Key words
gynaecology - epidemiology - abortion
Schlüsselwörter
Gynäkologie - Epidemiologie - Abort
Introduction
Over the past years interested physicians have been able to observe a nation-wide
trend in the appointment of new heads of medical departments. In general hospitals
providing standard care, leading positions that become available are no longer advertised
and filled with new applicants but are rather occupied on a part-time basis by a department
head or hospital director of a nearby medical centre [1], [2], [3]. A partnership is formed between the hospitals which are in effect in competition
with one another. The different financial bases of the hospitals may remain unaffected
but can possibly, in individual situations, also lie in one set of hands.
When the medical directorship of two hospitals lies in the hands of one senior physician
head while the financial bases are provided by two systems, both synergies and conflicts
can arise. This development carries both positive and negative aspects, chances and
dangers which will be formulated theoretically and illustrated on the basis of our
own experience.
General Considerations
The cooperation
From the viewpoint of the hospital management there are in principle several reasons
to implement a cooperation and simultaneous joint medical directorship of two hospitals
working at different health-care levels:
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The desire of the “smaller” general hospital for a strategic union with a medical
centre as guarantee for its continuing existence,
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Diagnosis-appropriate and adapted patient care with economic advantages for both hospitals,
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Increased capacity in the inpatient field,
-
Lack of or unsuitable applications after advertising the position of senior physician,
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Preparation for the take-over of the smaller hospital by the larger one.
Advantages and disadvantages of the personnel cooperation can be found on both sides
and are listed in [Table 1]. Planning security and a strategic linkage to a medical centre at a time when uneconomically
operating smaller hospitals are being shut down appears to be the major motivation
for the cooperation from the view point of the “smaller” hospital.
Table 1 Advantages and disadvantages of the personnel partnership of medical centres with
general hospitals.
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Advantages for the medical centre
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Advantages for the general hospital
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Reducing competition
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Obtaining new customers when specific consulting services take place only in the medical
centre (e.g., radiology, pathology, psycho-oncology, etc.)
-
Access to “normal” patient collectives (e.g., for purposes of research or further
training of assistant physicians)
-
Obtaining physicians in further training in the smaller hospital who may in future
as office-based specialists refer patients to the two hospitals
-
Performance of particular interventions in the smaller hospital which are not profitable
in the medical centre on the basis of its more expensive cost structure (e.g., outpatient
interventions)
-
Performance of certain operations in the medical centre which would lead to organisational
and financial difficulties in the smaller hospital (e.g., surgery of ovarian cancer)
|
-
Connection with a larger hospital for strategic direction and planning security
-
use of niches easier in the cooperation since the entire specialist field is covered
-
Linkage with and use of existing structures (e.g., certified cancer centres, urogynaecological
centres, etc.)
-
Occupation of medical positions possibly easier through the more “attractive” larger
hospital since, as a rule a higher grade of further training possibilities and initiative
competition are in existence
-
Expansion of certain surgical interventions
|
|
Disadvantages for the medical centre
|
Disadvantages for the general hospital
|
|
|
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For fields like surgery and internal medicine it can be very reasonable to concentrate
smaller operations and certain patients (e.g., geriatric patients) in the general
hospital in order to reserve the more expensive beds of the medical centre for complex
operations (e.g., transplantation surgery) or intensive care patients (e.g., care
of cardiac patients). This does not hold for gynaecology because practically all operations,
except for the interdisciplinary operations for ovarian cancer, can be performed in
all gynaecological departments. The result of this is that all gynaecological departments
are effectively in competition with each another. Thus when the medical direction
of two hospitals is in one set of hands a distinction between the patient collectives
is only difficultly possible and is frequently associated with deficits on the one
side or the other, unless, of course it is possible to attract new patients for both
hospitals.
The divided head physician
An elemental requirement for the double head physician position is a clear delineation
of the interests of the two hospitals. Whether or not a trustful cooperation is possible
depends on two principle questions: whether both departments must work in a profitable
manner or whether the one has more income at the cost of the other and the losses
of the other side can be compensated. This question arises especially when the two
hospitals have different financial foundations. In such a case divergent interests
arise since the partners may simultaneously be competitors for one and the same patient
collective. Clear agreements, preferably in written form, are then necessary in order
to avoid conflicts of interest from the very beginning. Compensatory payments can
then be considered which may become possible due to a decline in the case mix of one
of the hospitals.
