When a patient tries to get a doctor to focus on his or her specific situation, the least helpful words from the doctor are: “It’s hospital policy…” Add the doctor’s effort to calm the patient with “I understand your frustration,” and then combine it with the physician’s admission: “I haven’t reviewed your file.” Now try to restrain yourself as it becomes clear that she has no intention of ever doing so.
The VRE Mystery
In “Computerized Information Overload,” my VRE blood infection illustrated the problem of overwhelming health care workers with too much patient information. A few days after my post, a doctor’s essay in the Sunday New York Times reaffirmed more generally my observations about the problem.
In my living example, during my third hospitalization I contracted a blood infection — VRE — almost certainly as a result of minimally invasive procedures to stop a pesky GI bleed. Powerful antibiotics squashed the infection and I went home. When I showed up a week later in the emergency room, they put me in isolation. I had no idea why until 10 days later, when my nurse told me that my record showed that I had a history of VRE.
That evening, another nurse undertook a comprehensive view of my file and concluded that I never required isolation because the VRE infection was blood-based. The sign on my door came down; those entering my room no longer downed flimsy disposable “isolation” gowns.
Problem solved? So it seemed. For the next five days, no health care worker visiting me wore the plastic blue gowns.
Groundhog Day
On the sixth day, another nurse showed up wearing an isolation gown.
“I’m here to do your rectal swab,” she said.
“Why?” I asked. “Last week, a nurse went through my file to discover that I had a blood infection VRE. It’s been gone for weeks.”
“I’m just following the directions I got from the infectious disease nurse,” she said.
After I explained the backstory, my nurse acknowledged the confusion: “I’ll have the infectious disease nurse call you.”
“No,” I said. “Not a nurse. I want to talk to the infectious disease attending physician. Let’s straighten this out once and for all.”
An Incredible Conversation
About 15 minutes later, the phone rang.
“Mr. Harper, I’m the infectious disease doctor,” said the voice on the other end. “I understand you have some questions about our isolation policy.”
“No,” I answered. “I have a problem with the confusion surrounding the handling of my situation. I don’t know how familiar you are with my case.”
“I’m not familiar with your case at all,” came her stunning admission. “I haven’t reviewed your file.”
Seriously?
“I just want to explain to you what our policy is. When you have a positive VRE, you have to test negative by rectal swab for three consecutive weeks before you are removed from isolation.”
“Well, the fact that you’re not familiar with my file is the whole problem,” I said. “There’s no continuity of care in this place and important information about me is not getting through.”
I then explained my situation to her. She listened, and then responded as if she hadn’t heard a word I’d said.
“I understand your frustration,” she said. “But you understand that we have hospital policies to protect health care workers from transmitting VRE. We follow national guidelines in that respect. Hospital policy requires that you have three negative swabs — each one a week apart — before you can be removed from isolation.”
“Well, in my specific case,” I said, “about which you have told me you know nothing, you’ve already blown two other hospital policies,” I said. “No one swabbed me a week after my admission.”
Silence on the other end of the phone.
“Then, five days ago, my nurse determined that I never had VRE for which a swab is appropriate. She removed the isolation sign on my door. Every health worker since then has entered my room without putting on a disposable gown. So there’s policy violation number two.”
“You were in isolation because of your history of VRE,” she responded. Now she was talking in circles. “It’s up to the individual initiative of the nurse to take swabs that get patients out of isolation.”
“Are you an attending physician?” I asked. She said she was.
“Do me a favor,” I said as I concluded my losing battle. “In a quiet moment, I want you to reflect on this conversation. I don’t care whether I get swabbed. That’s not the point. The point is that you haven’t reviewed my file and you have no idea whether the policy you’re defending has anything to do with me, the patient.”
I hung up and summoned the nurse.
“I give up,” I admitted. “Go ahead and swab me.”
After the standard 72-hour period for processing the culture, the lab hadn’t posted the results. Day four: still nothing posted and none of the nurses could figure out why it was taking so long. Finally, five days after the swab and as I was getting discharged from the hospital, I asked the resident to see if the lab had posted the results.
“Here it is,” he replied as he viewed the computer screen. “It says ‘Rare VRE.’ I think it means ‘not very much.’ But the next time you come back to this hospital — hopefully never — it will carry forward to show that you’re VRE-positive.”
I didn’t care. After 19 days in the hospital — bringing my cumulative in-hospital tenure to 43 of the prior 60 days — I was going home.
By the way, lest you think that I have only bad things to say about America’s medical care delivery system, my next post will discuss its best feature: the outstanding health care workers who change patients’ lives for the better.
The Belly of the Beast 
Best wishes to you and your family during this difficult time. Keep these blog posts coming … for a long time.
