Letters To The Editor

I was never a hospital guy

To the Editor: …Up until this year, I took care of patients both in and out of the hospital, but this year I succumbed to the distinct yet subtle pressures at my hospital and turned over my inpatients to the hospitalists. We have a fine, conscientious group of hospitalists. Nevertheless, the transfer of care of my patients back to the community is suffering terribly from what it was when I was treating patients in both hospital and office. Despite the hospitalists’ best efforts to dictate, copy med lists, and review situations with the patients, the patients arrive in my office confused, taking medicines incorrectly, and with no idea of what happened to them. I was crushed with the first few. Never mind the load of guilt they all presented me with for abandoning them. It was not in words, but in their eyes. “How could you leave me to them?” was the question in their eyes. I had no answer.

Maybe I’ll get used to it after a while. My days are certainly more ordered. I am now more “efficient”…

…Dr. Mandell asked for solutions. I have a couple of suggestions. Put the medical students out in the offices. But put them with good doctors, practicing state-of-the-art medicine and happy with what they are doing…

I was never a hospital guy

To the Editor: …Up until this year, I took care of patients both in and out of the hospital, but this year I succumbed to the distinct yet subtle pressures at my hospital and turned over my inpatients to the hospitalists. We have a fine, conscientious group of hospitalists. Nevertheless, the transfer of care of my patients back to the community is suffering terribly from what it was when I was treating patients in both hospital and office. Despite the hospitalists’ best efforts to dictate, copy med lists, and review situations with the patients, the patients arrive in my office confused, taking medicines incorrectly, and with no idea of what happened to them. I was crushed with the first few. Never mind the load of guilt they all presented me with for abandoning them. It was not in words, but in their eyes. “How could you leave me to them?” was the question in their eyes. I had no answer.

Maybe I’ll get used to it after a while. My days are certainly more ordered. I am now more “efficient”…

…Dr. Mandell asked for solutions. I have a couple of suggestions. Put the medical students out in the offices. But put them with good doctors, practicing state-of-the-art medicine and happy with what they are doing…

I was never a hospital guy

To the Editor: …Up until this year, I took care of patients both in and out of the hospital, but this year I succumbed to the distinct yet subtle pressures at my hospital and turned over my inpatients to the hospitalists. We have a fine, conscientious group of hospitalists. Nevertheless, the transfer of care of my patients back to the community is suffering terribly from what it was when I was treating patients in both hospital and office. Despite the hospitalists’ best efforts to dictate, copy med lists, and review situations with the patients, the patients arrive in my office confused, taking medicines incorrectly, and with no idea of what happened to them. I was crushed with the first few. Never mind the load of guilt they all presented me with for abandoning them. It was not in words, but in their eyes. “How could you leave me to them?” was the question in their eyes. I had no answer.

Maybe I’ll get used to it after a while. My days are certainly more ordered. I am now more “efficient”…

…Dr. Mandell asked for solutions. I have a couple of suggestions. Put the medical students out in the offices. But put them with good doctors, practicing state-of-the-art medicine and happy with what they are doing…

Nails in the coffin

To the Editor: Dr. Lansdale’s commentary depicting the plight of general internal medicine struck a heartfelt, emotional chord with me. I am a 59-year-old general internist with 30 years on the job as a hospital- and office-based practitioner. I’ve enjoyed the opportunity of being the chairman of the hospital’s department of medicine, president of the medical staff, chair of the quality committee, and other assorted hospital responsibilities. I was the associate director of a medicine residency program for 3 years, so I share some of Dr. Lansdale’s issues regarding “bureaucratic lunacy.” The three other generalists in my practice have done the same. We all love practicing medicine in spite of the demands. Our incomes are 20% to 30% less than they were 10 years ago. We have 35,000 charts (not all active) but still accept new patients, even Medicare. Caring for an octogenarian with five to eight active medical ailments who is taking 12 medications, mostly prescribed by several different subspecialists, is more challenging than ever. I’m saddened when I see a patient who has had two or three recent MRIs ordered by different physicians for a back, chest, or abdominal complaint when some simple remedy with the proper dose of time, observation, and follow-up was all that was needed. In spite of the problems, I enjoy practicing medicine as much as ever, but the future appears dim.

What has caused this impending collapse of primary care, and what is the cure? The answer is simple. The value that exists between patients and their personal physicians has been forgotten. The payers have cunningly refocused the values elsewhere, and the medical community and the public have let them do it with almost no resistance. I won’t mention the facts or history of this disaster, as we all know the story pretty well. I will mention, however, some scary things that may seal the primary care coffin forever. Insurance ratings, tiering, pay-for-performance, and evidence-based economics will all be the nails, and not much hammer effort will be needed.

What can be done to stop the bleeding, or do we really care? When the system changes to reimburse primary care physicians as much as subspecialists, then the coffin will open. I believe the decision to do this will come from pressure on the government from the public. Somehow, the medical community must convince the public to initiate this pressure. In the meantime, primary care physicians must continue to render compassionate care to the patient. After all, isn’t that why we went to medical school in the first place?

Nails in the coffin

To the Editor: Dr. Lansdale’s commentary depicting the plight of general internal medicine struck a heartfelt, emotional chord with me. I am a 59-year-old general internist with 30 years on the job as a hospital- and office-based practitioner. I’ve enjoyed the opportunity of being the chairman of the hospital’s department of medicine, president of the medical staff, chair of the quality committee, and other assorted hospital responsibilities. I was the associate director of a medicine residency program for 3 years, so I share some of Dr. Lansdale’s issues regarding “bureaucratic lunacy.” The three other generalists in my practice have done the same. We all love practicing medicine in spite of the demands. Our incomes are 20% to 30% less than they were 10 years ago. We have 35,000 charts (not all active) but still accept new patients, even Medicare. Caring for an octogenarian with five to eight active medical ailments who is taking 12 medications, mostly prescribed by several different subspecialists, is more challenging than ever. I’m saddened when I see a patient who has had two or three recent MRIs ordered by different physicians for a back, chest, or abdominal complaint when some simple remedy with the proper dose of time, observation, and follow-up was all that was needed. In spite of the problems, I enjoy practicing medicine as much as ever, but the future appears dim.

