When I set out to observe life inside a major urban hospital for a year, I expected to find heartbreaking, inspirational and possibly alarming medical stories. I anticipated insurance entanglements, technological marvels and cultural conundrums.
I didn’t expect, however, to find classes to correct bad behavior. The classes — at Brooklyn’s Maimonides Medical Center in New York — were designed to enforce the hospital’s Code of Mutual Respect, and part of a national trend to help people in the medical field rediscover the value of that old-fashioned virtue called common courtesy.
Among the provisions that these doctors and nurses needed to be reminded of were not to use racial or ethnic slurs, or language that was profane or sexually explicit. Also, to refrain from intimidating behavior, “including but not limited to using foul language or shouting, physical throwing of objects.”
Slurs? Throwing things? Was this a hospital or a reform school, I asked one physician, a department chief. He shrugged and told me that such behavior was far more common than I might imagine.
Great article. I was in the O.R. yesterday and there was a surgical tech student who was sort of familiar. I went over and introduced myself and asked if we had worked together. She said that we did work together a few weeks ago and that I was the “surgeon that didn’t yell or throw things.”
I try to foster an atmosphere where everyone is on board in the effort to minimize bad outcomes (which still can happen unfortunately).
Insist that every physician has 8 hours sleep before his next shift (as nurses and pilots do) and insist that there is a minimum of a 24 hour off period once a week, and I think you may be surprised how pleasant some of those surgeons might be.
Unfortunately, physicians are not employees. Therefore, we are not paid to be on call, and therefore cannot simply have shifts, like nurses. It is not possible to make a living just seeing hospital patients (some hospitals pay for “hospitalists” few pay for specialists. These are expected to work as a condition of licensure.
I am not a surgeon, however I anticipate that a surgeon going on his 36 hour awake, tryng to control bleeding would be upset if he were handed the wrong instrument. Time matters in medicine. It is not uncommon for a frustrated surgeon to throw useless instruments accross the room.
What amazes me is the sense of entitlement that many patients and family members have. No, the hospital is not a reform school, and physicians should behave like human beings. However the hospital is also not a hotel where physicians and nurses provide concierge service. A hospital is most like a battlefield, where exhausted people push themselves to save lives in a time critical fashion.
Last night (about 1am) I was called in to attend a patient who was having an acute stroke, and who was completely paralyzed on the left side. The chances of complete recovery are much higher if such folks gets “clot busting drugs” (known as TPA) within 3 hours of stroke onset, and it takes 15 minutes for pharmacy to prepare this. The family waited 2 and one half hours before coming in because they didn’t want to have to stand around in the ER in the middle of the night, and then got nervous when he wasn’t getting any better. We rushed him off for a CT on arrival, while I got the history from the family. I explained about the time critical nature, and told them that we had only 20 minutes to see if he was a candidate for the drug, and to get TPA begun if he was to receive it. I informed them up front that therefore I could not take any questions other than the ones I was asking until I was completely finished (there is a long list of exclusions, as the drug is dangerous and can cause bleeding). Most of the family had the sense to shut up, and just answer the questions. There was one daughter who kept yapping on her cell phone to her boyfriend, and who kept asking irrelevant questions like “when will he be able to go to a hospital room, because he is very tired?” or “Will he need to have any other blood tests? They had to stick him twice when he got here, look at his bruise” or “Will he be seeing a nutritionist? I think he needs a better diet” or “When will his regular doctor come in to see him?”. After the fourth interuption, I asked her to leave. (Probably in what the author of the article would consider a nasty tone of voice).
On the good side, the patient got his TPA with 3 minutes to spare, and is moving his arm and leg almost normally today.
On the bad side, the daughter went and complained to the administration, so I presume I will have to write another stupid response.
I might add, that many neurologists simply refuse to see patients in hospitals, and confine themselves to all outpatient work. Accross the border, in Bentonville Arkansas there are no hospitals with neurologists, and patients therefore usually do not get TPA. Outcomes are worse, but physicians are happier and presumably more pleasant to be around.
And pleasant is what’s important isn’t it?
