Sunday, August 12, 2007

Pride and Joy

I hinted at it in my para-previous post: if there are things I can look back on with pride, near the top of the list is my involvement in establishing the surgery center in the clinic for which I worked. It was -- and is -- among the best of the best; and I think I can honestly take credit for some of it.

It was controversial at the time. There were, of course, politics involving the hospital as well as another local center. In fact, that local center was the one I'd been using, and I loved it. I knew that in building our own, we'd be hurting that one, and I felt bad about it. (In fact, I was later told, of all my fellow clinic docs, I was the only one that told them so. Among other things, I wrote them a letter stating the reasons -- purely selfish, at the bottom line -- and that I wished the reality weren't such that we felt we needed to do it. I still went over there frequently to say hello; eventually, we ended up assimilating them and many ended up working there still...) More difficult was convincing the rest of the partners that such a thing made sense. It was a big investment, and, to the non-surgical docs, a huge risk. To me, from the beginning, it was a no-brainer: the only question -- outside consultants to the contrary -- was whether we were thinking big enough. (They thought our design would satisfy our needs for nearly ever; I thought we'd fill it up in a hurry. The aforementioned "assimilation" indicates who was right.)

In several ways, the stars were aligned just right. At a time when physician reimbursement was being cut left and right, there was a trend to encourage outpatient surgery; so facility fees were still paid at a reasonable rate. And it was ideal for those patients who were on a capitated plan (meaning one that paid us a fixed annual amount to care for patients). Also, in my town the two hospitals had recently merged, and for many reasons there was a lot of frustration and dissatisfaction among the nursing staffs of both former entities. While they were being told by administration to shut up and stop complaining, we were hiring with the premise that we wanted the best and needed their input in setting things up. Getting good people was not a problem. At the top of the list was the woman -- let's call her Helen -- who'd headed up one of the former hospital's OR and was the best ever, anywhere: smart, efficient, knowledgeable, a problem-solver, and -- most importantly -- loved like crazy by everyone who worked with her. Fun was a priority with her. In a last-ditch effort to stave off financial collapse, her hospital had, before the merger, summarily axed its longest-tenured, highest paid (and best) nurses; Helen, included.

I can't claim to be the only one, but I trumpeted Helen most loudly and made it clear that hiring her to run the place would be a coup of the highest order. Administration, having held open auditions, had others on their list as well. To my everlasting credit, I (and some others) prevailed. Then, she went about hiring people to set up the various sections: pre-op, OR, recovery. Finding a place where their ideas were welcome, they came.

Meanwhile, our planning committee was addressing nuts-and-bolts issues: number of ORs, size, layout. Colors, even. And here's where I'm most proud: to that point, our clinic had been sort of industrial-efficient. Ugly, in other words. Cheap. The initial plans had a cramped waiting room, and a broom-closet for a staff lounge. I insisted that one of the keys to success for an out-patient center was patient comfort and satisfaction: it needed to provide a better experience than a hospital. Likewise, staff morale was an indispensable ingredient. Having Helen would go a long way; but the lounge is the heart from which the pulse is generated. A comfortable gathering place, with essential appliances and plenty of room for cookies -- that's what it takes.

On my first walk-through, I was floored. Literally. The floors said it all: beautiful patterns in the halls, a carpet in the family area which had soothing tones and elegant style. Our main building had never looked like that. Plus, there was nice lighting, comfortable furniture, elbow room. The ORs were bigger than some at the hospital, equipped with the good stuff. And the staff.... the staff were nothing but smiles and skills. To say the attitude differed there from that of the hospital is to understate titanically. And damn! It was mine! Operating there was heaven: what can we do to make it work for you and your patients? (And here's what you can do to make it work for us...) Patients -- literally without exception -- raved. One after another, they'd come to my office post operatively and say things like, "I never thought I'd say this about surgery, but that was a wonderful experience!" Or, "You have a fabulous staff there..." How great is that? (As a bonus, the wave of success and satisfaction swept over the rest of the clinic, which was steadily re-done in the image of the surgery center.)

Turnover time (the time between the end of one operation and the start of the next) can be the bane of a surgeon's existence. There, it was so fast I had to streamline my routine or I wouldn't have time to dictate, write orders, talk to the next patient and the previous family. In my four-hour blocks, working with the same great people over and over, I could do four gallbladders (with Xray!) or eight hernias. The ENT folk did tonsils by the pound. Every day in the lounge there was another dozen or more patient evaluation forms on the wall, raving. And, of course, pictures of staff pets, families, announcements of a picnic or a party. And food. Deliciously unhealthy food. I always brought cookies.

