Peeking Behind the Curtain: A View From Inside a Hospital
When author and journalist Julie Salamon was introduced to Maimonides Medical Center in Brooklyn, N.Y., she found an institution that in one sense faced all the problems of a large urban hospital in the 21st century: reimbursement hassles, bed shortages, the pressure to invest in new technology to stay competitive. But there was an added element; Maimonides's patients and employees are a crazy quilt of cultures, religions, traditions, beliefs, and personalities that reflect the surrounding Orthodox Jewish community and the wider world. And its strong tradition of openness and accessibility puts all the conflicts right out in the open. In Hospital (Penguin Press), she chronicles the year she spent reporting at the hospital, where she had access to every perspective, from the residents' to the patients' to the administrators'. U.S. News talked to her about her experience. Excerpts:
You describe Maimonides as "diversity on steroids," a place where patients speak 67 languages. What was good about that?
Just looking around and seeing the absolute mind-boggling diversity actually made me feel amazed about what good could happen in our country. Three or four years after 9/11, when everyone's nerves were still raw, in this hospital it was extremely routine to see [observant Jewish] men wearing skullcaps and religious Muslim women in head-to-toe coverings treating each other civilly. The hospital became a kind of DMZ [demilitarized zone].
And what was bad?
There's so much miscommunication, even if you're speaking the same language. A doctor [in the book] makes the point that patients have a lot of pre-existing conditions, and the language barrier is just one more. And there's all kinds of diversity beyond the multicultural dimension; there's class diversity—doctors are from one class, technicians from another, and yet they're all supposed to work together and have the same amount of concern for the patient on the operating table.
The book makes clear the tensions inherent in running a hospital and trying to make enough money to stay afloat. How could you sense that?
Where you could see it is that everybody seems to be rushing around all the time. In the last 20 years, led by Medicare, reimbursement became linked to something called diagnostic related groups. That means the hospital gets paid X for this disease, whether a patient stays six days or six weeks. If you stay six days, the hospital can break even. If you stay six weeks, it's costing the hospital every extra day. That may sound like an obscure insurance problem, but [as a result] the minute the patient gets into the hospital, the whole aim is to get him out.
You had the benefit of getting everyone's perspective. What's one thing about being a patient that hospital staff members should recognize?
When you're a patient in the hospital, so much can be very terrifying, but I saw over and over again how the simplest form of human communication—which can go by the wayside—makes a big difference. People want to be talked to, they want to be treated as human beings. One doctor would always make sure he sat down next to patients at eye level. When you're sick and frightened and fragile, that makes all the difference. I think that as an ethos, the hospital understands this, but it isn't always able to carry it out.
And what aspect of the doctor's perspective would you convey to patients?
Doctors may not always give clear instructions, but even when they do, it's not heard. In the cancer center, one patient was supposed to come in for radiation treatment and was told not to eat for X hours beforehand. Three times in a row, he came in eating a candy bar...and he got mad at them! He didn't speak English, but the interpreter made sure he understood it. Obviously, he didn't take it seriously. Patients, for their part, need to take more responsibility for themselves. You cannot expect miracles. If you don't take care of yourself in the most basic way, you can't complain if you're unhealthy.
Conventional wisdom says that the emergency room has become the place where the uninsured get their minor primary care. Did you see that?
I'd say the more common situation was for people to be really sick and without a primary-care doctor. One of the big problems, especially for the uninsured—especially immigrants—is that people would delay going to the doctor and then were very sick. A really bad cold that lasts for two weeks, you'd go to the doctor. But if you don't have one and wait, by the time you get to the ER, you have pneumonia. You actually did have fewer of the scraped ankles and headaches that are the regular ER problems.
