Having almost reached the ripe old age of forty-four, I find myself at the opposite end of a peculiar spectrum. At the beginning of my career as a pediatric hospitalist, I knew I was at the bottom of the food chain within the revenue cycle of the hospital system. Without a routine variety of high-priced procedures and diagnostic testing to be had, and a veritable windfall of patients covered by that stellar payer, Medicaid (ILLINOIS Medicaid, at that,) it was made clear throughout residency and beyond that Pediatrics was a zero-sum game at best, when it came to financials.

But, no matter. The name of our game as pediatricians is keeping kids healthy, alleviating their fears, and getting them out of the hospital as quickly as possible if they land there. My glory was in eking out a grin from a wary toddler with my artful performance via unicorn hand puppet. Wearing novelty t-shirts depicting internal organs as characters snuggling up for a group hug was a defining character trait that some felt was problematic. But, I was unapologetic. If you hold a medical staff meeting on October 31st, expect your vice-chair of pediatrics to arrive sporting a fuzzy cat ears headband and whiskers drawn on her face. It’s that simple.

Now, as a physician advisor, my involvement with patients is indirect. I review charts for hours on end and discuss clinical scenarios with doctors, case managers, and social workers without ever laying eyes on the topic of conversation. While my concentration remains on the health and safety of the patients, there is another focus at play, which is not so easy to see as patient-centric.

Assuring compliance with the rules and regulations of governmental payers not only lacks a sense of whimsy, but can be seen as downright insensitive. When it comes to medical necessity in relation to hospital care and length of stay, the rules we need to follow are relatively clear. Custodial care in the hospital will not be reimbursed. Pursuing outpatient testing before discharge to save the patient a drive back to the hospital will result in a financial loss to the hospital. Keeping a patient hospitalized for three midnights when only one was medically necessary could lead to a huge bill for the patient from the Skilled Nursing Facility when CMS reviews the stay years later. And, “soft admissions” from the emergency department for custodial care under the guise of failure to thrive or malnutrition potentially takes a bed away from a patient who truly requires acute hospital care and management. Lamenting over what is “fair” or makes sense won’t change things. Resist the urge to be apologetic. We have to abide by the rules, and figure out the best way to care for our patients within those constraints. It’s that simple.

In my former role, some hesitated to take me seriously because of my appearance. Today, I am acutely aware of the opinion of some that I am no longer a “real doctor” because I work in an administrative role. This was expected when I exchanged a dark call room for an office with a window, but it may be jarring for some entering the field. As physician advisors, we are often the harbinger of news or assessments that no one wants to hear. We need to stay focused on the reality that many do not consider: inefficiently-operated hospitals do not remain open. And, what greater disservice could we deliver to our patients than not being available to care for them?