As a Professor Emeritus in Family Medicine — I am struck by the insight and wisdom inherent in this excellent commentary by Professor Raymond. Whereas for those with good insurance and a true emergency situation (ie, acute coronary occlusion evidenced by new marked ST elevation or an obvious acute appendicitis or other clear surgical condition) — our system of medicine is THE BEST there is. But much of the time — it is the opposite (ie, U.S. spending much more than most other countries, yet not demonstrating better health care outcomes for all the expense — not to mention an ever increasing number of U.S. citizens not having access to appropriate medical care [impact of "politics"] — and not to mention those forced into bankrupcy by health care issues) — such that as an informed consent individual, I am ultra-conservative in medical services that I seek to access for myself — though striving not to be "blind" to the need for care when it truly exists (and hoping that need does not occur soon after July 1). Our THANKS to Professor Raymond — :)
I read in this essay something other than a ‘Hobbesian’ choice in hospitals - where the author as patient worked with the caregivers to improve his chance of a good outcome (eg, declining the Heparin and ultrasound for non-existent gallbladder)
I think there is unnecessary conflation in this OP of the theoretical ideal of “healthcare”, the natural inclination (and scientific evidence basis) of delivery systems to be geared towards actually only providing “sick-care”, and the role of the “hospital” therein.
No debate that the hospital environment is not necessarily the most empowering for patients. I practice in one, have never been on the consumer side myself, but have seen enough over the years to anecdotally support that premise.
That said, no one in their right mind would (nor should) go into the hospital, via a place literally labelled as the “emergency room” no less, in search of “preventative” “health-care”. This is straw-manning of the concept of “hospital”.
If the author is looking for “hospitals” to improve “long term health outcomes”, he is literally barking up the wrong tree. He is looking for a hospital whose point of entry would actually be labelled “non-emergency room”. And he will be looking for a very long time.
So, in the pursuit of something - can't articulate what it is - we have thrown the baby out with the bath water?
The 'something' is a lot of things that are camouflaged behind words like 'health' and 'care'.
I see this more and more clearly every nursing shift I work.
Among other factors, perhaps the contemporary behavior in the US that every problem is an emergency demands every health 'problem' be treated as an emergency.
Another factor is Americans denial of mortality and attempt to distance themselves from scenes of death, other than the fantasies of the enormous, pervasive entertainment industry. The cult of youth? The institutionalization of our parents, grandparents?
One must look at root causes and follow the money to understand what has happened to medicine during the past 50 years. Hospitals and their corporate-employed physicians are among the most heavily regulated “industries” by state and federal laws. Every year, hospital accreditation organizations show up with a new list of regulations to be added to the previous mountain of regulations and rules. Compliant and obedient hospital administrators eagerly require conformity from all employees and physician staff members (the vast majority of U.S. physicians have become hospital or large health care corporation employees required to follow all the rules, regulations, and algorithms). If the hospital is not compliant with the edicts and rules, funding (from federal and state government) will be lost. Insurance companies further add to all this regulatory and financial complexity. State laws against the corporate practice of medicine have become meaningless as universal exceptions have been granted to these historical laws that were designed to protect the safety and autonomy of patients. Meanwhile, U.S. lifespan is decreasing. All these laws and regulations should come with sunset provisions if studied patient outcome benefits can not be demonstrated.
..."test that I had severe hypophosphatemia, a common side effect of a medication that another physician had prescribed.²"...and therein lies a major problem with medicine. The utter refusal of acknowledging that most of these drugs can cause all kinds of problems in the body. The drug inserts read like a horror show....you never know which debilitation(s) you are going to suffer.
I am seeing it firsthand with my wife and taking pain medications. She is now terrified of taking them and so she doesn't and I do not blame her. The same with vaccines where the doctors believe it could NEVER be the vaccines causing the problems. This is a brain dead attitude by medical professionals. It gets people dead.
If you can avoid the drugs, you have avoided many of the future medical issues you will have. That is my motto and thus far after 75 years it is working quite well.