What has caused this impending collapse of primary care, and what is the cure? The answer is simple. The value that exists between patients and their personal physicians has been forgotten. The payers have cunningly refocused the values elsewhere, and the medical community and the public have let them do it with almost no resistance. I won’t mention the facts or history of this disaster, as we all know the story pretty well. I will mention, however, some scary things that may seal the primary care coffin forever. Insurance ratings, tiering, pay-for-performance, and evidence-based economics will all be the nails, and not much hammer effort will be needed.

What can be done to stop the bleeding, or do we really care? When the system changes to reimburse primary care physicians as much as subspecialists, then the coffin will open. I believe the decision to do this will come from pressure on the government from the public. Somehow, the medical community must convince the public to initiate this pressure. In the meantime, primary care physicians must continue to render compassionate care to the patient. After all, isn’t that why we went to medical school in the first place?

Nails in the coffin

To the Editor: Dr. Lansdale’s commentary depicting the plight of general internal medicine struck a heartfelt, emotional chord with me. I am a 59-year-old general internist with 30 years on the job as a hospital- and office-based practitioner. I’ve enjoyed the opportunity of being the chairman of the hospital’s department of medicine, president of the medical staff, chair of the quality committee, and other assorted hospital responsibilities. I was the associate director of a medicine residency program for 3 years, so I share some of Dr. Lansdale’s issues regarding “bureaucratic lunacy.” The three other generalists in my practice have done the same. We all love practicing medicine in spite of the demands. Our incomes are 20% to 30% less than they were 10 years ago. We have 35,000 charts (not all active) but still accept new patients, even Medicare. Caring for an octogenarian with five to eight active medical ailments who is taking 12 medications, mostly prescribed by several different subspecialists, is more challenging than ever. I’m saddened when I see a patient who has had two or three recent MRIs ordered by different physicians for a back, chest, or abdominal complaint when some simple remedy with the proper dose of time, observation, and follow-up was all that was needed. In spite of the problems, I enjoy practicing medicine as much as ever, but the future appears dim.

What has caused this impending collapse of primary care, and what is the cure? The answer is simple. The value that exists between patients and their personal physicians has been forgotten. The payers have cunningly refocused the values elsewhere, and the medical community and the public have let them do it with almost no resistance. I won’t mention the facts or history of this disaster, as we all know the story pretty well. I will mention, however, some scary things that may seal the primary care coffin forever. Insurance ratings, tiering, pay-for-performance, and evidence-based economics will all be the nails, and not much hammer effort will be needed.

What can be done to stop the bleeding, or do we really care? When the system changes to reimburse primary care physicians as much as subspecialists, then the coffin will open. I believe the decision to do this will come from pressure on the government from the public. Somehow, the medical community must convince the public to initiate this pressure. In the meantime, primary care physicians must continue to render compassionate care to the patient. After all, isn’t that why we went to medical school in the first place?

Focus on improving care

To the Editor: …The aspect of care that most of us found and continue to find rewarding—diagnosing difficult disease processes, adjusting medical treatment plans, discussing acute, chronic, and preventive care with patients and their families, and the bonding with patients and support staff—will be done in the outpatient arena. In order to make this aspect of health care more rewarding and to attract the best and brightest from the ranks of our medical schools, we need to focus on the processes that need to improve. We need to develop a team of caregivers working with the physician, just as we had in the hospital setting 20 years ago—nurses who had time to talk with patients and participate hands-on in their care. Therapists, nutritionists, and social care workers can add so much to the level of care a patients receives, and coordinating this care with the medical care given by the physician is rewarding to all involved.

Finally, we need to be fairly rewarded financially for this activity. Third-party payers, employers, and government agencies need to recognize the value in this coordination of care, the value in focusing on disease management and preventive care, and change the way we are reimbursed from the present system that only pays us for an office visit. If the average adult primary care physician had a better sense of accomplishment, could spend time on complex patients, and could be fairly compensated for this, we would have more than 2% of medical students going into medicine.

I have seen the rise and fall of satisfaction and enjoyment among internists, who can be a dour and whining group at times (I am one of them, remember). But I have also seen new physicians joining our group with enthusiasm and a realistic view of the profession they have chosen. We are focused on improving chronic care through disease management and of promoting those preventive care measures that will make a difference in the health of our patients. We are anxious to improve the system that supports these activities and controls the reimbursement for the work done to care for this growing population of our community. Finally, we want to see an improvement in the coordination of inpatient and outpatient care by the various specialists in medicine, which has always been a rewarding part of this field— colleagues working together to find the best solution for an ailing patient.

Focus on improving care

To the Editor: …The aspect of care that most of us found and continue to find rewarding—diagnosing difficult disease processes, adjusting medical treatment plans, discussing acute, chronic, and preventive care with patients and their families, and the bonding with patients and support staff—will be done in the outpatient arena. In order to make this aspect of health care more rewarding and to attract the best and brightest from the ranks of our medical schools, we need to focus on the processes that need to improve. We need to develop a team of caregivers working with the physician, just as we had in the hospital setting 20 years ago—nurses who had time to talk with patients and participate hands-on in their care. Therapists, nutritionists, and social care workers can add so much to the level of care a patients receives, and coordinating this care with the medical care given by the physician is rewarding to all involved.

Finally, we need to be fairly rewarded financially for this activity. Third-party payers, employers, and government agencies need to recognize the value in this coordination of care, the value in focusing on disease management and preventive care, and change the way we are reimbursed from the present system that only pays us for an office visit. If the average adult primary care physician had a better sense of accomplishment, could spend time on complex patients, and could be fairly compensated for this, we would have more than 2% of medical students going into medicine.

I have seen the rise and fall of satisfaction and enjoyment among internists, who can be a dour and whining group at times (I am one of them, remember). But I have also seen new physicians joining our group with enthusiasm and a realistic view of the profession they have chosen. We are focused on improving chronic care through disease management and of promoting those preventive care measures that will make a difference in the health of our patients. We are anxious to improve the system that supports these activities and controls the reimbursement for the work done to care for this growing population of our community. Finally, we want to see an improvement in the coordination of inpatient and outpatient care by the various specialists in medicine, which has always been a rewarding part of this field— colleagues working together to find the best solution for an ailing patient.

