Should a Thoracic Surgeon Transfer a Complicated Case to a Competing Medical Center Against the Hospital’s Order?

Abstract

Robert M. Sade, MD The Patient Protection and Affordable Care Act was signed into law several years ago, but the future of the emerging health care system remains unclear. The law is not popular and the political outlook for many of its key components is in doubt. Certain aspects of health care can be predicted with considerable confidence, however: an increasing role for bureaucracies and decreasing power of physicians. These trends pose dilemmas for surgeons, particularly when a conflict of loyalties is created when hospital administrators demand that physicians place the interests of the medical center before the interests of patients. The question of how to respond to such conflicts of loyalties was debated at the 61st Annual Meeting of the Southern Thoracic Surgical Association. The session focused on the case of a surgeon faced with a complex clinical situation that would require operative management, either in her own hospital, as demanded by an administrator, or in a competing hospital after referral to a surgeon more experienced in handling such cases. A Case of Divided Loyalties Dr. Elizabeth Black, a young cardiothoracic surgeon in a 400 bed community hospital, receives a call from the emergency department regarding a patient with a confirmed diagnosis of perforated esophagus, which occurred more than 24 hours ago. The patient is stable, but has early sepsis and multiple co-morbidities, including alcohol abuse. The hospital where the surgeon works has 2 groups of cardiothoracic surgeons in competition with one another, all of whom do cardiac surgery and most of whom also do some general thoracic surgery. None of the surgeons has special expertise with esophageal surgery — they generally refer elective esophageal cases to a large university hospital 50 miles away, which has an international reputation in the management of esophageal disease. Dr. Black feels it would be in the patient's best interest to be transferred to the university hospital instead of caring for him locally. When arrangements for transfer are begun, the hospital administrator informs the surgeon that she must accept the patient and care for him. The hospital is in the same market catchment area as the university and does not wish to lose patients to its competitor, especially a patient who has already been seen in its emergency department. Dr. Black feels uncomfortable in accepting this patient, and does not feel confident in her ability to optimize his chances of survival. Nonetheless, financial arrangements and competition with the other group of surgeons make it very difficult to refuse the hospital's demand – she is board-certified and through her education and training, she knows the correct care of the patient, and has done similar cases as a resident. The patient's social situation (no apparent family members) and current medical condition do not allow him to make an informed decision about his locus of care. In case of a bad outcome, legal repercussion are highly unlikely. Dr. Black asks two of her out-of-state surgical colleagues to advise her on what she should do.