What might surprise us about you or your activities?
For the last 20 years I have been a member of a writing group which meets monthly to hear a paper written by one of the members on a topic of the member’s choosing. I presented the paper below last year. It is very long compared to the other submissions in this collection of Reunion Profiles. I offer it not only as an account of my professional journey but as my perspective of what has been going on in the American medicine over the last 40 years.
Hippocrates Wept
2 June 1970. At Columbia University on the South Field in front of Low Memorial Library, thousands of students from the College and the graduate and professional schools sat in long rows in their heavy graduation robes waiting to receive their diplomas. The ceremony began with the administering of the Oath of Hippocrates to the 127 graduates of the university’s medical school. That the Oath and the medical school graduates would have such a prominent place in the proceedings was quite logical. The growth of the medical profession and the growth of the university, both as institutions in the service of mankind through knowledge and science, had been on a parallel track for centuries. In a sense Medicine was an embodiment of the university’s mission.
I was in that medical school class. The Chancellor of the University read the Oath of Hippocrates line by line and we repeated it responsively from a copy we had been given earlier. I paraphrase:
I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:
I will hold him who has taught me this art as equal to my parents and to live my life in partnership with him…
Whatever houses I may visit, I will come for the benefit of the sick…….
I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.
I will not use the knife… but will withdraw in favor of such men as are engaged in this work.
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, I will keep to myself,….
Finally...If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men…..
It was my intention to uphold this oath.
Training
Two weeks after the graduation ceremony I began my internship at St. Luke’s Hospital which was just around the corner from the university. My view of myself as a physician was simplistic and atomistic. I envisioned my future practice as being comprised of myself, my patients and Hippocrates. I chose internal medicine as opposed to surgery because I thought it was more humanistic. Yet, I did not want to be a generalist. As an undergraduate at Swarthmore I majored in chemistry and the clearly definable physiology of cardiology appealed to me. When I finished my internal medicine training program and completed my military service, I began the Cardiology Fellowship at St. Luke’s in 1975.
Cardiology in the 1970’s was undergoing major changes that were to revolutionize the field. Coronary care units, called CCUs, were coming into being. These were specialized units within the hospital where patients who were in the throes of an acute blockage of a coronary artery could be observed. These units had dedicated electrocardiographic and physiologic monitoring equipment. Life threatening events could be quickly treated and disaster averted.
Another major was an area known as interventional cardiology. Interventional cardiology consisted of placing catheters through arteries and veins into the heart to measure cardiac pressures and to inject radio-opaque dye to image cardiac structures. These procedures took place in a cardiac catheterization laboratory. While cardiac catheterization had been performed for at least a decade, it was most often done in patients with congenital and valvular heart disease and its use was relatively limited. What was new in the 1970’s is that cardiac catheterizion was being used to image coronary arteries. This meant that arteries narrowed by atherosclerosis could be bypassed by surgeons using both arterial and venous grafts. Later, cardiologists were to develop the technique of placing stents to open these arteries, thus avoiding the need for surgery.
At this time permanent cardiac pacemakers were evolving. These were devices that were implanted under the collar bone to take over the pacing function in patients, usually older, whose own pacing apparatus had become dysfunctional with age.
Finally, in cardiac diagnostics, another area was also immerging….noninvasive cardiology. Noninvasive cardiology includes techniques for obtaining information about the cardiovascular system that do not involve putting a catheter into, or invading, the heart. Two powerful modalities appeared. Echocardiography used high frequency sound waves to image the heart much the way sonar can image an object under water. Using echocardiography, the chambers and valves of the heart could be imaged in real time with very high resolution and, using Doppler technology, actual intracardiac pressures could be measured. The other major advance was nuclear cardiology. With this technique a map of coronary blood flow could be obtained and the presence of coronary obstruction detected.
Both echocardiography and nuclear cardiology were just coming into use at St. Luke’s while I was there. I was particularly keen on learning as much as I could about these techniques and, in my second fellowship year, I was asked to create and to be Director of the Noninvasive Laboratory at St. Luke’s at the conclusion of my fellowship. This was flattering and enticing but I wasn’t quite sure how I could square this with Hippocrates.
