More on the doctor shortage

I recently wrote about the growing shortage of physicians.

Dr. David Duggan of SUNY Upstate Medical University has brought to my attention documentation about the physician workforce shortage at the website of the Association of American Medical Colleges (AAMC). From the website:

Given the extended time required to increase U.S. medical school capacity, and to educate and train physicians, the nation must begin now to increase medical school and GME [Graduate Medical Education] capacity to meet the needs of the nation in 2015 and beyond.

The AAMC website includes Recent Studies and Reports on Physician Shortages in the U.S., a 10-page paper that identifies studies across the nation that document the physician shortage – from Arizona (“Still far below the national average”) to Wisconsin (“Who will care for our patients?”).

Worthy honorees

In about two weeks the Community General Foundation will honor a number of people for service to Central New York: Dr. Drew Merritt, the Auxiliary to Community General Hospital, and Local #43 of the IBEW.

The honors will be given at the Foundation’s annual gala, October 26, at the OnCenter in Syracuse. The gala’s theme is “Diamonds and Denim,” which seems to have left many people wondering just exactly what to wear. Blue jeans are OK, and I’ve heard people will wear “washed black denim” too. Western gear is fine – as, of course, are diamonds or otherwise sparkly things. The bottom line: attendance at the gala does not require formal attire.

In fact, informality is a hallmark of the annual gala. And that means the evening’s presentations are mercifully short too. The emphasis is on raising money for a good cause by dining, dancing, and enjoying the company of friends. Tickets are still available. Just call 492- 5079.

For service to profession, Dr. Merritt
Dr. Merritt, pictured below, will be honored for his service to the medical profession. He is a past president of the Community General Hospital Medical Staff who recently served as interim Vice President of Medical Affairs and Chief Medical Officer.

Dr. Merritt is Vice-Chair of the Department of Family Practice, a member and past president of the New York State Chapter of the American Academy of Family Physicians (AAFP), a member and past president of the Onondaga County Medical Society, and a member of the Medical Society of the State of New York (MSSNY), where he serves as chair of MSSNY Committee on Health Care, is an alternate delegate to national AAFP, and serves on the AAFP Commission on Practice Enhancement.

Beyond his roles in medicine, Dr. Merritt has served the community as a member of several organizations affiliated with the Town of Marcellus and as a coach for youth sports. He and his wife, Carol (who is also being honored), have three daughters - all of whom were born at Community General Hospital.

For service to hospital, the Auxiliary
The Auxiliary will be honored for 45 years of service to CGH. An important part of the hospital, the Auxiliary helps raise funds and provides community services. Since inception, the Auxiliary has donated over $2 million to the hospital, designating funds to such items as renovations to the Surgery Center, the Jim and DeDe Walsh Family Birth Center, and medical equipment in various patient care services.

The Auxiliary provides blood pressure screenings throughout the community and advocates for health care issues in Albany.

The group photo shows members of the Auxiliary’s Executive Committee, from left: Ted Topalian; Mary Lascaris; Carol Merritt, outgoing President; Kay Cudworth; Dottie DeSimone, incoming President; and Claire Wightman. Not shown are committee members Bernie Schmidt and Donald White. CGH is a very family-oriented place, and isn’t it fitting that both Drew and Carol Merritt will be honored on the same evening?

For service to community, IBEW Local #43
Being honored for service to community is the International Brotherhood of Electrical Workers, IBEW Local #43. Chartered in 1896, the union represents some 1,200 members, including quality electricians in Central New York. In the photo are Don Morgan, Local #43’s President, and Bill Towsley, its Business Manger.
The local chapter contributes to the Community General Foundation’s capital campaign that provides funds for capital projects such as the physical medicine & rehabilitation unit, the Jim & DeDe Family Birth Center, and the cardiac catheterization lab. Local #43 also supports the Foundation’s annual pro-am golf tournament as “presenting sponsor” for the past five years. Beyond its support of CGH, Local #43 assists numerous charitable causes throughout Central New York, with members regularly taking part in local fund raisers and volunteer work.