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Residents
I am a surgical resident at a large hospital in NJ. As a relatively new and inexperienced physician, I can say that working in a hospital in the US is a daunting matter at best. From my perspective, many patients do not understand the complexity of the system of care they receive in a hospital. They do not comprehend all the issues and costs that go into their day to day care. For instance, any given patient may have 4-5 resident physicians, an attending physician, a few RN's, social worker, dietician, etc., responsible for some aspect of their care. It is confusing and exhausting to the patients to try and identify each person who comes into the room for 5 minutes at a time. I certainly acknowledge this fact. I definitely agree with the author that many patients just want those moments of clarity and empathy and explanation they hope their doctor will provide. I think those expectations are warranted and appropriate. However, I could not agree more with the author's comment that patients do not take enough responsibility for their own care. I can't even count the number of times that a patient did not listen to instructions provided by RNs and doctors, despite multiple attempts at explaining a certain procedure or instruction to a patient. I know people may believe it is a matter of a lack of understanding, but believe me when I tell you people can be very stubborn when it comes to lifestyle changes or simple changes that could benefit their health. A lot of times patients just refuse to believe that simple things, like not eating before a procedure or test is important to their overall health. They blow off appointments or follow-up tests and end up coming right back to the hospital through the emergency room. It can be a very frustrating thing for a resident and in fact feels disrespectful to us, because we work extremely hard to try to provide the best care for our patients and expect that they will honor this commitment by taking part in their own health and to improve their quality of life. On the subject of disrespect, a lot of people do not realize how busy a resident and attending physician can be during the course of any given day in a hospital. Believe me it is nothing like Grey's Anatomy or one of those silly dramas on TV. I know that families and patients can get frustrated and angry when they wait to hear from their doctors. However, they should realize that we do make our best efforts to accommodate patients as quickly as we can. For perspective, my typical day as a surgical resident begins at 5:00 AM. From 5 to 7 AM, the team "rounds" on all 20-30 of the patients on my patient list-- that is, the census of patients that my particular surgical team follows on a daily basis. A surgical team consists of a group of Attending physicians, in my case 4 surgeons, who treat and admit patients to the hospital. These physicians can at any time admit, discharge, operate on or transfer patients to my service, and my team and myself are responsible for the day to day orders and care of these patients. Rounding is a challenging daily process. In 2 hours, we are expected to see 25 patients which includes asking how they are, finding out information about what may have happened overnight (i.e, vomiting, pain episodes, critical care issues, etc.), examining the patient which often includes changing dressings on wounds or changing surgical drains, etc. , writing a clear and precise note on the patient's condition, writing orders for the day, checking laboratories/xrays/imaging studies/etc. This is a VERY difficult time to really stop and talk with patients or families b/c of the time pressure, and is not a good time for families to ask questions, etc. And of course, despite this fact, we will always try to accommodate patients and families but frankly sometimes it is just very hard to. At 7:00 we meet the attending doctors and "run our list" which means that we discuss all our daily finding and physically see every patient on the list and then determine our plan for the day. At the same time, some of the surgical team break off to go see patients coming in to the hospital for elective surgeries. We often need to fill out stacks of paper work, talk to these patients, have them sign consent forms and answer questions at these visits. From there we typically start our operating days at 7:30. Which means we could be in the operating room from 7:45 AM to 6:00 PM. Many times procedures take much longer. I have been "scrubbed" into cases that go into the early morning hours (i.e. 2 or 3 AM) many times. All during this time, there are still 25-30 patients on the hospital wards, which require attention and close care. In addition, there are constantly new patients to see, that come in through the emergency room or that are in the hospital and need surgical issues addressed. With only 4 or 5 residents at any given time, this can be very challenging. Often there is only 1 resident covering the ward patients and seeing new consults while the other residents are in the OR. Even with all of these activities going on, we are still, in addition, holding office hours and surgical clinic hours. 2 to 3 days a week we have 20-30 clinic patients to see during any given 4 hour session. My typical day is 5AM to 7 PM. Every 3rd to 4th night I stay on-call, which means I work from 5 AM to 11AM or 12 PM the next day. I get 4 days off a month, which may sound like a lot, but again, my work week does not include weekends. So these 4 days usually mean I get 1 saturday or sunday off a week. So as you can see, it is not always so easy for us to respond to patients and families as often and as rapidly as we would like. After all, each of these activities we do, involves a human being, a patient, and every individual deserves our attention and support. When we are not seeing you right away, we are certainly spending our time addressing another person's concern. So please, be patient and be respectful to us as well.
Peeking Behind The Curtain
Ms Salamon left out the largest group of employees in a hospital that make the greatest difference in the type of care a patient receives. This group is the Registered Nurses.
I am an RN with 35 years of experience with bedside nursing and senior hospital management. After 20 years in hospital management I returned to the patient's bedside and now work 12-hour shifts in an Intensive Care Unit. What people do not realize is a doctor may see the patient 5-30 minutes a day. The RN is with the patient for 12 hours. Kindness, empathy, and caring are just the tip of the iceberg of an RN's duties. The RN is the person who monitors lab and diagnostic results, medications the patient is receiving, constantly assessing for changes in the patient's condition, educating families, dealing with bio-hazards such as body fluids, exposed to every virus and bacteria, confronting death,etc. Abnormalities or changes in the the patient's condition are communicated to the doctor by the RN.
Communication problems usually arise because of the doctor's inappropriate orders, poor handwriting, not returning the nurse's phone call, refusal to listen to the RN, and sadly the fear by a nurse of the doctor's reaction to his/her phone call.. Doctor's routinely verbally abuse RNs with the hospital management turning a blind eye. Physical abuse has also occurred with little negative ramifications to the doctor.
The media minimizes and trivalizes the important role of the RN. Nurses are seen as "background" or invisible. A great example of this is with Ms.Salamon's article. Nowhere in this article was the RN mentioned. If she had spent an entire year observing a hospital, surely she would have noticed the prominent and important role the RN plays in the care a patient receives and the outcome of of a patient's hospital stay.
By the way, the RN is greatly underpaid. Our pay ranks at the low end of career groups such as education and Social Services. RN wages are no where near what they ought to be based on the RN's responsibilities and education requirements.
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