The divided head physician must think about further rules concerning liability insurances
and on the usage of existing cooperations, e.g., in the framework of certified subsections
of the hospital (breast centre, genital centre, pelvis centre, etc.).
Whether or not the increased workload of the divided head physician results in an
increased salary depends upon the agreed contract. Of particular relevance are the
right to treat private patients and the civil servant status of the head physician.
On site representation
Since the divided head physician cannot of course be present in two places at the
same time deputies must be appointed in both hospitals who are able to make all decisions
on behalf of the head physician in his/her absence. They must possess the necessary
expertise to solve all difficult gynaecological and obstetric problems on their own.
A high degree of mutual trust is necessary. In most cases the new head physician will
bring own his/her deputy to the new hospital and only rarely will a senior physician
from the “old” team be named as deputy. The motivation to accept such a position is
probably closely correlated with the senior physicianʼs own prospective career planning
and the particular financial reimbursement.
Furthermore, this deputy must be registered with the local medical association as
a physician empowered to train others in order that the continuing medical training
responsibilities are fulfilled even when the head physician is not present in the
hospital.
Medical colleagues
The senior physicians and assistant physicians at the two hospitals may work separately
without any contact with the staff of the other hospital or alternatively work according
to a rotation system in both hospitals. Of course it must be assured that the individual
physicians really are in a position to fulfil the medical spectrum of both hospitals
(e.g., perinatology in level 1 centre) and that the hours of duty (possibly active
vs. standby duty) are comparable [4], [5].
The head physician also has responsibilities for further education. Here, especially
synergies can arise since deficits in training at the one hospital can be filled by
further training at the other one. Accordingly, by means of a rotation system a comprehensive
further education for all assistant physicians can be achieved and, possibly, also
specialist qualifications may be gained. In times of reduced applications in our specialty,
in particular, this can be advantageous for the general hospital. The physicians of
the medical centre can also benefit from this since they can learn interventions in
the general hospital that are very rarely encountered in the highly specialised medical
centre.
Medical liability insurance
The liability insurance company must be informed of the change in circumstances. They
must agree to the new situation. It appears to be particularly important to exactly
describe the rotation positions of the deputies, senior physicians and assistant physicians
and to have them checked. The liability insurance company must also be informed about
rotation systems for all other medical personnel [6].
Patient satisfaction
As a rule the patients react positively to these changes. They welcome the application
of modern standards of a medical centre in the general hospital. Furthermore, the
patientsʼ trust in the general hospital can be increased when the foundations for
certification (e.g., minimum number of treatments) are fulfilled by the cooperation.
Thus, smaller hospitals may also obtain certification (e.g., breast centre or urogenital
centre) which would otherwise not have been possible [7], [8].
When the capacity of one of the two departments is reached, it is possible to fall
back on the other one as a solution in the patientsʼ best interest.
Cost effectiveness
The cost structure of a hospital determines whether a medical service can be carried
out in a profitable manner. Up to now it is usually very difficult for most hospitals
to calculate whether individually defined treatments can actually be carried out economically.
Nevertheless, good controlling together with the head physician can establish which
services in each hospital are not economically worthwhile. This must not inevitably
mean that the same situation exists in the other hospital since this may have a different
cost structure. Thus it must be determined at regular intervals just which services
should be offered in each hospital. For the sake of orientation one could propose
that major gynaecological cancer operations are more economic in the medical centre
than in the general hospital since, in such cases in general, complex cases can be
better absorbed by the capacity. In the general hospital, as a rule, rather urogynaecological,
endoscopic, reconstructive
operations or cosmetic operations as self-paid services can be offered.
Illustration of an Existing Cooperation
Illustration of an Existing Cooperation
Cooperation between the surgical departments of Salem Hospital of the Evangelische
Stadtmission Heidelberg gGmbH (Krankenhaus Salem) and the University Hospital has
been in existence since 2003 under one professor and head physician (Prof. Dr. M.
Büchler) [3], [9]. In 2007 a successor was needed in the department of gynaecology and obstetrics.