Focus on improving care

To the Editor: …The aspect of care that most of us found and continue to find rewarding—diagnosing difficult disease processes, adjusting medical treatment plans, discussing acute, chronic, and preventive care with patients and their families, and the bonding with patients and support staff—will be done in the outpatient arena. In order to make this aspect of health care more rewarding and to attract the best and brightest from the ranks of our medical schools, we need to focus on the processes that need to improve. We need to develop a team of caregivers working with the physician, just as we had in the hospital setting 20 years ago—nurses who had time to talk with patients and participate hands-on in their care. Therapists, nutritionists, and social care workers can add so much to the level of care a patients receives, and coordinating this care with the medical care given by the physician is rewarding to all involved.

Finally, we need to be fairly rewarded financially for this activity. Third-party payers, employers, and government agencies need to recognize the value in this coordination of care, the value in focusing on disease management and preventive care, and change the way we are reimbursed from the present system that only pays us for an office visit. If the average adult primary care physician had a better sense of accomplishment, could spend time on complex patients, and could be fairly compensated for this, we would have more than 2% of medical students going into medicine.

I have seen the rise and fall of satisfaction and enjoyment among internists, who can be a dour and whining group at times (I am one of them, remember). But I have also seen new physicians joining our group with enthusiasm and a realistic view of the profession they have chosen. We are focused on improving chronic care through disease management and of promoting those preventive care measures that will make a difference in the health of our patients. We are anxious to improve the system that supports these activities and controls the reimbursement for the work done to care for this growing population of our community. Finally, we want to see an improvement in the coordination of inpatient and outpatient care by the various specialists in medicine, which has always been a rewarding part of this field— colleagues working together to find the best solution for an ailing patient.

We must work together to save health care in our country

To the Editor: Dr. Lansdale’s comments sadly illustrate all that is wrong with our health care system.1 Desperately ill patients are hospitalized for as few days as possible in order to receive substandard care from agency nurses. Physicians have become assembly-line workers who must order large batteries of tests and procedures because they don’t have the time to sit down, talk to, or examine their patients. This is the type of care that medical students, interns, and residents are learning to practice. Sadly, this is the type of care that patients now expect: an MRI provides better reassurance than a physician’s competent assessment. Business, not physicians, dictates how medicine is practiced.

Internists who care about quality, like Dr. Lansdale, are leaving the profession in droves. But rather than passively leave, they should become leaders in an effort to reclaim health care. If internists worked together, they might be able to enact major changes rather than passively watch as the ship sinks under them. There have been calls to do something.²

Some physicians are taking matters into their own hands by opting out of the system altogether; they no longer accept any type of insurance. While extreme, if done en masse this option could send a powerful message to policy makers and insurers that physicians will be pawns no longer. If physicians do decide to do this, they should make every effort to keep fees, tests, and procedures to a minimum in order to reduce costs.

The United States stands head and shoulders above all other industrialized countries in per-capita spending on health care.³ This level of spending is not sustainable, especially in a nation beset by worsening financial conditions. ⁴ The United States desperately needs its physicians to be leaders in addressing our health care woes. We must work together to save health care in our country: quitting should not be an option.

We must work together to save health care in our country

To the Editor: Dr. Lansdale’s comments sadly illustrate all that is wrong with our health care system.1 Desperately ill patients are hospitalized for as few days as possible in order to receive substandard care from agency nurses. Physicians have become assembly-line workers who must order large batteries of tests and procedures because they don’t have the time to sit down, talk to, or examine their patients. This is the type of care that medical students, interns, and residents are learning to practice. Sadly, this is the type of care that patients now expect: an MRI provides better reassurance than a physician’s competent assessment. Business, not physicians, dictates how medicine is practiced.

Internists who care about quality, like Dr. Lansdale, are leaving the profession in droves. But rather than passively leave, they should become leaders in an effort to reclaim health care. If internists worked together, they might be able to enact major changes rather than passively watch as the ship sinks under them. There have been calls to do something.²

Some physicians are taking matters into their own hands by opting out of the system altogether; they no longer accept any type of insurance. While extreme, if done en masse this option could send a powerful message to policy makers and insurers that physicians will be pawns no longer. If physicians do decide to do this, they should make every effort to keep fees, tests, and procedures to a minimum in order to reduce costs.

The United States stands head and shoulders above all other industrialized countries in per-capita spending on health care.³ This level of spending is not sustainable, especially in a nation beset by worsening financial conditions. ⁴ The United States desperately needs its physicians to be leaders in addressing our health care woes. We must work together to save health care in our country: quitting should not be an option.

We must work together to save health care in our country

To the Editor: Dr. Lansdale’s comments sadly illustrate all that is wrong with our health care system.1 Desperately ill patients are hospitalized for as few days as possible in order to receive substandard care from agency nurses. Physicians have become assembly-line workers who must order large batteries of tests and procedures because they don’t have the time to sit down, talk to, or examine their patients. This is the type of care that medical students, interns, and residents are learning to practice. Sadly, this is the type of care that patients now expect: an MRI provides better reassurance than a physician’s competent assessment. Business, not physicians, dictates how medicine is practiced.

Internists who care about quality, like Dr. Lansdale, are leaving the profession in droves. But rather than passively leave, they should become leaders in an effort to reclaim health care. If internists worked together, they might be able to enact major changes rather than passively watch as the ship sinks under them. There have been calls to do something.²

Some physicians are taking matters into their own hands by opting out of the system altogether; they no longer accept any type of insurance. While extreme, if done en masse this option could send a powerful message to policy makers and insurers that physicians will be pawns no longer. If physicians do decide to do this, they should make every effort to keep fees, tests, and procedures to a minimum in order to reduce costs.

The United States stands head and shoulders above all other industrialized countries in per-capita spending on health care.³ This level of spending is not sustainable, especially in a nation beset by worsening financial conditions. ⁴ The United States desperately needs its physicians to be leaders in addressing our health care woes. We must work together to save health care in our country: quitting should not be an option.

