A medical center is not a hospital

To the Editor: Dr. Thomas Lansdale’s provocative essay “A medical center is not a hospital” (September 2008) is, in many respects, on target. I share some of Dr. Lansdale’s disenchantment, but only some. Our profession is under the gun, and everyone expects more of us. But change is the fabric of life and gives us opportunities to advance our profession and alter the fate of our patients. And I haven’t changed in one respect: I am still a “hospital guy” and I still am having fun.

The pressures faced in practicing medicine are enormous. Simply put, when medicine needs a sophisticated environment such as a hospital, we need to figure out how to meet the mortgage.

This is a problem when hospital managers are not physicians and are not at the bedside enough. Their charge is different. My former chief operations officer (an MBA) used to jokingly say, “They (meaning the academic full-time Cleveland Clinic staff ) just don’t get it.” And I would say, “They (meaning the MBA management crew) just don’t get it.” Well, neither group usually does. They can’t. They are of different worlds—until the MBA gets sick with crushing chest pain or the physician-manager suddenly has to face the music of a Wall Street bond collapse.

We can complain all we want, but we exist in a world of profit margin and EBITDA (earnings before interest, taxes, depreciation, and amortization). The challenge is to preserve the bottom line while also protecting physician time for reasonable research and education programs.

I happen to share Dr. Lansdale’s love for diagnostic challenges presented by hospitalized patients. My specialty (advanced heart failure and cardiac transplantation) certainly remains exciting and challenging because of this.

And I cannot do what I do without a hospital—no heart transplants on my kitchen table! Let’s get real: for many of us the hospital is still the only place we can practice and the only place we can save lives and alter the often-dismal prognosis of our most ill patients.

Yes, our practice has changed. We no longer strain to see a glossy wet Polaroid of an m-mode echo to diagnose mitral stenosis, and we no longer have only lidocaine and a prayer for acute myocardial infarction. We don’t do our own Gram stains, urinalyses, and peripheral blood smears in the middle of the night, and AIDS is no longer called “thin-man disease.”

And what about safety of hospitals? Well, don’t forget history. Hospitals are no longer death houses. Hospital safety and clinical outcomes have never been better. Yes, they are not yet good enough, and egregious problems exist, but never before has so much attention and expense been paid to quality improvement, patient experience, and safety initiatives throughout the industry. No, hospitals are not perfect—never will be. But I am proud of what we are doing, what we have accomplished, and what we will accomplish in the future to make ill patients better when they are sick enough to require hospitalization.

So I am proud and happy to be a hospital guy. To Dr. Lansdale I say, don’t give up. Your effort to preserve the passion of our noble profession is essential. Oh, and remember that Osler of Baltimore struggled with the same issues as did Codman of Boston. The more things change, the more they stay the same—except for the fact that hospitals are better.

To the Editor: Dr. Thomas Lansdale’s provocative essay “A medical center is not a hospital” (September 2008) is, in many respects, on target. I share some of Dr. Lansdale’s disenchantment, but only some. Our profession is under the gun, and everyone expects more of us. But change is the fabric of life and gives us opportunities to advance our profession and alter the fate of our patients. And I haven’t changed in one respect: I am still a “hospital guy” and I still am having fun.

The pressures faced in practicing medicine are enormous. Simply put, when medicine needs a sophisticated environment such as a hospital, we need to figure out how to meet the mortgage.

This is a problem when hospital managers are not physicians and are not at the bedside enough. Their charge is different. My former chief operations officer (an MBA) used to jokingly say, “They (meaning the academic full-time Cleveland Clinic staff ) just don’t get it.” And I would say, “They (meaning the MBA management crew) just don’t get it.” Well, neither group usually does. They can’t. They are of different worlds—until the MBA gets sick with crushing chest pain or the physician-manager suddenly has to face the music of a Wall Street bond collapse.

We can complain all we want, but we exist in a world of profit margin and EBITDA (earnings before interest, taxes, depreciation, and amortization). The challenge is to preserve the bottom line while also protecting physician time for reasonable research and education programs.

I happen to share Dr. Lansdale’s love for diagnostic challenges presented by hospitalized patients. My specialty (advanced heart failure and cardiac transplantation) certainly remains exciting and challenging because of this.