Earlier in my Fellowship, I had been contacted by an old friend, Russ Fiore, who I had known while I was a resident in medicine and he was a cardiology fellow. While I was in the Army, he had graduated from the program and was in practice in Poughkeepsie, NY. Poughkeepsie was interesting because it was close to New York (and the opera), it had no cardiologist and it had a hospital, St. Francis, that had a Certificate of Need, or CON, for a cardiac catheterization lab. Would I like to visit?
So, one pleasant Saturday in the early fall of 1976, I drove with my wife to Poughkeepsie to spend the week end with the Fiores. Russ, I found, was doing very nicely. He had started CCUs in both of the hospitals in town, St. Francis and Vassar Brothers, including training the CCU nurses to assist in putting in cardiac pressure monitors and temporary pacing wires. He had trained the crews of the ambulance service in town to do emergency cardiac care. He was extremely busy doing hospital consultations and seeing office patients. He had even being putting in permanent pacemakers. He had simply been too busy to use the CON at St Francis to start a catheterization laboratory there much less add the performance of cardiac catheterization to his practice. He needed an associate. Would I think about it? I liked Russ’s offer. I always saw myself as having patients rather than an academic position. Technology aside, isn’t being a physician all about having patients which carries with it the sacred trust that I had sworn to uphold to Apollo and the other Greek gods in front several thousand of my fellow graduates at Columbia just 7 years before? I decided to join Dr. Fiore in the practice of cardiology in the City of Poughkeepsie. As was the practice of the day we set ourselves up as a group and called ourselves Hudson Valley
Cardiovascular Associates, HVCVA.
Early Practice
Initially my practice was the practice that I had envisioned. I was a physician whose professional life did not include anything that was not within the scope of the Hippocratic oath. When I came I had several ideas in mind about my career as a community cardiologist. I had walked away from a perfectly good academic job at a major teaching hospital. Why? My concept of the Hippocratic Oath was that I wanted to be a healer. Academic medicine is not about healing patients, it is about teaching and research. I wanted my career to focus on patients. And yet, I was not sure that was all my career should be. In Hippocrates day, the craft of medicine was stable. The body of knowledge from which one practiced remained without major change for centuries. In the twentieth century hardly a year went by without a major advance taking place, soon the rate of change came to be measured in months. It was quite clear, even in 1977 that the treatment of heart disease would require specialized physicians to properly disseminate this new knowledge.
It was the rapid development of medical knowledge particularly the development of new forms of imaging that gave rise to subspecialty medical practice within the overall rubric of Internal Medicine. Academic medicine programs all of the country began training cardiologists, gastroenterologists, nephrologists, oncologists, pulmonologists and infectious disease specialists. These newly trained specialists soon found their way into community practice and procedures that had hitherto only been done in University hospitals such as cardiac catheterization, renal dialysis, and complex cancer treatment began to be done in communities which did not have a tertiary medical center. This explosion of medical technology created major political problems in the Poughkeepsie medical community as it did in communities all over country. The major difference between HVCVA and the internists in town was that we only addressed our patient’s cardiac problems. Each of our patients was expected to have a primary care physician, usually an internist. This was a novel practice concept at the time and it was not well received most of the internists in town. They considered themselves to be consultants in all areas of adult medicine. They saw my joining Russ as a threat which would undercut their authority as the ultimate community authority in the treatment of heart disease. They saw the services that we were seeking to bring to town as inappropriate for a community hospital. What infuriated them further was that we were not just setting up a practice of cardiology but were establishing Cardiology (with a capital C) as its own specialty in the community. This was a turf/marketing conflict pure and simple.
But where did this fit in with Hippocrates? Actually, the Hippocratic Oath, in its down to earth language, addresses professional development when it says in the first paragraph, “To hold him who has taught me this art as equal to my parents” and goes on to say, “to share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.” This is nothing short of a key foundational component of a profession. We construed the “art” to be Cardiology and the “he who hath taught me this art” to be our cardiology training.
