The hospital where I do much of my elective surgery recently terminated the contract it had with a large Hospitalist group and announced plans to hire Hospitalists directly as hospital employees. A less publicized part of that move is an attempt through the credentials and bylaws committees of the medical staff to terminate the credentials of physicians who are associated with that group under an ‘exclusive contract’ provision in the hospital bylaws. In essence that provision states that certain areas are recognized as being best served by an exclusive contract and that physicians credentials to admit and treat patients under those arrangements are contingent on the continued contract.
This has been traditionally applied to services such as radiology, laboratory services and pathology. More recently (20 years) it was applied to Emergency Medicine. At my hospital is has not been applied to anesthesia, cardiology or hospitalist services. The administration would like to change that.
Standing in the way is specific language in the current bylaws that addresses this eventuality for those areas where exclusive contracts have not previously existed. The proposed change in the bylaws language was put forth by several employed physicians and almost got through committee until a sharp-eyed private practice physician on the committee noticed it and had it removed. (No, it wasn’t I who did that, but I applaud his vigilance)
Why should I care? After all, this is about Hospitalists. I rarely, if ever, use them for my own patients and the group involved does not consult me with any regularity. It would seem that I don’t have a dog in this hunt. But I do. And so does every private practice physician or surgeon who sees patients at this hospital.
This is just the latest in the low level war between private practice and the big healthcare companies (and their silent partners in the government). Under the guise of CMS/Medicare requirements, ‘best practice guidelines’, hospital service contracts, and the control of information through the Electronic Medical Record, BigHealth has made the hospital a hostile environment for the solo private practitioner. They have almost completely driven out the Internists. They are limiting the freedoms of the General Surgeon, and have made specialists into mere technicians.
To be sure, we have allowed this to happen to ourselves through complacency, inability to cooperate with each other and a willingness to cede authority to those with the desire to take it. Unfortunately, those willing to take that authority are employees of or shills for the company. The voice of the private practice doctor has nearly been stilled in favor of ‘clinical consensus groups’ and case managers who dictate everything from antibiotic choice to lengths of stay.
There was an old custom during the Edo period in Japan. A Samurai would display his daicho, the two-sword combination of wakizashi and katana, on a wall or stand in the household common room. If the swords were stored with the hilts to the left, the House was at peace since one would have to turn the sheath around for a right hand draw. If the swords were displayed with the hilts pointing to the right, the House was at war.
I turned my swords to the left when I resigned from the Chairmanship of the Surgery Department after eight years in the job. Within six months, every change I had fought against during my tenure had come to pass and the restrictions on surgeon choice and freedom have continued to increase. Perhaps it is time to turn the hilts to the right again, although I fear it will end as a grand futile gesture.

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