None of this is truly unique: surgery centers in general have an ethic of excellence and esprit de corps. It's just that this one was "mine," and was as good as it gets. I work in one now, and I like it. But that place... I miss it the most. When I left, I wrote to them that they were "an island of excellence in a sea of despair." At the time, that said it all.

[As an afterthought: it's one of the most amazing changes in the last couple of decades. When I trained, surgery centers didn't exist. When they started, it was very controversial: could or should general anesthesia be done in such a place? What sort of operations? Is it safe -- even ethical -- to send people home after "real" surgery? At first, it was mostly local anesthesia, and small operations. Doing hernias was a big step: when I was an intern, we kept hernia patients in the hospital for three days or more. I caused a stir, in practice, when I started sending them home the day after the operation. And we on the West Coast seemed to lead the pack. While we were doing bigger and bigger operations there, in the Midwest and East, they were still holding back. Now, there's almost no limit, everywhere: gallbladders, hysterectomy, ACL repair. Mastectomy. Lap-band in 400-pounders. Who'da thunk it?]


Lynn Price said...

Sid, this is probably a dumb question, but can you see a time where these full service clinics will take the place of hospitals? Seems to me that hospitals are a creaking dinosaur that is lumbering to keep up.

To be honest, I never knew about full service clinics such as yours and am amazed that you guys do the same types of operations the hospitals do. Hmm...I'm seeing my writer's wheels turning for Book 4's outline.

Buttercup said...

I counted seven different holding areas that I went through during the pre-op stages for day surgery at a large city hospital; at a small surgery center (with one of the best surgeons in the country in this specialty): one. Instead of feeling like a piece of meat on a conveyor belt I felt like a valued guest, and the efficiency must cut down on errors as well. Such a mentality seems to seep into every facet of care. Big city hospital, last observations before GA: being strapped down to a gurney with large belts, felt like that torture scene in "Brazil". Small surgery clinic: kindly nurse leaning in to say "We'll take good care of you." Indeed!

Anonymous said...

Of course, that conveyor belt also insures that, should anything go wrong, there is probably a vascular surgeon around, an anesthesiologist supervising, an on-site SICU and any number of other contingencies. Surgicenters are fine for ACLs and indeed hospitals are probably overkill. But as midlevel responsibilities expand and you get into the grey area of more serious surgery, personally I'd still have those done at a hospital. There are places where they don't even have to have an anesthesiologist on-site, which I am completely uncomfortable with. On the few occasions I've seen patients crump on the table, being able to step back as the anesthesiologist runs in to do his thing is priceless.

Sid Schwab said...

anon: I'm not talking about office surgeries; I'm talking about fully staffed surgical centers, with all the equipment, all the personnel of any OR, especially including anesthesia. And whereas it's true that not every specialty surgeon is on site at any moment, that's also true of any hospital OR at some given moments. The free-standing centers at which I've worked have all, on very rare occasion, had to arrange admission to a hospital. In no case that I've ever seen has that situation led to an untoward outcome because of that fact alone. There are some operations that never will -- and shouldn't -- be done at freestanding centers. Those that can be and are, are every bit as safe as those done in a hospital. And, I'd venture to say, because the staff are always familiar with the procedure being done, one could easily argue that they're more safe. Granted, the ones I've worked at have been the creme de la creme. But I'd say certain things are pretty much universal: especially the highly skilled and familiar staff. It's a beautiful thing.

Lynn: as I said, there are some cases that will always need a hospital setting; often not so much for the operative, but for the post-operative care. But there may well be, in the future, the culmination of the trend towards "centers of excellence," such that certain centers -- in-patient or out -- will be the place where certain procedures will be done, maybe by mandate. It may be good for results and costs; it'll be a hassle in terms of having to travel distances in various directions for various care.

Anonymous said...

Sid: Right, but I've heard of ambulatory surgicenters that are excusively staffed with CRNAs. I would not be comfortable operating in such an environment; I'm a resident so I don't know how prevalent this is out in the Real World.

Sid Schwab said...

anon: Can't say in general. In the ones at which I've worked, when CRNAs are present, there's always an MD on site as well. And, just in case any CRNAs read this: my experience with them has been extremely positive.

rlbates said...

Same here Sid, the outpt surg ctr I work in always has an MD anesth on site (and often in the room). Our CRNA's are great. However, I do know of a few physicians who have "surgery ctrs" in their offices and they do not. It scares me when I hear about some of the things they do in their "offices".

Mitch Keamy said...