Politics
The internists in town fell into two broad groups. There were the American educated, usually American born, physicians, most of whom had trained at very good university hospitals. Then, there were the usually foreign born and foreign educated internists in who had trained at lesser institutions. Most of our referrals came from this latter group.
The hospital admission practices of the two groups also differed. The American physicians admitted mostly to Vassar, the others admitted mostly to St. Francis. In fact St. Francis was established in the early 20th century by the Sisters of St. Francis to give doctors of ethnic origin a hospital to which they could admit their patients. This was a role Catholic hospitals played at the time when ethnic background automatically excluded a physician from having admitting privileges at most hospitals. In the late 1970’s, however, both hospitals were similar in the services and the quality of care they offered. Yet, for the purposes of the only two cardiologists in town, there were important differences. Vassar Brothers had just hired a group of young radiology attendings from Columbia-Presbyterian to refurbish their out-of-date Radiology Department. This group was essentially a private practice of radiology that did their own billing for interpretive services and, very importantly, had an exclusive contract to perform and read all the imaging studies at Vassar. That meant that it would be impossible for us to develop any a cardiac service at Vassar because we were not permitted to interpret any of the cardiac imaging studies. St. Francis had also hired a radiology group. Theirs was from Albany Medical Center. The St. Francis radiologists were of comparable quality to those at Vassar, but they worked for the Hospital as a salaried Department of Radiology. While the Vassar radiologists were wary of us as a possible threat, the radiologists at St. Francis were actually collegial and wanted to work with us to bring cardiac imaging to the hospital. Before I had even arrived, Russ had worked with them to introduce echocardiography at the hospital and was working to develop nuclear imaging services.
Additionally, the working atmosphere for us was different at the two hospitals. At Vassar, the American internists, who were hostile to us, held sway with the administration and the Board. One of these internists even led a spirited campaign to prevent us from implanting permanent pacemakers. Only after the fair-minded Chairman of the Surgery Department prevailed, did the pacemaker program continue. Meanwhile, the administration at St. Francis was positively welcoming. They had just brought on a new hospital CEO who was energetically trying to upgrade the hospital. He had brought in the above radiology group, and had begun plans for a new patient tower. He wanted to develop specialty medical services. Specialty medical services, such as cardiology, renal disease, gastroenterology, were anathema at Vassar because of the powerful cadre of internists. St. Francis was receptive to our setting up a Cardiac Rehabilitation Program and was particularly interested in bringing a cardiac catheterization laboratory to the hospital.
The Cath War
I had originally come to Poughkeepsie to start a cath lab with Russ. Initially Russ and I had been too busy with the practice to have the time to work on it. Vassar was hostile to us and St Francis was using its political capital to get approval to build the new hospital tower. By the mid1980s, however, we had added more cardiologists and had set up cardiology shop at St. Francis. St. Francis was our logical site for the cath lab for us since were doing all of our cardiac imaging there. And, if a cath lab were sited at Vassar, it wasn’t at all clear that we would be able to use it. St. Francis and HVCVA had common cause to get a cath lab and to get it first.
The 1980’s were a difficult time for hospitals looking to add major clinical services, such as a cath lab. During the Nixon years rising health care expenditures were under greater scrutiny. In the federal government in 1974 established over 200 regionally based Health System Agencies (HSA’s) to be run by boards with consumer majorities to review proposals for new health projects and to submit recommendations for Certificates of Need to the states. The states, meanwhile, were required to pass CON legislation. The CON held by St. Francis had expired and a new application would have to be submitted in what had become a complex and highly political bureaucratic process. A free standing cath lab, i.e., a cath lab in a hospital without an open heart program, was a particularly hard sell.
