Part One: In Defense of Medicine
Chapter XV. Is Medicine Still for the Patient?
The Patient Is Our Priority. In 1991, I said the following in answer to a question from an interviewer: "In a hospital, the sick person may be taken aback when confronted with all those machines and with an organization which seems so impersonal; but this organization is conceived to serve the patient, functions for the patient, and is manned by caring people." (106) I am not sure I would repeat this statement now, having watched the developments in American health care and the daily workings of several hospitals.
I recently spent a month, every day including weekends, in a large hospital in the Boston area, watching the proceedings. At some specialties' outpatient clinics all patients had to wait at least forty-five minutes, and often up to two hours past the scheduled time of their appointment; and this was not an exception, due to some emergency, but the rule. Lack of realistic planning? Certainly, but the underlying cause was a lack of concern for the patients.
In the wards, the intercom operators immediately answered a patients' bell, but actually getting to see a nurse, or a nursing assistant, could take anywhere from twenty minutes to twelve hours, especially if the patient was known for making frequent requests.
One night, an elderly patient with a grave ailment felt terribly sick, was afraid of dying, and begged a nursing assistant to stay with her for a while. This was refused, and the patient was given the usual lecture: "There are many patients on the floor, most of them sicker than you, and we have our priorities." Whatever their priorities, which I respect, there were behind the nurses' station, at all times, several nurses and nursing assistants engaged in lively conversation.
Procedures for which the patient must fast after midnight were scheduled for the next day's afternoon and then further delayed till late in the evening. The patient was given no explanation, and was kept waiting, hungry, thirsty, and exasperated. In two instances which I witnessed, even after the procedure the patient was denied food and drink, because the order "nothing by mouth" had not been cancelled.
A procedure involving some risk of infection was supposed to be done "under the cover of an oral antibiotic," but "nothing by mouth" had also been ordered, thus, the antibiotic was not given to the patient.
Another time, an antibiotic, augmentin, was ordered, and was to be given twice daily by mouth. The nurse scheduled it for 8 a.m. and 8 p.m. It was already 9 a.m., therefore, the patient was left without the antibiotic for the whole day.
Facing omissions and mistakes, the frightened patient begins to distrust the staff, the organization, and everything that is being done, and demands to see the attending physician. Such requests are seldom granted.
Spending Money on Palaces, Not on Nurses. Fund-raising activities and the pressure to cut costs have produced bizarre results. Wicked tongues say that brass plates with sponsors' names can only be put on buildings, not on nurses. Therefore, millions are spent on new, huge, magnificent buildings in which people get lost and transporting a patient to a lab becomes a long and difficult journey. Meanwhile, the nursing staff, found to be too expensive, is reduced to a skeleton. Nurses are replaced by semi-qualified and unqualified employees. The change is not only unsafe for the patients, it also is terribly aggravating.
Nursing, a Job Just Like Any Other? Nursing is understaffed and many nurses are no longer the conscientious, dedicated care-givers they used to be. But there are exceptions. A distinct generational divide has appeared. There still are, in the large hospital which I have closely watched, several nurses in Florence Nightingale's tradition, scrupulous, never tiring, unswervingly protective of the patients. They are now in supervising positions. Even among the younger hospital nurses there are exceptions to the general rule, for example, Miss Estelle d'Arcy, R.N. She is young, competent, dedicated, and wonderfully soothing. But most nurses of the new generation have been educated in a different way. They see nursing as a job just like any other. No special diligence or dedication is needed. These "modern" nurses are self-protective, and neither kind nor forbearing. They lecture the patients, argue with them, refuse to grant their requests, and punish the troublesome ones by abandoning them for hours at a time.
The Organization. There is a way of "natural growth," as when a group of people start doing work and then make this or that organizational arrangement when they feel it's needed. The other way is the "a priori" approach. Before any work is started, consulting firms make list of the tasks and then plan the organization, the division of labor, the hiring of various crews and the communication system. No grand project like building a mile-long bridge, drilling a tunnel, etc., would be possible without such planning. Applied to the workings of a hospital, as is now being done in the United States, organization conceived "a priori," operating in great numbers, inflexible, rigidly sticking to the division of labor, produces bizarre effects and is clearly detrimental to patient care.
