Sunday, February 17, 2013

UTSW-Parkland cage match

The Dallas Morning News has been deeply involved in following the many troubles of Parkland Memorial Hospital, and recently offered a story of deep divisions between the hospital and its affiliated medical school, University of Texas Southwestern Medical Center.  The picture given of this relationship provides an extreme example of dysfunctionality, but the underlying pressures that exist to create that strife exist to a greater or lesser degree in many cities in the US.

Academic medical centers are the crown jewels of American medicine, where extremely well intentioned people provide innovation in patient care, research, and education.  But they can also be the intersections of the worst characteristics of two sectors--medicine and academia--with people of great intelligence, big egos, and poor interpersonal skills.  If issues of governance and priorities are not addressed explicitly and with good will, there can be dangerous results for patients and unpleasant working conditions for all.

An excerpt:

Publicly, Parkland Memorial Hospital and its affiliated medical school, UT Southwestern Medical Center, present a united front.  Behind the scenes, however, the reality has been far different

The tension between the two institutions reflects their tangled relationship. Parkland actually has little control over the doctors working under its own roof. Most are employed by, or answer to, UTSW. Parkland’s priority is supposed to be patient care. Yet UTSW lists its missions as medical education, research and patient care — in that order.

The organizations’ divergent missions, business interests and turf battles contributed to a dysfunctional culture at Parkland over the last decade, jeopardizing patient care. Federal safety monitors have flagged the culture as a major factor in plunging Dallas County’s hospital for the poor and uninsured into its safety crisis.

Many times over the last decade, UTSW faculty physicians have failed to show up to care for Parkland’s patients. Instead, they see privately insured patients at the medical school’s separate system of hospitals, or focus on research. Resident doctors-in-training at Parkland often have been left with little or no faculty supervision. And front-line caregivers who report to the doctors, especially nurses, have felt powerless to resolve patient-care breakdowns.

Trust and transparency issues abound.

And further into the story, we get some details:

In reality, there are two separate chains of command inside Parkland.

Parkland’s chief medical officer, for example, is supposed to provide leadership over clinical affairs and quality of care at the hospital. Yet the UTSW president “is actively involved in the selection, regular evaluation and decision to continue or terminate the employment of the CMO,” according to the affiliation pact. The current interim chief medical officer is a UTSW faculty member paid by the university, not Parkland.

Employees say the system — what some call the “two-headed beast” — fosters confusion and chaos. UTSW medical directors, for example, are expected to collaborate with Parkland department directors on decisions. But the structure stymies cooperation.

“Ideally, they’re supposed to meet and discuss the best approach to provide the best of care for patients,” said a former Parkland nurse who has filed a legal claim against the hospital and requested anonymity for fear of retaliation. “What occurs is: they collide. Both have power and both want control.”


Anonymous said...

Not to defend this, but separation is pretty much required by law. The CPM doctrine is alive and well in Texas, and Parkland's physician staff woes are not so bad compared to others, just more public because the Dallas Morning News has focused in on them so hard

Anonymous said...

I don't know what the structural arrangement between the medical school and its (apparently more than one) hospitals are, but I wonder if Parkland is the less-favored safety net hospital for the med school, among others in more affluent circumstances. This is not an unusual arrangement unfortunately, and provides cheap but uninterested physician labor to cover the hospital, poorly it seems. I think you have hit upon a situation that hampers patient care in many cities.
I would be interested in a comparison of the cited situation with the Harvard medical school hospitals, for instance. How is the governance better there, to avoid such disparities?

nonlocal MD

Paul Levy said...

I've described the Harvard Medical School arrangement here:

It is very different in that HMS has no clinical authority at all in its affiliated hospitals. While attending physicians in the hospitals are members of the HMS faculty, their supervision and activities on clinical matters are solely the purview of the hospitals in which they work.

The Harvard hospitals are not formal safety net facilities, but all of them take care of a large number of indigent patients.

Anonymous said...

If you go to USTW's website, Parkland is not even listed as one of their affiliated hospitals. Perhaps that portrays the attitude best.


Miles Moffeit said...

Thanks for helping advance the discussion, Paul. Your first commentator should know that Parkland does fare worst than other Texas hospitals when patient safety indicators are applied.

See the below link. An excerpt:

"Parkland Memorial Hospital, now under U.S. government monitoring because of systemic failures in patient care, has for years been one of the state’s worst-performing hospitals on a broad federal measure of patient safety, a Dallas Morning News analysis shows.
Several other Dallas-area hospitals also ranked among the 10 worst large hospitals in Texas, including UT Southwestern University Hospital-St. Paul, which shares physicians with Parkland. Others were John Peter Smith Hospital in Fort Worth, Methodist Charlton Medical Center in southwest Dallas and Baylor Medical Center-Garland.
Only 10 of the 27 large hospitals in Dallas, Collin, Denton and Tarrant counties ranked above average on the patient safety measure, which was designed to track problems such as surgical accidents and hospital-acquired infections. And only one — Texas Health Harris Methodist Southwest Fort Worth — scored among the state’s 10 best large general hospitals, those with 200 beds or more. Dallas County’s top performer was Texas Health Presbyterian Hospital Dallas.''

I'm happy to provide Anonymous more info at


Peter said...

I trained at Baylor College of Medicine in Houston. My lab was a floor above Dr. DeBakey's O.R. As Chief Resident at The Methodist, I got to follow him and others of his ilk like a puppy dog. I recently attended a meeting held by the new Baylor CEO and was told, in passing, that the Methodist Hospital had dissolved its association with BCM. The Crown Jewels of medical care are falling out of the Academic Crown at an alarming rate. Where they will land, and what will become of them is a big Unknown, to me at least.

Paul Levy said...

Dear Anon,

I have rejected your comment because of its personal attacks.