In the face of what one longtime physician described as "decapitated leadership," the medical staff at Providence St. Patrick Hospital in Missoula took a unanimous vote of "no confidence" in the hospital's administrative structure at a three-hour emergency meeting last week.
The Missoulian obtained an audio recording of the unprecedented meeting at St. Pat's Broadway building on March 7, but is not publishing comments from anyone who attended but did not give explicit permission to use their remarks.
Physicians at the meeting and in later interviews with the Missoulian said they were concerned about:
• The lack of local decision-making within the corporate structure of Providence Health and Services.
• The forced departure last year of St. Patrick's CEO Jeff Fee and the elimination of the CEO role, lessening Missoula's autonomy to make decisions critical to its future and giving more power to out-of-state regional administrators.
• The departure of several longtime and well-respected physicians.
• The shuttering last year, with no physician input, of the Inpatient Rehabilitation Facility, which they considered an essential component of the hospital.
• The perception that their voices are not being heard.
“There are reports of very serious concerns about our future from every service line, department and program in our institution,” the lead-off speaker and longtime physician told the crowd at the emergency meeting. “Those reports have come to me almost uniformly with the insistence that the concerns be expressed anonymously.
"There is, in fact, widespread fear of retaliation and retribution within our physician community," said the doctor, who requested anonymity because of those fears, but whose speech was obtained and verified by the Missoulian. "The more I speak to people, the worse the situation appears to be. There is now a culture of fear and intimidation which is obviously inconsistent with the mission and values of Providence.”
That same physician later told the Missoulian that the “no confidence” vote means that the medical staff “does not believe (the hospital) is being led in the right direction by its management and that Missoula will suffer as a result.”
During the meeting, several physicians expressed concern over the loss of Fee and Dr. Matt Maxwell, the head of cardiovascular surgery at the hospital. Maxwell, who is highly respected by his colleagues, has announced his intention to resign June 1 in response to what several doctors called “utter frustration.”
The medical staff also voted unanimously to direct the hospital administration to do everything they can to convince Maxwell to stay.
Dr. Joseph Knapp, a cardiologist at the International Heart Institute of Montana inside St. Patrick Hospital, has worked there for 32 of the past 35 years. He also spoke at the emergency meeting to share his concerns.
“This is not a personal thing (and) is not about any individuals who occupy positions of leadership at St. Patrick Hospital," Knapp told the Missoulian.
"This is about the structural changes that have occurred in the last year or two … that have resulted in the elimination of the CEO at St. Pat’s, which resulted in the resignation of Martin Burke from the hospital community board, which I believe led ultimately to Dr. Matt Maxwell resigning as head of cardiovascular surgery.”
Knapp, who said he was speaking only for himself, said he considers the resignation of Maxwell a “sentinel” event.
“What I’ve experienced is almost a decapitation of the centerpiece of the leadership," Knapp said. "Our community leader, our corporate leader and our physician leader are gone, and I think that’s a travesty, personally.”
Knapp said that the environment in which he and his colleagues come to work every day has become progressively more distanced from the ability to do what they could accomplish 20 to 30 years ago, "which is to walk into a room with somebody who has a designated title, make a statement, and see something affected as far as the environment we live and work and breathe in."
Knapp said that the relationships that physicians have with referral institutions has been dramatically affected by the absence of a CEO.
“We no longer have executive officers, and in parallel there has occurred a centralization of fundamental administrative services which used to be within St. Pat’s that have been moved elsewhere,” he said.
“These are services that we rely on for day-to-day administrative support for clinical endeavors, such as IT support, outreach, relationships with outlying hospitals, contracting and a number of others that have been moved to western Washington and other places.
"It is an absence of executive leadership in our institution ... . It is the removal of vital support and services, administrative and business support services, from our institution to the West Coast.”
Knapp wanted to emphasize that his concerns are not about particular individuals, but about the structural changes undertaken by Providence.
“I personally do not fear any retribution, but then again I happen also to be 67 years old going on 68 and at a place in my career where I have done a lot of the clinical good I can do,” he said. “I want to see our institution kept full and fully functional.”
A letter titled “A Summary of Physician Concerns" was circulated among the medical staff last week. The Missoulian could not verify who wrote it, but several physicians who also requested anonymity said it reflected their feelings and the feelings of their colleagues.
“As physicians at Saint Patrick Hospital, we are deeply concerned by recent events that directly affect our ability to provide high quality care to patients of Missoula and the surrounding communities of western Montana,” the letter read.
It went on to state that there has been a loss of local organizational autonomy and governance at the hospital, which is part of Providence Health and Services, the Seattle-based, not-for-profit organization that operates hospitals and clinics across five states.
Last September, when Fee was forced out, Joyce Dombrouski, then Providence’s COO, had her role expanded to take on day-to-day operations at St. Pat’s and St. Joseph Hospital in Polson. Elaine Couture, Providence’s chief executive of its Eastern Washington/Montana Region, is the regional administrator.
The letter said physicians feel that local doctors are “disempowered” and that there are “increased pressures to simplify, define and create guidelines for patient care in an attempt to industrialize clinical medicine, thereby shrinking complex multifactorial decision-making into linear and easily measurable metrics that have little evidence-base.”
Physicians believe, the letter said, that critical health services are being relocated outside Missoula, and that Providence Health and Services wants to send those services to Spokane and other facilities “to the detriment of our local community.”
Finally, it said physicians perceive a “lack of incentive” to help recruit highly qualified, full-time doctors to key specialty positions and were concerned about the number of temporary physicians who have been recruited to fill critical roles.