This is what happens when good clinicians are put in charge of clinical operations. The navy would never let anybody run a naval base who hadn't commanded a ship; healthcare will not have clinicians running hospitals again until profit is not the primary mission. Good work, Sid, and good post; your pride is well deserved.

tom said...

Lynn; The real reason patients needs to be hospitalized is for nursing care not medical care.

sid has discovered (as have others) that hospitals can not be as efficient as ASC's. Several reasons for this-some good some not so good.

The good, ASC's don't do high level anesthesia risk patients. Generally the patients they do are healthy and quick to wake up from anesthesia-You will se very few 80year olds with emphysema and heart failure in ASC's.
The not so good, in a hospital the needs of the sickest and emrgencies all take priority, meaning non-emergencies wait and wait and ... well you get the picture. by the way nice picture. A final perspective , did you notice how Sid used the works "it's mine"

Sid Schwab said...

tom: what you say is generally true; however, in my current incarnation we do lap band procedures on people with BMIs of 50+ at a free-standing center. Most don't have major comorbidities, however. Those we do in the hospital.

Anonymous said...

Dear Dr. Schwab:

I believe I read that outpatient surgery centres skim off the (well-paying) cream of patients, those who formerly subsidised hospital budgets -- such as the ER that an outpatient centre lacks, such as the trauma team and the hot-standby OR, and so forth.

With EMTALA condemning hospitals to eat the costs of many emergent treatments and many, many, more screenings for non-emergent problems, what will they do? The law forbids them from not treating those who cannot pay (including the healthy 25-year old who prefers to spend on iPhones instead of iNsurance and gets run over by a truck); it also makes no attempt, beyond a rather empty symbol, to provide funding.

Are ASCs killing hospitals?

I would love to read your opinion on this -- I, obviously, see a problem, but I do not really see a solution.

Thank you,
Felix Kasza.

Sid Schwab said...

Felix: Your question is an important one; I'm not sure I have the latest data by which to give it the answer it deserves. In short, I think there's truth to what you say; however, many hospitals run surgical centers, too. The one at which I work now is in fact associated with the hospital next door. The one to which I referred in this post, run by my clinic, took medicare and welfare patients, as well as the uninsured. The latter in most cases worked out some sort of payment plan. It was not common, but not entirely rare, that I'd operate on a patient there and simply write it off. But yes; from the point of view of the clinic it was agreed to as a profitable business. And the hospital wasn't happy about it for that reason, among others. It's a good argument for some form of universal health care, isn't it? I can't cite all the reasons, but the local hospital, after a few years of financial problems, is now in the black. It has its own ambulatory surgery center; it recently opened a very fancy cancer center. So it's finding a way. I suppose that's good. But I wish everyone had care, so hospitals could focus on delivering care, and not finding ways to make profit.

Harry said...

do you think there is a danger that these surgical centres will take the most talented doctors away from more local hospitals?

i mean for elective operations, travelling to these centres would be okay. But emergency surgeries that require the most skilled surgeons (which may be employed in these surgical centres) in close proximity could perhaps have a negative effect?

oh dear i havent worded that very well at all..

Sid Schwab said...

Harry: most surgical centers (ok, centres) are just another place to work; by which I mean, surgeons go there to do some things, and to the hospitals to do others. So in a given community, all the surgeons are there; they just have more than one location at any given moment. Also, at least here in the US, there's a trend toward hospital-based emergency surgeons: surgical hospitalists, traumatologists, whatever you might call them. So if were to come to pass that there'd be "centers of excellence" (as opposed to surgical centers, which, as I'm referring to it, are simply operating rooms separate from hosptials, at which certain operations are performed), it would likely include dedicated trauma centers. In the US, we have such centers (they handle emergency surgery of all kinds, not just trauma) and a system for designation of level of service by which patients are triaged to them. It's a long way from universal, nor is access equal across the country, since there are relatively few "level one" (the highest, with 24 hour in-house surgical teams) centers.

rlbates said...

Our local surgery center insist that you have privedges at one or more of the local hospitals. That way, when an unexpected complication does occur, you can continue to help care for your patiet.

Anonymous said...

Dear Dr. Schwab:

Thank you for your thoughts on hospital survival by adopting the ASC idea for themselves; my favourite orthopaedic surgeon works in such an hospital-affiliated centre.

I was more thinking of inner-city hospitals, which care for a higher-than-average quota of non-paying patients than, say, schwanky Evergreen hospital which sits smack in the middle of all those Microsoft employees.