We agree that our system needs help. However if others have commented on the insurance industry’s control over our practice I missed the reference. After 30 years in the ER with many changes…
We are accountable for
patients per hour
ordering too few or too many imaging studies
door to clinician
door to dispo
sepsis metrics (among others)
patient satisfaction scores
admission rates (the lower the better)
X-ray discrepancies
pain management
inherent social issues complicating care
AND DO NOT EVER MAKE A MISTAKE
I loved sitting in a room with a patient/family and discussing everything I knew about a given set of symptoms, but that referenced waiting room meant quick answers and addressing the next patient. Despite any given bill, hospitals operate on a thin margin and insurance dictates what we can or cannot do, and what they will pay. Add liability into the mix and we have the perfect storm.
Your perception of this uncaring money making machine leaves out so much. Physicians burnout and suicide rates far exceed national average. I cannot imagine why.
Thank you for your story. Medicine seems to have gotten “cookie cutter” with the advent of the EMR…I remember hand written notes! Anyway, your story is a reminder that being a good patient that actually improves demands the best knowledge base about ourselves as thoroughly as we can make it. Sensible Medicine has helped me in this way. I ask better questions and get better care.
Sorry, I am not as impressed with this piece as Dr Cifu is. From the gratuitous "anonymous receptionist" jibe to the self diagnosis of no clot risk "because I exercise " , then admitting he did have a history of a serious blood clot, to declaring it should be the hospitals responsibility to address social problems that cause poor health, the author offers a litany of complaints without providing any specific suggestions for improvement.
While i do appreciate the author’s patient perspective I agree with the unrealistic expectations of what can be accomplished during a short hospitalization.
This was an excellent read and like Dr. Cifu I found myself nodding along and, if not getting defensive, at least feeling mildly put-off at times. The comments are infinitely more fascinating.
Although I am not a surgeon I partner with my surgical colleagues daily and not infrequently admit children to my service with small bowel obstruction. As I was reading Professor Raymond's story I could easily think of parents who would have insisted on immediate surgery for their child rather than waiting for an obstruction to clear on its own, even if we recommended a “wait and see” approach. Although we as medical professionals have been encouraged to engage in “shared decision making” with families for almost 20 years, I have seen families who are horrified by this idea (as reflected in one of the comments). Some caregivers don’t want this responsibility; they feel it is a burden they should not carry as parents. On the other hand are the families who regard “shared decision making” as a license to dictate the care they want their family member to receive, regardless of the recommendations of the medical team. Creating an effective partnership in this setting, given the urgency, emotion, power differential, variability in knowledge and even vocabulary between the medical team and patient/family, takes time and skill on the part of the clinician.
Perhaps I am naive but the idea that most hospital physicians are getting financial kickbacks related to their medical practice seems laughable. As a pediatric sub-specialist in one of the top Children's Hospitals in the country I receive a basic salary with no bonuses and no extras. Nothing from pharma or any other external companies. I love my job and recognize that I am financially in a better spot than most, but I am nowhere near the top 1% of earners in the United States.
I completely agree with the concept of somehow grading clinicians based on competencies. More important is ongoing training of physicians in real world clinical competencies. The system fails on both accounts. Once an MD/DO has completed formal medical training (residency +/- fellowship) they are considered clinically competent and there are little/no additional metrics for ongoing growth and development in frontline clinical skills. Promotion is not based on patient outcomes or experience. Within a practice or hospital system one knows who the expert clinicians are via word of mouth, but I am not aware of anyone who has developed an objective tool for assessing this metric.
Finally, and blessedly, I am a pediatrician. Having been in adult hospitals with family members and briefly, myself, I know it is NOT THE SAME. Yes, it is an institution, and there are a seemingly infinite number of guidelines/algorithms/protocols. And AI is here to stay (looking at you Open Evidence). And almost everyone smiles, and makes eye contact, and patients get stickers everywhere they go, and not one of my patients wants to transition to adult care. So I understand my perspective is skewed.