From the point of view of Salem Hospital the reasoning for cooperation was to establish
a strategic position. In spite of the fact that Heidelberg has the lowest birth rate
in Germany it maintains four departments of gynaecology and obstetrics. Since May
2008 the university gynaecological clinic and the department of gynaecology and obstetrics
of Salem hospital are under the medical direction of Prof. Dr. Christof Sohn.
Heidelberg university gynaecological clinic is a specialist medical centre with 103
beds, more than 5000 inpatients and ca. 1400 births per year. Gynaecological oncology
(breast centre with ca. 700 primary cases per year) and perinatology deserve mention
as particular specialties ([Fig. 4]).
Fig. 1 Case-mix index (CMI) per business year; the decline in Salem hospital correlates
with the increasing number of births.
Fig. 2 Inpatient cases of the gynaecological-obstetrics department per year.
Fig. 3 Number of births (spontaneous and vaginal operative births and caesarean section
deliveries) per year.
Fig. 4 Number of primary breast cancers per year.
Salem hospital is an academic teaching hospital of Heidelberg University with 238
beds maintaining, besides the gynaecological department, also surgical, internal medicine,
urology and anaesthesiological departments. The hospital and its departments have
always enjoyed a good reputation among the inhabitants of Heidelberg. The department
of gynaecology and obstetrics has 42 beds (21 for gynaecology, 18 for obstetrics).
With the sponsorship of the Dietmar-Hopp-Stiftung a nearby 19th century villa has
been lavishly converted to an exclusive maternity station on 3 floors. This was opened
simultaneously with the appointment of the new director.
Our concept provided for the following central points:
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Increase in the number of births, starting from ca. 700 in 2007 with a continuously
decreasing tendency, by a consequent positioning as individual, family obstetrics
services while maintaining university hospital standards and an exclusive cooperation
partner.
-
Extension of the certified breast centre to include Salem hospital.
-
Establishment of an interdisciplinary cooperation with the surgical and internal medicine
departments for the treatment of urinary incontinence and prolapse complaints.
-
Performance of smaller surgical interventions as well as vaginal and urogynaecological
operations in Salem hospital.
-
Performance of gynaecological-oncological interventions in the university clinic with
endoscopic standards.
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Creation of an adequate external image.
For optimisation of the obstetric procedures, after a short observation period the
previously applied standards were completely revised. Numerous routines were examined
and changed in cooperation with the medical and nursing staff and adapted to the contemporary
wishes of couples (episiotomies only in cases of an absolute indication, umbilical
blood sampling, less invasive measures, alternative means for inducing labour, reduction
of the number of caesarean sections, pleasant environment, late visiting hours, baby
photography). Care of the newborn babies in the maternity unit was transferred to
the neonatology department of the university hospital (department head: Prof. Dr.
J. Pöschl), who also took over responsibility for the emergency care in the delivery
room and the reanimation training programmes held every 3 months for the medical team.
Furthermore, high-risk pregnancies and births as well as deliveries before 36 + 0
weeks of pregnancy were cared for in the
university clinic. The newly renovated maternity villa in addition provides spacious
rooms, adroit partitioning, practical furniture, large bathrooms, pleasant breakfast
room and optimal prerequisites for rooming as if in a four-star hotel. Through these
measures a good acceptance of the new concept was soon achieved so that the number
of births has almost doubled up to 2010 (1283 births; [Fig. 3]), the rate of caesarean sections has declined from 40 % to less than 30 % and episiotomies
were only performed on 19 % of the patients (previously 40 %).
In surgical gynaecology the certified breast centre could be extended to Salem hospital
so that all university cooperation partners of the university gynaecology clinic can
also serve Salem hospital (pathological institute, radiology, radiotherapy, plastic
surgery [Berufsgenossenschaftliche Klinik Ludwigshafen], psychooncology). Breast care
nurses can also be trained in Salem hospital. Each patient is presented pre- and postoperatively
to an interdisciplinary tumour board. In this way, those patients who wish to be treated
in a religiously-based hospital or those who do want to be treated in a university
hospital can still profit from the high standards of a certified centre. The number
of breast cancer operations in Salem hospital has remained constant.