At this time Vassar was in disarray. It had fired its CEO and had not yet replaced him. Their administration was weak. St Francis had just completed in its new patient tower, the Cooke Pavilion, and was advertising regionally in Newsweek. It was arguably the better hospital in town. I worked with the St. Francis administration to start the cath lab application process. This entailed innumerable meetings with HSA and New York State bureaucrats as well as community leaders and physicians to build our case. We were looking to submit our application by the state mandated deadline, after which no applications would be reviewed for a year. If we submitted before the deadline, and Vassar did not, we would likely get the cath lab. Then, Vassar announced that they had hired a new CEO. I knew of this man. As the Chief Operating Officer of Shady Side Hospital in Pittsburgh, he had just opened a free standing cath lab. Clearly, he would want to do this at Vassar and he was arriving soon. It looked like we were going to be in a shooting war.
The battle was joined as both hospitals fought their way thought the complex NYS/DOH approval process. It went on for a year. In the end, so much community, political, and Archdiocese heat had been brought to bear that the New York State Department of Health and approved a freestanding cath lab in Poughkeepsie. But, because the community support for the location of the facility was so divided, they did not designate which hospital would get it. At a time when regional medical facility planning was the watchword of the day, the DOH left the location of the cardiac cath lab to be decided by the community.
Cath Diplomacy
The decision of the DOH to require a community process to determinate the location of the newly approved cath lab placed the Boards of St. Francis and Vassar Brothers in an interesting position. For years the two hospitals had be extremely competitive and not a little antagonistic toward each other. Now, they were supposed to work in the spirit of community development to decide the location of a service which would put the sited hospital in a market dominating position. The two boards created a working committee made up of five board members from each hospital Board as well as the CEO of each hospital and the President of each hospital’s medical staff. I was, by then, the President of the St. Francis medical staff and served on that committee. The new joint committee hired a consultant/ facilitator to help us make this decision.
It was clear from the outset that the cath lab could not be the only service on the table because, if all other services remained the same for each hospital, the hospital that had to the Cath Lab would become the major hospital in town. The only approach that could work would be one in which several services were in play. The concept of a “medical center without walls” became our model and our working group soon became the first Board of Directors of a new entity—the Mid-Hudson Medical Center in 1989. By 1991 the final plan for the medical center was rolled out. The cath lab would be at Vassar Brothers while orthopedics, trauma, cancer, and psychiatry would be at St. Francis. Vassar started to build the cath lab. In an earlier day that would is the disaster for us because of the exclusive imaging contract that the Vassar radiologists had with the hospital. However, by then, “the cardiologists” as represented by myself, had been so involved in the process of acquiring and siting the lab and had such a commanding market position in cardiology, that it was unthinkable that we would not be able to perform cardiac catheterization in the new lab. We had essentially outflanked the internists to establish ourselves as a Cardiology Section at Vassar. As it turns out, in all the years that had passed since Russ and I had come to Poughkeepsie we had not been performing any cardiac catheterizations. We, therefore, recruited into our group a recently trained cardiologist to actually perform the catheterizations. So sixteen years after I came to Poughkeepsie to join Russ Fiore to start a cath lab, we now had one and the irony was that neither Russ nor I would never perform a single catheterization.
Expansion
By then, HVCVA was 5 cardiologists. We knew we wanted to grow, but how? To give us a plan for our growth, we turned to a national consulting firm, J. O. Goodman & Associates, which advised cardiology practices and hospitals in developing their cardiology markets. John Goodman, in the first Bush administration, was chairing the Republican National Health Care Issues Committee, formulating alternatives for national healthcare reform. Then, under the Clinton Administration, he was on the Health Care Financing Administration’s (HCFA’s) Technical Advisory Panel. He and his partner, Conrad Vernon, had written several books on strategic planning for Cardiology services.