Money over common sense :-( A friend suddenly lost his short-term memory. After having every test known to man, a stroke was ruled out. Diagnosis: transient global amnesia. Even the ER nurse had recognized right away that it wasn't a stroke and suspected TGA. Yet he was kept overnight, awakened multiple times for a blood test. Then he had to wait for a particular doctor to examine him so he could be released. Unfortunately that doctor was playing golf and wouldn't be available until late afternoon. The bill was $20,000.
Being sick and in the hospital is no fun. I spent four days in ICU with sepsis near death after a prostate biopsy. If it is a rare complication, you can bet the physician patient will get it. Despite all the inconveniences, i.e. 13 arterial punctures for blood gases, were it not for the expert care I received I would have succumbed. There are a host of problems with Mr. Raymond's post:
1. Most hospitals got their start as homes where patients with tuberculosis were cared for. Most diseases are infectious diseases.
2. Although being fit is laudable, there are many other reasons for thrombosis that can aflect the fit just as much as those who aren not.
3. The refused US may well have explained the small bowel obstruction. It wasn't ordered to visualize the gall baldder. It is an "abdominal US", not a "gall baldder US". It would have facilitated the assesment. It is a painless procedure with no significant risk.
4. SBO's often resolve spontaneously with nasogastric tube decompression in a day or so. Unless there is an intra abdominal complication such as perforation, observation and decompression, not surgery is the preferred approach
5. Injectable iron is for signifcant iron deficiency refractory to oral supplementation, The underlying cause of the iron deficiency is unexplained.
6. The most likely explanation for the SBO is due to post surgical adhesions secondary to the prior cholecystectomy. If so, recurrence is likely.
7. A subclavian thrombosis can be suspected clinically but cannot be definitively diagnosed without imaging to confirm.
8. Finally, admission to acute care hospital is for patients who are acutely ill and at risk of death. Addressing chronic co-morbidities is not the focus of the acute care hospital. Not sending you home in a pine box is what we try to do. Anything than can be evaluated and managed as an outpatient should be.
None of the above is to suggest that patients deserve to be treated ignominiously. The hospital in the post needs to fous some attention on the patient experince.
Michael, we actually agree on much of the above, but I feel the need to add some additional information that is not included in my guest post. I'll label these additions according to some of the numbered points in your list.
3. I read the order for the abdominal US. It included the notation "GB," which I assumed meant "gallbladder." When I questioned the attending physician in the room about the order, she gave a vague, hand-wavy comment about checking to see if the bile duct was patent post-cholecystectomy. This had already been done as part of post-surgical follow-up, six months prior.
4. Exactly what I was arguing about with the surgical residents.
5. Anemia of chronic disease and malabsorption due to Crohn's. Thirty-five year history of iron IV supplementation; I only developed hypophosphatemia after a physician prescribed ferric carboxymaltose (FCM) that could be administered in office. Every hematologist I've spoken to since then has remarked about the high prevalence of FCM-associated hypophosphatemia they've seen clinically and I've also found it discussed in numerous published studies.
6. The SBO described here was 4 years after the cholecystectomy. It was CD-associated.
7. The imaging done for the subclavian DVT was a standard CXR, ordered by ER physician. As far as I know, CXR's do not effectively detect thrombi. The doppler was ordered after I returned to the hospital the next day, per insistence of the GP I spoke to on the phone.
“Modern medicine is a negation of health. It isn't organised to serve human health, but only itself, as an institution. It makes more people sick than it heals.”
