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?]