These are good people who have accomplished much for good causes. Please join me in saluting these worthy honorees.

An image of beauty and peace

Tom Watson is a photographer from Skaneateles, NY, who uses satellite image technology to take beautiful, sweeping panoramic photographs. A few months ago, he spent time in Community General Hospital when a loved one was hospitalized here, and he noticed a poster of an Ansel Adams photograph on Four North, across from room 456.

As Mr. Watson explained to me:

My wife, Sue, and I spent the afternoon at the beginning of my career with Ansel Adams and his wife, Virginia. His work has inspired me, his books have taught me and if he were alive today, I believe he would be working in the same (digital) technology that I do now.

Mr. Watson has donated one of his own digital photographs to the Four North waiting area, across from the public elevators. “I hope that it will also bring comfort to others attending their loved ones at CGH,” he said.

On my rounds this morning, I visited Four North and studied Mr. Watson’s five-by-two-foot print of Hesperis Matronalis,[1] shown above. When the illumination is complete and a plaque in place, we will have a small ceremony to acknowledge Mr. Watson’s generosity.

I am no expert on photography, but I know that Ansel Adams was remarkable as an artist, not just for his eye, which captured the grandeur of nature, but for his technique, which combined in a single photograph richly evocative shadows and brilliant highlights.

“We have digital image tools that Mr. Adams never imagined, but would wholeheartedly embrace. He was an artist and a technician,” explains Tom Watson in IATH Best Practices Guide to Digital Panoramic Photography[2]

Mr. Watson uses those digital tools to create his own detail-rich photos that capture the dynamics of light, dark, and color. When you are on Four North, take a moment to study the texture of the tree bark in Mr. Watson’s photograph. Then examine the colors of the lilacs, the sunlight on the tree leaves, and the shadows of the woods.

A smaller, signed print of Hesperis Matronalis is being offered as a premium gift to all who make donations of $250 or more in this fall’s Circle of Friends campaign, being conducted by the Community General Foundation. Other examples of Mr. Watson’s high-definition digital images may be seen in articles about him in Wired and AIArchitect.

Thank you, Tom Watson, for the gift of your art, which brings to our clinical world an image of beauty and peace.

- - - -

[1] Tom Watson explains: “This photograph, Hesperis Matronalis, represents 4 trips and 8 hours standing behind the camera waiting for the optimum conditions. I produced at least 20 different image files to then narrow my selection to this one image. This continuous panorama (no stitching) could only be produced with a view camera and a scanning, 144 mega pixel digital back.”

[2] In IATH Best Practices Guide to Digital Panoramic Photography, see section 2.5 and find the text written by Tom Watson. Go to Figure 6, a panoramic view of the Academical Village at the University of Virginia. By repeatedly clicking on the image, you zoom in to discover the many people present, each one very much an individual.

State funds will help compliance with Berger Commission

This morning’s Post Standard reports the allocation of $12.8 million of New York State HEAL NY funds for Community General Hospital and Van Duyn Home and Hospital. These funds will be used to comply with the requirements of the Berger Commission. I’ve written before about the Berger Commission.

The funds are necessary because the Berger Commission requires the affiliation of CGH and Van Duyn. These changes are part of a larger state plan affecting 74 institutions – the closure of nine hospitals and seven nursing homes, plus changes in the affiliations or bed configurations of another 48 hospitals and 14 nursing homes.

The state’s decision to fund changes at CGH and Van Duyn comes after many months of dialogue between CGH and Onondaga County, the operator of Van Duyn. County Executive Nick Pirro and his staff fought diligently for the affiliation scenario called “A,” under which the County would continue to own and operate Van Duyn. Scenario “B” would have involved the more complex and more costly process of transferring the ownership of Van Duyn to CGH. Both Onondaga County and the Civil Service Employees Association (CSEA) sued New York State to prevent such a change in ownership.

Our discussions with the County have been straightforward and cordial throughout this process. We have also had a number of discussions with the state, and these too have been helpful. The state remained noncommittal about scenarios “A” and “B” until about 5:00 p.m. last Friday, September 28, when it faxed the announcement of its grant allocation to the County and to CGH.

