Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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The Chicago Quartet: Volume Three: Who Needs Hospitals?: Examining the Need for Change of Role

Harry Heston, CFO and great curmudgeon of the Pennsylvania Hospital, was having lunch with me and Joe Nicholson one day. It wasn't exactly a happenstance, because Joe had expressed interest in seeing what a business doctor could diagnose in the financial pathology of hospitals. So, when Joe and I were having lunch in the hospital cafeteria, I spied Harry sitting alone (of course) at a table and asked him if he would like us to sit with him. He could scarcely refuse, and I set the conversation going on accounting issues. We chatted about fund accounting, and Harry allowed as how the Pennsylvania Hospital didn't use it. His system was to throw all money into a common pot and use it as best he could.

Fund accounting has the underlying concept that the trustees have to respect the varying wishes of the donors of various money, so they kept them from being commingled. My daughter had said that the underlying flaw in the system was that there was a need to have the books balance, so things were shifted around between funds in a way that no one could follow. In the process, management lost all of the information value of the accounting system, since things which always come out even don't tell you very much.

We touched on other matters, and then it came out. "George, you always have poked your nose into other people's business." Here emerged the real theme song of administration-medical staff relationships, as sung by administrators. The finances of the hospital are none of the doctors' business. If one of them occasionally makes the effort to understand matters, administration wishes he would shove off. It isn't that administration thinks it needs to hide something shameful from the doctors, it is that doctors should remain in their primary role, which is to fill the beds with paying customers, just as administrators should never, never comment on medical management. That's fair enough, isn't it?

Well, as a matter of fact, no. The implication that the medical staff and the bookkeepers are equals, forced to work together and therefore forced to be tactful about each other's undisputed area of dominance, is utterly impertinent. Someone once compared hospital administration with the deck officers of an aircraft carrier, and the doctors with the fighter pilots. A retort was made that a better analogy would be with the steersman of the landing craft and the soldiers in the hold. Both ideas miss the mark, but the concept of interservice friction is a good one to ponder. The history of all major wars is filled with tragic stories of the Air Force bombing its own artillery, or the artillery bombarding its own forward infantry, or the Navy sending the fighters off the carrier without enough fuel to return, or the Secret Service agent abandoned by the promised rescue boat. Interservice rivalry, interservice friction. Mind your own business, flyboy, this is our aircraft carrier.

Originally published: Monday, October 29, 2018; most-recently modified: Thursday, June 06, 2019