This next step of integrating Mass General Brigham will be the toughest one yet

Executives say the integration is necessary to streamline patient access and care amid increased demand.

“This creates a much simpler way for our patients to understand where they should go and who they should see,” said Dr. Ron Walls, chief operating officer for MGB, who is leading the clinical side of the system’s integration work. “The secondary benefit, the patient’s perspective, is that it helps the care be delivered in a much more uniform way.”

Yet shuffling egos at some of the country’s top hospitals will mark the most difficult stage of the integration yet, as clinicians struggle to envision the future of their work and find their place within the restructured environment.

Multiple physicians at MGB, who spoke on the condition of anonymity, said the uncertainty and change are causing anxiety for some, who feel disconnected from decisions made at the corporate level. Yet many agreed that the system has to evolve to become more efficient and accessible for patients.

Some long-time clinicians and leaders at the system have left over the course of the integration, including the chief of cardiology at Massachusetts General Hospital, Dr. Anthony Rosenzweig, and Dr. Prem Shekar, chief of the Division of Cardiac Surgery at Brigham and Women’s Hospital, who joined Lahey Health last year. Other departures have included Dr. Donna Polk, program director of the Cardiovascular Fellowship at Brigham and Women’s; Dr. Tsuyoshi Kaneko, a cardiac surgeon at Brigham and Women’s; and Dr. David Faxon, who retired as vice chair of Medicine for Strategic Planning at Brigham and Women’s. It’s unclear what role the integration played in their decisions, and none returned requests for comment.

Dr. Joe Loscalzo, chair of the Department of Medicine at Brigham and Women’s Hospital, also announced last year that he would step down, a move he pegged in part to the integration.

The MGB system was created in 1994 by flagship hospitals MGH and Brigham and Women’s, but it didn’t try in earnest to meld clinical services across its 12 hospitals until 2019, when it rebranded from Partners HealthCare to Mass General Brigham.

Executives have already integrated a number of systemwide hospital services, including pathology, radiology, anesthesiology, and emergency medicine. Marketing departments have been consolidated and, starting this year, all new hires have had to be approved at the system level.

Some smaller clinical services that only existed at the flagship hospitals have been stitched together as well, including a liver-transplant program in March 2021, and cardiac surgery beginning in July 2021.

Anne Klibanski, president and CEO for MGB, contested that the hardest work lay ahead, saying the foundational work done to date was complex and already set a narrative of change.

“To me, the main work done in all those other services sends the message,” she said.

But the broader changes on which the system will embark next month will directly impact many more patients than earlier stages of the process.

Instead of navigating the system on their own when they need to find a primary care doctor or specialist, patients will soon be referred to a website or call center, where care managers and navigators will check doctor availability, suggest alternative doctors if a patient’s first choice is booked, and schedule tests at a location nearest the patient’s home. Instead of each hospital managing its own resources internally as separate entities, the system will offer a platter of its resources all in one place.

Patients would still be able to access specific doctors if they chose, but Walls said that often patients don’t know they could see someone equally qualified sooner or closer to home.

MGB is building the digital platforms that will allow patients to see and book appointments with different doctors regardless of which MGB hospital they work for. Behind the scenes, all the doctors in different clinical services — from neurology to orthopedics — will have to standardize protocols, procedures, reporting, and test ordering, to make sure the care and quality are the same. Each will have a systemwide head, like Keaney, to oversee the standardization.

For certain diseases, the system will also establish “centers” that will bring different clinicians together to care for patients with a particular illness.

For example, in the past, a patient living with atrial fibrillation in Western Massachusetts might be referred to MGH to see a cardiologist, even if there are cardiologists closer to them at Cooley Dickinson Hospital. But an atrial fibrillation center could manage all of a patient’s care, coordinating a visit with a cardiologist closer to home, and then appointments with subspecialists elsewhere.

Although the system will streamline clinical operations, MGH and Brigham and Women’s will maintain distinct academic programs, leaders said. Each hospital will largely recruit and teach post-docs, medical students, and fellows separately as well as oversee its own research, faculty appointments, and mentorship of its physicians.

The hospitals will also still retain their own department chiefs even as many areas integrate. Keaney will continue to act as the Brigham’s chief of the division of cardiovascular medicine, overseeing approximately 150 Brigham cardiologists. MGH will have its own chief overseeing the over 100 cardiologists at that hospital. Local chiefs will manage day-to-day operations, while Keaney will be putting together groups to share ideas on working together more seamlessly.

He noted that the groups are trying to coordinate better, not merge cultures.

“There’s definitely a little bit of individualization,” Keaney said. “But we’ll do it in a way where we know the information about the other institutions. We’ve made some decisions about how to do things that are best for our patients and coordinate things best for them.”

The two flagship hospitals will embark on the work first, followed by the system’s other cardiology programs.

While many see benefits from integration, doctors speaking anonymously said some perceive the changes as a corporatization of MGB, one that has overridden the voices of physicians and centralized power at MGB’s off-site location in Somerville.

There also remains confusion for some about how care will be distributed. Some physicians feel certain, more-complex medical tests should be done by specialized clinicians rather than by community partners.

Institutional loyalty and pride are also playing a role. Some feel there is enough expertise within their own flagship hospital and little need to closely integrate with another hospital. Some also note the hospitals’ distinct cultures — with MGH emphasizing clinical prowess, and the Brigham clinical care based on research.

Uncertainty over the future is swirling at a time of burnout among many staff due to the pandemic and rising patient demand.

Dr. David Brown, president of Massachusetts General Hospital, acknowledged that there is still a level of “misunderstanding” about what the system is trying to accomplish, and said he had made it a priority to communicate what changes would look like.

He also said it is common for a number of departures to occur in an institution as large as MGB.

Dr. Antoine Bejjani spoke with cardiovascular medicine specialist Dr. Gregory Piazza at the Shapiro Cardiovascular Center at Brigham and Women’s Hospital.Craig F. Walker/Globe Staff

Some physicians are bullish about the changes and see them as critical to remaining innovative and competing with nationally recognized brands. Several acknowledged the need to reduce spending and be more accessible to patients.

“When you think about it from a coordination of care perspective, that’s huge,” said Dr. Malissa Wood, associate chief of cardiology for diversity and health equity at MGH. “The system before, as much as we’d like to say we’re coordinated, it’s a bit of the wild West.”

And although her lab coat had an MGB emblem on it, Wood noted it still said “Massachusetts General Hospital” on it, too, minus the crest. She saw the integration similarly — that she worked at MGH, which was part of a larger system.

Jessica Bartlett can be reached at jessica.bartlett@globe.com. Follow her on Twitter @ByJessBartlett.

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