Although the state has not formally accepted scenario “A,” the funds it has allocated are based on the costs identified for “A” – so “A” appears to be the de facto decision of the state. Here is a summary of what the scenario “A” affiliation involves:

1. CGH and Onondaga County will create a new not-for-profit corporation, called the Onondaga Hill Corporation (OHC) to conduct strategic planning for CGH and Van Duyn. The OHC’s plans are intended to create operating efficiencies, to improve organizational effectiveness, and to develop a more integrated continuum of care on the CGH-Van Duyn medical campus.
2. Van Duyn will remain a county-owned facility, subject to OHC planning activity. CGH will remain a private, not-for-profit organization with its planning also subject to the OHC. Both CGH and Onondaga County will appoint OHC directors, with CGH designating the majority of them.
3. CGH and the County will decertify a total 63 long term care beds. Van Duyn will decertify 13 beds, and Community General will ultimately close its 50-bed skilled nursing facility, converting that space into fully renovated acute hospital capacity. After these changes, there will remain 513 long term care beds on the campus, all of them at Van Duyn. (The Berger Commission did not require any change in CGH’s licensed 306 acute care beds.)

The state funds will reimburse Onondaga County and CGH for the legal and planning costs incurred in complying with the Berger Commission. The funds will also cover the transition costs involved in closing CGH’s 50-bed long term care unit, they will fund the planning work of the OHC, and they will fund facility renovations at both CGH and Van Duyn that are consistent with the Berger Report.

Changes for nursing home residents can be disruptive and stressful. That means we need careful plans for the closure of CGH’s sixth floor skilled nursing unit. These plans have yet to be developed, and they too will be subject to approval by the State Health Department. We are committed to assuring that transitions for residents and their families are fair and respectful.

Of CGH’s 1,200 employees, about 50 will be affected by the closing of the sixth floor long term care beds. These employees may be eligible for positions elsewhere in the hospital, and we expect some may transition to Van Duyn or other community long-term care facilities. We will do our best to communicate fully with employees and to work with SEIU1199 in assuring fair and respectful transition opportunities.

You’ll notice I’ve used the word “allocation,” not “award,” in describing the HEAL NY funds. That’s because there are a number of steps to be completed before the state money is actually awarded and paid. These steps include state approval of a work plan and the sign-off by the Office of Comptroller, among other things.

The state’s decision to fund compliance comes 10 months after the Commission issued its report. It is a necessary step. It is a positive step. But it isn’t the end of the process – only the beginning.

Our survey by the Joint Commission

Yesterday the Joint Commission re-accredited Community General Hospital for a full three-year term.

The preliminary award of accreditation was announced at the summation conference for senior management, following a three-day unannounced site visit that involved four surveyors. The re-accreditation is subject to review and finalization by the Joint Commission over the next week.

The review was detailed, and the surveyors identified a number of areas for CGH to make improvements – some of these are requirements for improvement (RFIs) for which we have 45 days to make changes that are acceptable to the Joint Commission. Other changes, called supplemental recommendations, are intended to improve CGH performance even further.

CGH received nine RFIs. Improvements are required in the provision of care, namely better documentation involving pain management and conscious sedation. We need to do better in two national patient safety goals: better medication labeling in the operating room and better measurement of the time frames involving critical test value reporting. Other RFIs involve a change in the Medical Staff’s policy on awarding temporary privileges to physicians in emergency situations and improvement in the signing of verbal orders by physicians. The remaining requirements involve the routine testing of the emergency generator and repairs and safety improvements in the physical plant.

We take the Joint Commission’s RFIs seriously, as we do the supplemental recommendations. We have already begun to make the changes needed.

The surveyors followed a “tracer” methodology. They identified patients at random, reviewed their charts, and traced the progress of their care. They interviewed the patients, spoke with their caregivers, and examined documentation and policies specific to the individual patient and the caregivers. The surveyors visited many areas of the hospital, including off-site departments. Noteworthy were comments they made about CGH employees: “bright,” “very knowledgeable,” “willing to listen,” and “not afraid to explain.” They also challenged us to be more consistent in our processes with comments such as “mandatory,” “not acceptable,” and “inconsistent” to describe areas where we need to improve.