I keep thinking how nice it would be if I would also close my practice to inpatient work or Medicaid. I’d be richer, I’d have more time. I’d probably be a nicer person. If I had more time, I’d probably be in better shape as I could develop hobbies or exercise. One more assh*le and I probably will. Right now, however, I still feel some responsibility to my community.
I think the nurses in the postpartum ward at the hospital I delivered in could have benefited from this class. The LDR nurses were great, except for the pain my labor was great because I was so well taken care of. But when I got moved to the postpartum room, things went downhill. It took four hours for my first nurse to come visit me after I was moved, they couldn’t find the Dr’s orders for my pain meds (and so wouldn’t give me any for hours), wouldn’t help me to the restroom even though it is hospital policy to assist mothers who had epidurals for the first three potty trips once the needle’s taken out (so we don’t, you know, fall down and hurt ourselves?).
They were rude, condescending, and always hours late for just about everything. When I asked why it took them so long to get to me the first time the nurse said “oh, I thought someone had come already”.
Everyone else at the hospital was great though, from the check-in, to the anesthesiologist, LDR nurses, my OB, nursery, etc. Everyone that is except the postpartum nurses. And they were like that for almost EVERY shift.
Back in the days when the nuns ran the hospitals (well, some hospitals), you never said anything bad in front of “Sister,” and you certainly would have to answer to the Sisters for bad behavior. With the secularization of the hospitals comes secular culture. This includes foul language, noise, loss of respect for indivduals, etc. Secular corporations have devised “sensitivity training” and similar plans to try to keep behavior in check. These corporations feel they cannot use religious based teaching for fear of litigation. Does religion have a role in people’s behavior under the stressful conditions of healthcare?
The most discourteous thing I ever observed was the behavior of an oncologist with my late wife. He bruskly told her, in essence, that she had three choices in the treatment available during the last week or so of her life. He told her to hurry up and make up her mind because he needed the consultation room for his next patient. What was really needed was an honest discussion of her condition and a concern for her comfort. It was left to me to tell her that she was losing the battle. Physicians should not receive their licensed until they pass Bedside Manners 101.
#5. I used to work at a Catholic hospital. They’re still around, but the ethos has changed. Mostly they are no different from secular hospitals, (in some ways much worse) and “sister” has been replaced by a secular hospital administrator.
The problem is that most hospitals are bleeding red ink. This results in short staffing for both nurses, ER staff, OR staff and others. Hospital administrators are under major pressure to limit lengths of stay, because the Federal government will only pay for so many days care, calling everything overthis “unnecessary”.
Twenty five years ago, when I was a resident, if a patient came in with a relatively simple problem (let us say new onset seizures) they would be admitted, they would be evaluated by both a resident and senior neurology resident the same night, or by a physician’s assistant if private, and would receive a CT in the emergency room. The next day they would receive an EEG, the attending (together with the residents/nurse) would sit down and go over the CT scan and discuss the issues related to seizures for quite some time with the patient, and formulate appropriate choice of antibiotics, and the patient would be begun on these, a day or two would pass, while any side effects were dealt with, and then (3-4 days after admission) the patient would be discharged.
The resident would have no more than 10 patients to deal with, and would not be in clinic while dealing with them. The attending would have clinic 4 half days/week, and would deal with the patients the other half day. There would be a day off to compensate for the fact that the weekend would be spent on call.
Surprisingly enough I recall it being extremely busy, and I ususually went home late, however I usually spent a good 45 minutes with each patient, and a dying patient with complex chemotherapeutic options could easily take several hours. Having said that, usually there were only a few time critical emergencies, and these did not occur often. Thus, one could spend lots of time with one’s patients, and not be interupted.
