EDITORIALS Academic General Internists and Managers of Teaching Hospitals: An Agenda for Collaboration

HOSPITAL ADMINISTRATORS a n d physicians with ap- plied r e sea rch skills a re beginning to col laborate for their mutual benefit. This associat ion is creat ing a new ca ree r p a t h w a y for the genera l internist in aca - demic medicine. In the comments that follow, we review the factors responsible for this t rend and the scope of opportunities ava i lab le for proper ly pre- p a r e d physicians.

Hospitals a re coming under increasing pressure from sometimes conflicting d e m a n d s to reduce the cost of heal th ca re while maintaining or improving the quality of care . Government a n d employers a re becoming increasingly unwilling to p a y even the current costs of heal th care, and will continue for the fo reseeab le future to r educe paymen t s to hospitals. At the s ame time, the public is demand ing higher- quality heal th ca re and increased accountabil i ty from the heal th professions. Federa l and state gov- ernments a re re leas ing compara t ive cost and out- come data, while regulatory and accredi t ing bodies a re moving toward quality a s su rance efforts that focus on outcomes ra ther than on process alone.

Under these pressures, teaching hospitals a re finding it increasingly difficult to fund new programs or to secure the expens ive technology n e e d e d to re- main at the leading e d g e of developments in medi- cal practice. As revenues from patient ca re decline, costs of opera t ing the hospital must be r educed if flexibility for new programs is to be maintained. The hospital administrator is thus faced, more a n d more, with the di lemma of how to al locate a shrinking pot of money a m o n g existing and proposed new pro- grams, not all of which can be supported. And, of course, e ach proponent of a new program or service touts the reasons why his should h a v e priority.

Enter the academic generalist, whose training includes the skills to systematical ly examine heal th pract ices and to provide a scientific basis for man- agemen t decisions. What a re s o m e of the a r ea s where the efforts of such individuals c a n help the hospital respond to these pressures? First, the hospi- tal administrator needs help e a c h y e a r in al locating sca rce capital resources. Among the items of equip- ment reques ted a re some that a re essential for the ma in t enance of high-quality care, some that a re simply not needed , some with p roven efficacy but that represent margina l ga in over existing equip-

Supported in part by a grant from the W. K. Kellogg Foundation.

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ment, and some whose eff icacy has not yet b e e n established. The academic general is t c a n play a n important role here since technology assessment is usually a part of his a rmamentar ium.

Second, the a c a d e m i c general is t c a n apply the methods n e e d e d for the analysis of medical pract ice to high-cost a reas . The Pareto principle is evident on some hospital services, where 80% of the costs a re incurred by 20% of the patients. 1 C a n one apply the methods of "prediction re sea rch" to better s epa ra t e patients who might benefit from the use of expens ive resources from those who will not? The work of Knaus et al. in developing predictors of outcome a m o n g patients on intensive ca re units is important in this regard. 2 Work of this kind can be ex tended to other a r e a s of the hospital or to m a n y other catego- ries of patients and can help ensure the more effec- tive use of scarce resources.

Third, there iS a role for the academic general is t in col laborat ing with the hospital 's nursing service to systematical ly ana lyze nursing practices. The funds a l located for nursing usually represenf the single largest item in a hospital 's budget . Requests for more nurses a re increasingly frequent as in-hospital ca re becomes more complex and the severity of illness increases. The hospital budget cannot accommo- da te a continuing esca la t ion in the number of nurses. National shor tages of nurses, part icularly in the a r e a s of critical care, a re rate-limiting as well. Among the tradit ional as well as more recent ele- ments of nursing practice, which significantly influ- ence outcomes of ca re and which do not? Today 's well-trained nurses h a v e m a n y good ideas for more efficient care, but lack the expert ise n e e d e d to dem- onstrate their efficacy. Here is where collaboration with an academic general is t can help. Not only a re good ideas me rged with an appropr ia te study de- sign, the nurse /phys ic i an t eam can explore patient ca re pract ices more comprehens ive ly than either might individually. One example of this a p p r o a c h is at the University of Rochester Medical Center. With the ass is tance of a grant from the W. K. Kellogg Foundation, faculty of the Gene ra l Medicine Divi- sion a re beginning to col laborate with nurse faculty counterpar ts to study the impacts on costs a n d out- comes of patient c a r e of a number of al ternat ives to convent ional nursing care.