- Ivan Illich, “Medical Nememis”, 1976
This has only become more true in the fifty years since. Socializing costs and privatizing profits cannot sustain itself. A fiduciary responsibility to shareholders is at direct odds with a commitment to the patient first. Great post by Prof Raymond, and a clear call to each of us still trying to save this healing profession of ours
As a Professor Emeritus in Family Medicine — I am struck by the insight and wisdom inherent in this excellent commentary by Professor Raymond. Whereas for those with good insurance and a true emergency situation (ie, acute coronary occlusion evidenced by new marked ST elevation or an obvious acute appendicitis or other clear surgical condition) — our system of medicine is THE BEST there is. But much of the time — it is the opposite (ie, U.S. spending much more than most other countries, yet not demonstrating better health care outcomes for all the expense — not to mention an ever increasing number of U.S. citizens not having access to appropriate medical care [impact of "politics"] — and not to mention those forced into bankrupcy by health care issues) — such that as an informed consent individual, I am ultra-conservative in medical services that I seek to access for myself — though striving not to be "blind" to the need for care when it truly exists (and hoping that need does not occur soon after July 1). Our THANKS to Professor Raymond — :)
I read in this essay something other than a ‘Hobbesian’ choice in hospitals - where the author as patient worked with the caregivers to improve his chance of a good outcome (eg, declining the Heparin and ultrasound for non-existent gallbladder)
I think there is unnecessary conflation in this OP of the theoretical ideal of “healthcare”, the natural inclination (and scientific evidence basis) of delivery systems to be geared towards actually only providing “sick-care”, and the role of the “hospital” therein.
No debate that the hospital environment is not necessarily the most empowering for patients. I practice in one, have never been on the consumer side myself, but have seen enough over the years to anecdotally support that premise.
That said, no one in their right mind would (nor should) go into the hospital, via a place literally labelled as the “emergency room” no less, in search of “preventative” “health-care”. This is straw-manning of the concept of “hospital”.
If the author is looking for “hospitals” to improve “long term health outcomes”, he is literally barking up the wrong tree. He is looking for a hospital whose point of entry would actually be labelled “non-emergency room”. And he will be looking for a very long time.
So, in the pursuit of something - can't articulate what it is - we have thrown the baby out with the bath water?
The 'something' is a lot of things that are camouflaged behind words like 'health' and 'care'.
I see this more and more clearly every nursing shift I work.
Among other factors, perhaps the contemporary behavior in the US that every problem is an emergency demands every health 'problem' be treated as an emergency.
Another factor is Americans denial of mortality and attempt to distance themselves from scenes of death, other than the fantasies of the enormous, pervasive entertainment industry. The cult of youth? The institutionalization of our parents, grandparents?
One must look at root causes and follow the money to understand what has happened to medicine during the past 50 years. Hospitals and their corporate-employed physicians are among the most heavily regulated “industries” by state and federal laws. Every year, hospital accreditation organizations show up with a new list of regulations to be added to the previous mountain of regulations and rules. Compliant and obedient hospital administrators eagerly require conformity from all employees and physician staff members (the vast majority of U.S. physicians have become hospital or large health care corporation employees required to follow all the rules, regulations, and algorithms). If the hospital is not compliant with the edicts and rules, funding (from federal and state government) will be lost. Insurance companies further add to all this regulatory and financial complexity. State laws against the corporate practice of medicine have become meaningless as universal exceptions have been granted to these historical laws that were designed to protect the safety and autonomy of patients. Meanwhile, U.S. lifespan is decreasing. All these laws and regulations should come with sunset provisions if studied patient outcome benefits can not be demonstrated.
..."test that I had severe hypophosphatemia, a common side effect of a medication that another physician had prescribed.²"...and therein lies a major problem with medicine. The utter refusal of acknowledging that most of these drugs can cause all kinds of problems in the body. The drug inserts read like a horror show....you never know which debilitation(s) you are going to suffer.
I am seeing it firsthand with my wife and taking pain medications. She is now terrified of taking them and so she doesn't and I do not blame her. The same with vaccines where the doctors believe it could NEVER be the vaccines causing the problems. This is a brain dead attitude by medical professionals. It gets people dead.
If you can avoid the drugs, you have avoided many of the future medical issues you will have. That is my motto and thus far after 75 years it is working quite well.
Nothing short of being a patient ourselves completes our education as healthcare providers. The view from the inside out is invaluable.
Brilliant work. Complex content made accessible through clear, eloquent writing.
