Posts etiquetados ‘Hospital Management’

I recently read a wonderful article in the New Yorker which is a very poignant reminder of our values in health care. Many health care professionals start out with high ideals and a deep desire to help every patient. However, unfortunately this often quickly dissolves into disillusionment, cynicism and in an isolated hospital/clinical environment into ignorance of the real underlying problem and needs.

Ask any doctor about their worst or “heart-sink” patients and they will easily identify the frequent flyers, the poorly controlled diabetics that visit the ER every other week, the ones that don’t take control of their physical illness – often those with social issues and little social support.

In the isolated world inside a hospital it is all to easy for management and health care staff to focus on the numbers, the physical illness, the test results, the hospital outcomes and performance in terms of mortality and discharge rates. But without leaving our comfortable safety net of the hospital indicators and biomedical medicine we can not understand nor identify the actual underlying problems and make a difference to those patients that need it the most. And ironically, those patients we are treating inadequately and dismissing as frequent flyers are costing us the most.

Sometimes the more cost-effective solution to a patients poorly controlled diabetes is not frequent readjustments to their medication, frequent admissions due to decompensation but linking them in with social workers and community support to assist with obtaining adequate housing, understanding their medication and autocontrol of their illness and improving social support.

To quote Gawande in the New Yorker – Lower Costs and Better Care for Neediest Patients

… You might decide to increase his insulin dose and change his blood-pressure medicine. But you wouldn’t grasp what the real problem was until you walked up the cracked concrete steps of the two-story brownstone where he lives with his mother…

Gawande further develops his argument by saying that

…“Emergency-room visits and hospital admissions should be considered failures of  the health-care system until proven otherwise,” he told me—failures of  prevention and of timely, effective care….

This last statement is slightly provocative and thought-provoking, but has an element of truth. There is much scope for preventative measures and health promotion. Social and community issues are vital parts of an individuals and community health and should not be forgotten. Although arguably we can shift responsibility for this from the hospital to primary care medicine or public health. We can and should be using the ER admissions and re-admissions as indicators of areas of need in the community and identify social and health needs of a community. In treating each patient we need to remember the importance of the psychosocial factors influencing their health.  And ultimately in economic and managerial terms it may be beneficial for a hospital identify problem areas and to invest in their catchment zone – either directly or indirectly.

We need to get out of our doctors office and reconnect with our community. We should try to identify and understand the underlying issues of our patients remembering that the solution to a health problem may be better solved from a social context,

and ignoring this is costing us more.

— MT —


Doctors as Managers????

Publicado: 18 febrero, 2011 en Uncategorized
Etiquetas:, ,

Source: Student BMJ

When referring to doctors as Managers, many make the mistake of assuming that this would mean putting doctors in managerial roles without adequate formation/training. This assumption leads to the immediate discarding of the idea without reviewing the possible advantages.

One often quoted idea is that doctors lack managerial training. Another often used argument, as written by Edwards in the BMJ 2003 is “If doctors decided that their principal concern was to ensure the smooth running of the system and the delivery of policy irrespective of the consequences for the patient in front of them, then both the quality of care and public support would collapse.”

The latter does not go against the argument that doctors can and should be good managers. But cannot and should not take on both roles at once. These are two different concepts and should not be confused. The former argument omits the possibility of a clinician to undertake managerial training and employ experience and expertise in both fields to ensure better hospital outcomes.

I’d like to put forward the argument that clinicians could be very effective in management and their clinical experience and knowledge should be used in management to improve hospital outcomes.

There is no doubt in the argument that both doctors and managers have different backgrounds, training and skills. Differences also exist in terms of their job roles, their approaches to health care and their primary objectives. However they also have a lot in common, both medical and managerial roles require analytical skills, problem solving skills and the ability to make decisions. From this perspective both parties have a lot to learn and benefit from each other for the effective running of a hospital.

A manager/administrator needs to know his organization and product. This means that a manager with no clinical background this requires extra education/learning to fill this gap. The same goes for a doctor filling a managerial role – they need to fill the education gap of administration/finance.

In both the NHS and Australasian Medical College a Residents training programme has been developed to train clinicians in hospital administration after having benefited and gained clinical experience after a number of years “at the coal face”. In the USA it’s being increasing common for a combined MD/MBA  programme. These programmes aim to fill the managerial education gap and increase clinician involvement in management.

The premise being that  combining the knowledge, skills and experience of a clinician, who understands the coal face of a hospital, the day to day challenges of clinical care and more importantly has a strong foundation in evidence based medicine and health care, and combining that with managerial formation/training can give a great advantage in the effective management of a hospital or health organization.

Where is the evidence for this? One article worth mentioning on this is a recent article in the Economist. This article discussed an analysis of hospitals internationally for “best management practices” and on “standardised measure of medical success”. Out of the five characteristics associated with the management of successful hospitals, employing clinically qualified staff in management scored better than those that do not.

Does this mean that a hospital manager must be a clinician? No. But that there are many potential advantages and benefits to be gained from employing clinicians in management.

Links of interest:

Stephenson, Doctors in Management, BMJ 2009; 339:b4595                   

What can doctors and managers learn from each other? – a lot, BMJ vol 326 22 MARCH 2003

Edwards, Doctors and Managers: a problem without a solution? BMJ vol 326 22 MARCH 2003

How to save lives: Five simple rules for running a first-class hospital, The Economist, Oct 21, 2010

 Wai-Ching ,Career focus: studying for an MBA, studentBMJ 2000;08:131-174 May