Hospital Medicine

Let's not retreat

To the Editor: It would be rare to find a physician who has witnessed the changes in the last several decades of medicine who does not share many of the sentiments and observations of Dr. Lansdale. The key to a solution lies in examining a very telling phrase of Dr. Lansdale: “retreating to the privacy of clinical medicine.”

We are living in an era of unprecedented opportunity for physicians to lead us to new levels of care by combining molecular and population levels of understanding of disease and health that will greatly dwarf the many public health victories of the mid-20th century. We need the deep and careful clinical descriptions of individual patients to inform genetic and molecular understanding. But we also need every practicing physician linked to wider improvement of both rare and common diseases through research registries and through practice-level and population strategies. We need various specialties to link efforts around patients rather than to retreat into their own intellectual and economic silos. We need to reclaim leadership stature by putting ourselves in service of solving the heath care crisis rather than retreating to the privacy of clinical medicine…

…The problem is that as the focus of medical care and medical education naturally and inevitably widened beyond the hospital, we have not developed the infrastructures to support this broadened approach. One of the fundamental ingredients to begin building this infrastructure is the community orientation of physicians. Let us not lament the great community spirit of the training hospital environment of old. Instead, let us translate it to the larger medical community beyond the confines of the hospital.

Let's not retreat

To the Editor: It would be rare to find a physician who has witnessed the changes in the last several decades of medicine who does not share many of the sentiments and observations of Dr. Lansdale. The key to a solution lies in examining a very telling phrase of Dr. Lansdale: “retreating to the privacy of clinical medicine.”

We are living in an era of unprecedented opportunity for physicians to lead us to new levels of care by combining molecular and population levels of understanding of disease and health that will greatly dwarf the many public health victories of the mid-20th century. We need the deep and careful clinical descriptions of individual patients to inform genetic and molecular understanding. But we also need every practicing physician linked to wider improvement of both rare and common diseases through research registries and through practice-level and population strategies. We need various specialties to link efforts around patients rather than to retreat into their own intellectual and economic silos. We need to reclaim leadership stature by putting ourselves in service of solving the heath care crisis rather than retreating to the privacy of clinical medicine…

…The problem is that as the focus of medical care and medical education naturally and inevitably widened beyond the hospital, we have not developed the infrastructures to support this broadened approach. One of the fundamental ingredients to begin building this infrastructure is the community orientation of physicians. Let us not lament the great community spirit of the training hospital environment of old. Instead, let us translate it to the larger medical community beyond the confines of the hospital.

Let's not retreat

To the Editor: It would be rare to find a physician who has witnessed the changes in the last several decades of medicine who does not share many of the sentiments and observations of Dr. Lansdale. The key to a solution lies in examining a very telling phrase of Dr. Lansdale: “retreating to the privacy of clinical medicine.”

We are living in an era of unprecedented opportunity for physicians to lead us to new levels of care by combining molecular and population levels of understanding of disease and health that will greatly dwarf the many public health victories of the mid-20th century. We need the deep and careful clinical descriptions of individual patients to inform genetic and molecular understanding. But we also need every practicing physician linked to wider improvement of both rare and common diseases through research registries and through practice-level and population strategies. We need various specialties to link efforts around patients rather than to retreat into their own intellectual and economic silos. We need to reclaim leadership stature by putting ourselves in service of solving the heath care crisis rather than retreating to the privacy of clinical medicine…

…The problem is that as the focus of medical care and medical education naturally and inevitably widened beyond the hospital, we have not developed the infrastructures to support this broadened approach. One of the fundamental ingredients to begin building this infrastructure is the community orientation of physicians. Let us not lament the great community spirit of the training hospital environment of old. Instead, let us translate it to the larger medical community beyond the confines of the hospital.

The perfect is the enemy of the good

To the Editor: My initial impression is sadness—sad that a dedicated physician should feel this way about his career. I’m not an internist, but rather a cardiac and transplant pathologist and member of the editorial board of the Cleveland Clinic Journal of Medicine and recently retired from Cleveland Clinic. Two days ago, at a social event, a grandmother approached me and told me with pride that her son was doing well in pre-med and was interested in oncology. She asked for my thoughts. I told her that I had had a great career, that I thought medicine was terrific, always stimulating and exciting, as well as demanding, and that I was well compensated. I still feel that way. I sympathize with Dr. Lansdale but wish he had taken to heart the message from Future Shock, ie, that the current rate of change is far faster than it has ever been, and that the rate of change is constantly accelerating…

…I’d like to end with another thought: the perfect is the enemy of the good. I found medicine to be a great career, and I’m afraid that too many physicians are dissatisfied because it isn’t perfect.