General internal medicine is extinct

To the Editor: General internal medicine has become extinct. Its practitioners have been pushed out of their leadership roles, have been pushed from clinical practice due to red tape and impediments of frustration, and have been marginalized by specialties and subspecialties, our so-called brethren. Only through revolutionary metamorphosis such as clinical homes or other unique systems by which primary care is delivered at high-quality levels such as MDVIP can general internal medicine survive.

Hospitalists are not general internists. Family practitioners are not general internists. Nurse practitioners are not general internists. And certainly none of the subspecialists are general internists. We must forge a new identity and role in the health care system because our previous identity has been destroyed.

Without our unique ability to temper high tech with clinical judgment, our system fails on quality and cost.

The article by Dr. Lansdale was more eloquent than I could express, but I believe the words written above are more accurate and to the point.

General internal medicine is extinct

To the Editor: General internal medicine has become extinct. Its practitioners have been pushed out of their leadership roles, have been pushed from clinical practice due to red tape and impediments of frustration, and have been marginalized by specialties and subspecialties, our so-called brethren. Only through revolutionary metamorphosis such as clinical homes or other unique systems by which primary care is delivered at high-quality levels such as MDVIP can general internal medicine survive.

Hospitalists are not general internists. Family practitioners are not general internists. Nurse practitioners are not general internists. And certainly none of the subspecialists are general internists. We must forge a new identity and role in the health care system because our previous identity has been destroyed.

Without our unique ability to temper high tech with clinical judgment, our system fails on quality and cost.

The article by Dr. Lansdale was more eloquent than I could express, but I believe the words written above are more accurate and to the point.

General internal medicine is extinct

To the Editor: General internal medicine has become extinct. Its practitioners have been pushed out of their leadership roles, have been pushed from clinical practice due to red tape and impediments of frustration, and have been marginalized by specialties and subspecialties, our so-called brethren. Only through revolutionary metamorphosis such as clinical homes or other unique systems by which primary care is delivered at high-quality levels such as MDVIP can general internal medicine survive.

Hospitalists are not general internists. Family practitioners are not general internists. Nurse practitioners are not general internists. And certainly none of the subspecialists are general internists. We must forge a new identity and role in the health care system because our previous identity has been destroyed.

Without our unique ability to temper high tech with clinical judgment, our system fails on quality and cost.

The article by Dr. Lansdale was more eloquent than I could express, but I believe the words written above are more accurate and to the point.

The name of the devil

To the Editor: Dr. Lansdale’s commentary¹ reveals the price we pay when we focus on one important goal to the exclusion of others. He illustrates that reductions in health care cost were paid for with reduced health care quality, and a loss of camaraderie and job satisfaction. Missing from his commentary, however, is any acknowledgment that reducing the cost of health care is an important and worthy goal—and his wistfulness for the old days suggests his willingness to trade increased cost for better quality and job satisfaction.

Unfortunately, the biggest problem in this conflict is not that Dr. Lansdale and his former administrators disagree on whether cost is more important than quality and job satisfaction, but that both mistakenly agree that each must be traded off for the others. This hidden agreement is the chief mischief in health care today.

For example, much of the effort to improve health care quality has been oblivious to costs and employee satisfaction. Efforts to reduce errors have led to additional process steps, new checkers and coordinators, and expensive IT systems. These have increased costs, while frequently reducing job satisfaction and in some cases even failing to improve quality. Computerized order entry systems have been shown, for example, to disrupt physician-nurse communication patterns that were one of the major ways the old system prevented errors, and were a source of job satisfaction to both parties.² In some cases, patient mortality rates increased after they were implemented.³ Another new system plans to police handwashing by putting video cameras in patient rooms.⁴ Costly, yes, and the consequences for clinical-staff jobsatisfaction are predictable.

The core problem is focusing on one-dimensional outcomes, instead of insisting that cost, quality, and job satisfaction are all vital, and that we will not truly achieve any of them until we achieve all three. Poor quality is wasteful, and waste costs money. Employees are most satisfied where they are productively employed providing high-quality services, and productive employees cost less in the long run than unproductive ones.

How can we have high-quality, low-cost, high-satisfaction health care? By fundamentally redesigning the way care is delivered, radically simplifying care processes to focus on the limited number of elements that produce health outcomes for the patient. Toyota has demonstrated that it is possible for a manufacturer to be high-quality, low-cost, and high-satisfaction by using an analogous approach, and the many manufacturers that have followed its example testify that Toyota was no fluke.⁵ Early efforts are underway to apply so-called lean approaches in health care settings, but most are pruning the branches of waste instead of pulling it out by the roots, for example, redesigning labs and supply closets far from the patient’s side.^6,7

A former boss was fond of quoting economist Kenneth Boulding: “The name of the devil is suboptimization!” Let’s begin by agreeing that cost, quality, and job satisfaction are all important, and commit to working to achieve all three together.

The name of the devil

To the Editor: Dr. Lansdale’s commentary¹ reveals the price we pay when we focus on one important goal to the exclusion of others. He illustrates that reductions in health care cost were paid for with reduced health care quality, and a loss of camaraderie and job satisfaction. Missing from his commentary, however, is any acknowledgment that reducing the cost of health care is an important and worthy goal—and his wistfulness for the old days suggests his willingness to trade increased cost for better quality and job satisfaction.

Unfortunately, the biggest problem in this conflict is not that Dr. Lansdale and his former administrators disagree on whether cost is more important than quality and job satisfaction, but that both mistakenly agree that each must be traded off for the others. This hidden agreement is the chief mischief in health care today.

For example, much of the effort to improve health care quality has been oblivious to costs and employee satisfaction. Efforts to reduce errors have led to additional process steps, new checkers and coordinators, and expensive IT systems. These have increased costs, while frequently reducing job satisfaction and in some cases even failing to improve quality. Computerized order entry systems have been shown, for example, to disrupt physician-nurse communication patterns that were one of the major ways the old system prevented errors, and were a source of job satisfaction to both parties.² In some cases, patient mortality rates increased after they were implemented.³ Another new system plans to police handwashing by putting video cameras in patient rooms.⁴ Costly, yes, and the consequences for clinical-staff jobsatisfaction are predictable.

