Thanks for sharing! I’m still laughing at your quote of one-fifth of care being unnecessary. It’s likely more than 50%, imo, if not even higher.
I suspect the system creates much more illness than it “cures”, at this point, and that’s not including the endless burden of death and illness delivered to us in the name of vax.
These observations also apply to rehab centers to which patients recovering from surgery are sent. My widowed mom whose kids are either out of state (me) or work full time or both was in rehab where received on 1/2 hr physical therapy 2x week and was not allowed to get the simple walking and fresh air and sunshine she needed to actually get better. And the food was awful. Staff was most doing best they could it were overworked. Sigh.
Regulatory and QI efforts, albeit designed to improve safety and outcomes, have led to an obsession with measurement of all things measurable, and more broadly to a rise in algorithmic, protocolized and less personalized care. This often means that required measurements, surveys, imaging, procedures or labs may be irrelevant or at worst harmful, when they take the clinician or staff focus off of the actual person in front of them and the ability to think critically about the patient's concerns or observe/interpret signs/symptoms.
Thoughtful piece and much rings true. I have always been struck how dissociated hospital care is from addressing the true determinants of health. I kid with colleagues about how easy the medicine part is as we really spend most of our time grappling with the psychosocial part. I also could not agree more that we spend huge amounts of unnecessary time measuring things that have nothing to do with patient outcomes. I don’t know what I would do with my vast free time if I weren’t negotiating ridiculous blood pressure parameters with the nurses. Solutions do not come easily as it will require a total medical culture overhaul.
A major sign of the dissociation that you refer to is the huge amount of resources expended on people in the last few months of life; i.e., the medicalization of dying. I saw this with my own father, who had end-stage pulmonary fibrosis and was resuscitated after coding in the hospital despite a DNR. He was brain-dead but put on a ventilator in the ICU with his other organs failing. Luckily I had medical power of attorney and could order staff to turn off all the machinery once I arrived.
Most of the problems with hospitals and the entire medical care system are caused by the steady advance of bureaucratization over the past several decades. When I started practice at a large community hospital in the 1970s, we had one hospital administrator with one assistant and one secretary. The hospital had over 600 acute care beds. Practically everything was run by committees of staff doctors that were all in private practice except for the pathology and radiology departments. The administrators merely executed the plans laid out by the relevant committees. Government intervention in the medical field kick-started the decline and the resultant corporatization finished the job. Staff doctors are now mostly hospital employees and given incentives that detract from the traditional doctor-patient relationship that held sway in earlier times. The resultant decay has been obvious and, unfortunately, probably irreparable.
Yes, the pattern of bureaucratic takeover has been essentially the same for many useful occupations that have been converted to institutions. It all started with the railroads 150 years ago. Current generations view the situation as the norm. Perhaps they are fortunate in not knowing how things used to work.
So interesting to hear this perspective from a doctor. Fortunately my only personal experience with hospitals was giving birth, but it was so bizarre. I could barely move during labor I was strapped to so many monitors, even though my baby and I were low risk and doing fine. When things started going wrong, I had to fight a team of doctors for a c section. They told me later I was right and couldn't have delivered my huge baby naturally without complications, but they put me through hours of pain for nothing. It felt like they had learned in med school that natural birth was best so that's what they were going to do, with no actual thinking or judgement of the situation in front of them. During my stay afterwards I had to beg the nurses to stop me from being disturbed for a few hours at a time so I could rest. Otherwise there was a constant stream of people waking me up all day and night doing mostly useless tasks. The food was soaked in either sugar or grease. Worst of all (I still get choked up over this), they separated my baby from me and put her in the NICU over a weird X-ray with no other symptoms. I understand being cautious with a newborn, but the downsides of the stress on her from being separated from us and filled with IVs and tubes wasn't taken into consideration at all.
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.
Agreed or accompanying a family member to appointments and hospital stays. I witnessed the horrible nursing care - resulting in complications. Could have been dramatically improved just by employing additional nursing assistants- some of the most cost effective hospital employees.
Except apparently when propaganda pushes fear over facts and we ban visitors. We never ever ever needed to ban loved ones from their patients bedside. Yes I’m talking about Covid. How many died without family advocating? How many died from poor care because of fear from staff? How did we go from bad cold season to OMG WE ARE ALL GONNA DIE literally in span of 48 hours? And the fear that was pushed with it?
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.
Thanks for sharing! I’m still laughing at your quote of one-fifth of care being unnecessary. It’s likely more than 50%, imo, if not even higher.