The perfect is the enemy of the good

To the Editor: My initial impression is sadness—sad that a dedicated physician should feel this way about his career. I’m not an internist, but rather a cardiac and transplant pathologist and member of the editorial board of the Cleveland Clinic Journal of Medicine and recently retired from Cleveland Clinic. Two days ago, at a social event, a grandmother approached me and told me with pride that her son was doing well in pre-med and was interested in oncology. She asked for my thoughts. I told her that I had had a great career, that I thought medicine was terrific, always stimulating and exciting, as well as demanding, and that I was well compensated. I still feel that way. I sympathize with Dr. Lansdale but wish he had taken to heart the message from Future Shock, ie, that the current rate of change is far faster than it has ever been, and that the rate of change is constantly accelerating…

…I’d like to end with another thought: the perfect is the enemy of the good. I found medicine to be a great career, and I’m afraid that too many physicians are dissatisfied because it isn’t perfect.

The perfect is the enemy of the good

To the Editor: My initial impression is sadness—sad that a dedicated physician should feel this way about his career. I’m not an internist, but rather a cardiac and transplant pathologist and member of the editorial board of the Cleveland Clinic Journal of Medicine and recently retired from Cleveland Clinic. Two days ago, at a social event, a grandmother approached me and told me with pride that her son was doing well in pre-med and was interested in oncology. She asked for my thoughts. I told her that I had had a great career, that I thought medicine was terrific, always stimulating and exciting, as well as demanding, and that I was well compensated. I still feel that way. I sympathize with Dr. Lansdale but wish he had taken to heart the message from Future Shock, ie, that the current rate of change is far faster than it has ever been, and that the rate of change is constantly accelerating…

…I’d like to end with another thought: the perfect is the enemy of the good. I found medicine to be a great career, and I’m afraid that too many physicians are dissatisfied because it isn’t perfect.

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.

Dr. Thomas Lansdale’s commentary in the September issue (Cleve Clin J Med 2008; 75:618–622) resonated with many physicians because he so eloquently captured the increasing frustration many physicians feel:

• Frustration at the loss of a hospital culture that many of us loved;
• Frustration at the increasing challenges of providing effective medical care;
• Frustration with the increasing difficulty of providing outstanding education to future generations of physicians;
• Frustration at the escalating pressure to increase productivity and efficiency, shorten length of stay, reduce cost, improve quality, and enhance patient safety and satisfaction, all at the same time;
• Frustration at the nursing shortage and the need for more and more paperwork that takes physicians and nurses away from the bedside;
• Frustration with the ascendancy of third-party payers who dictate reimbursement and deny payment for care that is often necessary; and
• Frustration with hospital administrators who themselves are struggling to maintain the viability of our institutions at a time of escalating financial stress in health care.

Not all change has been for the worse

I trained in the same era as Dr. Lansdale and Dr. Brian Mandell (editor of CCJM), though at a different institution. Dr. Lansdale perfectly captured the ethos of the hospitals where I worked. Those were the days when house officers and nurses were in it together and bonded, when “everybody knew everybody,” when house staff and nurses ran patient care, and when we kept patients in the hospital for as long as we deemed necessary and got reimbursed for it. Those were also the days (before Libby Zion) when attending oversight was sometimes marginal (attending rounds happened on the wards three times a week for 45–60 minutes), when 36-hour shifts without sleep were common, when hospital-acquired infections were felt to be the cost of doing business and were not tracked (let alone prevented), when quality and patient safety were not articulated as drivers, when medication errors weren’t on the radar screen, when professionalism was not a core competency and we jokingly referred to some patients as “gomers,” when patient satisfaction didn’t matter, and when answering a question that came up on rounds required a trip to the library to sort through textbooks and journals in the stacks, rather than a few minutes on the computer. A lot has changed in hospitals and health care over the last 30 years, and not all of it for the worse.

