CSA Online First

CSA Online First is a weekly blog featuring insights from CSA members themselves.

Edited by Rita Agarwal, MD, FAAP, with contributions from CSA’s Committee on Professional and Public Communications, Online First is a place where knowledge and opinion from any one of our 3200 plus physician-anesthesiologist members can be shared, discussed and deliberated to advance the specialty of anesthesiology, the practice of medicine and society in general.

"Better solutions to difficult problems are usually made when all sides are heard."

Steven Goldfien, MD

 

A Hospital Too Far, Part 3: Henry vs Three Giants and the Birth of G2

by
  • Chow, Harrison, MD
| Nov 25, 2019

Harrison_Chow“A Hospital Too Far” is a series of ongoing real-time articles describing the challenges and ultimate structural demise of a long time San Jose medium-sized anesthesia practice, formerly known as “GAS” or Group Anesthesia Services, that has been the core of anesthesiologist staffing for a West San Jose Valley practice centered around Good Samaritan Hospital.

This series attempts to describe the events, entities and perspectives that have led to this outcome, and does not affix “blame” to any one party or individual, but hopes the readers, better understand the changing and dynamic corporate world of hospital-based anesthesia care and staffing. The author notes he has had a long-standing working relationship and friendship with the current CSA President, Christina Doyle, MD, FASA, (Vituity) and the President-Elect Jeff Poage, MD,  (Envision). In the author’s opinion there are no villains in this real-life ongoing corporate play, just observations and questions.  

Good Samaritan Hospital anesthesia medical staff, has now re-formed as a partnership-based group, G2 Anesthesia Medical Group, and has the anesthesia services contract beginning November 1, 2019. The G2 anesthesia group has begun patient care beginning October 24, 2019.

Previous articles in the series:

Part I - A Hospital Too Far: Trauma Night at The “Regional”

Part II - A Hospital Too Far, Part II - Bleeding Anesthesia at Good Samaritan Hospital (San Jose), The High Price of Free

******

Shortly after we received the memo announcing our Vituity contract termination and the awarding of the anesthesia contract for Good Samaritan Hospital and Regional Medical Center to Envision by HCA, the remaining Good Sam anesthesia department called an emergency meeting.  Envision had already signed and assumed the contract and had contacted many of us about staying on Good Sam and Regional medical staffs in a few short months of the transition between Vituity and Envision. Signed, sealed, and delivered. What next?

In a dark, mobile modular meeting room, with vinyl card tables under the fluorescent light bulbs, we all sat glum, quiet and dejected. We were defeated. Vituity had been rejected by HCA, successfully bid out by Envision. The giant battleship Vituity had been sunk and we would all soon be scrambling for career lifeboats. It was incongruous to many of us, for years the Good Samaritan Anesthesia Department had been ranked the highest by both the hospital and medical staff.  Now our practice had been sold out from under us. We had joined Vituity purposefully to avoid this moment. How did this happen?

As we sat in that room, we were defeated. We all chatted, as word of the Envision contract had spread through the anesthesia community, many of us had started to receive other offers of opportunities from throughout the Bay Area. Anesthesia jobs were everywhere.

“Show of hands, how many of us”,  asked the meeting organizer, Dr. Henry Kamali, there was fire in his voice, “have been contacted by Envision about a Good Sam or Regional position?’ Most of the hands went up, quietly.   

“How many of us have been contacted by another group about another position outside of Good Sam?” All of the hands went up this time.

“How many of us want to stay right here and practice together as a group?” What, were we hearing this right?

******

My mind wandered to a different time and to a different place for an entirely different reason a few months earlier.  An outspoken critic of the Vituity partnership from the beginning, Henry had never quite fit in to the Vituity model, and largely had stayed out of the Vituity management. As Good Samaritan surgical medical director he had watched with dismay as increasing efforts by Vituity to clinically integrate with Regional Medical Center had left the old GAS partnership increasingly without say in our local practice and financially exposed. Largely he had kept those thoughts to himself.

Henry and I go back to UCSF residency training together and though not the best of friends, we have always been able to communicate together openly, largely because we saw the world through the same lenses. The child of hard-working immigrant parents, Henry always felt everything had to be earned not given. If you wanted something, you would have to work for it and possibly fight for it. A natural leader, from the school of hard work, Henry always gravitated to medical leadership positions, wherever he could shape things with his own hands and mind.

Henry and I had, these past several years shared a different bond, we had both suffered catastrophic illness in our families. In this way we were bonded like brothers. We would get together sometimes just a few minutes in the halls or his office at Good Sam, to hug and to make sure we were okay. Two grown men in blue OR scrubs hugging each other in the OR hallways in between surgery. Yeah we did that.   

I had made a social call, a get together at a local Los Gatos bar, Vivas, which was a short walk from Henry’s house. As we sat at the bar, over beers, we mixed with the local neighbors and caught up with our families, talked about how much we loved our children and how difficult it was to protect them from the death and illness that had threatened and disrupted their lives. Bitter medicine at times, but truly a heartfelt conversation.

Our conversation briefly drifted to work and Vituity’s difficulty negotiating a contract with HCA.  “I don’t have a good feeling about it”, confided Henry. “Give Vituity a chance, they have experience with this”, I offered with cautious reassurance.

Henry just chuckled, I was always the optimist with Vituity; a Vituity apologist I’m sure to many in my group.

We talked about what would happen, if the contract bottom fell out, if we became our own group, GAS again. What would we do? Would we sell out?  Would we retire in a coastal Italian village like so many other anesthesiologists who had sold out their practice?

The Italian retirement joke was particularly funny to Henry and myself, our difficult personal family circumstances made the likehood of such a cliched anesthesiologist retirement pathway almost mythically comical.