Charles D. Tetrault
Bravo for pointing out the policy violations to the attending. If only she had taken any part of your conversation to heart.
I suggest you write a short guide to navigating health care in a major medical center. It will be a best seller among us anxious baby boomers. I’d buy one for myself and each of my two ex-husbands! (After a while, the hostile burns itself out.)
Glad that this installment closed with the news you were going home. Long may you stay there.
Most of realize and appreciate the fact that there is a core medical community that deserve nothing but honors and praise. Unfortunately there are a good deal of ‘practice variations’ that require exposures and the light of day. It does not seem at all that you are only saying bad things about America’s medical care delivery. The problem is that too many people are hiding in the good reputations of others, and the system itself is often at cross purposes due to mixed messages and hidden agendas between administration and patient care. It is actually very refreshing to hear from someone competent on the action base delivery system itself. HIPPA for one, does not only protect “some” patients privacy rights. It also protects the hospital, the ‘expedience’ of benign neglect; the physician that has failed to properly and appropriately deliver service; the insurance companies themselves…, and anyone that benefits by hiding facts from people that actually have a good reason, and perhaps a moral right to know.
Speak the truth,…and forget apologies. There are enough excuses and apologies already.
I think you need to look at this from the attending’s point of view. If you do, you may reconsider some of your conclusions on the health care system.
One thing that annoys physicians who work at prestigious hospitals are all the “entitled” patients. In fact many physicians say they’d prefer to be at Cook county than deal with all the entited patients at Northwestern or U Chicago.
When the attending was told a patient was refusing go along with the VRE protocol until she spoke with him, I’m sure she thought you were just another entitled patient. She thought don’t understand how busy she is or you just don’t care. She is only paid to be at the hospital for a limited amount of time and during that time she needs to devote her attention to solving real health care problems rather than explaining to the privileged why the rules apply to them just like everyone else.
In fact, and this may surprise you, the only reason she even needed to call you was the MBA culture. MBAs are focused on customer satisfaction. Doctors are focused on making people healthy. If we could just get the MBAs out, she wouldn’t have to waste her time talking to people like you, instead she could focus on helping the sick during her limited time at the hospital. If you were at Cook County she’d just tell the resident or the nurse to explain the protocol to you.
But the MBAs are in charge at the prestigious hospital and so she needs to call you. Of course she is not going to read your chart. She was told you wouldn’t go along with the protocol, not that there was a question about whether the protocol should apply to you.
So she calls you and, since the MBAs have made customer satisfaction a priority, she tries to be very nice. She doesn’t say you need to go along with the protocol. She says, “I understand you have some questions about our isolation policy.” Then you try to take up more of her scarce and valuable time by questioning her about the chart. Its not her job to read the chart. That’s what residents and nurses are for. But she thinks to herself, this guy is so entitled, he just doesn’t care at all about my time. So she employs a standard customer service technique, be polite but don’t give in. If only the MBAs were not running the hospital, then she could just tell you to talk to your nurse or resident, and would not have to waste all this time.
But then, she gets lucky. After you make what she considers to be a very condescending suggestion you hang up. Once again, the attending thinks to herself, I really don’t get paid enough to put with all these entitled, arrogant patients.
The moral to the story is that things wouldn’t necessarily be better if the MBAs were not running the hospital, in fact they could be much worse. But we don’t need to speculate. Is there any evidence that health care was better when doctors were in charge of everything? What we do know is that during that “golden age”, before the MBAs, patients did what doctors told them to do. And they certainly did not argue with an attending physician or tell them to “reflect on this conversation.”
Were things worse then? Probably. You posts have highlighted one mistake by physicians after another and the way in which you protected yourself by fighting back (e.g. stopping them from taking you out of the ICU too early). Before the MBAs that would not have been possible.
One more thing, you say that many doctors tell you that your analysis is right on. Is that really surprising? It is well known that health care in the U.S. costs twice as much as that in other countries and yet we have worse health outcomes. It is well known that there are many problems with the U.S. health care system. How is it in any way surprising that doctors would embrace an analysis that blamed all the problems on MBAs and suggested that if we could just put the doctors back in charge everything would be great?
Let’s see if we can cut through this:
1. You ask for evidence that patient care was better when doctors ran hospitals. I cited that evidence (a 2011 study reported in the NY Times) in my immediately preceding post: “Big Law — Big Med — Big Mess” – https://thelawyerbubble.com/2015/03/23/big-law-big-med-big-mess/. In fact, that study also undermines your assertion that “MBAs have made customer satisfaction a priority.” It demonstrates that patient satisfaction suffers when MBA’s run hospitals.