I have been in medical leadership positions for the past 16 years, as a division chief for 10 and as a chair of medicine for the past 6. Maybe I’ve been lucky, but I have worked at institutions where there has been a commitment to medical education and to quality and patient safety. My current institution has quality as the dominant strategic goal, and we have tried to put our money where our mouth is. Hospital administrators and physician leaders are remarkably aligned in support of this goal, and we have won numerous national awards for the quality of our care. Educational innovation is another institutional strategic goal, which we have supported with hard money to fund teaching time for our faculty. Despite these commitments, physicians in our community share many of the frustrations articulated by Dr. Lansdale. Even at institutions with physician and hospital leadership aligned around goals of importance to doctors, these are tough times.

In the editorial that accompanied Dr. Lansdale’s commentary, Dr. Mandell asked not just for complaints, but for ideas and potential solutions. Here are a few, none of them an easy or quick fix.

• Never in the history of medicine has physician leadership been so important. We need more physicians in senior leadership positions at health care institutions and hospitals. Physician leaders need to better collaborate with and influence hospital leaders to accomplish the goals we care about. We also need to recognize the very real stresses that hospital administrators face and to work with them as partners rather than adversaries. Similarly, hospital administrators need to partner with and not marginalize physicians.
• Physicians and physician leaders need to accept and manage change. Doctors don’t like change, but we need to better influence it to the advantage of our patients, our profession, and the next generation of physicians we train. As an example, Dr. Lansdale correctly laments poor hand hygiene practices. We as physicians are often the worst offenders. If physicians don’t drive adoption of this simple but vitally important practice, who should?
• We need to re-engineer care in hospitals to drive it back to the bedside. This means developing multidisciplinary-team care that is patient- and family-centered. Technology needs to be used to support rather than impede that care. For example, as Dr. Lansdale noted, physician order entry and computerized software that provides medication alerts will not prevent all errors, but will prevent some. Physician leaders must partner with others in their organizations to develop systems that prevent the administration of the wrong medications to the wrong patients, such as positive patient identification.
• For those of us at teaching hospitals, we as physician leaders must protect the educational and academic missions and convince our colleagues in hospital administration of the vital importance of doing so. For teaching, this means finding money to fund faculty time.
• We also need to develop innovative educational strategies that enhance the education of medical students, residents, fellows, and nurses in this era of declining hospital length of stay, where providers see only a very short segment of a patient’s entire illness. This will require redesigning residency and medical student curricula to include shorter alternating block schedules of inpatient and outpatient time that enable residents and students to follow their patients after hospitalization through the continuum of care. We need to employ simulation technology to teach students and residents technical and critical thinking skills.
• We also need to embed quality measurement and improvement, patient safety, and the development of teamwork skills into our medical school and residency curricula. These are vital skills for the future.
• For better and worse, hospital medicine is likely here to stay. The system has many advantages but some disadvantages, mainly related to the lack of nuanced knowledge about new patients and the issue of handoffs. We need to devise seamless and standardized systems that optimize communication and patient safety at admission, during hospitalization, and through the continuum of care.
• We need to be far more aggressive at challenging denials from third-party payers for care that is appropriate. That said, we as physicians and physician leaders also need to look for ways to provide more efficient and effective care. This means constantly re-examining our practices. Our patients and insurers have every right to expect quality, and we have an obligation to provide it. In turn, third-party payers have an obligation to pay for it, and not just with paltry quality incentives whose true goal sometimes appears to be to deny payment and reduce overall reimbursement.

Medicine is still a great profession

My oldest daughter, Sarah, is a third-year medical student at another institution and is now completing her last core clerkship. She chose to apply to medical school after working for several years after college. My wife and I, both physicians, were silent about a career in medicine until she ultimately asked our opinion. Despite the many challenges outlined by Dr. Lansdale, we encouraged her. Medicine is still a great profession where, despite our challenges, one can wake up every day and make a contribution to peoples’ lives. I talk with Sarah each evening. For her, the excitement of the hospital is no different than what Dr. Lansdale and I experienced 30 years ago.

For me, the most discouraging thing about Dr. Lansdale’s commentary is its conclusion. I do not know Dr. Lansdale personally, but I know of him. He has the reputation of being a superb clinician and teacher. It’s disappointing that he has hung up the cleats. We desperately need people like Dr. Lansdale in the game because it is far more than a game. If we as physicians and physician leaders don’t solve the problems we face, who will?

