Back in the 1990s and early 2000s I was part of a Memory Disorder Clinic that eventually became a Memory Disorder and Geriatric Psychiatry Clinic. When I joined there were 3 physicians a neurologist, a geriatrician/internist, and myself. We also had a social worker and an RN. We did detailed evaluations of cognitive problems of people in people ranging from their late 40s to their 90s. We saw a significant number of people with brain injuries and probably the most people with hypoxic brain injury that I had seen anywhere. We had multidisciplinary conferences and met with families in those conferences to discuss our recommendations. We also offered some research protocols and tacrine – the first centrally acting acetylcholinesterase inhibitor (ACEI) until safer medications from that class became available. We saw and followed a unique group of people with chronic delirium who we followed until they improved. I was developing a resource for people with aggression and dementia and thinking about how to do telepsychiatry at that facility for rapid access. At the time there were no facilities that dealt with that problem and it typically resulted in discharge or prolonged hospitalization. Since most of those patients were admitted to my acute care unit it would also decrease inpatient utilization. We had a small number of examination rooms, a nurse’s office and a shared conference room in a large medicine and medical specialties clinic. Nothing fancy - I went there for my own care but I may have been seeing it through the rose colored glasses of an altruist. After all - we were on a mission - all of us. We had a good referral base and many primary care physicians liked our service, referred patients to us, and consulted with us by email or phone. At the time we were all part of a private multispecialty group in a Level I trauma center – dedicated to provide care to anyone in our metro area.
Flash forward a few years. We have been acquired by a
managed care company. The details of that acquisition were never clear to me
but it did not take long to impact the clinic. The inpatient neurology service was eliminated. They were not a source of referrals for us –
but that change had an impact on my neurology colleagues. I had a personal connection to that service because a few years earlier I did the neurology rotation of my internship there and had many positive memories. There was
also a rumor that neurology would no longer be consulted on strokes but they
would be done by a hospitalist who “had an interest in strokes.” Both of those developments had a profound
impact on morale. There were rumors of early retirement and looking for jobs elsewhere.
We lost our geriatrician and then our social worker. It was down to me, the neurologist, and our RN
who gathered a significant amount of collateral history before the patients
came to the clinic. Word eventually came
down that “we can no longer afford the RN.”
The neurologist and I looked at one another and decided that would be
the end of the clinic. We both had other
jobs and did not have the time to spend additional hours rooming patients and
collecting preclinic data. We also knew
we needed that data to do an adequate job. It is impossible to assess and treat people with significant cognitive problems without collateral information. About a year later, the neurologist left
to head an Alzheimer’s Clinic at a major university medical center.
Flash forward to today. I am standing in front of a shiny new Neuroscience
Center. For the past 9 months – I have had a new onset of headaches on top of
rather chronic headaches that are related to cervical spine problems that
probably date back to when I was a kid playing football. I set this appointment
up myself after being assessed as having “tension headaches” and a “non-focal
neuro exam.” This post is not about the
differential diagnosis of headaches (although it could be) – so I am not going
to elaborate on the symptoms. I will
only say that I have street cred in neurology and had additional thoughts
on the headache type and whether you should image the brain of an old man with a new onset significant headache.
Refocusing on the neuroscience center it is immense and
obviously very expensive. I go the neurology clinic
on the 3rd floor and it is a large airy atrium with southern
exposure glass. It is so large that the
entire medicine and medicine subspecialty clinics that contained our little
memory disorder clinic could fit inside of it – it could possibly contain 2 or
3 of them. The other striking feature
was that there were hardly any people there. There were 4 demarcated pods with
seating for about 24 people in front of each pod. It was 2 o’clock and only two of us were
sitting there. I happened to be there
only because I got on a cancellation list – my original appointment made in January was not until
September.
The patient waiting area was impressive but as I was called
to go into an exam room – I was not prepared to see the staff support on the
other side of that door. There was a sea of cubicles stretching to the back of
the building – many containing staff who all seemed very busy. As I sat in the
exam room – I watched the big screen TV on the wall proclaim that this was the
largest free standing neuroscience center in the Midwest. I noticed that they did not specifically
refer to physicians or medical doctors only “clinicians” despite naming every
other profession on the team.
The examination itself was uneventful and “non-focal.” A
couple of minor errors were made but nothing to mention here. I am scheduled for brain imaging and a follow
up appointment.
What was prominent on my mind? What happened to my Geriatric Psychiatry and Memory Disorder Clinic? The same management that decided one nurse was too expensive for my clinic sharing space with internists and minimizing neurology, was providing a raft of support in a $75 million state-of-the-art building for neurologists, neurosurgeons, PM&R and associated specialists. Of course at that time there was considerable confusion and spin about the relative value unit (RVU) system of physician work units. Did work RVUs or total RVUs count? At one point they tried to tell us that only one psychiatrist in our large department was covering their salary. That went to RVUs needed to pay for rent and other staff. It seemed like there was always plenty of Hollywood accounting. It is another mystery of modern healthcare management and how middle managers increase exponentially in number. There is probably something to be said for market concentration as well and how American governments tend to provide corporations with much more leverage than individuals or smaller businesses.
At any rate it seems like they finally figured it out....
George Dawson, MD, DFAPA
