Medical Directors: Why Do You Abdicate Your Advocacy With Nursing Homes?

      Nursing home medical directors are in short supply, and there is great demand for their services. The age-old law of supply and demand places physicians in a position of strength when they are negotiating medical director relationships with the nursing homes where they will dedicate a significant portion of their career.
      But medical directors appear to hesitate to employ the advantage they have in these negotiations: the evidence of their own advocacy is scant, if nonexistent. The silence of medical directors in promoting their professional interests — in sticking up for themselves — is not only deafening, but perplexing.

      The Value of Medical Directors

      The value that medical directors extend to nursing homes has been recognized since at least 1974, when Medicare required the position of a medical director in nursing homes to improve the quality of care. In 1991, the American Medical Directors Association (the previous name of AMDA — the Society for Post-Acute and Long-Term Care Medicine) first articulated the desirable goals and attributes of physicians serving in this role. In 2001, the Institute of Medicine urged facilities to give medical directors greater authority and hold them more accountable for the medical services delivered in nursing homes. And in 2006, the Centers for Medicare & Medicaid Services issued new guidance on the medical director’s role in nursing homes.
      With the integration of medical directors into nursing homes came a bevy of expectations and demands, requiring a unique set of knowledge and skills. These include an understanding of the principles and practice of geriatric medicine and knowledge of drug prescribing for older patients, pertinent regulations governing long-term care facilities, and systems of care delivery. The medical director must also be able to work effectively as part of an interdisciplinary team, act as a spokesperson for the community, and provide education to the community’s employees and patients. In addition, federal regulations governing nursing facilities make medical directors responsible for the coordination of medical care, and they must be involved in developing and implementing resident care policies and procedures.
      To ensure medical directors are capable of providing such services, nursing homes (legitimately and appropriately) pile on yet additional requirements, including extensive background checks, confirmation of education and training, review of prior employment, board certification, and other assurances of clinical competence.

      The Medical Director Perspective

      But from a medical director’s perspective, nursing homes can be opaque: they offer very little information about themselves. The lack of full disclosure about a nursing home to which they may dedicate their career puts potential medical directors at a disadvantage.
      For example, prospective medical directors may find it useful to be provided with pertinent background information about their facility or the facility’s parent corporation, such as the facility’s financial stability, its measures of customer satisfaction, and its employee turnover. They should provide evidence of the nursing team’s competence in cooperatively following physician directives and managing the safe and effective care of their residents. All these issues directly impact the day-to-day function of the medical director as well as his or her professional reputation, employment stability, and estimates of job and career satisfaction.
      The contracts that nursing homes require of their medical directors reflect these disproportionate expectations. Medical director responsibilities often consume four to five pages or more of detailed expectations. By contrast, the nursing home’s responsibilities are more vaguely described and are often limited to just a few lines of text.
      A nursing home’s ability to maintain an efficient daily workflow is essential for medical directors to provide optimal health care and achieve their professional goals. At a minimum, the nursing home should enable or provide the following:
      • Staff who are trained to communicate informatively, efficiently, and with appropriate timing.
      • Someone who assists with scheduling patient visits to prevent wasted time searching for patients within the nursing home.
      • Someone who assists with positioning patients and removing or replacing dressings during wound examinations.
      • A dedicated location to see and examine residents. Examinations should not have to be conducted in a double-occupancy room separated by nothing more than a curtain from roommates and their visitors, with constant interruptions by the comings and goings of staff and visitors.
      • A space for confidential discussions with patients and family members. Personal health information should not be overheard by passersby and roommates.
      • Required meetings set on a schedule that does not conflict with the medical director’s other responsibilities.
      • Patient records and an electronic health records that can be easily accessed, and a dedicated computer to avoid having to compete with the other staff completing their documentation.
      • Attendance at educational sessions (such as in-service presentations) by an engaged and interested staff. When the medical director has taken the time and effort to prepare sessions for the staff, it can be disheartening when job demands constantly pull staff away from these teaching rounds.

      Final Thoughts

      To the Society: While you are to be commended for being a valued resource for the educational products and services you make available to your members, you stop short in not being more forthright in advocating more strongly for the interests of your medical directors, as described in this column, and you have a history of being highly critical of physicians’ performance in nursing homes without balancing your dialogue with advocacy for your medical directors’ perspective.
      To the medical directors: Considering the supply and demand advantage is weighted in your favor in post-acute care, why do you settle for such disproportionate relationships with your nursing homes? And why do you so passively abdicate your own advocacy?
      Dr. Fuller is a triple–board-certified physician-entrepreneur and vice president and corporate medical director of Presbyterian Senior Living, which has communities in Pennsylvania, Delaware and Maryland. He can be contacted at [email protected] .