Times are tough, but I’m still a hospital guy.

Dr. Thomas Lansdale’s commentary in the September issue (Cleve Clin J Med 2008; 75:618–622) resonated with many physicians because he so eloquently captured the increasing frustration many physicians feel:

• Frustration at the loss of a hospital culture that many of us loved;
• Frustration at the increasing challenges of providing effective medical care;
• Frustration with the increasing difficulty of providing outstanding education to future generations of physicians;
• Frustration at the escalating pressure to increase productivity and efficiency, shorten length of stay, reduce cost, improve quality, and enhance patient safety and satisfaction, all at the same time;
• Frustration at the nursing shortage and the need for more and more paperwork that takes physicians and nurses away from the bedside;
• Frustration with the ascendancy of third-party payers who dictate reimbursement and deny payment for care that is often necessary; and
• Frustration with hospital administrators who themselves are struggling to maintain the viability of our institutions at a time of escalating financial stress in health care.

Not all change has been for the worse

I trained in the same era as Dr. Lansdale and Dr. Brian Mandell (editor of CCJM), though at a different institution. Dr. Lansdale perfectly captured the ethos of the hospitals where I worked. Those were the days when house officers and nurses were in it together and bonded, when “everybody knew everybody,” when house staff and nurses ran patient care, and when we kept patients in the hospital for as long as we deemed necessary and got reimbursed for it. Those were also the days (before Libby Zion) when attending oversight was sometimes marginal (attending rounds happened on the wards three times a week for 45–60 minutes), when 36-hour shifts without sleep were common, when hospital-acquired infections were felt to be the cost of doing business and were not tracked (let alone prevented), when quality and patient safety were not articulated as drivers, when medication errors weren’t on the radar screen, when professionalism was not a core competency and we jokingly referred to some patients as “gomers,” when patient satisfaction didn’t matter, and when answering a question that came up on rounds required a trip to the library to sort through textbooks and journals in the stacks, rather than a few minutes on the computer. A lot has changed in hospitals and health care over the last 30 years, and not all of it for the worse.

I have been in medical leadership positions for the past 16 years, as a division chief for 10 and as a chair of medicine for the past 6. Maybe I’ve been lucky, but I have worked at institutions where there has been a commitment to medical education and to quality and patient safety. My current institution has quality as the dominant strategic goal, and we have tried to put our money where our mouth is. Hospital administrators and physician leaders are remarkably aligned in support of this goal, and we have won numerous national awards for the quality of our care. Educational innovation is another institutional strategic goal, which we have supported with hard money to fund teaching time for our faculty. Despite these commitments, physicians in our community share many of the frustrations articulated by Dr. Lansdale. Even at institutions with physician and hospital leadership aligned around goals of importance to doctors, these are tough times.

In the editorial that accompanied Dr. Lansdale’s commentary, Dr. Mandell asked not just for complaints, but for ideas and potential solutions. Here are a few, none of them an easy or quick fix.

• Never in the history of medicine has physician leadership been so important. We need more physicians in senior leadership positions at health care institutions and hospitals. Physician leaders need to better collaborate with and influence hospital leaders to accomplish the goals we care about. We also need to recognize the very real stresses that hospital administrators face and to work with them as partners rather than adversaries. Similarly, hospital administrators need to partner with and not marginalize physicians.
• Physicians and physician leaders need to accept and manage change. Doctors don’t like change, but we need to better influence it to the advantage of our patients, our profession, and the next generation of physicians we train. As an example, Dr. Lansdale correctly laments poor hand hygiene practices. We as physicians are often the worst offenders. If physicians don’t drive adoption of this simple but vitally important practice, who should?
• We need to re-engineer care in hospitals to drive it back to the bedside. This means developing multidisciplinary-team care that is patient- and family-centered. Technology needs to be used to support rather than impede that care. For example, as Dr. Lansdale noted, physician order entry and computerized software that provides medication alerts will not prevent all errors, but will prevent some. Physician leaders must partner with others in their organizations to develop systems that prevent the administration of the wrong medications to the wrong patients, such as positive patient identification.
• For those of us at teaching hospitals, we as physician leaders must protect the educational and academic missions and convince our colleagues in hospital administration of the vital importance of doing so. For teaching, this means finding money to fund faculty time.
• We also need to develop innovative educational strategies that enhance the education of medical students, residents, fellows, and nurses in this era of declining hospital length of stay, where providers see only a very short segment of a patient’s entire illness. This will require redesigning residency and medical student curricula to include shorter alternating block schedules of inpatient and outpatient time that enable residents and students to follow their patients after hospitalization through the continuum of care. We need to employ simulation technology to teach students and residents technical and critical thinking skills.
• We also need to embed quality measurement and improvement, patient safety, and the development of teamwork skills into our medical school and residency curricula. These are vital skills for the future.
• For better and worse, hospital medicine is likely here to stay. The system has many advantages but some disadvantages, mainly related to the lack of nuanced knowledge about new patients and the issue of handoffs. We need to devise seamless and standardized systems that optimize communication and patient safety at admission, during hospitalization, and through the continuum of care.
• We need to be far more aggressive at challenging denials from third-party payers for care that is appropriate. That said, we as physicians and physician leaders also need to look for ways to provide more efficient and effective care. This means constantly re-examining our practices. Our patients and insurers have every right to expect quality, and we have an obligation to provide it. In turn, third-party payers have an obligation to pay for it, and not just with paltry quality incentives whose true goal sometimes appears to be to deny payment and reduce overall reimbursement.

