
                         Roanoke Times
                 Copyright (c) 1995, Landmark Communications, Inc.

DATE: MONDAY, May 23, 1994                   TAG: 9406030060
SECTION: EDITORIAL                    PAGE: A-5   EDITION: METRO 
SOURCE: By LEONARD LASTER
DATELINE:                                 LENGTH: Medium

THE MEDICAL BUSINESS

RECENTLY, MY wife and I drove from Worcester, Mass., to Boston to meet our daughter at a major teaching hospital where she was scheduled for outpatient surgery. When the hospital came into view, we found ourselves in a long line of vehicles inching toward the hospital's ``Valet Parking'' sign. At the booth, the attendant said that both the valet and non-valet parking structures were full.

I started to explain that we had to park quickly so we could see our daughter before her surgery, but drivers behind us began tapping on their horns. The attendant asked me to move on. My wife got out of the car and went to find the surgical suite, while I drove off and found a parking place. I finally reached the surgical suite and spent a few minutes with my wife and daughter, and the surgery went well. But for me the encounter with the parking system remains a moment out of Kafka.

Since then, the hospital has announced plans to merge with another medical colossus in Boston, one with similar parking amenities, and I have enjoyed a recurrent nightmare: My wife and I pull up at a branch of the merged hospital 15 minutes before surgery and Mr. Valet Parking tells us that our daughter's procedure has been transferred across town to the other branch.

Mergers, complete or partial, are happening in city after city (Brigham and Women's Hospital and Massachusetts General in Boston, Thomas Jefferson University and Pennsylvania hospitals in Philadelphia, Jewish Hospital and Barnes in St. Louis). Many others are rumored in what seems to be yet another phase in the industrialization of American medicine.

Hospitals are virtually under orders from society to behave more like businesses. Their survival demands much more effective management systems and cost-containment practices. The merging hospitals hope to achieve operational efficiencies, enhance ``sales'' and acquire ready cash by selling off unnecessary assets, but these gains come with equivalent setbacks.

As we see in other kinds of business, a merger may lead to cannibalization of one of the companies and sale of its divisions part by part. Or a shotgun merger of dissimilar corporate cultures can cripple the day-to-day functions of the new organization.

Such complications could beset hospital mergers as well, but other potential outcomes concern me even more: What's in store for the patients? What will happen to the training of medical students and residents? Will the evolving giant hospitals deteriorate into unconcerned and insensitive facilities, or will they preserve the islands of empathy that now characterize our better medical centers?

Internal antagonisms that sometimes percolate within organizations are often intensified by mergers. It is not uncommon even today for a patient who has been referred from one hospital clinic to another to show up and be told by an irritated desk clerk that it is the wrong time or the wrong day and that ``those people in the other clinic have screwed up again.'' If the mere appointment process can generate confusion of this sort, can one rely on teamwork in operating rooms or at the blood bank when two huge branch hospitals try to work together?

Teaching functions may be especially vulnerable to mergers. We want to train tomorrow's doctors to care for patients with compassion and as distinctive human beings. The larger the hospital, the more difficult that becomes. If medical students see patients consistently shunted around like clinical raw material, they may come to regard that behavior as acceptable.

Society wants hospitals to produce more new doctors who are willing to forgo large financial rewards and work in primary-care fields. But what role models will students find in the new mega-hospitals? The organizational complexity will require exceptionally talented managers, which probably means physician chief executives with incomes of up to $1 million or $2 million a year plus perks. That is hardly what one can expect to earn from primary-care pediatrics or family medicine. In a large organization driven by economic considerations, activities that lose money, such as teaching and basic research, will have difficulty surviving, let alone prospering.

If it takes profound economic and managerial changes to preserve the country's outstanding teaching hospitals, and if these can be effected without compromising the hospitals' caring functions, the patients will benefit greatly. Far better to have the services of those hospitals than to lose them. But compulsive emphasis on shrewd money management, reliance on finely tuned, machine-like organizational systems and blind faith in the value of greater size could do far more harm than good.

Leonard Laster is distinguished university professor of medicine and health policy, and chancellor emeritus, at the University of Massachusetts Medical Center in Worcester.

The Washington Post

by CNB