I sincerely appreciate the attention and respect afforded the surveyors by the CGH family, but most of all I thank employees and managers for the preparation, competence, and professionalism they bring to patient care every day.

The surveyors noted with interest our preparations for computerized physician order entry (CPOE), which will be rolled out at CGH next year. They said the introduction of CPOE, electronic medical records and other information technology in the coming years should help improve our processes, further lower the risk of error, and avoid some of the documentation issues that were encountered.

I thank members of the Board of Directors and Medical Staff who participated in the Joint Commission leadership conference: Steve Infanti and Chet Amond, current and past Board chairs; as well as Drs. David Halleran, Thomas Hartzheim, Andrew Merritt, and Howard Weinstein, representing Medical Staff leadership. I appreciate the assistance of Mary Kinneman, interim Chief Nursing Officer, who helped the Nursing Division and the management team improve standards compliance and survey readiness. Dr. Fred Goldberg, new in his role as Chief Medical Officer, was helpful in this survey. Thanks also to Brendan McGrath, interim Vice President – Operations.

I especially acknowledge the staff of the Quality Department, which helps the entire hospital monitor and maintain compliance with our policies and with the Joint Commission standards, particularly Sally Ramsden, Director of Quality and Education, and Wendy Tarby, Director of Performance Improvement.

Last month CGH was honored as one of the Thomson Top 100 Performance Improvement Leaders among the nation’s hospitals. This demonstrated our progress in recent years in reducing mortality, improving patient safety, improving length of stay performance, as well as other measures. Maintaining Joint Commission accreditation is further evidence that Community General Hospital provides quality and safe care for our patients – and that we are committed to making ongoing improvements.

Thank you all, and congratulations.

The firmament

Earlier this year the Medical Staff, with the help of the Auxiliary, began a recognition award for doctors who bring to their medical practices particularly human qualities. They demonstrate sensitivity, thoughtfulness, appreciation and respect – STAR is the acronym.

What do the medical STARs do? They play chess with nursing home residents. They treat others as equals. They have a rapport with their nursing colleagues.

Last March the STAR honor went to Joseph T. Barry, MD, a chess player who, if he loses a game, buys pizza for the residents. I wrote about Dr. Barry’s honor recently. An internist specializing in geriatric medicine, Dr. Barry is in private practice with Preventive Medicine Associates, PLLC, Camillus, NY. He is also the medical director of Community General Hospital’s sixth floor skilled nursing facility and the Iroquois Nursing Home, located in Jamesville, NY.

Dr. Barry “sets aside time to play chess with multiple residents” at Community General where his “genuine humor and lighthearted challenge to residents has created a splash of excitement.”[1] Dr. Barry is also “a man of the people” who is “always approachable” and who “totally immerses himself in medical problems from the patient’s perspective.”

Daniel L. Dombroski, MD, who received the STAR award in June, is a general surgeon who “treats everyone as his equal and has the ability to make the patients and staff members feel like they matter.” To him “the patient’s feelings and needs are just as important as their medical condition.”

Dr. Dombroski maintains a private practice in Physicians Office Building – North on the CGH campus. He participates in the hospital’s Wound Care Management Center, and he was honored by LeMoyne College in 2001with its Distinguished Alumni Award.

The September STAR honor went to James Watts, MD, an internist with “a wonderful bedside manner,” who has “a great rapport with nurses and other staff.” Dr. Watts is “always willing to go out of his way to help” and is considered by the staff on Three West to be “a breath of fresh air during a stressful day.”

Dr. Watts is in private practice with the FamilyCare Medical Group PC, which has more than 20 locations throughout the Syracuse area. Dr. Watts’ office is in Physicians Office Building – North. He is Co-chairman of the Medical Records Committee.