We agree that our system needs help. However if others have commented on the insurance industry’s control over our practice I missed the reference. After 30 years in the ER with many changes…
We are accountable for
patients per hour
ordering too few or too many imaging studies
door to clinician
door to dispo
sepsis metrics (among others)
patient satisfaction scores
admission rates (the lower the better)
X-ray discrepancies
pain management
inherent social issues complicating care
AND DO NOT EVER MAKE A MISTAKE
I loved sitting in a room with a patient/family and discussing everything I knew about a given set of symptoms, but that referenced waiting room meant quick answers and addressing the next patient. Despite any given bill, hospitals operate on a thin margin and insurance dictates what we can or cannot do, and what they will pay. Add liability into the mix and we have the perfect storm.
Your perception of this uncaring money making machine leaves out so much. Physicians burnout and suicide rates far exceed national average. I cannot imagine why.
Thank you for your story. Medicine seems to have gotten “cookie cutter” with the advent of the EMR…I remember hand written notes! Anyway, your story is a reminder that being a good patient that actually improves demands the best knowledge base about ourselves as thoroughly as we can make it. Sensible Medicine has helped me in this way. I ask better questions and get better care.
Sorry, I am not as impressed with this piece as Dr Cifu is. From the gratuitous "anonymous receptionist" jibe to the self diagnosis of no clot risk "because I exercise " , then admitting he did have a history of a serious blood clot, to declaring it should be the hospitals responsibility to address social problems that cause poor health, the author offers a litany of complaints without providing any specific suggestions for improvement.
While i do appreciate the author’s patient perspective I agree with the unrealistic expectations of what can be accomplished during a short hospitalization.
This was an excellent read and like Dr. Cifu I found myself nodding along and, if not getting defensive, at least feeling mildly put-off at times. The comments are infinitely more fascinating.
Although I am not a surgeon I partner with my surgical colleagues daily and not infrequently admit children to my service with small bowel obstruction. As I was reading Professor Raymond's story I could easily think of parents who would have insisted on immediate surgery for their child rather than waiting for an obstruction to clear on its own, even if we recommended a “wait and see” approach. Although we as medical professionals have been encouraged to engage in “shared decision making” with families for almost 20 years, I have seen families who are horrified by this idea (as reflected in one of the comments). Some caregivers don’t want this responsibility; they feel it is a burden they should not carry as parents. On the other hand are the families who regard “shared decision making” as a license to dictate the care they want their family member to receive, regardless of the recommendations of the medical team. Creating an effective partnership in this setting, given the urgency, emotion, power differential, variability in knowledge and even vocabulary between the medical team and patient/family, takes time and skill on the part of the clinician.
Perhaps I am naive but the idea that most hospital physicians are getting financial kickbacks related to their medical practice seems laughable. As a pediatric sub-specialist in one of the top Children's Hospitals in the country I receive a basic salary with no bonuses and no extras. Nothing from pharma or any other external companies. I love my job and recognize that I am financially in a better spot than most, but I am nowhere near the top 1% of earners in the United States.
I completely agree with the concept of somehow grading clinicians based on competencies. More important is ongoing training of physicians in real world clinical competencies. The system fails on both accounts. Once an MD/DO has completed formal medical training (residency +/- fellowship) they are considered clinically competent and there are little/no additional metrics for ongoing growth and development in frontline clinical skills. Promotion is not based on patient outcomes or experience. Within a practice or hospital system one knows who the expert clinicians are via word of mouth, but I am not aware of anyone who has developed an objective tool for assessing this metric.
Finally, and blessedly, I am a pediatrician. Having been in adult hospitals with family members and briefly, myself, I know it is NOT THE SAME. Yes, it is an institution, and there are a seemingly infinite number of guidelines/algorithms/protocols. And AI is here to stay (looking at you Open Evidence). And almost everyone smiles, and makes eye contact, and patients get stickers everywhere they go, and not one of my patients wants to transition to adult care. So I understand my perspective is skewed.