Medicine is still a great profession

My oldest daughter, Sarah, is a third-year medical student at another institution and is now completing her last core clerkship. She chose to apply to medical school after working for several years after college. My wife and I, both physicians, were silent about a career in medicine until she ultimately asked our opinion. Despite the many challenges outlined by Dr. Lansdale, we encouraged her. Medicine is still a great profession where, despite our challenges, one can wake up every day and make a contribution to peoples’ lives. I talk with Sarah each evening. For her, the excitement of the hospital is no different than what Dr. Lansdale and I experienced 30 years ago.

For me, the most discouraging thing about Dr. Lansdale’s commentary is its conclusion. I do not know Dr. Lansdale personally, but I know of him. He has the reputation of being a superb clinician and teacher. It’s disappointing that he has hung up the cleats. We desperately need people like Dr. Lansdale in the game because it is far more than a game. If we as physicians and physician leaders don’t solve the problems we face, who will?

Times are tough, but I’m still a hospital guy.

Dr. Thomas Lansdale’s commentary in the September issue (Cleve Clin J Med 2008; 75:618–622) resonated with many physicians because he so eloquently captured the increasing frustration many physicians feel:

• Frustration at the loss of a hospital culture that many of us loved;
• Frustration at the increasing challenges of providing effective medical care;
• Frustration with the increasing difficulty of providing outstanding education to future generations of physicians;
• Frustration at the escalating pressure to increase productivity and efficiency, shorten length of stay, reduce cost, improve quality, and enhance patient safety and satisfaction, all at the same time;
• Frustration at the nursing shortage and the need for more and more paperwork that takes physicians and nurses away from the bedside;
• Frustration with the ascendancy of third-party payers who dictate reimbursement and deny payment for care that is often necessary; and
• Frustration with hospital administrators who themselves are struggling to maintain the viability of our institutions at a time of escalating financial stress in health care.

Not all change has been for the worse

I trained in the same era as Dr. Lansdale and Dr. Brian Mandell (editor of CCJM), though at a different institution. Dr. Lansdale perfectly captured the ethos of the hospitals where I worked. Those were the days when house officers and nurses were in it together and bonded, when “everybody knew everybody,” when house staff and nurses ran patient care, and when we kept patients in the hospital for as long as we deemed necessary and got reimbursed for it. Those were also the days (before Libby Zion) when attending oversight was sometimes marginal (attending rounds happened on the wards three times a week for 45–60 minutes), when 36-hour shifts without sleep were common, when hospital-acquired infections were felt to be the cost of doing business and were not tracked (let alone prevented), when quality and patient safety were not articulated as drivers, when medication errors weren’t on the radar screen, when professionalism was not a core competency and we jokingly referred to some patients as “gomers,” when patient satisfaction didn’t matter, and when answering a question that came up on rounds required a trip to the library to sort through textbooks and journals in the stacks, rather than a few minutes on the computer. A lot has changed in hospitals and health care over the last 30 years, and not all of it for the worse.