I suspect the system creates much more illness than it “cures”, at this point, and that’s not including the endless burden of death and illness delivered to us in the name of vax.
These observations also apply to rehab centers to which patients recovering from surgery are sent. My widowed mom whose kids are either out of state (me) or work full time or both was in rehab where received on 1/2 hr physical therapy 2x week and was not allowed to get the simple walking and fresh air and sunshine she needed to actually get better. And the food was awful. Staff was most doing best they could it were overworked. Sigh.
Regulatory and QI efforts, albeit designed to improve safety and outcomes, have led to an obsession with measurement of all things measurable, and more broadly to a rise in algorithmic, protocolized and less personalized care. This often means that required measurements, surveys, imaging, procedures or labs may be irrelevant or at worst harmful, when they take the clinician or staff focus off of the actual person in front of them and the ability to think critically about the patient's concerns or observe/interpret signs/symptoms.
Kudos, Dr. Cifu for posting this. It is unfortunate that this probably happens more often than we can imagine.
Thoughtful piece and much rings true. I have always been struck how dissociated hospital care is from addressing the true determinants of health. I kid with colleagues about how easy the medicine part is as we really spend most of our time grappling with the psychosocial part. I also could not agree more that we spend huge amounts of unnecessary time measuring things that have nothing to do with patient outcomes. I don’t know what I would do with my vast free time if I weren’t negotiating ridiculous blood pressure parameters with the nurses. Solutions do not come easily as it will require a total medical culture overhaul.
A major sign of the dissociation that you refer to is the huge amount of resources expended on people in the last few months of life; i.e., the medicalization of dying. I saw this with my own father, who had end-stage pulmonary fibrosis and was resuscitated after coding in the hospital despite a DNR. He was brain-dead but put on a ventilator in the ICU with his other organs failing. Luckily I had medical power of attorney and could order staff to turn off all the machinery once I arrived.
Most of the problems with hospitals and the entire medical care system are caused by the steady advance of bureaucratization over the past several decades. When I started practice at a large community hospital in the 1970s, we had one hospital administrator with one assistant and one secretary. The hospital had over 600 acute care beds. Practically everything was run by committees of staff doctors that were all in private practice except for the pathology and radiology departments. The administrators merely executed the plans laid out by the relevant committees. Government intervention in the medical field kick-started the decline and the resultant corporatization finished the job. Staff doctors are now mostly hospital employees and given incentives that detract from the traditional doctor-patient relationship that held sway in earlier times. The resultant decay has been obvious and, unfortunately, probably irreparable.
As someone with 25+ years in higher education, this is eerily familiar.
Yes, the pattern of bureaucratic takeover has been essentially the same for many useful occupations that have been converted to institutions. It all started with the railroads 150 years ago. Current generations view the situation as the norm. Perhaps they are fortunate in not knowing how things used to work.
So interesting to hear this perspective from a doctor. Fortunately my only personal experience with hospitals was giving birth, but it was so bizarre. I could barely move during labor I was strapped to so many monitors, even though my baby and I were low risk and doing fine. When things started going wrong, I had to fight a team of doctors for a c section. They told me later I was right and couldn't have delivered my huge baby naturally without complications, but they put me through hours of pain for nothing. It felt like they had learned in med school that natural birth was best so that's what they were going to do, with no actual thinking or judgement of the situation in front of them. During my stay afterwards I had to beg the nurses to stop me from being disturbed for a few hours at a time so I could rest. Otherwise there was a constant stream of people waking me up all day and night doing mostly useless tasks. The food was soaked in either sugar or grease. Worst of all (I still get choked up over this), they separated my baby from me and put her in the NICU over a weird X-ray with no other symptoms. I understand being cautious with a newborn, but the downsides of the stress on her from being separated from us and filled with IVs and tubes wasn't taken into consideration at all.
Lack of sleep in hospital is shocking bad!! I went home 24 hours after having my 3rd so I could actually sleep when I could!!
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 — :)
You're too kind.
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.
Agreed or accompanying a family member to appointments and hospital stays. I witnessed the horrible nursing care - resulting in complications. Could have been dramatically improved just by employing additional nursing assistants- some of the most cost effective hospital employees.
Except apparently when propaganda pushes fear over facts and we ban visitors. We never ever ever needed to ban loved ones from their patients bedside. Yes I’m talking about Covid. How many died without family advocating? How many died from poor care because of fear from staff? How did we go from bad cold season to OMG WE ARE ALL GONNA DIE literally in span of 48 hours? And the fear that was pushed with it?
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.