February 2004
Volume 28 • No. 2

'Real World' benefits can flow from 'real time' licensure visit in Apri

TECH Desk
demystifies for medical staff

4Cs of Communication are the Corner Stones of patient safety

Eight unaccepable abbreviations/chart.pdf

Bryan Bohman sees medical board service more like medicine than anesthesia

Advanced Med Center / Cancer Center Quick List

HIPAA Tip

Profiles added to physician credentialing

Physician photos makeup slated

Quality Corner:
New UPDATE feature

Bryan Bohman, like several of his colleagues on the Medical Board, has a variety of Stanford experience he hopes to use in fostering communication among the medical staff. He is currently a partner in Associated Anesthesiologists, a half-century-old community practice group.

Bryan Bohman sees Medical Board service more like medicine than anesthesia: progress can be nuanced

Serving on the Medical Board is probably more like practicing medicine than anesthesiology, says Bryan Bohman, who is board certified in both fields but has practiced the latter in the Stanford community for 20 years.

Bohman was elected to the Medical Board and is serving a three-year at-large term that started late last year. He said he was encouraged to seek the office by a community physician colleague.

"I'm a little bit impatient - which perhaps correlates with the rapid feedback one gets while practicing anesthesiology," said Bohman, who was elected to the Stanford Hospital and Clinics board last fall. "But I really believe you do need people on the Medical Board who are a little impatient, or at least not complacent and self-satisfied. You can't just sit there at meetings and say, 'Wow, we're doing great; where then is the impetus to improve?'"

Bohman has served with the nine-partner Associated Anesthesiologists (AA) Medical Group of Palo Alto for 13 years after completing residencies in both medicine and anesthesia. During his final year on the house staff, 1985-86, he was associate chief anesthesia resident. While practicing at AA, Bohman was deputy chief of the anesthesia service, 1994-98, representing community physicians in the medical staff leadership structure. He has also represented his regional anesthesia colleagues as an elected Delegate to the California Society of Anesthesiologists.

As an anesthesiologist, Bohman said in a recent interview that he enjoys practicing the quality communication skills required in a limited time to make a patient feel comfortable during a stressful time.

"But medical board meetings go on longer than that," he quipped. "Maybe that's where my internal medicine training can help.

"This is a great institution, and I feel lucky to be a part of it, but of course we need to continue to improve, and we really must facilitate an atmosphere where constructive criticism is encouraged and responded to appropriately. I hope to contribute to that as a member of the Medical Board.

"I think in private hospitals and smaller institutions, it is easier for the decision makers to get feedback from the primary caregivers, but in a facility of this size, it takes an extraordinary effort on the part of the administrators to stay in touch with those concerns. The converse is also true; in smaller institutions it is easier for the medical staff to understand and get involved with various administrative issues. In any case, the more transparent and understandable the decision making process can be, the better."

As for Stanford staff leadership, "it might also improve feedback, in our own medical staff structure, if the elected position of president of the medical staff could be invested with a little more power and responsibility. It stands to reason that an elected officer would be more in touch with and responsive to medical staff concerns as compared to the chief of staff, which is an appointed position.

"At Stanford and I'm sure many other large organizations there is a tendency to make changes by edict and then to gradually amend those decisions in response to negative feedback. But that can be an inefficient and divisive approach. It's much better when decisions are reached through consensus as much as possible, with involvement of the affected parties along the way. It may take a bit longer, but it avoids resentment and alienation and leads to a much superior product.

"For example, recently the university changed the titles of voluntary clinical faculty from 'clinical' to 'voluntary'. I can see the arguments both ways. The community physicians who are donating time and expertise may have seen 'volunteer' as demeaning, while full-time faculty members saw 'volunteer' rather than 'clinical' as a more descriptive title that perhaps better reflected their own full-time commitment. Eventually, the school changed the title to 'adjunct faculty'. My question is, 'Why didn't they solicit feedback, and involve those affected, before making the decision?' So much wasted time, effort and conflict could have been avoided if the process had been more collaborative from the beginning."