For gynaecological oncology it was decided that patients could receive diagnostic
treatment in Salem hospital (stereoscopy, curettage, ionisation, biopsies, etc.),
whereas, with the patientʼs agreement, operative treatment of disease would be carried
out in the university clinic since the latter can offer laparoscopic procedures and
in the near future also robot-assisted surgery. Furthermore, surgical flexibility
is greater in the university clinic.
In cooperation with the urological department of Salem hospital, a urogynaecological
surgery has been created and is headed by a female senior physician. Preoperatively
or for consultation, many patients are referred here by general practitioners or to
the surgery in the university gynaecological clinic. Operations on the patients are
performed in Salem hospital by the urogynaecologist Dr. Maleika (AGUB III), who is
a senior physician at the university clinic and deputy head physician at Salem hospital.
For optimisation of the external image, the press centre of the university hospital
has created an appropriate internet web site, the contents of which were initially
prepared by the medical staff. The previously prepared brochures have been completely
revised with the help of the press centre. A parent information evening has been established
and is held twice each month; this is announced in the offices of general practitioners,
in the internet and in local newspapers in appropriate optical forms. These parent
information evenings are not only well adapted to the requirements of women in Heidelberg
but also encompass midwives and sisters of the maternity villa so that couples are
introduced to a team representing the mutually established vision of obstetrics at
Salem hospital. Finally the authors visited also all office-based gynaecologists in
the area to explain the new concept to them.
A rotation of the assistant physicians in training was initiated. Surprisingly, experience
showed that the rotation between the two hospitals did not occur with equal motivation.
Physicians of the university clinic have consciously chosen their career planning
within a medical centre and rather view a temporary switch to a general hospital sceptically,
whereas the colleagues in Salem hospital show a high motivation to gain new experiences.
Furthermore, from the view point of the university physicians there is the fear that
the absence could lead to scientific disadvantages.
Discussion
Our specialty gynaecology and obstetrics is facing difficult times. Many departments
are suffering from declining case numbers, especially in obstetrics. Thus, new concepts
are needed to counter this trend, before political interventions occur, for example,
in the form of the definition of minimum case numbers. Cooperations – as described
here – may represent one option to work together against this trend.
The introduction of new diagnostic, operation and systemic treatment methods into
gynaecological oncology will lead to the creation of specialist centre even if at
the moment there is the widespread opinion that all gynaecological tumours can be
operated and treated classically in all departments [10]. This ignores the fact that endoscopic procedures, robot-assisted surgery, intraoperative
radiotherapy and special systemic therapies cannot all be offered by one clinic. Even
so, the patients have accepted the creation of specialised oncological centres and
prefer to undergo treatment in them [11]. In future there will rather be further specialisations in gynaecological oncology.
Furthermore our specialty must assert itself in competition with other specialties
in which alternatives to our procedures can be performed. For example, this is the
case in urogynaecology or surgery. We can counter this threat, for example, by demonstrable
competence in the respective field and by interdisciplinary dialogues.
By cooperation between two departments of gynaecology and obstetrics, the two hospitals
can be strategically guided within a region and thus ensure the continuing existence
of both departments. In Heidelberg this procedure resulted in a stimulation of both
clinics. The number of births increased in Salem hospital through the new standards,
university cooperation partners and a well-conceived publicity without impinging on
the patient collective of the university clinic specialising in high-risk obstetrics.
In gynaecology an increased number of patients with gynaecological tumours could be
recruited for the university clinic. Thus the case-mix indices in both hospitals remain
constant with increasing case numbers ([Fig. 1] and [2]). Certainly some of these developments would have occurred without the cooperation
(e. g., increasing number of births due to the renovated maternity villa in Salem
hospital; increasing
number of gynaecological oncology patients in the university clinic). However, it
is not certain that these developments would have been equally effective without the
additional supporting synergisms (exclusive cooperation with the university paediatric
clinic; structuring of the patient collective). Numerous developments would not have
been possible at all.
As a limitation, we have also noted an in part critical point of view by some office-based
gynaecologists who now refer fewer patients than previously to the two hospitals.
This appears to be due, among others, to the fear that university medicine could develop
an excessively large dominance in the region. A responsible, humane and highly qualified
treatment of our patients will hopefully convince these colleagues in future of the
advantages and utility of the partnership.
