Dr. G’s Hard Medicine

As Garthwaite predicted, the news from the docs had a positive spin. Ophthalmology and urology referrals at Long Beach Hospital are up. Average number of days’ wait for a clinic appointment there is down. And the hospital has managed to increase services with no additional money: an anticoagulation clinic for diabetics, a podiatry center and expanded walk-in hours. By meeting’s end, though, talk turned to the need for more funding. “We can be creative,” one doctor said, “but ä there’s only so much we can do given what we have to work with.” Garthwaite was sympathetic. He took notes and asked questions but made no promises.

After the meeting, several staffers stuck around to talk. Lewis Lewis, the county’s director of physician relations, scheduled a meeting to discuss intern positions that could be eliminated. “Let’s face it,” Lewis said, “Tom has to start his implementation and it’s going to get ugly.”

 

Thomas Leonard Garthwaite never planned to be a bureaucrat. His mother was a teacher and his father owned the town grocery in tiny Port Allegheny, Pennsylvania. He has a flat, slightly nasal way of speaking, most apparent when he says “measure,” or may-sure, as in: “If you measure things, they will improve, because you will have a standard from which to work.”

Garthwaite occasionally worked in his dad’s store, but devoted most of his spare time to sports. He played football, basketball, baseball and golf and competed in javelin, discus, high jump and hurdles. He was voted most likely to succeed in his senior year of high school.

He continued to run track as an undergrad at Cornell, holding the school record for several years. He got his medical degree from Temple University, interned in Milwaukee and then took a job as an endocrinologist for the VA. While working on a research project, he complained about the long waits for access to test subjects and was drafted to reform the process. Thus began his shift from practitioner to administrator. Looking back, he said, he’s more than satisfied with the change. “In the end more people were affected by what I did in management than by what I could do in an exam room,” he said. “When you reform a system, you can’t point to the person you’ve helped, but you can be sure intellectually that you did.”

Health-care systems are generally considered among the hardest bureaucracies to fix, in no small part because doctors are notoriously independent. When Cedars-Sinai Medical Center recently tried to set up a computerized patient-tracking system, the doctors revolted and the effort failed. At County-USC, a glitch in the new data-tracking system shut down the entire network for two days in late April, causing chaos and leading some doctors to declare the project a disaster. But Garthwaite remains optimistic that changes can succeed. “One good piece of news is I’ve worked in a very large system that’s been successful in making changes,” Garthwaite said. “And secondly also being a physician, I kinda know what’s BS and what isn’t.”

In 1995, when Garthwaite took the VA undersecretary job, a federal probe had just recommended disbanding the entire VA health-care operation. As Garthwaite likes to describe it, those were the days of the VA à la Born on the Fourth of July, when service was shoddy and saying you worked for Veterans Affairs was worse than saying you worked for Ma Bell. Instead of shutting down, the institution underwent a major shift, opening 600 new clinics and reducing the number of hospital beds by half. From 1995 to 2000, the agency cut registered nurses by 10 percent and nursing assistants by 30 percent, relying heavily on contract workers to fill the void.

The staff cuts brought sharp criticism from some veterans and from health-care workers, who said that the quality of care was compromised. “In many ways the VA’s health care is still reeling from the budget cuts that occurred during that period,” said Linda Bennett, a lobbyist for the American Federation of Government Employees, which represents VA health-care workers. The average waiting time now for veterans to see a physician for non-emergency care is six months. Still, Bennett said, it would be “a misrepresentation” to single out Garthwaite for blame. Instead, she says, the responsibility lies with Congress and with both the Clinton and Bush administrations, which cut the VA’s budget dramatically. “He clearly did the best he could in an era where we are expected to do more with less,” she said. “But the budget was unacceptable, and ultimately the VA is doing less with less.”

In spite of those constraints, however, Bennett and others say Garthwaite significantly improved the system. The VA became the national leader in patient safety, computerized patient records and prescription services and began measuring performance in ways unheard of anywhere else. In one hospital, the computerized prescription program cut dosage errors by 70 percent. The percentage of patients who could identify their primary-care physicians went from about 25 percent to more than 80 percent.

At the VA, he said, he required every manager to sign a contract directly with him detailing work responsibilities and goals. When this program was put in place, he said, “There were certainly a lot of tight sphincters and gulps around the room. But I think this is really what turned the VA around.”