Dr. Andy

Reflections on medicine and biology among other things

Wednesday, March 02, 2005

My health care is killing me

Uberblogger Glenn Reynolds shares some of the frustration of being a patient or relative of a patient in a hospital today:

Being in the hospital is an exhausting, draining experience even if you aren't
sick. I spent a lot of time, and a couple of nights, there, and I felt like I
had been run over by a truck. Imagine how I'd have felt if I had been, you know,
a patient with something actually wrong with me.

As he notes, and I've said before, a lot of the problem comes from health care being organized for the convenience of doctors (and to a lesser extent nurses and other staff), not patients. This manifests itself in a myriad of ways, from inpatients being woken all night, to inconvenient hours.

I had knee surgery during graduate school and it was a real eye-opener. I remember being put on a PCA (Patient Controlled Analgesic) pump, where you can inject your own morphine for pain control, subject to certain built in limits No one told me how to use it, so, being the stoic type, I tried to use as little as possible. A nurse from the pain control team came by the next morning and gave me instructions in its use. She nicely informed me that by giving yourself a little bolus when you first started feeling the pain you ended up with better pain control and less total morphine use. Nice thing to learn, one hour before the PCA was disconnected and I was sent home.

In my practice, the earliest available appointment is 8:30 and the latest 4PM, and the 4PM is only for return patients. The latest new patient slot is 8. Would you take your car to a dealer who could only fit you in for service between those hours? Of course not, you'd find someone else.

What makes it worse is that our practice, a major children's hospital, thankfully has a commitment to care for the underserved. Therefore, our allergy/immunology practice is one of the few to see kids who are on Medicaid. So the single working mom with little job flexibility has to take off time to bring her kids on our schedule. Crazy. I'd actually be happy to do an evening clinic to free up a half day during the week, but at this point the system is so ossified it is almost impossible to organize something like that.

Andy Stedman also had a recent post about his experience in the ED. He makes the following observation
Restaurants and tire stores, like emergency rooms, never really know how much
business to expect. However, it is unusual to have to wait hours for a meal or
new tires, whereas in emergency rooms it seems to be the norm to wait hours for
treatment. They’re not full, either, they’re just woefully understaffed

I'm not so sure I completely agree. I have spent a lot of time waiting in car dealerships, although they seem to have gotten much better about scheduling appointments for all but the most urgent repairs (it may also be that now that I've gone more upscale in the cars I drive and so the quality of service provided by the dealer is better). I suppose most tire centers can get you in and out quickly, but I suspect they benefit some from people who either schedule appointments or leave their car for the whole day.

Restaraunts are about the same. While you can always get served at McDonalds if you are willing to wait a few minutes, I don't think you'll have much luck walking in to, say, Charlie Trotter's or The French Laundry on a Saturday at 7, no matter how long you are prepared to wait.

But I do agree that healthcare is not organized for patient convenience (or even benefit). I think there will be a lot of opportunities going forward for doctors and firms that cater to patients: botique practices, expanded clinic hours, open scheduling, "consults" via cell phone camera, email, etc.

UPDATE: My colleague (and fellow ultrarunner) Geoff Kurland wrote a book about his own experience with leukemia. It is on my to read list.


At 2:24 PM, Anonymous Anonymous said...

No matter how "patient-friendly" one can make an environment, the main issue is cost. People don't want to pay for it. All this and lunch is exected to be provided free of charge. People have no idea how much things really cost and they won't so long as "insurance" pays for it. That includes "insurance" like Medicaid and Medicare and in that case not one patient cares (except county taxpayers) how much it costs because it costs the beneficiary nothing.

So who picks up the fee for the cab ride home, the unreimbursed cost of pain meds for the Medicaid pending? The hospital. If that isn't patient friendly, I don't know what is.

frustrated nurse

At 2:51 PM, Anonymous Anonymous said...

I would be curious to know what a hospital budget really looks like. The fantastically high rate per day for inpatients (thousands of dollars) is far more than you get if you add up the salaries of nurses and the "hotel" costs of the hospital. The previous comment talks about "lunch provided free of charge". This is $5 out of the hundreds that an emergency room visit costs. This is not where medical inflation is coming from!

At 2:53 PM, Blogger Steve White said...

As a doc, one frustrating thing about my practice (a university clinic and inpatient service) is that the hospital has organized itself to run at 100% capacity at all times. If I were building cars, and I was selling every car I made, I'd expand the factory to make more. Not the hospital -- no matter how long the admission list, how many patients backed up in the ER, and how long the wait for an appointment as a new patient in my clinic -- it refuses to add capacity. It would rather run flat out full and harried all the time rather than have some slack periods.

And all the while they want us to see more patients and generate more revenue (for them, not us, silly me).

