"A Hospital Too Far” is an article describing the challenges of the changing and dynamic corporate world of hospital-based anesthesia care and staffing. The author notes that he has had a long-standing working relationship and friendship with the current CSA President, Christine Doyle (Vituity), and the President-Elect, Jeff Poage (Envision). In the author’s opinion, there are no villains in this real-life ongoing corporate play, just observations and questions. These corporate changes can be indiscriminately sweeping, affecting both patients and physicians, with the extremes being the Hahnemann University Hospital bankruptcy. And whether or not they make the news, they are very much happening, in every community.
The partnership of Group Anesthesia Services or GAS became part of Vituity, a multi-specialty national physician partnership, in 2015. The group is now swept up in a corporate effort to remove Vituity practice (Emergency Room, Hospitalists, and Anesthesiologists) from San Jose’s only remaining private hospitals, Good Samaritan Hospital (West San Jose) and Regional Medical Center (East San Jose) by Nashville-based Hospital Care of America (HCA), replacing physicians by staffing from Envision (Anesthesia), and Team Health (ER and Hospitalists) by November 1, 2019.
A Hospital Too Far: Trauma Night at The “Regional”
It all started innocently enough. It was just another afternoon, a colleague and myself in a surgery center on a coffee break. An electronic missive made my watch vibrate. “Hi Importance ! To : Medical Executive Committee,” read the preview.
“What is it?” asked my colleague, also responding to a vibrating iPhone. He called up the same e-mail, briefly sighed, and grimaced. He showed it to me and asked, “Is that saying what I think it’s saying?”. I looked at the e-mail on his phone (I had yet to look at it on my iPhone - a self-preservation technique I had learned over the last few years).
“Yeah I think we just got fired from Good Sam and Regional,” I said with a resigned tone. Actually, it wasn’t surprising. But why was the e-mail sent to us? Neither one of us was still on the MEC, and the e-mail was addressed for the following week.
More watch vibration, and another “Hi Importance!” e-mail appeared, this one was entitled “RECALL”.
My colleague, still reading his phone, said, “It’s the same message, just saying RECALL from Outlook. What do you think now?”. The e-mails were just 5 minutes apart.
“I think the hospital CEO’s administrative assistant just sent the first one out to the entire medical staff by accident,” I replied.
My colleague just laughed, “Oh, that person is so fired!” We both broke out laughing. Misery loves company. The memo was a terse 3-paragraphs long that can be succinctly summarized into today’s Twitter-speak as “GTFO”.
My mind wandered. No surprises here. Hospital and group site negotiations with our parent organization, Vituity, had been so acrimonious at times that any day the Good Sam Hospital-based partners, including myself, expected the proverbial other shoe to drop. But the magnitude of this termination, revealed by the fat-fingered errant e-mail memo, was breathtaking. HCA had decided to fully uproot the entire Vituity-integrated medical services— ED, hospitalists and anesthesiologists— across two San Jose hospitals or roughly 80 full-time physicians for largely economic reasons. It was a total hospital-based physician foundational uprooting.
How did we get here?
I thought immediately of a young trauma patient at Regional Medical Center I had taken care of last Fall. As part of Vituity’s contract with HCA, the Good Sam Hospital physicians had crosstown medical privileges at our sister Eastside HCA hospital, succinctly known as “Regional”. Two days earlier a frantic group e-mail had called for volunteers to cover overnight OB and trauma shifts. I had taken a few weeks off to take care of some family matters, so I had volunteered a few night shifts to help my colleagues cover Regional.
Though I had been through orientation and a walkthrough months earlier, I showed up an hour early at 6pm. I met the young, fresh-faced Medical Director and two just-out-of-residency staff anesthesiologists. Rookies, full of bounce, optimistic hope and whip smart. They effortlessly walked me around the OR and the trauma ED bay at the hospital, and showed me the trauma call room located in a deserted patient wing of the aging hospital. The thought crossed my mind, I hadn’t done trauma call since 1998, as a UCSF resident, at the old San Francisco General Hospital. Who was the rookie now?
As the thought of old trauma-call memories flashed through my head, the trauma phone went off. “Head trauma MVA coming to the ED bay, possible crani and hematoma evacuation at 7pm,” said the voice on the line – right at the start of my first trauma shift in 20 years. The youngsters, having delivered the news, while still on my trauma orientation tour, kind of looked amused. We can do it, they offered the senior “rookie” anesthesiologist graciously . “I think that would be prudent”, I agreed. Thank God for the kids.
The trauma group, breaking up the orientation, flew into the action, sweeping the patient from the ED to the OR in what seemed like minutes. I smiled as I saw the team in action. They moved so fast, so sure, as only the young, skilled and the smart can move. Trauma call is a physical sport. Is it a young person’s game?, I wondered.
As they started the arterial line and stabilized the patient as a team, I first wondered about Jane Doe, the patient on the OR table, her head being shaved for the crani. A young, Asian woman in her 20s, she had been in a rush hour car accident (was she the source of the traffic on my drive here?), her bloodied face swollen from a head collision. “She must have been lovely,” I thought as I said a quick prayer.
