By Noam Scheiber | January 9, 2016
Early in the morning on Aug. 12, 2015, a 68-year-old man named Barry turned up at PeaceHealth Sacred Heart Medical Center in Springfield, Ore., confused and feverish.
The case was not a candidate for even a minor subplot on “House.” The admitting doctor stopped one of the patient’s medications and inserted an IV to deliver fluids, and by late the next morning, he had largely recovered.
Still, Dr. Rajeev Alexander, the hospitalist who took over his care, was determined to make an accurate diagnosis.
For nearly half an hour, Dr. Alexander, a perpetually rumpled man, chatted with Barry and Linda, his sister, about the events that had landed him in the hospital, the food processing plant where he once worked, the stroke that had impaired his mind. “It was a very scary night last night,” Linda, his caretaker, said. “He was just sitting on the floor, like you would sit a 6-month-old when they haven’t got their balance.”
Dr. Alexander considers it proper technique to review each mundane detail with a patient. He is full of scorn for the eureka style of medical diagnosis depicted on television, and by his own admission, he reads a CT scan with the sophistication of a barber.
Eventually, Dr. Alexander would discard the more exotic theories that had crossed his mind — meningitis, or possibly a condition known as serotonin syndrome — and settle on a far simpler malady: dehydration, which aggravated a chronic kidney problem.
He was nonetheless unapologetic about the time he had invested.
“Real life is all about the narrative,” he said. “It’s sitting down and talking about bowel movements with a 79-year-old woman for 45 minutes. It’s not that interesting, but that’s where it happens.”
Dr. Alexander’s method is at the center of an emotional debate in medicine, in which the imperative to increase efficiency in a high-cost health care system is often at odds with the deference traditionally accorded to doctors.
It’s a debate that came home to Sacred Heart in the spring of 2014, when the administration announced it would seek bids to outsource its 36 hospitalists, the hospital doctors who supervise patients’ care, to a management company that would become their employer.
The outsourcing of hospitalists became relatively common in the last decade, driven by a combination of factors. There is the obvious hunger for efficiency gains. But there is also growing pressure on hospitals to measure quality and keep people healthy after they are discharged. This can be a complicated data collection and management challenge that many hospitals, especially smaller ones, are not set up for and that some outsourcing companies excel in.
“They assure you of relief of some headaches,” said Dr. John Nelson, a past president of the Society of Hospital Medicine. He compared outsourcing doctor groups to a management company to hiring a lawn service. “You’re relieved of having to get the mower out. You’re not necessarily assured that you’re happier with your yard.” In recent years, according to the society, 25 to 30 percent of hospitalists have worked for multistate management companies, which also employ doctors in other disciplines, like anesthesiology and emergency medicine.
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Outsourced hospitalists tend to make as much or more money than those that hospitals employ directly, typically in excess of $200,000 a year. But the catch is that their compensation is often tied more directly to the number of patients they see in a day — which the hospitalists at Sacred Heart worried could be as many as 18 or 20, versus the 15 that they and many other hospitalists contend should be the maximum. (Mark Hamm, executive vice president of EmCare, a physician services firm based in Dallas that has no connection to Sacred Heart, said the hospitalists employed by many staffing companies typically see 15 to 18 patients a day, though he said that was true of those who were directly employed by hospitals as well.)
It was the idea that they could end up seeing more patients that prompted outrage among the hospitalists at Sacred Heart, which has two facilities in the area, with a total of nearly 450 beds. “We’re doctors, we’re professionals,” Dr. Alexander said. “Giving me a bonus for seeing two more patients — I’m not sure I should be doing that. It’s not safe.” (A hospital representative said patient safety was “inviolate.”)
Some Sacred Heart hospitalists left for other jobs, and the rest formed a union, one of the first of its kind in the country.
To everyone’s surprise, Sacred Heart’s administration agreed to junk its outsourcing plan, but this retreat did not usher in a love fest. Instead, there has been a long, grinding negotiation with the administration over the proper role of the hospital doctor, which continues to this day.
Dr. Alexander and his colleagues say they are in favor of efficiency gains. It’s the particular way the hospital has interpreted this mandate that has left them feeling demoralized. If you talk to them for long enough, you get the distinct feeling it is not just their jobs that hang in the balance, but the loss of something much less tangible — the ability of doctors everywhere to exercise their professional judgment.
A Job Born of Efficiency
As recently as the mid-1990s, there was no one called a hospitalist. Most doctors would simply scramble from their offices to the hospital when they had to tend to patients there. But the discipline grew rapidly thereafter — to roughly 50,000 hospitalists nationwide in 2015 from about 11,000 in 2003, according to industry estimates.