When I was medical director of a hospital, I dealt with a Dr. Noneg, a prominent member of the medical staff.  Noneg entered practice near the time as I was changing my role to hospital medical director from neurologist.  Because of personality clashes, he soon left the practice that hired him.  He wouldn’t budge on his demands, but he was new to the practice, so there were choices, but not very good ones.  He could lessen his demands, or he could leave.  He left and began his own practice.  He was against insurance companies, as many were, and for some time got a great deal of press because of his outspokenness.

Noneg occasionally practiced outside his field.  When we were both in practice, he handled carotid artery disease cases, something I believed then and now only a neurologist should do.  Since 1984, I had tracked outcomes and referred my patients to only one surgeon, whose outcomes were slightly better than untreated disease.  I made my data available, but the local surgical community slammed me for my data and approach.  I was the only one to deal with this issue using outcomes at my local hospital.  Dr. Noneg did not.  He handled MS cases, which an internist can, but really a neurologist should.  For me, it was a matter of doing what is best for the patient; I wasn’t protecting my turf. Indeed, I wanted less work, not more.

Noneg and I clashed when it came to coverage of the emergency department at night.  Many patients who come to the emergency department don’t have physicians.  If it were a particular specialty, that patient would be assigned to the physician on call for that speciality.  Each physician was on call in a rotation that lasted a month, and several of us had several months a year we had to take new patients.  When one was building a practice, this was a way to do it, unless, of course, the patient couldn’t pay for the services.  I wrote off $30,000 a year in unpaid bills for over a decade.  It was considered normal, but I made good money in spite of it.

Noneg didn’t like this coverage arrangement, and he convinced many of his colleagues that the hospital should pay for such, $500 a night per specialty.  Needless to say, this would have been a great expense for the hospital, since there were at least ten specialties a night that would need payment.  Noneg wouldn’t negotiate.  Not a bit.  In many ways, he reminded me of the Republican Party.  There was no give or take.  If you did what he wanted, he was a nice guy.  If you didn’t, he was an enemy.  Had the hospital capitulated, I certainly would have been laid off, which I could have dealt with, but then the physicians would have had to deal with their issues (yelling at nurses, turf wars) themselves, which physicians, for all their power, are loath to do.  By the way, physician behavioral issues were the single biggest problem I faced as medical director.  I counted.  “Administration is the problem,” was said, until there was a thorny issue, and then “administration needs to fix it.”  Substitute “government” for administration, and you have a common national refrain.   We hate government, until a Cat 5 or an EF4 devastates our town, and then we can’t have enough of it.

Back then, we had nurses from managed care companies review patient charts to see if continued care was necessary in the hospital.  On the one hand, it was a physician’s decision whether or not to discharge a patient, not an insurance company’s.  On the other hand, many physicians would write “Doing well” for days, without any indication of why if the patient were doing so well why they needed hospitalization.  Hospital resources were consumed, not the physician’s worry.  But if somebody is paying the bills, that somebody usually wants to have some control over the costs involved.

An additional issue with utilization occurred in winter, because the city had an influx of visitors, and hospital beds were in short supply.  Getting patients discharged was necessary to allow new admissions, otherwise having to go on “divert,” which was not good for the city.  It was not uncommon for patients to stay in the Emergency Department 24 hours, no bed being available.  This was not good care.  When we didn’t have a bed, because a physician hadn’t visited that day, the physician said the patient wasn’t ready to go, without any documentation in the chart, or because the person covering for a physician refused to make a decision, we had one less bed we could fill.  Dr. Noneg responded to the notes from managed care nurses, polite as they were, with a simple “Drop Dead.”

In a hospital, that is not particularly funny.  Nor was it helpful.

Dr. Noneg persuaded his colleagues that the care of emergency department patients was the hospital’s problem, and the physicians stopped accepting them.  Accordingly, the hospital hired people willing to practice in the hospital full-time, called hospitalists.  They took care of these patients, and during their stay, found a physician willing to care for them after discharge.  I would have liked that job: regular hours, taking care of sick patients, then not having to manage their problems in the office afterwards.

Soon, hospitalists started caring for more and more inpatients.  For some physicians, who were very busy in their office, this was a good idea.  For others, who found that they were no longer going to be able to take care of their patients in the hospital, this was resisted.  The state medical association tried to intervene, but when physicians give up control of taking care of emergency patients, sometimes there are consequences.

Not negotiating has consequences outside of medicine.  It has tied Congress in knots over a host of issues, all of which could be dealt with given some creative thinking and a little willingness to let the other side have something.  But if you are Dr. Noneg, or a member of the Tea Party, you simply don’t negotiate.  Maybe the other guy caves, maybe not.  I learned early in life that the world isn’t going to do what I demand it do.  I had a lot of temper tantrums.  Some apparently do not learn that.

Eventually, Dr. Noneg set up a boutique practice, where he would be available 24/7 for his patients, each of whom paid him $1500 a year.  It wasn’t for the money that Dr. No did this, of course, except whenever somebody says it isn’t for the money, it is always for the money.  Dr. Noneg tried to have his patients jump the queue in Emergency Departments, but one soon learns in medicine that ED physicians and nurses are extremely strong-willed individuals who work in a high stress environment and deal with it well.  They don’t negotiate, either.  Dr. Noneg lost, and his patients had to wait.  The $1500 didn’t cover hospital or consultant costs, although I suspect–but cannot prove–many patients thought it would.

A while back, I got a call at home from Noneg’s office, wanting “my staff” to pull a chart of a patient I had once treated.  I haven’t practiced in over 20 years, and my charts, if still intact, would have remained with my group.  I was surprised that Noneg didn’t know that.

I was also surprised he didn’t demand I produce the charts. That would have been an interesting negotiation.  I would have enjoyed it.  But the world doesn’t always work the way I want it to.


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