Conrad Vernon had his first visit with us in 1990. He was a good ol’ Texan who had grown up in Lubbock and, in an earlier life, had been a guitarist in Buddy Holly’s band. He had scoped out our potential market area which included 3 counties with over a half a million people. He knew the age and income demographics. He knew the population growth statistics. He knew the driving times between strategic points. He made himself knowledgeable about the area hospitals and the lines of tertiary referral. What he told us then has shaped our strategic vision to this day. The bedrock of his assessment was that our area was extremely underserved by cardiology services compared with comparable demographic areas across the country. We could triple the number of cardiologists in our practice and still not be at the national average. He said we need more doctors, more space, more territory. We needed to be comprehensive in our services. We needed to further develop our relationship with the hospitals. Most importantly, we needed a brand.
Brand. With more doctors and an expanding market, we needed to create a market identity. At that moment we were only five cardiologists. . We did business as Hudson Valley Cardiovascular Associates. This name seemed to be too technical and limited. We needed name that was more expansive. We chose the name Hudson Valley Heart Center, which eventually became known as The Heart Center.
Comprehensive. When Conrad first visited us, it was clear that there would be a cath lab at Vassar Brothers, as noted above, and, eventually, an open heart surgery program. We were building strong ties with administration at Vassar and it was certain that would be participating fully in any cardiology services they developed. But, until then, there was still plenty we could do. We were still doing all of our imaging at St. Francis Hospital. That would include nuclear imaging and echocardiographic imaging. Those services had to be brought into our practice so that it could be part of our brand and under our control. Our brand had to include the full range of Cardiology diagnostic and therapeutic products that would be offered by a University Department of Cardiology. When the cath lab and opened heart program were in place, we would be able to offer the same cardiology services done at a University Hospital short of cardiac transplantation.
Growth. The In order to create the patient volume to make these services profitable, we needed more cardiologists. For more cardiologists we needed more space. The space issue had two components. We needed more space in Poughkeepsie for are cardiology and our equipment but we also needed to expand into other markets. With more territory we had more patients in our practice. This was important not only to provide volume for the services our practice offered, but to create volume for the Cath Lab and open heart surgery program at Vassar Brothers.
Conquest
By 1994 the Heart Center had gotten to the point where we were ready to look to new territory. Newburgh, a small city 15 miles south of Poughkeepsie, appeared to be the logical choice. It was relatively close, and, although it had two cardiology groups, the area was rapidly growing and the two groups did not have our sophistication. We decided rather than just set up an office and rotate doctors through it, which was the common approach, we would have just one of our cardiologists be the Newburgh cardiologist who would establish relationships with the Newburgh physicians and admit to the Newburgh hospitals. The cath saga behind us, I became a logical person to head the Newburgh campaign and I started commuting to Newburgh. I spent several months gathering information about the medical community. I learned that the doctors in Newburgh were suspicious of the Heart Center seeing us as an agent of Vassar Brothers looking to take patients out of the Newburgh community….suspicious to the point of paranoia. The community was sharply divided along ethnic lines with most of the physicians foreign born and trained at inferior institutions. A small group of the better trained American physicians, mostly specialists, were happy to see us come, hoping that our presence would raise standards and help to break up the provinciality of the medical community.
The environment in Newburgh was hostile and things were slow initially. I spent a lot of time in the doctors’ lounge reading the New York Times and taking doctors out to dinner. Eventually I started getting consults from some of the less paranoid doctors. I referred patients to Newburgh doctors. The practice started to gain a decent market share. It took two years. In spite of the success, the situation called for a Heart Center cardiologist to actually live in Newburgh in order to grow the practice to its full potential. Jon Portelli joined us in 1996 and I was able to return home.
Our expansion into Newburgh was a pivotal evolution for the Heart Center. It defined us as, not just a community cardiology practice but as a regional resource which, with Vassar Brothers, could establish dominance in cardiology services in the Hudson Valley.
