The Hospital: A Total Institution

A Sensible Medicine guest post

We are lucky at Sensible Medicine to be able to feature people who see healthcare through different lenses. I especially liked this piece by Chad Raymond as it had me nodding along and getting defensive at the same time.

Adam Cifu

5:37 a.m. on a Thursday morning. My wife has just driven me to the nearest emergency room, where I will spend the next fourteen hours, followed by an overnight hospital stay, because of a small bowel obstruction. I had entered, per the sociologist Erving Goffman, a total institution.

In his 1961 book Asylums, Goffman defined total institutions as places for people whom society deems in need of some fundamental change to the self. To effect this change, total institutions subject their clients to a highly regimented environment under the direction of specialized authorities. The American hospital is now the epitome of a total institution. Originally poorhouses for the dying, American hospitals evolved into places where cadres of experts and cutting-edge technologies promise to restore the sick to health. Yet this transformation has left hospitals incapable of meeting this promise, for four main reasons.

First, total institutions require that their clients be complicit in their own objectification. In the name of “care,” hospitals deprive patients of physical activity, sleep, and nutritious meals—the same practices that caused many of them to need hospitalization in the first place. The hospital’s control over these basic elements of life sends patients the message that they need not, nor should not, take responsibility for their own health, which helps explain why the modern hospital has done nothing to reduce rates of obesity, drug addiction, depression, and other common causes of death in the United States.

When I had entered the ER, an anonymous receptionist sitting behind a plexiglass barrier attached a barcode to my wrist. After waiting with strangers in various degrees of distress, an attendant escorted me to an exam room, and a nurse told me to don the standard shapeless gown that marked my position at the bottom of the hospital hierarchy. A physician interviewed me. A new nurse started an IV. Another nurse entered and administered morphine. Then someone else directed me to sit in a wheelchair and moved me to a second waiting area with more strangers, also in gowns. A pair of radiology technicians performed a CT scan. The sequence of brief encounters and rushed conversations with different hospital employees continued until I arrived on a gurney in a curtained bay. Eventually another nurse arrived to administer a heparin injection, which I refused. As an avid exerciser who ran twenty miles per week, I had no elevated risk of blood clots.

Second, total institutions prioritize service provision over service quality. The fee-for-service business model of the American hospital incentivizes this hierarchy. Doing something is invariably better than doing nothing, and prevention is far less profitable than cure. As a result, an estimated one-fifth of medical care is unnecessary.

Two surgical residents entered the bay, and insisted that I needed emergency surgery, ignoring my ability to walk and talk, the absence of fever, and a lack of vomiting. They did not discuss possible complications. I found myself forced to debate what constituted a reasonable plan for my own care while under the influence of a narcotic, and not having eaten or slept for thirty-six hours.

Third, the total institution’s obsession with measurement causes its staff to mistake the map for the territory. Technological advancements have allowed hospitals to subject patients to increasingly elaborate forms of testing, making illusory precision endemic in medical decision making. In a parody of Goodhart’s Law, hospital personnel gather reams of diagnostically irrelevant patient data while ignoring evidence that they could instead glean from cursory observation.

Just before 8:00 p.m., an orderly wheeled me to a room upstairs, where staff sent my wife home—visiting hours were long over. Nearly four more hours passed before the hospital allowed me to sleep. I had plenty of time to remember previous hospitalizations elsewhere:

• when ER physicians dismissed the possibility of a clot in my subclavian vein based on an x-ray, despite my having a central line and unilateral chest and upper arm edema¹;

• my refusal of an abdominal ultrasound to image my gallbladder—because a surgeon had removed it a few months prior, as documented in my medical record and as demonstrated by the scars on my unexamined belly;

• when, after eighteen months of debilitating pain, MRIs, an echocardiogram, the cholecystectomy, and other procedures, an endocrinologist fresh out of fellowship discovered from a simple blood test that I had severe hypophosphatemia, a common side effect of a medication that another physician had prescribed.²

Last, the total institution inexorably expands in scope and complexity, until, as Goffman wrote, it only offers what its clients cannot accept while rejecting what its clients are able to offer. Because modern hospitals are not designed to address underlying social problems that drive illness, they expend far more resources trying to extend life than on improving its quality. Hospitals resemble Starbucks in terms of their efficacy in bolstering long-term health outcomes for the communities that they ostensibly serve.

Hospitals—and the American medical system writ large—now present people with a Hobbesian choice: either unconditionally surrender to the demands of a total institution and all the risks that this entails, or seek an alternative that might be even less effective, but which allows them to retain some amount of agency over their lives.

The obstruction cleared on its own overnight; I was discharged the next day.

Chad Raymond is a professor of political science and international relations at Salve Regina University in Newport, Rhode Island.

1. The upper extremity DVT was correctly diagnosed by a GP over the phone the next morning. The diagnosis was later confirmed by doppler ultrasound.

2. The drug was ferric carboxymaltose, Injectafer.

Photo Credit: Adam Cifu