December 2018, Volume XXXII, No 9
A practice built on principle
Taking a stand
fter 35 years of service, 12,775 overnight shifts, and countless life-changing encounters with families and patients at our Children’s Hospital Minneapolis location, Minnesota Neonatal Physicians is moving into the North and West Metro. It would be lying to say this change isn’t difficult and emotional. The relationships we’ve built with medical staff and families of medically fragile newborns are deep and, we hope, lasting.
My first job out of fellowship training was in another state, as a hospital-employed neonatologist in a community hospital. Our family of five, including a six-month-old, picked up our roots to begin life in a new state, away from friends and family. I started the job with optimism and energy, ready to share my knowledge and skills, gleaned over 14 years of post-high school education, with the patients, families, and staff in my new home. I knew how to work hard, how to share child-rearing responsibilities with my spouse, and most importantly, how to take care of medically fragile babies. What I didn’t know or understand was the concept of expendable physicians in a health care system. I realized two things very quickly:
The skills I had trained so hard and long to learn were not valued by my new employer.
Doctors in that system were considered interchangeable; if one left, he or she could easily be replaced.
Most alarming to me was that if patient care got short-changed in the course of changing doctors, so be it.
Unable to practice neonatal medicine according to my principles, I left that position and headed home to Minnesota. A private practice neonatology group in Minneapolis had reached out to me. I didn’t know much about the group at that time, other than that they took care of sick babies. That sounded pretty good to me. It was in June 2000 that I had the good fortune to join Minnesota Neonatal Physicians.
When I arrived, I knew I had found my “tribe” in the world of neonatal medical practice. My partners were doctors with a never-before-seen dedication to their patients:
They were the first neonatologists in Minnesota to work 24/7 in the hospital, not because of administrative mandates, but because it was best for their patients.
They sought out participation in the initial clinical trials which resulted in FDA approval for surfactant treatment in premature babies. In fact, their site provided the largest number of patients in the trial.
They brought ECMO (extracorporeal membrane oxygenation) to the hospital, a life-saving technology that could better support critically ill babies.
They were surrounded by nurses, nurse practitioners, respiratory therapists, and physician colleagues who were equally devoted to the primacy of clinical care.
In such a perfect environment, the results were astounding:
Survival rates of infants born near the edge of viability unequaled throughout the world.
Survival of infants with congenital diaphragmatic hernias, again, in the top of national registries.
More importantly, because they survived and thrived, babies were able to go home, grow up, graduate from high school and college, have families, and enter the work force. These are children, born in the early 1990s, that would not be routinely resuscitated in many hospitals in the U.S. even in 2018.
"Physicians are commonly perceived as intellectually incapable of making business decisions … . That perception is wrong."
And then things began to change
Work hour rules were ushered in to increase the safety of patients and balance education and service demands. In 1999, the Institute of Medicine released a report entitled “To err is human: building a safer health system.” This report initiated a cascade of events culminating in common duty hour requirements for residents. The results are far from impressive. A 2015 Journal of Graduate Medical Education article concludes that focusing on duty hours alone has not resulted in improvements in patient care or resident well-being. But the genie was out of the bottle, and the concept of work-life balance took on a life of its own … except in our private practice group.
As a group, we agreed to not abandon our primacy of care ethos, despite the trends we saw around us. We continued to work three out of four weekends a month, treated holidays like any other day, and grew prematurely gray from chronic sleep deprivation. We missed ball games, school conferences, you name it. We told our children and family members that we are lucky to be healthy, that holidays are about spending time with family, not a day on a calendar, and that the babies in the hospital needed care. Most importantly, we believed it. We kept our group small by design, waiting to hire physicians who shared our passion for providing direct patient care to babies. We had no attrition, despite some urging from our spouses that we “work too much.” Our kids survived, even thrived, and so did we. We had a purpose, and purpose gives people energy.
Impact to NICU families
By keeping a “baby-centric” approach at the core, our business decisions and care model grew organically. We worked 7-day stretches in the NICU to provide continuity of care that seemed paramount to achieving optimal outcomes. As a result, parents knew us all by name and were part of the team treating their child. By alternating rounding weeks, it was not uncommon for a family to have only two or three physicians rounding on their child over the course of a four–six week hospitalization; unheard of today when physicians in some systems change daily. We balanced this intense work with stretches of time off to spend with our families or pursue outside interests. The benefit of our ability to control our own work schedule, work load, and number of partners was no burnout in our group. If your personal or family needs required that you cut back, you did just that. Sometimes we had to hire more people to cover the loss, but it was our group that worked out the needs to support our practice.
Impact to the business
Meanwhile, the hospital thrived. From a 12-bed unit in 1979, the NICU grew to have over 100 neonatal beds and three affiliated hospital systems. We saw our program grow and we were excited to see other programs in our hospital prosper. We developed a transport program that brings mobile intensive care to the five-state region. We grew neonatal research from a single study site to a much sought-after partner in multi-center national trials. With our cardiology and cardiovascular surgery colleagues, we saw the creation of a cardiac intensive care unit. We saw the creation of a fetal treatment center. We are seeing the birth of a cardio-pregnancy center. All innovation conceived of and nurtured to completion by private practice physicians championing the needs of their patients. We thought we could continue to serve our patients along with our colleagues until our individual careers had reached their natural conclusion. Then our contract was terminated, we were offered employment by the people who terminated us, and everything changed.
Over time we witnessed private practice groups merge or become part of larger group and multispecialty practices. Some were acquired by hospital systems. We saw hospitals merge, align, re-align, split, and then reconnect with former partners. And that was just in the Twin Cities. Nationally, Dignity Health and Catholic Health Initiatives plan to have a national chain of hospitals in 28 states. Hospital Corporation of America is a for-profit operator of health care facilities that went public in 1969, private in 2006, then public again in 2011. It currently trades at $132/share. Its CEO reportedly earned $21,331,574 in 2016. A recent article reflects the consequences of these changes. It reports a 93 percent increase in medical center CEO compensation from 2005–2015, a 10 percent increase in physician salaries, and a 7 percent increase for non-clinical workers. Notable was the growth of non-clinical workers over this same time frame, accounting for 27 percent of the growth of overall health care workers. Nowhere is it mentioned that the patients received better care, were safer, or were more satisfied with their care.
People talk about changes in health care, for example the move for hospitals to employ physicians, as “business decisions.” As if to say that every business decision is a good one. Physicians are commonly perceived as intellectually incapable of making business decisions, because all we ever studied was medicine. That perception is wrong. The move for hospitals to employ physicians is multifactorial: issues with private practice physicians recruiting new partners, cuts in Medicare payment for office-based imaging, the burden of “meaningful use” in the EMR and value-based payment schemes, and the effort to gain more favorable rates from insurers, to name a few. Yet a recent Harvard Business Review article demonstrates that many large health care systems’ physician operations are operating at a loss.
It’s not to say it can’t be done. Hospitals and systems that work together can be successful, as exemplified by the Mayo system. “The needs of the patient come first” is written on Mayo Clinic stationery. Similar quotations from the Mayo brothers continue to be perpetuated and realized in how the organization is run. While not perfect, the Mayo Clinic continues to achieve worldwide recognition and is financially sound. Because physicians are at the core of any health care enterprise, they must be in alignment with management. Physicians and administration in opposition is a recipe for failure.
"As physicians, we put patient care first."
Jeanne Mrozek, MD, is a native Minnesotan and a graduate of the University of Minnesota, with degrees in chemistry and medicine. She completed her pediatric and neonatal training at the University of Minnesota. In addition to her work as a neonatologist, she is the founder and president of Minnesota Neonatal Foundation.