Being kind and respectful is not merely good citizenship. These are the attributes of individuals who build positive relationships with other members of the caring team. This can aid communications at all levels. Better communications help reduce risks for patients – and reduced risks mean better patient safety. Being a pleasant person is good medicine too.

If you want to acknowledge another STAR within our medical staff, pick up a nomination form in the Medical Affairs office (first floor, west wing) and in other locations throughout the hospital. You can also find a copy on the hospital’s intranet – go to CGHNet, find “Forms” in the drop-down menu and click on “Physician STAR Award.”


[1] All quotes are from the nominating forms submitted about the physicians by members of the CGH family.

Hospital mortality rates

A wry pathologist once explained to me the reason for post mortem examinations. “Patients die,” he said, “for one of two reasons – patient failure or doctor failure. We ought to know which.”

Today we understand that many factors contribute to hospital outcomes. It is not just what a doctor orders or what a doctor does. Hospital outcomes are affected by the doctor working with the entire caring team, as well as by the effectiveness of hospital processes and support systems. Hospitals are complex places.

Last June the federal government's Hospital Compare website began reporting risk-adjusted 30-day mortality data for hospital heart patients.[1] The government’s report shows that 98.5% and 99.5% of all hospitals treating heart attacks and heart failure, respectively, had mortality rates that were consistent with the national rates.[2] Community General and the other Syracuse hospitals were all within the mortality rate mainstream of the nation’s hospitals.

The government’s website does not show hospital-specific mortality rates, and this lack of detail has been criticized by some. USA Today said that, by not listing hospital-specific death rates, the government’s web page “leaves 98% of the hospitals in the USA statistically indistinguishable from one another.” The newspaper also quoted a source at the Robert Wood Johnson Foundation as saying, “I would want to know if my hospital has higher death rates than the hospital across town.”

But others worry that mortality rates, even after statistical risk-adjustment, do not capture underlying differences that may be affected by patients’ own decision-making, particularly the end-of-life decisions made by the sickest patients. The authors of a recent article in the Journal of the American Medical Association (JAMA) suggest that the public reporting of hospital mortality rates might actually encourage the “overly aggressive treatment” of patients in their final weeks of life at the expense of effective pain control.

Several years ago, an insurance company published misleading mortality data about the pneumonia patients cared for at Community General Hospital. As reported, the pneumonia patients’ mortality was significantly higher at CGH than at other area hospitals. After investigation, we determined that the company did not take into account patients’ advance directives.[3] An examination of the records of the patients found that that 90% of the pneumonia patients who died had a DNR order.[4] In other words, most of the pneumonia deaths occurred among patients who had decided they did not want extraordinary measures used to prolong their lives. Of the non-DNR pneumonia patients cared for at CGH, the death rate was less than one percent. I discussed this situation in 2005.

Interestingly, JAMA reports that the federal government will likely add the mortality rates of pneumonia patients to its website in the future. According to the commentary in JAMA:

“Mortality is a good quality measure for individuals with acute illness who are not supposed to die…However, mortality is a poor quality measure for the majority of patients with multiple chronic diseases who are near the end of their life, and may be engaged in…decisions that result in an earlier (or less delayed) death.”

Hospital report cards are good things, and they will improve over time. As patients and families learn to use these report cards, they will become more informed about differences among hospitals – as well as about limitations of the report cards themselves.


[1] Risk-adjustment is a complex statistical process that takes into account differences in the complexity of patient conditions and differences in hospital service programs so that the mortality rates are, in fact, comparable among hospitals.
[2] The data reflect patients discharged from hospitals from October 2005 through September 2006.
[3] Advance directives are the written instructions patients give to doctors and hospitals that specify the care the patients want to receive (or don’t want to deceive) in the event they cannot make future medical decisions for themselves.
[4] DNR (“do not resuscitate”) is one form of advance directive.

To the nursing shortage, add doctors

Most people are familiar with the nursing shortage. But there’s another health care story that deserves our attention – the growing shortage of doctors.

