Friday, April 15, 2011

Recruitment to Hospital Hell

Here is a hypothetical scenario, and a possible one.  A brilliant surgeon, trained in a subspecialty on the very high tech from the best surgical residency training program in the state.  She is approached by recruiters.  Every recruitment firm gives her a list of the most attractive positions and practice opportunities.  Some are so with income guarantee to open her own practice.  Some are employed positions with a hospital.  Some are employments with a group, with the possibility of partnership in 2-3 years.  Recruiters are quite excited for her.  One recruiter spots for her the dream practice opportunity.  A nice community hospital in a small town that is a bedroom community to a city that consistently ranks high as to the quality of life.  Outdoors, indoors, you name it, it's there.  Schools, colleges, an international airport, arts, museums, galleries,concerts, a symphony orchestra, all there.  Ocean beeches, there too.  What else?  A very supportive community.  A collegial atmosphere.  The opportunity is to start own practice as a solo surgeon.  The hospital believes that reintroducing that specialty to the hospital will capture so many patients who had to be sent away.  Now they will be treated in the hospital, boosting the revenues and serving the community locally.  There are others on staff who belong to the specialty, but not very active in this hospital anymore.  So, they will not be competing.  And the financial package is competitive.  Site visit is warm and very encouraging.  The young fellow accepts.  Life is good. Then a shock: within a year her career is totally ruined.  She loses her livelihood.  All the long hours of medical school.  The loans.  The ruthless internship.  The long residency training for a full general surgery program of five years.  The two years of fellowship training.  The qualification for two specialty board exams.  All gone, just like that.  Is that possible? What happened?  Read on.
The hospital CEO's entire plan to recruit a surgeon with that high level of training but very little independent experience was simply that, recruit her and give her a referral basis, or at least, ED calls to start building her practice.  The young fellow in her entire training had been in the fully supported environment of a university hospital.  There are highly qualified residents, faculty, nurses, technicians, etc.  An environment where things just go so smoothly.  Being a tertiary center, the most challenging cases are treated well, and they do as well as could be.  The young fellow was realistic that such a level of support would not be duplicated in a small community hospital.  But, with a great attitude from the administration, and lots of hard work and determination, and confidence in her abilities, her practice will be the best in the small town.  She has not yet felt her way as to which cases should or should not be done in that hospital.  Being a solo surgeon, no senior partners to guide her.  She does some cases with great success.  She becomes confident of her abilities and the abilities of the hospital to support her professional needs.  She becomes somewhat arrogant and rude, just a little bit.  But that does not sit too well with the OR supervisor/director, who will from now on put that fellow under the microscope.  Also being all by herself building the new specialty service, she becomes chronically tired.  The after midnight ED calls make her chronically sleep-deprived.
The young surgeon takes a challenging case to surgery, to find that she is given a technician that is not used to work with her, and is not familiar with some of the details of those types of surgeries.  She complains to the OR supervisor, but with a vicious smile she is told that she should be able to work with that technician if she was competent enough.  Though uncomfortable, she decides to go ahead with the scheduled surgery.  She gets into a technical difficulty, but there is no back-up surgeon in that specialty in this hospital.  Working the best she could with the inexperienced technician results in the patient bleeding, suffering an injury, re-bleeding, then dying.  The exhausted surgeon is devastated.  She talks to the family and feels their pain, and she has to live herself the pain.  She manages the paper-work including calling the coroner and explaining.  Then she has to see her other patients on the floor.  She comes back to see if the grieving family have any unanswered questions, then totally drained-out she finally goes home near midnight.  Life and work in this hospital is becoming hell, but that is just the beginning.  The OR director, who herself is an unpleasant grumpy person, keeps questioning the competence of the surgeon.  She does not make it easy for her to be assigned the best technicians.  The surgeon learned a lesson about real life outside the university medical center.  She decides to be more selective accepting that her skills and professional abilities cannot grow in this hospital.  She decides that she should move to another hospital.  Read on ....
In the meanwhile, the OR director voices "serious concerns" about that surgeon's competence to the Quality Improvement Director.  The case is sent to an external reviewer.  The external reviewer decides that the care of that case was substandard, that is, below the standard of care.  The surgeon gets suspended from practice and an immediate investigation is started.  The surgeon is stuck.  She cannot go to another hospital now, being under investigation.  If she resigns her privileges while under investigation, she will have to be reported to the National Practitioner Data Bank (NPDB).  If the suspension remains for more than 30 days, she also has to be reported to the NPDB.  If the hospital decides to put any limitations or restrictions on her scope of privileges because of medical concerns, she has to be reported to the NPDB.  A report to the NPDB may result in the surgeon losing her career, since it will be very hard for her to be employed.  The collegial medical executive committee, being hammered by quality concerns from the OR director, fearing they lose reputation as being lax about patient safety, become hawks.  They have to protect the public.  This is what the OR director keeps reminding the key players from behind the scenes.  She also throws in, just for good measure, several other insignificant events to draw a bigger picture of alarm.  Now everyone is scared.  The potential liability to the hospital becomes the biggest anxiety of all.  They ask their lawyer, can we revoke that surgeon's privileges to be on the safe side?  Of course the lawyer tells them it is possible, and he is confident that the law is on his side.  There is immunity for the peer review process.  The young surgeon, who has barely started her career, is delivered the death sentence to that career.  All her privileges in this hospital are revoked.  Story ends.