As for universal healthcare being the solution for this problem, I only have disjoint glimpses on that topic. If healthcare is a scarce resource (and it is), rationing will happen: Either by ability to pay, or by government fiat. Having had experience with both, I prefer the first.

But rationing, either kind, would be less necessary if we all learned (again) that spending half a million to vegetate for three months on a high-dose fentanyl drip, sedated to the gills because of being tubed, and hovering at death's door is not a pleasant way to go. Fentanyl? By all means. But my advance directive states clearly that I want no intubation, no heroic measures.

Perhaps if people started paying for healthcare out of their own pockets again -- perhaps that would lead to a re-evaluation of the value of a few more weeks of pain-ridden existence.


Sid Schwab said...

Felix: I agree with nearly everything you said. I don't have the numbers at my fingertips, but it's a huge percent of the healthcare dollar that's spent in the last three or six months of life. Much of it futile care. As to paying for oneself: I wish it were so, to the extent that many decisions would certainly be made differently. On the other hand, it would widen the gap even further between those that can, and those that can't. And -- the non-economist speaking here -- if care were paid properly for everyone, there might not be such a difference between Evergreen and the inner city hospital. In my posts a couple of weeks back on "my solutions" the need for rationing was clearly stated. Of course the truth is, I have no solution, and no one else seems to, either. It's like the bridges: we wait till they fall down and even then, no one really wants to raise the money to pay to rebuild. I used to think that at least by the time it's a clear crisis our leaders would act. But now, I think not.

Dr. Rob Oliver said...


I'd be interested in your insight on the financial sustainability of ASC's. It sound like you were initially involved with this in a different era from today. As I've heard it explained, there is an increasingly shrinking margin on these facilities profitability (as facility fees are getting lowered progressively) as an investment vehicle. Physicians frequently underestimate the capital expenditures, liability exposure, and oppurtunity costs of these endeavors.

I've listened to lectures from some practice analysts at our national meetings who are really pessimistic on the future of ASC & office surgery suites.

Sid Schwab said...

Rob: I'm sorry to say I really have no personal current knowledge. I know that when we opened ours, it rapidly became a significant revenue source for the clinic. I was never involved in the day to day business, only in the initial planning, and in the regular and professionally pleasurable use of it. But I knew the data in a general way. Having not been involved for the last five + years, I can't say if they're still as profitable as they were. I know they're still extremely busy. One thing that makes it unique is that we were a pretty large clinic, and the surgery center was strictly for the use of clinic docs. That meant there was no need for CON. It also meant we had control over practice behavior, etc, in a way that those that serve a more general population may not. The surgery center that I mentioned as the one at which I first worked before we opened our own ended up in financial difficulty, for reasons I'm not particulary knowledgable about. We took it over eventually. It had been jointly owned by a number of docs and other investors. Our clinic owned ours, and it was not any sort of investment vehicle. How that differs, I have no real idea. My main source of "pride and joy" was in the way in which it functioned: providing superb care which was easily recognized by our patients and the community at large; and allowing me a place to work in which the whole team was always on the same page. It was fun, and as close to perfect as a surgical experience can be!

Anonymous said...

Can medical students or doctors in training participate in these surgical centers?

rlbates said...

At ours (the one I work in, no financial interest, but on the med advisory board) we often have residents from the local medical school (especially gen surg and ortho) who get priviledges as assistants and then come over and "assist" the surgeon they are assigned to with the stipulation that they are not left alone (the surgeon must be there at all times).

Sid Schwab said...

anon and rl: Yeah, and I've often thought it'd be good to see anesthesia residents working there as well (in none of the ones I've used have there been residents/students of any sort, but there's no specific reason why not other than neither associated hospital was a "teaching" one.) The techniques involved in short general anesthesia with rapid turnover, patient coming in and leaving within an hour on either side of the operation aren't often seen in a training program, where a half-hour operation takes four, and waking up bright-eyed is irrelevant... The anesthesia group I'm working with now are nothing short of geniuses; able fully to paralyze and analgese, and then rapidly reverse massively obese people and have them ready to go home an hour later. I don't think they learned that in training!

Anonymous said...

The liability exposure of a well-run ASC is fairly minimal, and is less than that of a typical hospital OR. The primary reason for this is patient selection: ASC patients are generally healthier than those patients with sufficient co-morbidities such that they can only be safely done in a hospital.

As long as an ASC can effectively handle anesthesia and airway emergencies, and has an attentive post-op recovery crew, patient safety should be the equal or better of a typical hospital.

I have been fortunate to avoid surgery as an adult, but should I require general surgery, I would have no qualms in having it done at my local ASC.

The Enormous Clini