Bohman added that the proliferation of e-mail in recent years makes communication easier, "but we're inundated with messages and we need some titration to focus communication to people who really care about particular issues - OR issues should be sent to people with a stake in the OR, and so forth. We'll read those. In fact we've used e-mail very effectively to talk among ourselves in the physician community about the 'volunteer faculty' issue. Now we need to find good ways to communicate that information to those responsible for making related decisions in a more proactive manner.

"One area where communication between decision makers and caregivers really needs to improve is in the way we respond as an institution to the regulatory process. Frequently, policies intended to satisfy regulatory requirements are put in place at the most rigorous level possible. But often there are viable, more doctor-, more patient-friendly options that we can propose if we're consulted," he said. "We've got to stop justifying over-zealousness with the response, 'We've got to do this, because it's required by the joint commission', as though that is automatically the end of the discussion. Often we don't; often there are more palatable, efficient, safe alternatives.

"There needs to be a balance between ensuring the highest quality of care and patient safety on the one hand, and preventing the system as a whole from being unduly burdened by excessive rules and redundant documentation, on the other. I think there has been a tendency to over-regulate and to devalue critical thought by the individual practitioners who actually provide the care and often know best how to deliver it. We have to remember that there is not always only one best way to do things, and we must value the diversity of approaches that provide the raw material for an evolutionary process of improvement in medical care, both administratively and clinically."

Although Bohman does see himself as an advocate for community physicians, "I really don't see 'town/gown' issues as the central force. Certainly the overall relationship between community and faculty physicians is collegial - many of us trained together and now we work together, we socialize together. I really think there is more of a gap between physicians and the administrative structure of the hospital than between various groups of physicians."

Nevertheless, there are some definite differences in perspective, he said. "While faculty are increasingly dealing with more hands-on issues, including doing more procedures and the resultant paperwork, they usually have the help of residents in their clinical activities. However, many community physicians do all of their cases without resident support. As a result, faculty members remain a bit insulated from some of the implementation problems associated with policies which affect clinical care on a day to day basis.

"For example, the Physician Order Entry System had a significant learning curve, especially for community physicians who use the system infrequently without the help of residents to make the entries. And I think just about everybody now admits that the system was just not user-friendly enough and should have been improved prior to implementation.

"But despite these various issues which need continuing attention, most of us are here because we really want to be. There is obviously an attraction working in such an excellent medical center with the great people that it attracts. Most of us enjoy working with trainees, and from my experience as a house staff member, I think trainees appreciate getting a slightly different perspective on patient care from the community physicians. And the community members of course appreciate that their personal physicians have access to a world-class medical facility.

While his focus now is on clinical and leadership issues, Bohman came to Stanford after graduating from the University of Chicago's medical school in 1981 with hopes of pursuing a research career.

"I focused on getting into the best research-oriented medical school I could and then the best house staff program I could, first in medicine, then in anesthesia. ("I had done some neurochemistry research and anesthesiology was a good place to apply that.")

Following training, largely for personal reasons, Bohman said he opted to stay in the Bay Area and forego the years of bench research training he'd previously planned. "It turned out I liked clinical anesthesia a lot more than I thought I would, and when the opportunity came to stay in the area and practice anesthesia at Santa Clara Valley Medical Center, I decided to do that."

It's turned out to be a good choice: my practice has been really enjoyable through the years, and I've also enjoyed developing many relationships in the community - with my partners, other anesthesia colleagues, surgeons, nurses, and also patients and their families.

After five years at Valley Medical Center, followed by a year of freelance practice at several private hospitals in Northern California and Utah, Bohman joined the AA Group in Palo Alto. He currently practices anesthesia at Stanford and at several surgicenters and physician offices throughout the area.

Now will his term on the Medical Board make a difference?

"It's worth a try," he said.