Fourth, the academic general is t c an be an im- portant resource to the hospital 's administrat ive and

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medical staffs in studying the efficacy of early hospi- tal discharge or, in some cases, alternatives to hos- pitalization. Stimulus for the latter comes from capi- tation as opposed to case-based payment plans. The separat ion of patients with as thma s and pneu- monia 4 into those who need hospitalization and those who can be treated safely at home are exam- ples of such studies.

Fifth, more needs to be done to develop better guidelines for the use of expensive resources among patients, once hospitalized, and to measure actual use once the guidelines are established. Inappropri- a te utilization of diagnostic and treatment resources varies widely among teaching hospitals throughout the country. There is thus clear rationale for the pres- ence of hospital-specific groups of physicians to fa- cilitate the development of improved s tandards for that hospital.

Quality assurance must be an integral part of all these cost-containment initiatives, both to ensure the most appropriate use of scarce resources general ly and to develop s tandards of practice for specific conditions. The academic generalist is uniquely suited to help the hospital provide high-quality care that is, at the same time, affordable.

Changes are occurring in the organization and m a n a g e m e n t of teaching hospitals that should aid the development of these roles for the interested physician. Decentralized management , with in-

creasing authority and accountability for budgets and for the use of resources at the level of clinical programs (i.e., Medicine, Surgery, Obstetr ics/Gyne- cology, etc.) is one example. Improved decision sup- port through the use of modern hospital information systems will also help.

Roles for faculty in divisions of General Medi- cine will continue to evolve in m a n y directions. The ones described in these pa rag raphs represent an opportunity to enhance the scholarly activities of ac- ademic generalists while providing an important service to their hospitals and to the public. - - Paul F. Griner, MD, General Director, and Leo P. Brideau, MHA, Director of Hospital Operations, Strong Me- morial Hospital, University of Rochester, Rochester, New York.

REFERENCES 1. Drucker WR, Gavett JW, Kirshner R, Messick W J, Ingersol G. Toward

strategies for cost containment in surgical patients. Ann Surg 1983; 198:284-300

2, Knaus WA. Draper EA, Wagner DP, Zimmerman JE. APACHE 11: a severity of disease classification system. Crit Care Med 1985; 13:8 ~ 8-29

3. Fischl MA, Pitchenik A, Gardner LB. An index predicting relapse and need for hospitalization in patients with acute bronchial asthma. N Engl J Med 1981 ;305:783-9

4. Black ER, Mushlin AI, Griner PF, Suchman AL, James RL, Schoch DR. Predicting the need for hospitalization in ambulatory patients with pneumonia. Submitted for publication.

"Redesigning the Future" 1

HEALTH CARE IS ENTERING an era of change that is comparable in scope and consequence to the Indus- trial Revolution. The movement of the worksite from cottage to factory profoundly influenced the social behavior of mankind. It is fortunate for physicians that they were able to escape involvement with the first revolution and yet enjoy its fruits.

Today, another revolution is afoot. The Indus- trial Revolution is giving a w a y to a Service Industrial Revolution with Medicine at its center and fueling its growth. In the last few years, human service indus- tries have surpassed the product industries in size. Today, service industries produce 60% of the gross national product and employ 71 To of the workforce in the United States. This second revolution is also changing social behavior.

Confused and threa tened combatants in this revolution are genera t ing myths and conjuring up visions from the nineteenth century of physicians working in bureaucratic, hierarchical sweat-shops dominated by shareholder interest and monitored by gnomes in green eyeshades . While there are in- s tances of this happening in some places, it is clear that these myths a n d visions do not describe the re-

ality in m a n y of the high-technology service indus- tries and even in some of the more a d v a n c e d prod- uct industries.

The worksite and the worker are continuing to evolve with the new revolution. A number of social trends are driving the change. Most important is a malaise of the worker caused by the failure of the authoritarian organization of the product industries in the United States. Equally important is the dissat- isfaction of the ave rage citizen with malfunctioning in both product and service industries. Shareholder- dominated, authoritarian, hierarchical organiza- tions, with rigid systems of control that allow policy to originate only at the top, are not working--wi tness the once powerful American automobile industry, the chaotic transportation system, and the irrespon- sible banking industries.

Dissatisfaction is felt most in the human service industries, where customer contact is so critical. S tandard work rules fail because services fre- quently are highly technical dependent on the worker's sensitivity, and commonly applied to prob- lems of great uncertainty.

Coming out of the earlier revolution, modern cit-