Retiring doctors often are unable to find replacements for themselves, especially when they are in solo practice. Sobering facts: 28% of New York’s doctors are in solo practice, and 34% of the state’s doctors are over age 55[1], meaning their retirement is in the foreseeable future.

Why do retiring doctors have a hard time finding younger physicians to replace them?

For one thing, finding a replacement doctor costs money (advertising, travel, and recruitment firm, not to mention the new doctor’s salary). Many practices operate on tight margins, and money spent on recruitment has to come directly out of the budget for staff salaries, including the doctor’s own.

New doctors often come into practice burdened with high debt from their medical schooling. They need a decent income quickly, and they cannot afford to wait, gradually building their patient base over several years as in the “good old days.”

Another concern, physicians need coverage. New physicians need to join a coverage group immediately – that is, a set of doctors who agree to cover the new doctor’s patients on a scheduled basis after office hours and on weekends. Every physician needs such coverage, and those who fail to get it cannot practice indefinitely with self-coverage. No one can work (or be on call) 24 hours a day, seven days a week.

Some parts of the country – those with booming economies or year-round pleasant weather – have advantages when recruiting doctors, just as they do when recruiting engineers or other professionals. Although Central New York's rolling hills, clear lakes, and four seasons are beautiful, its slow-growth economy does not add to its charm.

“At a time when the aging baby boomer population finds itself in need of more medical services,” reported the New York Times recently, “fewer young doctors want to work in many of the distressed cities and towns throughout New York State.”

Add to these complications, a doctor supply problem. In a recent Post-Standard op-ed article, Dr. David Smith, President of SUNY Upstate Medical University, wrote that “too many of the doctors now in training are not choosing the most needed specialties. Primary care physicians, general surgeons, and obstetricians are in high demand.”

And, according to the Wall Street Journal,

[p]rimary-care doctors, including internists, family physicians, and pediatricians are in short supply across the country. Their numbers dropped 6% relative to the general population from 2001 to 2005….The proportion of third-year internal medicine residents choosing to practice primary care fell to 20% in 2005, from 54% in 1998.

Why are fewer doctors going into primary care? Money. The median income of primary care doctors is about 45% below that of specialists, according to the Journal. Remember, doctors have to pay off those medical school loans, which can amount to hundreds of thousands of dollars.

Last year's report by the Center for Health Workforce Studies shows the supply of primary care doctors in Central New York at 64.4 per 100,000 population. That compares with 76.0 per 100,000, the median ratio among all regions of the state. The report also shows that CNY’s physician supply lags other regions in such specialties as pediatricians, neurologists, infectious disease, psychiatry, and others. Although CNY has 2.7 endocrinologists per 100,000 population (which is slightly better than the 2.2 median for all state regions), a recent story reported that several endocrinologists are leaving Syracuse.

If the nursing shortage is a major problem, the doctor shortage is not far behind.


[1] Armstrong DP and Forte GJ. Annual New York Physician Workforce Profile, 2006 Edition. Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany. December 2006.

Another 'not guilty' in New Orleans

The owners of a New Orleans nursing home, who were on trial for the negligent homicide of 35 nursing home residents in the aftermath of Hurricane Katrina, were found not guilty Friday (September 7) after a mere four hours of jury deliberation.

According to a report in the New York Times:

[The] theory of the hurricane’s destruction — that it resulted mostly from government ineptitude and inaction — is fervently adhered to by many in New Orleans, and apparently in the state’s interior as well, as evidenced by Friday’s swift verdict.

I wrote about this case on August 9.

Labor Day

Labor Day has been celebrated since the 1880s. The first Labor Day parade was held by the Knights of Labor in New York City, and Congress made Labor Day a national holiday in 1894.

This Labor Day, September 3, Community General Hospital will be caring for patients. Many members of the CGH family will honor this holiday, as they do each year, by working.

Ours is not easy work. It is always exacting work. And what we do benefits society in the most fundamental ways: helping maintain and improve a patient’s function, bringing into the world new human life, easing another’s pain, caring for patients with dignity in their last hours or days.

Thank you, members of the CGH family, whose labor helps others every day... including Labor Day.