“What would you do Henry?”, I asked.

Henry thought about it, at that bar. “I’d have to fight, Harrison, I don’t know any other way. I want to be remembered as a fighter and champion for this group, not a quitter.”  

As Henry spoke, I realized what was at stake. What our children would think of our lives, the character we displayed, and they would hopefully inherit, mattered most.

“Ok I’ll toast to that, who needs Tuscan sun anyway”. Brave words over beers at a neighborhood bar between a would-be corporate warrior and a Vituity apologist.

******

“How many of us want to stay right here and practice together as a group?”, Henry repeated in the modular meeting room. Slowly some hands came up one at a time.   

“Was this even possible? How would this work? We don’t even have a contract or the support of the hospital,” rapidly blurted out some. The hands all went back down.

“I’m not saying this is going to be easy, but there is a path, a small one,” said Henry, “and we will probably still fail”.

As Henry went through game plan of forming a new group, I could see my friend was tired, he hadn’t been sleeping well. Warriors are like that they don’t sleep before battle. 

The unfairness of the situation dawned on me. Our group, the highest rated department at Good Samaritan Hospital, had joined a giant corporate entity CEP/Vituity to provide better clinical integration and better contract negotiations, and now our entire practice had been sold to another corporate giant Envision by another corporate giant HCA. Our labor had been bought and sold without our knowledge, input or consent. 

In the battle of corporate giants, we had lost our practice through no fault of our own.  Our practice lives, our families’ futures sold like a commodity. And now here was my tired friend, away from his family, acting out of instinct fighting the impossible fight. He deserves better, he should be sitting in a renovated farmhouse in Tuscany not here putting up with this mess.

For the next hour, a sleep-deprived Henry answered question-after-question as he put together a business plan for a new group. As risk-averse anesthesiologists we crave certainty. All the certainty that previously was held by Vituity now was owned by Envision. To be bought or sold without consent. We’d have to fight our way to freedom if we wanted it bad enough. The only certainty, if we did nothing, was inevitable defeat.

The odds were daunting. HCA didn’t want Vituity. Vituity wouldn’t release and support us. Envision owned the contract and their anesthesiologists were already on staff at Good Samaritan Hospital. As the meeting was going on, a few anesthesiologists were receiving texts from Envision offering them their jobs back. We all nervously laughed about that. How could we win this battle?

I worriedly looked at my friend, as he patiently went through business logistics. As a business case this was nuts, it was a David vs Goliath. Giant corporations and MBAs vs a small group of practicing MDs. No. Correction, it was Henry vs the Three Giants. Could the odds be any longer?

At the end of the lengthy presentation on that July night, Henry asked the question again. “Are you willing to fight for it as a group?” This time most of the hands went up.   

One of the younger anesthesiologists who had just joined our practice as Vituity earlier in the week, confused by the significance of the vote, asked out loud “can you address what the partnership track of this proposed group would entail?”. I nudged the young anesthesiologist, and whispered loud enough the others to hear, “I think what Henry is saying is: if you raise your hand now and am willing to fight for this group you are a partner right now”. Henry, smiled at me from across the room, and agreed “yes that’s the deal, get it while its hot”. The remaining hands quickly shot up.  

One detail remained, what to call the group? “Gas 2.0 for now, we can pick a real name later”, the group quickly decided as we left the meeting.

As I left the meeting, I thought about how to describe what I just saw. How would I describe the leadership of my friend?  There was a story here that I would have tell one day.

I remember a story of leadership I had heard on NPR radio once about how Coastal Commission in California was formed to battle deep-pocketed developers to block development on the coast. As activists they were disliked, but eventually prevailed by sheer force of will. They were described, respectfully as their foes, as “unreasonably, unreasonable”. That describes Henry in this battle, anybody listening to reason would be sipping fine Chianti in that Italian villa. But some leaders, the best of them, have a warrior heart. You can’t buy that heart. Unreasonably, unreasonable Henry.

In the months to come Gas 2.0 became abbreviated as G2. Papers were filed, assurances were sought, and largely most of the anesthesiologists stayed. Complaints were flying about from every direction, it was a bad time, every day a gut check, to smile at work.

I would stop by Henry’s office to check on him, week-by-week the odds of success kept changing. The Henry odds kept changing though….10%, 25%, 40%, 50%.... until wait until the ink dries and the patients are under anesthesia. Vituity grudgingly granted us our release, Envision was unable to get enough coverage, the medical staff revolted and HCA capitulated. Regional Medical Center would be covered by a different anesthesia entity.    

And then the day came, would G2 assume the Good Samaritan Hospital Anesthesia contract? Hey what ever happened to the name change?

******

I’ve been asked by my CSA colleagues, what was it like to be between three corporate giants, alone in a financial battle for survival?  My answer is always that as partners, as colleagues, you have to stick together. That whatever comes along, you have a better chance of survival if you are group. Even alone, already discarded for death in a corporate arena against better armed foes, an anesthesia department with the right stubborn leadership and the willingness to fight together can survive.

We had been dumped by HCA, sold to Envision, and left defenseless by Vituity. From the ashes arose G2, a frankly amazing story of leadership and a case study of group survival, teamwork and courage.  A medical group molded from the clay of corporate battle. A still small group of veteran and reluctant anesthesiologist-warriors.    Unreasonably, unreasonable and free – for now.

“Stay together and you will survive. “ -  From the Academy Award-winning movie Gladiator. 

Harrison Chow, M.D. is a frequent contributor to the CSAOF.  He currently is an independent contractor for G2 Anesthesia and is a staff anesthesiologist with 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 is a current Delegate for the Hospital-Based Practice Forum at the California Medical Association.

 

 

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