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What Snyderman is doing is not unique, but it is much talked about in medical circles. If it works, he's a genius. If it doesn't, Duke could go the same route as the University of Minnesota, which sold its hospital, or the University of Pennsylvania, which reported a $40 million deficit this year. Much of the money for the expansion comes from borrowing--$280 million. But Snyderman is convinced that growth will pay off, in no small part by making Duke the hospital of choice for enough patients and doctors that it can obtain more favorable contract terms...
...doubt that Duke needed to change in order to survive, but to some doctors Snyderman represents a shift of power from the stethoscope to the calculator. In 1993, he replaced a longtime department chair with a doctor who also held an M.B.A. A group of dissidents petitioned Duke's board of trustees protesting the changes. But Snyderman survived, and last May his contract was extended again for five years...
...Duke doctors complain that the volume of patients they must see each year has exploded. "Doctors are expected to do patient evaluations in 10 minutes," says a former division chairman at the hospital. "We used to have 30 to 40 minutes." Periodically, harried clinical researchers get profit-and-loss statements that compare the costs of their scientific work with the revenue they generate through patient care...
Shoe was Shah's first patient at Duke's outpatient clinics three years ago, when he was a first-year resident, and the two have established a comfortable rapport. "Oww, that hurts!" she says, wincing as he inserts an otoscope into each nostril. "That hurts? I'm not even touching you," he counters as he peers into her nose. Shah suspects that the bleeds are triggered by her dry nasal cavities and recommends an over-the-counter nasal saline spray, available at any drugstore. He spends a few more minutes chatting with Shoe, then reminds her to return...
Even at a hospital like Duke, where the emphasis is on specialty and cutting-edge medicine, almost half the 130 residents in the department of medicine are training to become primary-care physicians. This is the future of health care--a back-to-basics return to the profession's roots, when small-town doctors made house calls and were expected to deal with everything from births to a burst appendix. "Our mission is to train residents in the reality of where medicine is practiced, and that's in the outpatient setting," says Dr. Barton Haynes, chairman of the department...