I have been in medical leadership positions for the past 16 years, as a division chief for 10 and as a chair of medicine for the past 6. Maybe I’ve been lucky, but I have worked at institutions where there has been a commitment to medical education and to quality and patient safety. My current institution has quality as the dominant strategic goal, and we have tried to put our money where our mouth is. Hospital administrators and physician leaders are remarkably aligned in support of this goal, and we have won numerous national awards for the quality of our care. Educational innovation is another institutional strategic goal, which we have supported with hard money to fund teaching time for our faculty. Despite these commitments, physicians in our community share many of the frustrations articulated by Dr. Lansdale. Even at institutions with physician and hospital leadership aligned around goals of importance to doctors, these are tough times.

In the editorial that accompanied Dr. Lansdale’s commentary, Dr. Mandell asked not just for complaints, but for ideas and potential solutions. Here are a few, none of them an easy or quick fix.

• Never in the history of medicine has physician leadership been so important. We need more physicians in senior leadership positions at health care institutions and hospitals. Physician leaders need to better collaborate with and influence hospital leaders to accomplish the goals we care about. We also need to recognize the very real stresses that hospital administrators face and to work with them as partners rather than adversaries. Similarly, hospital administrators need to partner with and not marginalize physicians.
• Physicians and physician leaders need to accept and manage change. Doctors don’t like change, but we need to better influence it to the advantage of our patients, our profession, and the next generation of physicians we train. As an example, Dr. Lansdale correctly laments poor hand hygiene practices. We as physicians are often the worst offenders. If physicians don’t drive adoption of this simple but vitally important practice, who should?
• We need to re-engineer care in hospitals to drive it back to the bedside. This means developing multidisciplinary-team care that is patient- and family-centered. Technology needs to be used to support rather than impede that care. For example, as Dr. Lansdale noted, physician order entry and computerized software that provides medication alerts will not prevent all errors, but will prevent some. Physician leaders must partner with others in their organizations to develop systems that prevent the administration of the wrong medications to the wrong patients, such as positive patient identification.
• For those of us at teaching hospitals, we as physician leaders must protect the educational and academic missions and convince our colleagues in hospital administration of the vital importance of doing so. For teaching, this means finding money to fund faculty time.
• We also need to develop innovative educational strategies that enhance the education of medical students, residents, fellows, and nurses in this era of declining hospital length of stay, where providers see only a very short segment of a patient’s entire illness. This will require redesigning residency and medical student curricula to include shorter alternating block schedules of inpatient and outpatient time that enable residents and students to follow their patients after hospitalization through the continuum of care. We need to employ simulation technology to teach students and residents technical and critical thinking skills.
• We also need to embed quality measurement and improvement, patient safety, and the development of teamwork skills into our medical school and residency curricula. These are vital skills for the future.
• For better and worse, hospital medicine is likely here to stay. The system has many advantages but some disadvantages, mainly related to the lack of nuanced knowledge about new patients and the issue of handoffs. We need to devise seamless and standardized systems that optimize communication and patient safety at admission, during hospitalization, and through the continuum of care.
• We need to be far more aggressive at challenging denials from third-party payers for care that is appropriate. That said, we as physicians and physician leaders also need to look for ways to provide more efficient and effective care. This means constantly re-examining our practices. Our patients and insurers have every right to expect quality, and we have an obligation to provide it. In turn, third-party payers have an obligation to pay for it, and not just with paltry quality incentives whose true goal sometimes appears to be to deny payment and reduce overall reimbursement.

Medicine is still a great profession

My oldest daughter, Sarah, is a third-year medical student at another institution and is now completing her last core clerkship. She chose to apply to medical school after working for several years after college. My wife and I, both physicians, were silent about a career in medicine until she ultimately asked our opinion. Despite the many challenges outlined by Dr. Lansdale, we encouraged her. Medicine is still a great profession where, despite our challenges, one can wake up every day and make a contribution to peoples’ lives. I talk with Sarah each evening. For her, the excitement of the hospital is no different than what Dr. Lansdale and I experienced 30 years ago.

For me, the most discouraging thing about Dr. Lansdale’s commentary is its conclusion. I do not know Dr. Lansdale personally, but I know of him. He has the reputation of being a superb clinician and teacher. It’s disappointing that he has hung up the cleats. We desperately need people like Dr. Lansdale in the game because it is far more than a game. If we as physicians and physician leaders don’t solve the problems we face, who will?

Times are tough, but I’m still a hospital guy.