The core problem is focusing on one-dimensional outcomes, instead of insisting that cost, quality, and job satisfaction are all vital, and that we will not truly achieve any of them until we achieve all three. Poor quality is wasteful, and waste costs money. Employees are most satisfied where they are productively employed providing high-quality services, and productive employees cost less in the long run than unproductive ones.

How can we have high-quality, low-cost, high-satisfaction health care? By fundamentally redesigning the way care is delivered, radically simplifying care processes to focus on the limited number of elements that produce health outcomes for the patient. Toyota has demonstrated that it is possible for a manufacturer to be high-quality, low-cost, and high-satisfaction by using an analogous approach, and the many manufacturers that have followed its example testify that Toyota was no fluke.⁵ Early efforts are underway to apply so-called lean approaches in health care settings, but most are pruning the branches of waste instead of pulling it out by the roots, for example, redesigning labs and supply closets far from the patient’s side.^6,7

A former boss was fond of quoting economist Kenneth Boulding: “The name of the devil is suboptimization!” Let’s begin by agreeing that cost, quality, and job satisfaction are all important, and commit to working to achieve all three together.

The name of the devil

To the Editor: Dr. Lansdale’s commentary¹ reveals the price we pay when we focus on one important goal to the exclusion of others. He illustrates that reductions in health care cost were paid for with reduced health care quality, and a loss of camaraderie and job satisfaction. Missing from his commentary, however, is any acknowledgment that reducing the cost of health care is an important and worthy goal—and his wistfulness for the old days suggests his willingness to trade increased cost for better quality and job satisfaction.

Unfortunately, the biggest problem in this conflict is not that Dr. Lansdale and his former administrators disagree on whether cost is more important than quality and job satisfaction, but that both mistakenly agree that each must be traded off for the others. This hidden agreement is the chief mischief in health care today.

For example, much of the effort to improve health care quality has been oblivious to costs and employee satisfaction. Efforts to reduce errors have led to additional process steps, new checkers and coordinators, and expensive IT systems. These have increased costs, while frequently reducing job satisfaction and in some cases even failing to improve quality. Computerized order entry systems have been shown, for example, to disrupt physician-nurse communication patterns that were one of the major ways the old system prevented errors, and were a source of job satisfaction to both parties.² In some cases, patient mortality rates increased after they were implemented.³ Another new system plans to police handwashing by putting video cameras in patient rooms.⁴ Costly, yes, and the consequences for clinical-staff jobsatisfaction are predictable.

The core problem is focusing on one-dimensional outcomes, instead of insisting that cost, quality, and job satisfaction are all vital, and that we will not truly achieve any of them until we achieve all three. Poor quality is wasteful, and waste costs money. Employees are most satisfied where they are productively employed providing high-quality services, and productive employees cost less in the long run than unproductive ones.

How can we have high-quality, low-cost, high-satisfaction health care? By fundamentally redesigning the way care is delivered, radically simplifying care processes to focus on the limited number of elements that produce health outcomes for the patient. Toyota has demonstrated that it is possible for a manufacturer to be high-quality, low-cost, and high-satisfaction by using an analogous approach, and the many manufacturers that have followed its example testify that Toyota was no fluke.⁵ Early efforts are underway to apply so-called lean approaches in health care settings, but most are pruning the branches of waste instead of pulling it out by the roots, for example, redesigning labs and supply closets far from the patient’s side.^6,7

A former boss was fond of quoting economist Kenneth Boulding: “The name of the devil is suboptimization!” Let’s begin by agreeing that cost, quality, and job satisfaction are all important, and commit to working to achieve all three together.

To the Editor: Dr. Thomas Lansdale’s provocative essay “A medical center is not a hospital” (September 2008) is, in many respects, on target. I share some of Dr. Lansdale’s disenchantment, but only some. Our profession is under the gun, and everyone expects more of us. But change is the fabric of life and gives us opportunities to advance our profession and alter the fate of our patients. And I haven’t changed in one respect: I am still a “hospital guy” and I still am having fun.

The pressures faced in practicing medicine are enormous. Simply put, when medicine needs a sophisticated environment such as a hospital, we need to figure out how to meet the mortgage.

This is a problem when hospital managers are not physicians and are not at the bedside enough. Their charge is different. My former chief operations officer (an MBA) used to jokingly say, “They (meaning the academic full-time Cleveland Clinic staff ) just don’t get it.” And I would say, “They (meaning the MBA management crew) just don’t get it.” Well, neither group usually does. They can’t. They are of different worlds—until the MBA gets sick with crushing chest pain or the physician-manager suddenly has to face the music of a Wall Street bond collapse.

We can complain all we want, but we exist in a world of profit margin and EBITDA (earnings before interest, taxes, depreciation, and amortization). The challenge is to preserve the bottom line while also protecting physician time for reasonable research and education programs.

I happen to share Dr. Lansdale’s love for diagnostic challenges presented by hospitalized patients. My specialty (advanced heart failure and cardiac transplantation) certainly remains exciting and challenging because of this.

And I cannot do what I do without a hospital—no heart transplants on my kitchen table! Let’s get real: for many of us the hospital is still the only place we can practice and the only place we can save lives and alter the often-dismal prognosis of our most ill patients.

Yes, our practice has changed. We no longer strain to see a glossy wet Polaroid of an m-mode echo to diagnose mitral stenosis, and we no longer have only lidocaine and a prayer for acute myocardial infarction. We don’t do our own Gram stains, urinalyses, and peripheral blood smears in the middle of the night, and AIDS is no longer called “thin-man disease.”

And what about safety of hospitals? Well, don’t forget history. Hospitals are no longer death houses. Hospital safety and clinical outcomes have never been better. Yes, they are not yet good enough, and egregious problems exist, but never before has so much attention and expense been paid to quality improvement, patient experience, and safety initiatives throughout the industry. No, hospitals are not perfect—never will be. But I am proud of what we are doing, what we have accomplished, and what we will accomplish in the future to make ill patients better when they are sick enough to require hospitalization.

So I am proud and happy to be a hospital guy. To Dr. Lansdale I say, don’t give up. Your effort to preserve the passion of our noble profession is essential. Oh, and remember that Osler of Baltimore struggled with the same issues as did Codman of Boston. The more things change, the more they stay the same—except for the fact that hospitals are better.