Peace Time
When I returned from Newburgh in 1997, I thought that for the first time in 20 years, patient care would have 100% of my focus. I was honored at the1997 Vassar Gala. This honor is usually awarded to a physician at the end of his career for making a contribution to community health care, usually because of his clinical excellence. For me, however, I sensed the honor was for the cath lab which was an asset for the community and for Newburgh which was an asset for Vassar Brothers. But I thought Hippocrates was trying to tell me something. Enough of this practice building and market positioning. The essence of the Hippocratic oath is that the physician/patient encounter is for the benefit of the patient….to cure him if possible and to prevent further harm from befalling him. But I rationalized. Surely my patients benefit from having a cath lab and a community medical center as a regional center of excellence. And, besides, when I was with my patients I was with them and thinking only of them. So I continued to engage in extra patient care activities.
I took on the clinical operations for the Heart Center. This included developing all the protocols involved in patient care from how patients were scheduled to how our doctors were deployed in the hospital. It was an exercise in consensus building and it was a thankless job. I instituted computerized imaging report generation. This was received better as it saved time and tedium. Practice marketing also came under my purview, an activity which most of our doctors regarded as a waste of money.
By 1999 our patient census in the hospital was very high and was becoming unmanageable. We had three physicians in the hospital, each with their own service. It was looking that we were going to have to take more physicians out of the office to cover our hospitalized patients. I started a mid-level program to free up our cardiologists. We stated with one nurse practitioner. We now have 10. Another issue: Keeping track of which patients were on which service and billing for their services was a major headache. I worked with Vassar Brothers IT to develop a web based Portal to perform these functions. Additionally the Portal could be used to review hospital patients’ laboratory data and imaging results online. At that time, this was a big deal. Later, we added a bulletin board function linked to each patient so that our doctors could sign out to each other. Later the hospital emulated our system to develop a Hospitalist program.
By now Hippocrates was starting to get a little annoyed, but he could not really say anything, because, nothing I was doing was impacting my own doctor patient interaction. I hadn’t yet crossed the line…yet.
The Electronic Medical Record
By 2007, the American Recovery and Reinvestment Act was being discussed in Congress. This law would provide incentives for doctors to use electronic health record systems in their practices and to require doctors to report quality-related measures to Medicare. After 2015, physicians who failed to do so would face financial penalties. With my role in developing the Vassar Portal and computer generated imaging reports in the office, I was the obvious choice to implement an EHR at the Heart Center. I became what was called the Champion for the computerization of the practice. Truthfully, I had been anticipating this role for years and relished the thought of it. There was great excitement (mostly from me) about choosing our medical records software and setting up the infrastructure within the practice to support it. We actually set up an IT Department. We traveled to Burlington, VT to learn how to use the new EHR. We setup the practice workflows to exploit it. We trained the clinical staff and the doctors in its use. We planned its roll out. The EMR came into the Heart Center without major glitches. We had no breakdowns. We had no interruption in patient care. We lost no data. We had good interoperability between the health record part of the product and the financial/scheduling part. For a project of this complexity, it went extremely smoothly.
In spite of all this, it gradually became clear that we were not dealing with an EHR whose fundamental purpose was to help us take care of our patients. To schedule patients? Yes. To document points for coding services? Yes. To attach diagnosis to support billing levels? Yes. To organize clinical information in a useful way and to enable us to communicate with each other and our referring physicians? Not nearly as well. There didn’t seem a way for us get the EHR to do what we needed it to do clinically. At first, we thought we were not aware of all the program’s features, but as we dealt will the EHR support people, it became evident that the program wasn’t designed with clinical care in mind. It was designed to help the insurance companies and the government manage us.
Other Distractions
When Medicare was enacted in the mid 1960’s physician fees were generous in order to assure physician participation. Medicare paid for physician services using "usual, customary and reasonable" rate-setting. By the 1980’s the costs of medical care were skyrocketing and physician fees were seen to be a component of this increased cost. The Omnibus Budget Reconciliation Act of 1989 enacted a Medicare fee schedule, and by 2010 about 7,000 distinct physician services were listed and designated a Relative Value Unit or RVU. The RVU is a composite of physician time spent, skill required, and complexity of the medical problem. With the emergence of the EHR, the submitted charges based on RVUs could be more closely scrutinized. This put further pressure on the office visit. While most of the visits in a subspecialty practice are of high complexity, documenting that all of a patient’s problems have been considered during a visit added time to the creation of the visit note, which took time away from interacting with the patient. All of this just to make sure we were being paid for the work we were doing.
