that we should make all efforts to adopt a system that is all-in-one, user friendly, and consistent throughout all hospitals. Another topic that has been prioritized is patient safety. No one would argue that patient safety is one of the highest priorities that hospital administrators and physicians are focused on. As a collective unit, I am confident that everyone is engaged in the practice of reducing adverse events. This is true in the clinic setting, hospital ward, and the operating room. Minimizing the occurrence of unforeseen or unanticipated events is on everyone’s radar and is clearly a positive disruption. To minimize the risk of an adverse event in the operating room, many hospitals have adopted the checklist concept, much like the checklist that airline pilots use before each flight. Of the 15 or so items on a preprinted preoperative checklist at one hospital, a few are relevant and most are not. I agree that surgeons should verbalize the scheduled operation, confirm antibiotic delivery, and ensure deep venous thrombosis prophylaxis. I am not sure that it is relevant to confirm the patient’s identity two or three different times (once is enough), or that I know the name of every student, resident, certified registered nurse anesthetist, student registered nurse anesthetist, nurse, or anesthesiologist that is in the room, or that I mention the existence of a high-risk fire protocol. Some may rebut and say that it only takes a few minutes so why not. I would rebut and say let the surgeon choose what is important to mention based on the operation being performed and not based on a generalized, mostly irrelevant, and prefabricated checklist. I understand that administrators and lawyers created this checklist, but the fact that it cannot be modified implies that it is not solely about patient safety but rather ensuring compliance in this increasing world of administrative bureaucracy and regulation. A completed checklist provides confirmation to administrators and outside agencies that the hospital is in compliance. I applaud the hospitals that seek physician input on this to make it more efficient and relevant. I appreciate that these preprinted checklists have reduced adverse events in third-world and developing countries, but I seriously doubt that they have been effective in developed and progressive hospitals. In a recent publication in the New England Journal of Medicine, it was demonstrated that the implementation of a surgical checklist in Ontario, Canada was not associated with a significant reduction in operative mortality or complications.1 I would dare to wager that the prefabricated checklist makes no difference in surgical outcome because inefficient hospitals and sloppy surgeons will continue to make mistakes, checklist or not. Maybe I am naive and shortsighted and fail to appreciate the absolute necessity of these checklists, but I have been a surgeon for over 20 years and have yet to make a mistake based on anything that is on this checklist. That said, I appreciate that the mistakes of a few have spoiled it for the many. Another negative disruption is that at the end of each operation, we have a mandatory debriefing that is also in a preprinted checklist format. The irony is that there is no place to write a comment if there is a relevant item to debrief. All that matters is that we are in compliance because the checklist has been completely filled out. The common denominator in these scenarios is that physicians are losing their voice when it comes to hospital policy and regulation. These factors and others have made me wonder what the role of the physician has become in our evolving hospital environment. At one time, physicians were actively engaged in the decision-making process and worked closely with administrators to improve the quality of health care. The unfortunate reality is that many surgeons are becoming frustrated and angry because hospitals are no longer focused on them or their opinions. Surgeons used to have some degree of control, power, and autonomy; however, with all the changes that have occurred, most are not provided the choice or option to participate in the decision-making process regarding policy, equipment, working conditions, or future planning. Many are told what materials they can use, what tests they can order, and what antibiotics they can or cannot prescribe. Annual physician satisfaction surveys are completed and analyzed, but nothing seems to change, at least at some hospitals, thus creating more frustration. Many physicians have essentially been downgraded to interchangeable providers working within a hospital system that on the surface is striving for excellence but in reality is satisfied with mediocrity. As long as surgeons remain in compliance, assume a subservient role, and do not rock the boat, they are considered model employees. Many hospital administrators continue to paint a doom-and-gloom reality for physicians within this current system of health care based on declining reimbursement, increased patient load, skyrocketing malpractice insurance, and increased regulation. Because of this, many are opting to become employed by a health care institution or system. My fear is that physicians are surrendering their autonomy and will be subject to the forces that all employees face, namely, being told what they will do and when they will do it. They will lose the ability to adequately negotiate and advocate for their patients and themselves. For some, this may work; for others, it may not. I recall a senior hospital administrator speaking at a medical staff conference during which time he paraphrased the famous John F. Kennedy quote: “ask not what this hospital can do for you but instead what you can do for this hospital.” That pretty much sums it up in a nutshell. In summary, I suspect that the future generations of physicians and surgeons may not complain about the evolving health care model because they will not have experienced medicine and surgery as we once knew it. Most will probably work a 40-hour week and accept the rules and restrictions imposed on them. I can only hope that administrators, who do not understand why we choose to enter this noble profession, do not compromise the art and science of medicine and surgery. The medical profession has always attracted the best and brightest; I hope this will continue.

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