To the Editor: Dr. Thomas Lansdale’s provocative essay “A medical center is not a hospital” (September 2008) is, in many respects, on target. I share some of Dr. Lansdale’s disenchantment, but only some. Our profession is under the gun, and everyone expects more of us. But change is the fabric of life and gives us opportunities to advance our profession and alter the fate of our patients. And I haven’t changed in one respect: I am still a “hospital guy” and I still am having fun.

The pressures faced in practicing medicine are enormous. Simply put, when medicine needs a sophisticated environment such as a hospital, we need to figure out how to meet the mortgage.

This is a problem when hospital managers are not physicians and are not at the bedside enough. Their charge is different. My former chief operations officer (an MBA) used to jokingly say, “They (meaning the academic full-time Cleveland Clinic staff ) just don’t get it.” And I would say, “They (meaning the MBA management crew) just don’t get it.” Well, neither group usually does. They can’t. They are of different worlds—until the MBA gets sick with crushing chest pain or the physician-manager suddenly has to face the music of a Wall Street bond collapse.

We can complain all we want, but we exist in a world of profit margin and EBITDA (earnings before interest, taxes, depreciation, and amortization). The challenge is to preserve the bottom line while also protecting physician time for reasonable research and education programs.

I happen to share Dr. Lansdale’s love for diagnostic challenges presented by hospitalized patients. My specialty (advanced heart failure and cardiac transplantation) certainly remains exciting and challenging because of this.

And I cannot do what I do without a hospital—no heart transplants on my kitchen table! Let’s get real: for many of us the hospital is still the only place we can practice and the only place we can save lives and alter the often-dismal prognosis of our most ill patients.

Yes, our practice has changed. We no longer strain to see a glossy wet Polaroid of an m-mode echo to diagnose mitral stenosis, and we no longer have only lidocaine and a prayer for acute myocardial infarction. We don’t do our own Gram stains, urinalyses, and peripheral blood smears in the middle of the night, and AIDS is no longer called “thin-man disease.”

And what about safety of hospitals? Well, don’t forget history. Hospitals are no longer death houses. Hospital safety and clinical outcomes have never been better. Yes, they are not yet good enough, and egregious problems exist, but never before has so much attention and expense been paid to quality improvement, patient experience, and safety initiatives throughout the industry. No, hospitals are not perfect—never will be. But I am proud of what we are doing, what we have accomplished, and what we will accomplish in the future to make ill patients better when they are sick enough to require hospitalization.

So I am proud and happy to be a hospital guy. To Dr. Lansdale I say, don’t give up. Your effort to preserve the passion of our noble profession is essential. Oh, and remember that Osler of Baltimore struggled with the same issues as did Codman of Boston. The more things change, the more they stay the same—except for the fact that hospitals are better.

To the Editor: Dr. Thomas Lansdale’s provocative essay “A medical center is not a hospital” (September 2008) is, in many respects, on target. I share some of Dr. Lansdale’s disenchantment, but only some. Our profession is under the gun, and everyone expects more of us. But change is the fabric of life and gives us opportunities to advance our profession and alter the fate of our patients. And I haven’t changed in one respect: I am still a “hospital guy” and I still am having fun.

The pressures faced in practicing medicine are enormous. Simply put, when medicine needs a sophisticated environment such as a hospital, we need to figure out how to meet the mortgage.

This is a problem when hospital managers are not physicians and are not at the bedside enough. Their charge is different. My former chief operations officer (an MBA) used to jokingly say, “They (meaning the academic full-time Cleveland Clinic staff ) just don’t get it.” And I would say, “They (meaning the MBA management crew) just don’t get it.” Well, neither group usually does. They can’t. They are of different worlds—until the MBA gets sick with crushing chest pain or the physician-manager suddenly has to face the music of a Wall Street bond collapse.

We can complain all we want, but we exist in a world of profit margin and EBITDA (earnings before interest, taxes, depreciation, and amortization). The challenge is to preserve the bottom line while also protecting physician time for reasonable research and education programs.

I happen to share Dr. Lansdale’s love for diagnostic challenges presented by hospitalized patients. My specialty (advanced heart failure and cardiac transplantation) certainly remains exciting and challenging because of this.

And I cannot do what I do without a hospital—no heart transplants on my kitchen table! Let’s get real: for many of us the hospital is still the only place we can practice and the only place we can save lives and alter the often-dismal prognosis of our most ill patients.

Yes, our practice has changed. We no longer strain to see a glossy wet Polaroid of an m-mode echo to diagnose mitral stenosis, and we no longer have only lidocaine and a prayer for acute myocardial infarction. We don’t do our own Gram stains, urinalyses, and peripheral blood smears in the middle of the night, and AIDS is no longer called “thin-man disease.”

And what about safety of hospitals? Well, don’t forget history. Hospitals are no longer death houses. Hospital safety and clinical outcomes have never been better. Yes, they are not yet good enough, and egregious problems exist, but never before has so much attention and expense been paid to quality improvement, patient experience, and safety initiatives throughout the industry. No, hospitals are not perfect—never will be. But I am proud of what we are doing, what we have accomplished, and what we will accomplish in the future to make ill patients better when they are sick enough to require hospitalization.

So I am proud and happy to be a hospital guy. To Dr. Lansdale I say, don’t give up. Your effort to preserve the passion of our noble profession is essential. Oh, and remember that Osler of Baltimore struggled with the same issues as did Codman of Boston. The more things change, the more they stay the same—except for the fact that hospitals are better.

To the Editor: As a grateful patient of Dr. Lansdale, and as a fortunate, rather healthy soul without medical knowledge and without, up to now, much experience as a hospital inmate, I fully acknowledge that you may well deem me a dubious, uninformed, and even biased commentator on “A medical center is not a hospital.” However, I deeply appreciated Dr. Lansdale’s important essay, and I commend you for publishing it. The conditions he describes contrast dramatically with those of yore.

Dr. Lansdale’s essay took me back many years to the time of my mother’s illness, when medicine was practiced differently, and, as she suffered bravely and eventually died of cancer, I recalled myself watching warily with the keen eyes of a child.