Closely related in the fragmentation of the patient visit was the implementation of quality assurance methodology at the Heart Center. An EHR can facilitate documentation of patient care quality for a practice or an individual physician. It can create reports showing, for example, what percentage of patients with a certain diagnosis code are getting certain guideline mandated medications. The Heart Center used this methodology to win the Bridges to Excellence Award from the American College of Cardiology in 2012, one of only 12 practices in the country to do so. We did this not only because we delivered quality care, but, more importantly, because we were able to document it. Although this kind of recognition improved the Heart Center’s market position, the documenting for each patient was time and attention consuming.
So, although the EHR was helping us to perform certain practice functions, it was not helping us, and, in fact, was a distraction, to patient care. Between EHR deficiencies and RVU and Quality Assurance documentation, seeing a patient in the context of the EHR, became like driving a car while playing checkers simultaneously. Hippocrates was sad. But he was to get even sadder.
HealthQuest
By 2010 the Heart Center had grown to 24 cardiologists and 10 Midlevels operating in three counties. We provided university level noninvasive diagnostic imaging, interventional cardiology and electrophysiology services. We had a first rate practice management and staff. We had national recognition as a cardiology practice of excellence. Yet, we did not believe that we were fully ready for the future. It was our belief that the future would see reconfiguration private and government payment for medical care from the care of disease in an individual to the promotion of health for the community, from payments to individual providers (that would be hospitals and physicians) for each incident of care for patients with chronic illnesses, to payment to an organization for the management of the chronic disease for all of its patients over time. Central to this new order is not providers but systems. These new systems are currently known as Accountable Care Organizations. These organizations require strong vertical integration to be successful. Care of cardiac patients, for example, requires not just proper hospital care but strong outpatient services to keep patients with heart disease out of the hospital and thereby make health care more affordable. It also means keeping people from developing clinical atherosclerosis in first place.
Over the last 15 years as the Heart Center was abuilding, three of our local hospitals, of which Vassar Brothers was by far the largest and offered the most comprehensive services, were joined into a health care system call HealthQuest. The hospitals within HealthQuest are highly integrated with a single administrative structure. The fit between the Heart Center and HealthQuest was clear and an association between the two almost inevitable.
While the affiliation of the Heart Center with HealthQuest will likely provide cardiac care at less cost down the road, it puts the physicians in the Heart Center in a different position. They will still be charged with the development and implementation of cardiology services, but the doctors will no longer own their practice. This has a subtle effect on patient care because the doctors are no longer working for the patient, they are working for the system and, with that, the covenant between the patient and the physician is broken. To make matters worse the physicians within HealthQuest are paid according to the number of patients seen because that is the way HealthQuest is paid. This has meant that the number of patients seen per day has markedly increased. This has placed an even greater burden on our patient encounters.
What We Have Become
As I reflect on my years as a physician I have seen the Heart Center become emblematic of major trends in American medicine over the last thirty five years. I have seen the Heart Center bring cutting edge technologies into the community. I have seen the Heart Center make possible the dissemination of advanced clinical practice to our region. I have seen the Heart Center become part of a system which is going to become the model for healthcare delivery in the future. For much of this I have been a major participant. I should be proud, and, on a certain level, I guess I am. But on another level I am sad and frightened. The focus of the patient encounter has changed. The patient is no longer the object of the encounter. Proper coding, quality assurance, utilization management, and, with becoming part of HealthQuest, productivity concerns rob time and attention from the patient. The patient visit is no longer focused on the patient’s needs but the requirements of the system. I am not longer the patient’s physician. I am an agent of an organization which provides physician-like services.
…
I went out for coffee the other day with Hippocrates. I described for him how technology, economics, and politics had shaped medicine into the direction that it is going to take. He understood this, but then he said, “You know, this is the end of medicine as a profession” and he began to weep.
