The other day I tallied up all the hospitals where I’ve been directly involved in patient care since entering medical school. This counts hospitals where I had some kind of active role, but not where I merely shadowed providers as an observer. To date, I’ve worked in some capacity at 11 hospitals in four states. Included in that total are several major teaching hospitals, a few large regional medical centers, a community hospital and a private hospital. I’ve had a pretty decent sampling of the health care smorgasbord from a provider’s perspective.
Last weekend I had a visit from a friend and former co-worker. We spent a lot of time at a few of the same hospitals several years ago, often overlapping at various points. As is our wont, we spent much of her visit kibitzing about people we used to work with. One point of agreement between us was which hospital was the worst with regard to competent providers and appropriate patient care.
Any guesses?
Without a doubt, of all the hospitals where I’ve worked, the one that consistently offered the worst care was the private hospital with the affluent clientele.
Many of the pediatricians that admitted there accepted no insurance, and were notably affluent themselves. (I’ll never forget the moment one of them arrived on the floor and draped her Lagerfeld fur coat across a chair before sauntering in to see her patient.) They would admit mildly ill patients for treatments that could just as easily have been given at home, and then keep them there for days. The pediatric surgeon on staff would take patients for surgery when a halfway decent physical exam excluded plausible surgical diagnoses. The weights in the charts were recorded in pounds, but medications are dosed based on kilograms, so there were frequent medication errors. The care was uniformly, jaw-droppingly, ironically bad.
What made it so awful? In large part, it was because the patients had ceased to be treated as such, and were seen as customers. There’s a difference.
A truism in business is that the customer is always right. Keeping customers satisfied is what keeps businesses open. To a certain extent, this is an unavoidable truth for everyone, including medical providers. But, as with many professions, physicians are often ethically obligated to do or say things that make those in their care unhappy. Parents may be frustrated and anxious when their child has a respiratory infection that keeps her up coughing all night, but I can’t justify admitting her to the hospital if there’s nothing she really needs there, no matter how much of a relief it might be to her parents. Not only would she occupy a bed that could go to a patient that truly needs to be there, but there is a higher risk of infection for hospitalized patients that outweighs the minimal benefit of admission. Dissuading people from getting tests or taking medications they don’t need is a regular part of my job, and sometimes it’s not what people want to hear. Making an effort to explain the reasoning behind my recommendations goes a long way toward ameliorating feelings of dissatisfaction, but you can’t please everyone.
When the balance is tipped toward keeping customers happy as the highest goal, then delivering competent care is going to suffer as a consequence. There’s no way to reconcile those ends all the time. The wealthy parents with the healthy, hospitalized children thought they were getting wonderful care, because they were getting exactly what they wanted. Unfortunately, in those cases the customers weren’t actually right.
But were they getting bad care? Or were they getting unnecessary care and you’re defining “bad” as including “unnecessary”?
When someone says “worst” in relation to medical care, that typically refers to the quality of the procedures performed, and the rate of complications and failures during the course of treatment. Overtreatment is a second-order effect; if patients are to be expected to take ownership of their health and their health care, then you have to expect that sometimes they’re going to insist on getting care that’s unnecessary in the provider’s opinion.
If you’re saying “the providers at the hospital encouraged overtreatment just to pad their pockets and I think that’s wrong”, then I can’t disagree with that, but it’s not the same thing as “poor quality of procedures performed”, which is what’s implied when you say “the worst care”.
Unnecessary surgery is clearly bad medicine. Even if the surgeon performed the procedure in a technically correct manner, exposing the patient to the risks surrounding something so invasive without a clear justification is (in my opinion) pretty awful.
There is a lot of overlap between “bad” and “unnecessary.” I’ve been lucky enough to avoid working in hospitals where patients were consistently given treatments that failed or caused proximate harms, though it’s hard to count treatments that were never going to do any good as a “success.” Consistently admitting and keeping patients for flagrantly unnecessary care is, thus far, the worst I’ve witnessed personally. I’m sure at many hospitals in the same city I could have witnessed patients being more acutely harmed by their care. Much of what I write about here is anecdotal.
However, persistently delivering unnecessary care in order to fill one’s coffer strikes me as bad enough. Being in hospitals exposes one to risk of nosocomial infection. The individual pediatricians may not have accepted insurance, but the hospital certainly did, which means that the costs were passed on to the company (and other consumers downstream). Giving patients antibiotics they didn’t need increases the risk of resistant organisms developing.
Was it the “worst” care possible? No. Was it worse than anywhere else I’ve practiced? Yes.