Sunday, January 17, 2010

Our fraying social contract

During his two years as medical staff president, Dr. Dave Halleran used the word “collegiality” in most meetings. "Collegiality,” in his lexicon, reflects a social contract between hospitals and their medical staffs. In recent years, that social contract has been in need of mending.

“Collegiality” refers to that combination of obligation and respect that exists among doctors within their medical groups, within their specialties, and among the departments at the hospitals where they have privileges. That combination is meant to serve patients well, supporting the availability of care as well as care that reflects experience, judgment and skill.

Today it is not uncommon for one or more hospitals in a given community to have gaps in specialty on-call schedules at their emergency rooms. There are not enough available (or willing) physicians to complete the roster. Nor is it unheard of for one specialist to assert it is really another specialist’s duty to respond to a patient’s specific need in this or that hospital at this or that time of the day. On-line educational credits have replaced in-hospital educational meetings for many physicians, and hospital department meetings are both less frequent and less well attended than they were, even ten years ago.

These are examples of a fraying social contract.

The acute care hospital used to be a more essential part of – indeed, the center of – a physician’s professional life. The hospital provided the 24-hour staff and services, the high-tech equipment, and the array of specialists a doctor needed to care for her patients. Today many physicians focus so much of their time in outpatient settings they may never come to the hospital, or rarely so.


Because the things for which patients used to be hospitalized can often be accomplished in the office or in an outpatient setting. Government-driven payment models have tended to reward outpatient and procedure-based care, more so than hospital care. Reductions in payments have encouraged doctors to form larger medical groups, and these groups have developed both the patient base and the capital base to provide outpatient services that were once a big part of the hospital world.

All this means that private doctors are less able – and less willing – to come to hospitals in the middle of the night to take care of an emergency patient they may have never met before. This may be a point of annoyance among medical specialists who may not know each other or, even if they do, whose collegiality may be tested since they haven't seen much of one another for some period of time.

At the medical staff meeting last week, Dr. Halleran, a colon-rectal surgeon, stepped down as staff president and handed the gavel to Dr. Richard Lockwood, a specialist in internal medicine. In his farewell remarks, Dr. Halleran recalled a time “when doctors used to talk about patient care with each other. Today our discussions,” he lamented, “seem to be more about insurance payments or government rules.”

During the meeting, Dr. Halleran paid tribute to his father, once an internist in midtown Manhattan, whom he affectionately called “a real doctor.” He explained that his father “had office hours five and one-half days a week, went to the hospital seven days a week, and still managed to visit patients regularly in their homes.”

Dr. Halleran served as a medical staff president before. About a decade ago, he performed that service for another medical staff where he is a member in good standing, at St. Joseph’s Hospital Health Center. That means Dr. Halleran has demonstrated his medical staff “good citizenship” twice.

You don’t get elected staff president two times and at two different hospitals, unless you are someone special.

Dr. Halleran is.

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