Shortly afterwards, Jane Doe was safely transported to the OR-adjoining SICU. It had been a quick crani and subdural hematoma evacuation with a drain. Life-saving stuff - all done in literally one-hour and change. I had just finished my cup of coffee with the staff and hugged some nurses I knew from my home hospital, Good Sam. The youngsters, all family-oriented, had hung around past their Jane Doe case and shift to talk with me. They had many questions. What kind of a group was Vituity? Should they buy a house? Where to buy a house? What could they afford? What kind of school district were they looking for? How should they invest their retirement funds? We talked for what seemed another hour. How did I get so old? Somehow, I was now wearing the senior partner OR cap, advising the youngsters. The rookies had so many questions.
I answered the questions with nuance and depth, the best I could. In the end, the rookies wanted something elusively simple - a good and fulfilling job; a stable organization they could believe in, and a house in a quality school district to raise a family. Not an easy feat in Silicon Valley. “How do I get there?”, all their questions seem to ask. I reassured them and urged them to get home to their families. What will happen to these young anesthesiologists now?
Case over, trauma phone given over, I walked around my new spacious surroundings. Formerly known as Alexian Brothers, Regional had suffered the same fate as almost every American metropolitan hospital, with better paid patients often migrating to the suburbs. The wealthier, more-educated moved away down the newly built Highway 85 suburbs, and the poorer, less-educated were left behind in the San Jose urban core. Regional had been bought from Alexian Brothers by then-Columbia/HCA in 1998; Good Sam had been sold to HCA in 1995.
In Regional’s case, left behind was a spacious and aging hospital. Entire wings of the giant complex seemed virtually abandoned. It was kind of creepy as night fell. Are there ghosts? I fought back the fear. I went on with my quiet intra-hospital hike, wandering about the old linoleum. I was making good progress on my iPhone pedometer. Such a contrast to the Good Samaritan Hospital, on the nicer side of San Jose, in which every room was occupied, and there was nary a quiet place in the entire hospital. Time to make it back to the OR and the ED to do a night checkout, I thought.
As I retraced my path to the OR to check out before going to back to my call room bed, I ran across a giant Asian family outside the OR. They were the patient’s family – over-spilling the tiny plastic-chaired OR waiting area. Two hours had gone by. “Rookies!”, I thought to myself with forgiving smile. “They forgot to tell the family!”
“Is she okay?” asked a short older man, perhaps the father, in a familiar broken Asian accent, tears streaming from his face. Jane Doe was Vietnamese! How different things worked here. Small waiting areas, no volunteers, and large loving families.
An older lady, perhaps Jane Doe’s grandmother, reached out to touch my hands. The small hands were rough blue-collar hands, hands that had known hard work. Her family thanked me profusely. They bowed. They treated me like some mythological doctor to be idolized. Having unsuccessfully tried to tell them I had not been involved with the surgery, I politely accepted their thanks and reassured them I would get somebody from the care team to come out of the OR to tell them her condition. Never had I been thanked so much for just drinking coffee!
The rest of the night was quiet. No ghosts. Not a single call. As I left in the morning, after chatting with the Medical Director again, I headed out the exit again to the physician’s parking lot. Stuck outside the security entrance was the whole Jane Doe family, this time having grown even bigger. I used my badge to let them in, getting around the main hospital security and calling the ICU to talk to them. More thanks, and bowing, but I cut the family off after a few minutes. I wanted to get home to see my own family.
The drive home is mercifully short on a Saturday morning. No traffic. The familiar redwood trees of Los Gatos and Saratoga soon come into view off the freeway. How isolated we were from the world of the Jane Doe?. How many anesthesiologists were avoiding what I had just done? I was silently thankful for the doctors who regularly cared for these indigent patients – at great sacrifice to themselves, both financially and physically. I appreciated them and their work, even though I suspected few members of the public, to even our profession realize the sacrifices they had made – not the stuff of Instagram and Facebook “likes”.
I haven’t been back to Regional since that trauma shift. I flashed back to Jane Doe’s face, bloated and bleeding in the OR trauma room months ago, brought to life after the flubbed memo before me. Uninsured trauma and other indigent coverage had been a weight too much for our anesthesia practice. In all fairness it may be a burden too great for Santa Clara County, HCA, or any medical organization for that matter.
Lumping acute intensive county hospital indigent patient care with insurance-based private patient care delivery, spread across two hospitals on the opposite sides of metropolitan San Jose, may be an unsolvable problem - both culturally and economically. The whole merger endeavor with Vituity, unfunded mandates and all, had led to our collapse as a group, as a corporation, and even as friends. Now we had just been fired by a GTFO e-mail memo.
I remain skeptical that the uninsured and the poor can be covered by any unfunded entity and how the young doctors can make a living doing it. A good question is: who is going to take care of the Jane Does and the rookies at Regional?
What will happen to them, and to us?
Harrison Chow, M.D. is a frequent contributor to the CSAOF. He currently is a Vituity partner and staff anesthesiologist and maintains medical privileges at Good Samaritan Hospital (West San Jose) and Regional Medical Center (East San Jose). He is also a former Department of Anesthesia Chair of Good Samaritan Hospital and former Coordinator of Vituity Advocacy and is a current Delegate for the Hospital-Based Practice Forum at the California Medical Association.