“Having new providers each week, who may never return again, raises concerns about consistency, and ultimately, dysfunction of the healthcare team,” the letter read.
Couture, the chief executive of Providence Eastern Washington and Montana, said in a statement that “despite ongoing challenges,” Providence is committed to "supporting and growing Providence St. Patrick Hospital’s distinction as the tertiary center of excellence" in western Montana while "maintaining the high level of clinical care" in Missoula.
“There is no escaping the challenges and impacts caused by the volatility of our current health care industry – rising drug costs, lower reimbursement rates, higher volumes and sicker patients,” Couture said.
“These trends promise to continue with unpredictable variance, and no one is exempt from this unpredictability. While external forces will continue to impact, we remain committed to maintaining the highest clinical quality care to all people – most notably, the poor and vulnerable. This is our reality and our responsibility. In order to do that, we need to work as a united team of physicians and administrators.”
Joyce Dombrouski, now the CEO of Providence’s Western Montana Service Area, said in a statement that physician engagement is "key."
“Physicians are the foundation of our work,” she said. “While a recent physician resignation has intensified the platform to respond to physician concerns, their involvement and guidance have always been essential to the success at St. Pat’s. So much so that we realigned our governing model over the last 24 months by creating two new physician administrator positions on the Western Montana executive team.”
Dr. Matt Maxwell said he has been at St. Pat’s for 20 years and recently gave his 90 days' notice.
“I was one of the founding members of the International Heart Institute, but I felt like it was time to leave,” he said.
The reasons, he said, are "plain enough." And the physicians' letter of concerns is “reflective of many physicians' feelings."
“We have a company that’s not based in this state and is making decisions that affect us locally, and sometimes frustrations occur,” Maxwell said. “But I don’t want to suggest that I’m speaking for anybody but myself.”
Maxwell said he thinks the issues at St. Pat’s reflect a lot of changes in medicine nationwide. He also believes there are constructive solutions.
“You can’t unionize in medicine, but as a group you have a stronger voice,” he said. “That changes the dynamic in a positive way. We certainly depend on a functional and appropriate hospital just as they depend on a physician workforce.”
Maxwell said he is "actively pursuing other jobs as a cardiovascular surgeon" but does not want to move family, including an eighth-grader and a sixth-grader, out of Missoula.
"So I am going to commute," he said. "I feel like opportunities are better elsewhere right now. I have a different vision about how I would want to serve our community, and have decided my vision isn’t compatible going forward.”
At the emergency meeting, Knapp said several things have changed at St. Pat’s recently, many of them not for the better.
“For me the basic sense is many of the things that are responsible for the day-to-day functionality have effectively been taken away from us,” he said. “I don’t think this is a mission problem and I don’t think this is a problem of money, although we’re in financial straits.
"I think, personally, this is a problem that many corporations run into, which is a lack of people feeling like they have any control over the day-to-day functionality.”
Knapp said that the two recruiters who are responsible for replacing Maxwell are based out of state.
“Our contracting is being done by people who don’t understand who we are and how we do it,” he said. “We have specific concerns about the direction and opportunities for turning this whole project around. This is a remarkable institution and I find this an incredibly admirable place. I want to be able to die here.”
Chris Price, an orthopedic surgeon at Missoula Bone and Joint, was also at the meeting. Although not employed by St. Pat’s, the meeting was open to all medical staff who collaborate with the hospital.
Price confirmed the “Summary of Physician’s Concerns” letter had been widely circulated and that the physician who spoke about a “fear of retaliation” was not off base.
“I think it was clear that evening that a large percentage of the physicians share those same feelings,” Price said. “Our biggest concern is for the patients in western Montana and continuing to get the highest quality healthcare they can possibly get.”
None of the physicians the Missoulian spoke to believed that the quality of patient care has been negatively affected by anything going on with the leadership at St. Pat’s.
“But I am concerned that it could affect the healthcare in the future," Price said. "The whole administration, I believe, is trying to do the best they can to provide good health care. But I’m not sure that the larger corporate goals align well with the patient needs in western Montana.”
Price said he's concerned that decisions about the future of health care are being made at the corporate level that will negatively affect health care in western Montana.
“There needs to be more local decision-making,” he said. “I think the restructuring of leadership and taking away the CEO position of St. Patrick Hospital is evidence that decisions are being made outside the Missoula region.”
Kirk Crews, a physician who resigned from St. Pat’s last December after 12 years, said there’s a “lot of unhappiness” at the hospital right now.
“The truth is Seattle doesn’t care,” he said. “To them we might as well be Sula. I feel like I voted with my feet. The most powerful thing I could do was quit and start my own practice. But the loss of Matt Maxwell is going to have a direct impact on the quality of care that people in Missoula get on a daily basis. That guy has given his life to creating the St. Pat’s heart program.”
Dr. Bill Bekemeyer, the Western Montana Community Ministry Board Chair, said that St. Pat’s continues to lead Montana hospitals in clinical and quality outcomes.
“We are proud to point to the innovative models and advancements that place us in the highest national care levels,” he said. “Our hospital and providers are esteemed and valued for such excellent care. That hasn’t changed just because administrative leadership did.”
Dr. Alan Thomas, the chief of the medical staff at St. Pat's, could not be reached for comment on Tuesday. Calls to chief physician executive for acute care Dr. James McKay, and to chief physician executive for ambulatory care Dr. Samer Khodor were not returned.