An excerpt from Confessions of a Surgeon: A Deeper Cut.
He screwed us over. I slowly sank deeper into my chair, attempting to digest the letter my group had received from the local hospital CEO. “Thank you for your group’s interest in our hospital. I appreciate your long-standing dedication to the care of our patients. However, our organization has decided to go in a different direction. I wish your practice the best of luck.”
Months earlier, he approached us wearing a Grinch-like smile, talking about “joining his team.” Our practice was to be the next domino to fall. From the beginning, we were skeptical of his motives. When it came to following through with commitments to physicians, his performances over the last two decades were mediocre at best. Physicians in small towns have long memories, especially those who get undermined by broken promises. Still, we had no choice but to listen. Our referrals were already diminishing because of the competing surgeons hired by this very same CEO. His goal was to “complete” his surgical department by adding our group to his staff. The competing hospital across town was going through growing pains and had no interest in buying up practices.
Sadly, the sun was quickly setting on our group surgical practice. Despite our historical reputation for stellar surgical care, corporate competition, and salary inflation left us mortality wounded. Two of our senior partners were also retiring. We could not compete in the recruiting process to replace them. We had no “extra” financial incentives to entice new surgeons into joining our practice. In addition to the hospital using its clout to stifle our referrals, the bureaucratic costs of running a business were rising. It was a perfect storm blowing, affecting practices throughout the country. We had to let go of the past in order to survive the present.
Over the years, our group had managed to resist the economics forcing many surgeons in private practice to jump on the corporate ship. Our naivety, ego, or lack of foresight prevented us from seeing the rolling for-profit landscape of patient care. We knew we were late in coming to the “company” party. I hated being in this position. I never thought, in a million years, that I would be selling my services to the highest bidder. In our case, the only bidder.
Our group had been in business for close to a half-century, serving patients at two hospitals with no financial strings attached. For years, primary care doctors referred patients to us knowing they would get excellent care. Plain and simple. Money or employer pressure was never part of the equation. There were no promises to operate at a specific hospital in return for the patient business. We naively assumed doing what we do best would sustain our group forever and provide immunity to the pressures squeezing everyone else. Wrong assumption. They were political and corporate pressures that had nothing to do with the ability to efficiently remove a colon cancer or perfectly repair a complex hernia. They had nothing to do with a dedication to stay with a patient’s family for hours, offering support. These pressures had everything to do with controlling the services physicians provided and maximizing the RVUs. Hospitals were building higher fences around their around their physician-owned perimeters. Fences that locked patients in, restricted their choices, and maximized every dollar their illnesses generated. The concept of shark territoriality among competing hospitals was alive and well. The days of a patient choosing his or her own surgeon were on life support. They ended when hospitals started buying up practices, forcing patients to stay within their walled-off network. They ended when the community surgeon lost control of his or her own destiny.
Lately, the hospital had been buying up primary care doctors in town like it was Black Friday. The “gatekeepers” of patients, as they were once fondly penned, were also feeling the same financial pressures we were. Only their pressures to produce magnified once they became employed by corporate medicine. Primary care physicians are vital to a hospital’s revenue stream. However, many cannot generate the daily revenue for hospitals that surgeons can. Operating rooms are big business for hospitals, crucial to their bottom line. As a result of their financial clout, each has its own unique personality, business model, and revenue stream. First and foremost, there is the robot room. It often is the largest. Robots need a lot of room to flex their titanium arms. The cardiac surgery room (along with its sister cardiac physiology suite) is also a heartful source of revenue for any operating room. The vascular suit also makes up part of this revenue brood along with the joint room and bariatrics room. General surgeons are the Rodney Dangerfields of any community operating room. Despite being necessary, we do not get any respect and often do not have our own room. Our cases get handed off like orphans to different rooms throughout the day.
In the end, of course, the hospital did not hire us. Its CEO never intended to hire us. From the beginning, he was eager to know how much revenue our group created each year. The future business plan for his hospital’s surgical department never included our surgical group. His goal was to put us out of business. It was easy to do when you have deep pockets and own half of the primary care physicians in town. Teddy Roosevelt’s words in 1906 still ring true today. “If you’ve got them by the balls, their hearts, and minds will follow.” This CEO clearly had us. Yet, he had no intention of making our hearts and minds follow him.
Paul Ruggieri is a general surgeon and author of Confessions of a Surgeon: A Deeper Cut.