2. I don’t understand why you think that a customer who “hangs up” at the end of an absurd conversation thereby let’s the attending as the hospital’s “customer service representative” “off the hook.” Do you think she fulfilled that function? She certainly could not have thought so. (Incidentally, I didn’t end the discussion abruptly; it had reached an obvious endpoint. She was talking in circles and refusing to review my situation. My suggestion that she acquaint herself with my file before talking further about my situation was not condescending; she should have done that on her own. I just called her on her failure to do so.)
3. You suggest that physicians have become weary of dealing with “entitled” patients — presumably including me. If you’ve been following my posts about the confusion surrounding the handling of my VRE situation, then you know that I was simply trying to get a straightforward answer to a question that — to that point — medical workers had been resolving in completely contradictory ways. Every patient is “entitled” to clarity. Calling ongoing confusion to the attention of the attending physician is an appropriate way for any patient to get a definitive resolution to such confusion.
4. You suggest that it’s not the job of the attending physician to know the patient’s situation. That is absurd. What do you think the attending physician’s job is? Every doctor I know says that understanding his or her patients is the attending physician’s principal responsibility. Residents, interns, and nurses rely on the attending physician to provide definitive answers to patient situations. If the attending can’t do that job, who can?
5. Once I explained my confused situation to the attending, she could have said, “Now that I understand your concern based on your unique situation [in which — one way or another — hospital policies had already been violated], let me take a look at your file and get back to you.” But she didn’t offer to do that. Was it laziness? Did she simply not care? It would have taken her 10 minutes to review the five-page final report from the infectious disease attending physician who had handled my original VRE blood infection more than a month earlier. If she didn’t have time to do even that, it’s because the MBA-mentality emphasizing short-term “productivity” metrics have squeezed doctors to the point that patient care is a casualty.
Of course, there are and have been excellent non-doctors running hospitals. But they listen to their physicians. They give patient care the top priority that should be the center of a functional medical care system. And they’re not obsessed with short-termism and the metrics accompanying that mindset — both of which are central to the MBA mentality dominating medicine and law.
My point is not that the attitudes I suggest the attending had are correct but rather that the attitudes of physicians are a reason for the problems in the health care system.
I think its simplistic to assume that all of the problems in medicine are due to MBAs. For example, you suggest that if the attending did not have time to look at your chart it was due to “the MBA-mentality emphasizing short-term “productivity” metrics have squeezed doctors to the point that patient care is a casualty.” I think it could also be due the attending’s unwillingness to spend the time reading your chart. She might prefer to spend the time taking a long lunch, surfing the internet or having a discussion about an issue unrelated to work with a colleague.
I am also surprised that you would cite a newspaper article about an academic study as evidence. I’ve been reading the New York Times for years and know it often fails to fully understand the academic studies it reports on. Not only that, academic studies make mistakes as well. I’ve looked at the study and I find it questionable. Its sole metric of hospital quality is how high up the hospital is in the U.S. New and World Report rankings. The article doesn’t provide an in depth explanation of why these rankings are reliable (nor does the New York Times article). There are other metrics a serious study could use such as risk adjusted survival rates or compliance with protocols (e.g. what percent of elderly patients were vaccinate for the flu).
Just as importantly the article says nothing about causation. Its possible physician run hospital rank higher because they are run by physicians. But its just as possible that physicians have more power in prestigious hospitals and so its easier for a physician to become CEO at such a hospital.
Finally, if you really think things are better when doctors are in charge, I think you need to confront what’s happened with medical residencies. When doctors were in charge, residents worked 36 hour shifts and were often severely sleep deprived. After widely published cases of patients dying due to mistakes by sleep deprived residents, residency programs, which are run by doctors have been forced to cut back on hours. I think this is a good thing but its something that was forced upon the doctors who run medical education.
1. You asked for evidence of improved patient satisfaction in physician-run hospitals. I offered it. (I, too, read the underlying study, not just the Times summary.) You have offered no contrary evidence supporting your speculation that the short-termism and related metrics of the MBA-culture has improved patient satisfaction.
2 You say that business-oritneted people at the top — those who impose the incentive structures that drive medical worker behavior — share none of the blame for the current medical system’s dysfunction. Instead, you suggest that the real problem is doctors: they prefer to take “long lunches” or speak with colleagues about “unrelated issue.” That’s silly.
3. As for 36-hour shifts, I saw plenty of residents working long hours. Do you think that MBA’s running hospitals pushed the rule change to 28 hours from 36? They didn’t. That change came about because the Accreditation Council for Graduate Medical Education imposed the new limit in 2003. But here’s the thing: Residents are still working beyond those limits. See, e.g., “Medical Residents Work Lon Hours, Despite Rules,” http://www.npr.org/blogs/health/2012/12/04/166477987/medical-residents-work-long-hours-despite-rules
Facts are stubborn things.