Our experience with Mother’s nurses and doctors was unforgettable, for, in nearly every case, we knew we were dealing with men and women of the profoundest dedication. Mother’s nurses at the Harkness Pavilion of the Columbia-Presbyterian Medical Center treated her (she died the day JFK was elected president) with unbounded tenderness, compassion, and patience.

They moved gracefully, walked quietly in her room, spoke softly but clearly to her, and to me, a girl, they seemed like angels. Nothing was too much; they fluffed her pillows, propped the window to give her fresh air, refrained from rattling or jarring the equipment, and seemed to sense what she was feeling and to provide accordingly. Her care was a kind of devotion, I felt, and there was no sense of rush or artificial curtailment of their responses to her. They always had a kind word for me as well.

And where has this sense of vocation gone? I have no doubt there are still many who enter the health professions with a deep desire to alleviate the suffering of others, but, as Dr. Lansdale’s essay shows, these people are now constrained, limited, and held back. Their care is degraded and seen as a job, a workload. What has happened to the sense of joy in alleviating even a moment of pain by administering a cold washcloth, finding a warm blanket, or holding a hand? This I saw years ago.

As for Dr. Lansdale himself, when I had the first and only major operation of my life, he appeared unexpectedly in my hospital room on a Sunday morning a couple of days later. In his arms were a container of soup he had made himself and a tiny vase of flowers grown by his wife. Tears filled my eyes after he left because he made me realize that he saw me not just as a broken body but as a human being who loved loveliness and who was on the way back to health.

The ancient Greeks understood that medicine and nursing are arts. They still are. And artists must be given the freedom, time, and chance to follow their best instincts. They deserve our honor and trust.

To the Editor: As a grateful patient of Dr. Lansdale, and as a fortunate, rather healthy soul without medical knowledge and without, up to now, much experience as a hospital inmate, I fully acknowledge that you may well deem me a dubious, uninformed, and even biased commentator on “A medical center is not a hospital.” However, I deeply appreciated Dr. Lansdale’s important essay, and I commend you for publishing it. The conditions he describes contrast dramatically with those of yore.

Dr. Lansdale’s essay took me back many years to the time of my mother’s illness, when medicine was practiced differently, and, as she suffered bravely and eventually died of cancer, I recalled myself watching warily with the keen eyes of a child.

Our experience with Mother’s nurses and doctors was unforgettable, for, in nearly every case, we knew we were dealing with men and women of the profoundest dedication. Mother’s nurses at the Harkness Pavilion of the Columbia-Presbyterian Medical Center treated her (she died the day JFK was elected president) with unbounded tenderness, compassion, and patience.

They moved gracefully, walked quietly in her room, spoke softly but clearly to her, and to me, a girl, they seemed like angels. Nothing was too much; they fluffed her pillows, propped the window to give her fresh air, refrained from rattling or jarring the equipment, and seemed to sense what she was feeling and to provide accordingly. Her care was a kind of devotion, I felt, and there was no sense of rush or artificial curtailment of their responses to her. They always had a kind word for me as well.

And where has this sense of vocation gone? I have no doubt there are still many who enter the health professions with a deep desire to alleviate the suffering of others, but, as Dr. Lansdale’s essay shows, these people are now constrained, limited, and held back. Their care is degraded and seen as a job, a workload. What has happened to the sense of joy in alleviating even a moment of pain by administering a cold washcloth, finding a warm blanket, or holding a hand? This I saw years ago.

As for Dr. Lansdale himself, when I had the first and only major operation of my life, he appeared unexpectedly in my hospital room on a Sunday morning a couple of days later. In his arms were a container of soup he had made himself and a tiny vase of flowers grown by his wife. Tears filled my eyes after he left because he made me realize that he saw me not just as a broken body but as a human being who loved loveliness and who was on the way back to health.

The ancient Greeks understood that medicine and nursing are arts. They still are. And artists must be given the freedom, time, and chance to follow their best instincts. They deserve our honor and trust.

To the Editor: As a grateful patient of Dr. Lansdale, and as a fortunate, rather healthy soul without medical knowledge and without, up to now, much experience as a hospital inmate, I fully acknowledge that you may well deem me a dubious, uninformed, and even biased commentator on “A medical center is not a hospital.” However, I deeply appreciated Dr. Lansdale’s important essay, and I commend you for publishing it. The conditions he describes contrast dramatically with those of yore.

Dr. Lansdale’s essay took me back many years to the time of my mother’s illness, when medicine was practiced differently, and, as she suffered bravely and eventually died of cancer, I recalled myself watching warily with the keen eyes of a child.

Our experience with Mother’s nurses and doctors was unforgettable, for, in nearly every case, we knew we were dealing with men and women of the profoundest dedication. Mother’s nurses at the Harkness Pavilion of the Columbia-Presbyterian Medical Center treated her (she died the day JFK was elected president) with unbounded tenderness, compassion, and patience.

They moved gracefully, walked quietly in her room, spoke softly but clearly to her, and to me, a girl, they seemed like angels. Nothing was too much; they fluffed her pillows, propped the window to give her fresh air, refrained from rattling or jarring the equipment, and seemed to sense what she was feeling and to provide accordingly. Her care was a kind of devotion, I felt, and there was no sense of rush or artificial curtailment of their responses to her. They always had a kind word for me as well.

And where has this sense of vocation gone? I have no doubt there are still many who enter the health professions with a deep desire to alleviate the suffering of others, but, as Dr. Lansdale’s essay shows, these people are now constrained, limited, and held back. Their care is degraded and seen as a job, a workload. What has happened to the sense of joy in alleviating even a moment of pain by administering a cold washcloth, finding a warm blanket, or holding a hand? This I saw years ago.

As for Dr. Lansdale himself, when I had the first and only major operation of my life, he appeared unexpectedly in my hospital room on a Sunday morning a couple of days later. In his arms were a container of soup he had made himself and a tiny vase of flowers grown by his wife. Tears filled my eyes after he left because he made me realize that he saw me not just as a broken body but as a human being who loved loveliness and who was on the way back to health.

The ancient Greeks understood that medicine and nursing are arts. They still are. And artists must be given the freedom, time, and chance to follow their best instincts. They deserve our honor and trust.