Kathy Campbell, Pediatric Transplant Hepatologist, Cincinnati Children's Hospital
Money over common sense :-( A friend suddenly lost his short-term memory. After having every test known to man, a stroke was ruled out. Diagnosis: transient global amnesia. Even the ER nurse had recognized right away that it wasn't a stroke and suspected TGA. Yet he was kept overnight, awakened multiple times for a blood test. Then he had to wait for a particular doctor to examine him so he could be released. Unfortunately that doctor was playing golf and wouldn't be available until late afternoon. The bill was $20,000.
Being sick and in the hospital is no fun. I spent four days in ICU with sepsis near death after a prostate biopsy. If it is a rare complication, you can bet the physician patient will get it. Despite all the inconveniences, i.e. 13 arterial punctures for blood gases, were it not for the expert care I received I would have succumbed. There are a host of problems with Mr. Raymond's post:
1. Most hospitals got their start as homes where patients with tuberculosis were cared for. Most diseases are infectious diseases.
2. Although being fit is laudable, there are many other reasons for thrombosis that can aflect the fit just as much as those who aren not.
3. The refused US may well have explained the small bowel obstruction. It wasn't ordered to visualize the gall baldder. It is an "abdominal US", not a "gall baldder US". It would have facilitated the assesment. It is a painless procedure with no significant risk.
4. SBO's often resolve spontaneously with nasogastric tube decompression in a day or so. Unless there is an intra abdominal complication such as perforation, observation and decompression, not surgery is the preferred approach
5. Injectable iron is for signifcant iron deficiency refractory to oral supplementation, The underlying cause of the iron deficiency is unexplained.
6. The most likely explanation for the SBO is due to post surgical adhesions secondary to the prior cholecystectomy. If so, recurrence is likely.
7. A subclavian thrombosis can be suspected clinically but cannot be definitively diagnosed without imaging to confirm.
8. Finally, admission to acute care hospital is for patients who are acutely ill and at risk of death. Addressing chronic co-morbidities is not the focus of the acute care hospital. Not sending you home in a pine box is what we try to do. Anything than can be evaluated and managed as an outpatient should be.
None of the above is to suggest that patients deserve to be treated ignominiously. The hospital in the post needs to fous some attention on the patient experince.
Michael, we actually agree on much of the above, but I feel the need to add some additional information that is not included in my guest post. I'll label these additions according to some of the numbered points in your list.
3. I read the order for the abdominal US. It included the notation "GB," which I assumed meant "gallbladder." When I questioned the attending physician in the room about the order, she gave a vague, hand-wavy comment about checking to see if the bile duct was patent post-cholecystectomy. This had already been done as part of post-surgical follow-up, six months prior.
4. Exactly what I was arguing about with the surgical residents.
5. Anemia of chronic disease and malabsorption due to Crohn's. Thirty-five year history of iron IV supplementation; I only developed hypophosphatemia after a physician prescribed ferric carboxymaltose (FCM) that could be administered in office. Every hematologist I've spoken to since then has remarked about the high prevalence of FCM-associated hypophosphatemia they've seen clinically and I've also found it discussed in numerous published studies.
6. The SBO described here was 4 years after the cholecystectomy. It was CD-associated.
7. The imaging done for the subclavian DVT was a standard CXR, ordered by ER physician. As far as I know, CXR's do not effectively detect thrombi. The doppler was ordered after I returned to the hospital the next day, per insistence of the GP I spoke to on the phone.
One further addendum to #7: This event occurred in 1997.
“Modern medicine is a negation of health. It isn't organised to serve human health, but only itself, as an institution. It makes more people sick than it heals.”
- Ivan Illich, “Medical Nememis”, 1976
This has only become more true in the fifty years since. Socializing costs and privatizing profits cannot sustain itself. A fiduciary responsibility to shareholders is at direct odds with a commitment to the patient first. Great post by Prof Raymond, and a clear call to each of us still trying to save this healing profession of ours
Law of The House of God: The essence of medical care is doing as much nothing as possible…