There's a consequence to this, of course: the nurses are more harried, the docs are busier, the techs have less time to get things done, and so we encroach on our patient's time as you, Glenn Reynolds, and others have documented. It's the only time we have and so we take it.

At 5:14 PM, Anonymous indecguy said...

As a physician and a person who could not afford health insurance as a student, i can tell you that all the things which can be wrong or troublesome with the medical care in hospitals cannot compare with the trouble people without heath insurance in this country go through, i dont consider myself as a liberal or support government funded health care but i do hope somebody can come up with a solution.

At 6:30 PM, Anonymous Dicty said...

Restaraunts are about the same. While you can always get served at McDonalds if you are willing to wait a few minutes, I don't think you'll have much luck walking in to, say, Charlie Trotter's or The French Laundry on a Saturday at 7, no matter how long you are prepared to wait.True, but people would expect to have to make a "reservation" at the Mayo Clinic, too. The French Laundry is atypical even for fine dining establishments. Most, at least in my area, can find you a seat if you're willing to sit at the bar for half an hour.

One possibility: restaurants have less ability to force people to wait until the restaurant finds it convenient to serve them. With the exception of places like Charlie Trotter's, if Restaurant X can't get someone a seat in a reasonable period of time, the customer will go to Restaurant Y down the street, or go home. This motivates the restaurant to build in some excess capacity--because if the customer turns out to like Restaurant Y, they may never darken the door of Restaurant X again.

On the other hand, a person in an emergency room can't decide to put the visit off until a quieter night, by and large.

At 7:13 PM, Blogger Dr. Andy said...

First, welcome to everyone and thanks for taking the time to post a comment.

In some ways I agree with both "frustrated nurse" and first anonymouos: it is all about cost, yet the focus is on all the wrong places. Health care is like the family that doesn't tip at TGIFriday's to save money, but owns 3 sports cars on credit.

Too much money gets pissed away on all the administrators, etc. (I will try to dig out a fascinating graph that appeared maybe 5 years ago in the New Englad Journal of Medicine showing that if current trends continued by 20XX US hospitals would have no patients but a near infinitie number of administrators.) It seems like every hospital cuts beds but needs new offices for more administrators. Bureaucracy is a big part of the problem.

I agree with "Steve White" that hospitals never want to add capacity, especially in the ED. I am not sure why. I agree with indecguy that the uninsured are a huge problem. As I see it, their lack of insurance is not only a problem for them (obvious) but for society since they don't get cost effective care and therefore use too much care inefficiently (e.g. they don't get antibiotics early in an infection so end up hospitalized for IV therapy)

I have more thoughts about the restaraunt analogy that I'll expand into a whole post in the next few days

Dr. Andy

At 11:26 AM, Blogger Carsten said...

On the other hand, a person in an emergency room can't decide to put the visit off until a quieter night, by and large.I disagree - by and large, they can. Over 60% of ED visits were considered "inappropriate" in numerous studies, i.e. coming in for non-emergency primary care complaints. They either can't/don't want to get an appointment with their primary MD, or they mistakenly think that since they think they have an emergency they will be whisked right through. What most people don't realize is that ED's need to treat those with life-threatening issues first, thus waiting time is inversely proportional to the likelyhood that you will die/suffer serious complications.

At 7:44 PM, Anonymous jb said...

Let's take the hospital/McDonalds analogy a little further. This McD has to be prepared to serve just about any meal on an "emergency" basis, 24/7, whether a bag of fries, Lobster Newburg, kosher, vegan, or macrobiotic. There are highly trained experts available at all hours, tasked with figuring out if you are hungry for a snack, a drink, Happy Meal, or Big Mac, and if they are wrong, it could end their career. It has to have a panel of cooks, counter people, and suppport folks on call 24/7, ready to come in from home to clean up your mess, slice your spuds, or smile the way you want. There's a law that says that anyone who shows up hungry has to be fed first, then asked if he has any intention of paying, and maybe he pays and usually he doesn't. There may be a third party that pays a part of the bill, but not for several weekes or months. Every customer has a lawyer available if he gets a bellyache after his (free) meal. Every meal is documented by a squad of folks who describe in detail how each item was prepared, who ordered it, how long it takes to eat, whether eaten with utensils or the fingers, and whether each customer washed his hands before eating. If the McD manager wants to expand his dining room, he has to get a Certificate of Need from the state, which does not like to give them out because it will only lead to more Gluttonaid expense.

I'm considering changing careers.

At 8:38 AM, Blogger tom naka said...

I have a breakfast restaurant site. It pretty much covers breakfast restaurant related stuff. Check it out if you get time :-)


Post a Comment

<< Home