To the Editor: I read with great interest Dr. Davidson’s commentary article¹ about the Ezetimibe and Simvastatin in Hypercholesterolemia Enhances Atherosclerosis Regression (ENHANCE) trial.² However, his conclusion that ezetimibe (Zetia) still has a role as an add-on to statin therapy for patients who have not achieved their low-density lipoprotein cholesterol (LDL-C) target is of great concern to me and my patients. Based on this trial, I have taken many of my patients off of ezetimibe and have wondered if this is the right decision. I also have several physician patients who have told me that ezetimibe causes muscle cramping and other symptoms often found in patients who cannot tolerate statins, and in fact one of these patients was found to have congenital cirrhosis of the liver.

Ezetimibe is mainly active in the GI tract. What relationship does this medication have in those patients who have liver disease, ie, cirrhosis? Is it safe to give ezetimibe to patients who cannot take statins? I doubt it.

Consequently, I agree with Dr. Taylor’s editorial,³ which in essence states unless you are in a clinical trial, beware of ezetimibe!

To the Editor: I read with great interest Dr. Davidson’s commentary article¹ about the Ezetimibe and Simvastatin in Hypercholesterolemia Enhances Atherosclerosis Regression (ENHANCE) trial.² However, his conclusion that ezetimibe (Zetia) still has a role as an add-on to statin therapy for patients who have not achieved their low-density lipoprotein cholesterol (LDL-C) target is of great concern to me and my patients. Based on this trial, I have taken many of my patients off of ezetimibe and have wondered if this is the right decision. I also have several physician patients who have told me that ezetimibe causes muscle cramping and other symptoms often found in patients who cannot tolerate statins, and in fact one of these patients was found to have congenital cirrhosis of the liver.

Ezetimibe is mainly active in the GI tract. What relationship does this medication have in those patients who have liver disease, ie, cirrhosis? Is it safe to give ezetimibe to patients who cannot take statins? I doubt it.

Consequently, I agree with Dr. Taylor’s editorial,³ which in essence states unless you are in a clinical trial, beware of ezetimibe!

To the Editor: I read with great interest Dr. Davidson’s commentary article¹ about the Ezetimibe and Simvastatin in Hypercholesterolemia Enhances Atherosclerosis Regression (ENHANCE) trial.² However, his conclusion that ezetimibe (Zetia) still has a role as an add-on to statin therapy for patients who have not achieved their low-density lipoprotein cholesterol (LDL-C) target is of great concern to me and my patients. Based on this trial, I have taken many of my patients off of ezetimibe and have wondered if this is the right decision. I also have several physician patients who have told me that ezetimibe causes muscle cramping and other symptoms often found in patients who cannot tolerate statins, and in fact one of these patients was found to have congenital cirrhosis of the liver.

Ezetimibe is mainly active in the GI tract. What relationship does this medication have in those patients who have liver disease, ie, cirrhosis? Is it safe to give ezetimibe to patients who cannot take statins? I doubt it.

Consequently, I agree with Dr. Taylor’s editorial,³ which in essence states unless you are in a clinical trial, beware of ezetimibe!

To the Editor: Dr. Davidson concludes his article saying “we should remember [that ezetimibe] is safe and well-tolerated.” Yet, he admits there is a lack of outcomes data for the drug. So, how does he know it is safe if we don’t have the mortality outcomes? The just-published Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) trial indicated that there may be an increase in cancer mortality.¹ The point is that we need more data. Until we have that outcomes data we should not be saying a drug is safe as a matter of fact. Physicians need to learn the lessons we should have learned from drugs such as torcetrapib² or erythropoietin³ and so many others. We often think we are doing a good thing by correcting lab values, but we often learn too late that we harmed the patient at a staggering ethical and financial cost.

Dr. Davidson also references the impressive LDL-C lowering of Senator McCain while taking ezetimibe. Senator McCain has a publicized history of melanoma. Hopefully, ezetimibe doesn’t increase his cancer mortality risk because his physicians are proud of his LDL-C lowering. My advice to the senator is to use one of the many other proven methods of LDL-C lowering until there is good mortality outcome data with ezetimibe (but I’m not a Republican, so he may want to get a second opinion).

To the Editor: Dr. Davidson concludes his article saying “we should remember [that ezetimibe] is safe and well-tolerated.” Yet, he admits there is a lack of outcomes data for the drug. So, how does he know it is safe if we don’t have the mortality outcomes? The just-published Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) trial indicated that there may be an increase in cancer mortality.¹ The point is that we need more data. Until we have that outcomes data we should not be saying a drug is safe as a matter of fact. Physicians need to learn the lessons we should have learned from drugs such as torcetrapib² or erythropoietin³ and so many others. We often think we are doing a good thing by correcting lab values, but we often learn too late that we harmed the patient at a staggering ethical and financial cost.

Dr. Davidson also references the impressive LDL-C lowering of Senator McCain while taking ezetimibe. Senator McCain has a publicized history of melanoma. Hopefully, ezetimibe doesn’t increase his cancer mortality risk because his physicians are proud of his LDL-C lowering. My advice to the senator is to use one of the many other proven methods of LDL-C lowering until there is good mortality outcome data with ezetimibe (but I’m not a Republican, so he may want to get a second opinion).

To the Editor: Dr. Davidson concludes his article saying “we should remember [that ezetimibe] is safe and well-tolerated.” Yet, he admits there is a lack of outcomes data for the drug. So, how does he know it is safe if we don’t have the mortality outcomes? The just-published Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) trial indicated that there may be an increase in cancer mortality.¹ The point is that we need more data. Until we have that outcomes data we should not be saying a drug is safe as a matter of fact. Physicians need to learn the lessons we should have learned from drugs such as torcetrapib² or erythropoietin³ and so many others. We often think we are doing a good thing by correcting lab values, but we often learn too late that we harmed the patient at a staggering ethical and financial cost.

Dr. Davidson also references the impressive LDL-C lowering of Senator McCain while taking ezetimibe. Senator McCain has a publicized history of melanoma. Hopefully, ezetimibe doesn’t increase his cancer mortality risk because his physicians are proud of his LDL-C lowering. My advice to the senator is to use one of the many other proven methods of LDL-C lowering until there is good mortality outcome data with ezetimibe (but I’m not a Republican, so he may want to get a second opinion).