And I cannot do what I do without a hospital—no heart transplants on my kitchen table! Let’s get real: for many of us the hospital is still the only place we can practice and the only place we can save lives and alter the often-dismal prognosis of our most ill patients.

Yes, our practice has changed. We no longer strain to see a glossy wet Polaroid of an m-mode echo to diagnose mitral stenosis, and we no longer have only lidocaine and a prayer for acute myocardial infarction. We don’t do our own Gram stains, urinalyses, and peripheral blood smears in the middle of the night, and AIDS is no longer called “thin-man disease.”

And what about safety of hospitals? Well, don’t forget history. Hospitals are no longer death houses. Hospital safety and clinical outcomes have never been better. Yes, they are not yet good enough, and egregious problems exist, but never before has so much attention and expense been paid to quality improvement, patient experience, and safety initiatives throughout the industry. No, hospitals are not perfect—never will be. But I am proud of what we are doing, what we have accomplished, and what we will accomplish in the future to make ill patients better when they are sick enough to require hospitalization.

So I am proud and happy to be a hospital guy. To Dr. Lansdale I say, don’t give up. Your effort to preserve the passion of our noble profession is essential. Oh, and remember that Osler of Baltimore struggled with the same issues as did Codman of Boston. The more things change, the more they stay the same—except for the fact that hospitals are better.

To the Editor: Dr. Thomas Lansdale’s provocative essay “A medical center is not a hospital” (September 2008) is, in many respects, on target. I share some of Dr. Lansdale’s disenchantment, but only some. Our profession is under the gun, and everyone expects more of us. But change is the fabric of life and gives us opportunities to advance our profession and alter the fate of our patients. And I haven’t changed in one respect: I am still a “hospital guy” and I still am having fun.

The pressures faced in practicing medicine are enormous. Simply put, when medicine needs a sophisticated environment such as a hospital, we need to figure out how to meet the mortgage.

This is a problem when hospital managers are not physicians and are not at the bedside enough. Their charge is different. My former chief operations officer (an MBA) used to jokingly say, “They (meaning the academic full-time Cleveland Clinic staff ) just don’t get it.” And I would say, “They (meaning the MBA management crew) just don’t get it.” Well, neither group usually does. They can’t. They are of different worlds—until the MBA gets sick with crushing chest pain or the physician-manager suddenly has to face the music of a Wall Street bond collapse.

We can complain all we want, but we exist in a world of profit margin and EBITDA (earnings before interest, taxes, depreciation, and amortization). The challenge is to preserve the bottom line while also protecting physician time for reasonable research and education programs.

I happen to share Dr. Lansdale’s love for diagnostic challenges presented by hospitalized patients. My specialty (advanced heart failure and cardiac transplantation) certainly remains exciting and challenging because of this.

And I cannot do what I do without a hospital—no heart transplants on my kitchen table! Let’s get real: for many of us the hospital is still the only place we can practice and the only place we can save lives and alter the often-dismal prognosis of our most ill patients.

Yes, our practice has changed. We no longer strain to see a glossy wet Polaroid of an m-mode echo to diagnose mitral stenosis, and we no longer have only lidocaine and a prayer for acute myocardial infarction. We don’t do our own Gram stains, urinalyses, and peripheral blood smears in the middle of the night, and AIDS is no longer called “thin-man disease.”

And what about safety of hospitals? Well, don’t forget history. Hospitals are no longer death houses. Hospital safety and clinical outcomes have never been better. Yes, they are not yet good enough, and egregious problems exist, but never before has so much attention and expense been paid to quality improvement, patient experience, and safety initiatives throughout the industry. No, hospitals are not perfect—never will be. But I am proud of what we are doing, what we have accomplished, and what we will accomplish in the future to make ill patients better when they are sick enough to require hospitalization.

So I am proud and happy to be a hospital guy. To Dr. Lansdale I say, don’t give up. Your effort to preserve the passion of our noble profession is essential. Oh, and remember that Osler of Baltimore struggled with the same issues as did Codman of Boston. The more things change, the more they stay the same—except for the fact that hospitals are better.