Every move in the large institution I have watched depended on the various detachments of the ancillary staff. Scheduled ultrasound tests had to be rescheduled for another day when the "escorts" supposed to transport the patient failed to appear. Nobody else would dare to push the patient's bed along the corridor to the ultrasound lab. Outpatients who came for a transfusion of blood had their blood promptly matched with the donor's, and thick I.V. needles inserted, but had to wait long hours for the transfusion because only a "courier" was qualified to bring a pint of blood from the Blood Bank located on the same floor, and no couriers happened to be available.
At 11 a.m., the floors in patients' rooms were still littered with used facial tissues, scraps of paper, etc., waiting for the cleaning crew to sweep it. In the corridors, huge, open bundles of soiled linen created that untidy picture which so surprised me when I first visited American hospitals in 1987. In Western European hospitals, which charge three to four times less for a hospital day, every ward is kept shining clean by a single worker responsible to the ward's chief nurse.
Meanwhile, in a Smaller Boston Hospital, which I closely watched in 2003, in the congestion of people and events in the ward's narrow space, I could see that this institution, with too few nurses, was in fact incongruously, ludicrously overstaffed. Waves of various crews, the cleaning people, the restaurant room service, the electricians, the floor-polisher with his noisy machine, the escorts from the X-ray department, invaded the floor, with here and there a couple of plumbers, a security man, the newspaper carrier, the librarian, and the medical gas technician. Patients under the care of various specialists were kept in the same ward; as result, I watched seven doctors standing around the nurses' desk at the same time, gesticulating, loudly talking to the nurses or on the phones, reading the charts and writing orders. There has recently been much concern about hospital mistakes. Instead, I wonder how in that bedlam any orders are correctly issued and understood.
The Hospital Mergers. A wave of hospital mergers flowed over New England in the late 1990s. These deals, presented as the way to salvage financially shattered institutions, were negotiated and carried out by hospital managers, business consultants, accountants, and lawyers. I wonder if much thought was given to possible repercussions on patient care. Yet a negative effect of some mergers could have been predicted, and did occur.
A good hospital is a place where state-of-the-art services are offered in several medical specialties, and attention is paid to the safety, needs, comfort, and feelings of every patient. Examples given by good doctors and nurses, a sensitive management, the recruitment of good people, and attrition of those who would not adopt the spirit of the place, ultimately create an environment where dedication to serving the patient becomes the prevailing attitude.
Institutions with these qualities do not suddenly appear from nowhere: they gradually evolve over the years. It does not take long to damage and destroy them. In 1998, a Boston hospital well known for several world-famous departments and an exemplary patient-friendly atmosphere merged with a larger teaching hospital, academically excellent, but not particularly renowned for kindness to patients. As the larger hospital's bureaucracy invaded the smaller institution, imposing their own ways and values, and the two crews intermingled, dealing with patients was quickly reduced to the larger hospital's soulless standards. Some patients were dismayed and left for other institutions. An exodus of highly qualified workers followed. The team of anesthetists left, and while temporary measures were taken to replace them, a series of errors of anesthesia occurred. Then the excellent hepatobiliary surgical department and liver transplant unit left for another hospital, taking with them the nurses, the secretaries, and the patients. Incidentally, the hospital's financial situation after the merger proved worse than before.
Do Hospitals Still Exist for the Patient? One cannot but admire the tremendous diagnostic and therapeutic powers of the great American hospitals. This is not only a matter of equipment, but also of skills and organization. It is awesome how much the doctors in these hospitals can do to help the sick and save lives.
Yet many patients feel abandoned, confused, even unsafe. They no longer have the feeling that sick people used to have in the modest hospitals of fifty years ago: the feeling of being in good hands.