Currently, an easy patient (like the above) would be admitted, would have a CT in the ER, an EEG the next morning, and would need to be discharged in less than 23 hours (otherwise the hospital would not get paid). The hospitalist physician admitting the patient would be also caring for some 18 previously admitted patients, as well as admitting 4-5 new patients (if a hospitalist). If a neurologist was involved (for more than reading the EEG, and usually they would not bother to call us), that neurologist would be caring for 10 other hospitalized patients, while having spent the time between 8am and 6pm seeing about 5 new clinic patients and 10 follow up patients. Discussions of seizure types, risks , medications options therefore have to be done in rapid fire fashion. If a patient doesn’t understand something, usually one gives them printed materials off the computer and suggests that they read them and we will go over them in clinic. There is no time for long pregnant pauses. There are other patients waiting. If the ER calls with a true emergency (somebody in status epilepticus, or somebody with an acute stroke who needs TPA) the neurologist rushes over to the ER, returning to his irate clinic patients later.
Discussion of therapeutic options, are obviously much briefer now than in earlier years. This is not a matter of courtesy. It is a matter of minutes. There are only so many minutes in a day, and nobody I know plays golf. On non call weeks one usually begins at 7am in the hospital, goes to clinic at 8, finishes clinic around 6, and finishes in the hospital a around 8pm. On call weeks one rarely gets out before midnight, with every expectation to be called in, and one will still be making rounds at 7am, and will have a full clinic load. Seeing hospitalized patients must be done before and after clinic (unless again it is a true emergency in which case one rushes over.
One is paid the same for this schedule, as one was for the previous one. This is because at least twenty percent of the patients one sees will be uninsured, another third have medicaid, which doesn’t come close to paying costs, and about 40 percent have medicare which also doesn’t cover costs. (One makes a profit on the 10 percent who have private insurance, but the bottom line is that hospital work is essentially done free by anybody who isn’t a surgeon (procedures are better reimbursed). Thus, the hospital load can only be done after the practice costs have been met via the clinic. Those practice costs have soared, thanks to liability, and regulation. It used to be that physicians could work out of their homes with their wives as nurse and practice manager. Our practice has at least 15 people. Their salaries need to be paid, before a physician gets paid.
The fact that somebody is ill and needs extra time, doesn’t mean that extra time is available to fill that need. This is true for physicians whose outpatient practices tend to have the sickest patients (healthier patients going to urgent cares staffed by nurse practitioners, or county vaccination clinics). It is also true for hospital nurses (whose loads have increased, while their training has dropped from RN to LPN to the current, ubiquitous “med tech”.
Further, patients are much sicker today than they used to be. And they too are juggling jobs, children, finances and are angrier and more worried. They need more time than they used to, and we can’t give it to them.
I don’t have a good solution to this problem. I do know that it is not a problem that can be solved by well rested hospital administrators providing “sensitivity training” or seminars in good manners.
A little appreciation would go a long way to solve the problem, on both sides, however.
#7 Clueless, Why would anyone go into Medicine these days?
Why go into Medicine? It can be very rewarding to help care for people. Yes, there are frustrations especially in situations when you are tired, or have several demands at the same time. No one should go into medicine looking to make money. Yes, you can make a good living, but if your motivation is money, you will be disappointed.
I understand and sympathize with Clueless, it has to be hard to be a Neurologist, especially in a busy teaching center.
I don’t know what the answer is. I know that I love being a doctor. I love being able to help people recover from life threatening illness. Is it perfect? No, but nothing this side of heaven will be. You do your best with what you have.
Regarding the article, one should always treat people as you would have them treat you. This applies to all, from the most senior surgeon to the lowest whatever. Unfortunately, some doctors adopt the “God complex” and believe they are above mere rules of decent behavior because they are “important”.
Clueless,
I believe every word you say and thank God you keep doing what you do despite these conditions.
I seriously doubt that 1% of those who complain about doctors and hospital healthcare providers could spend a day in their shoes or pass a basic college biology exam.
Albany* #10:
I think your second sentence is simplistic, elitist and arrogant. One percent? Come on! If you want to make a statement about percentages, you could make your case better without dismissing the problem or belittling other professions or vocations.
#8: Why does anybody go into the military?
Before the military had it’s slogan “be the best you can be” I was asked by my interviewer why I wanted to be a physician. I said that I thought it would make me the person I wanted to be, and I wanted to be that person. (He didn’t say anything, he just looked at me, crosseyed).
I am not the person I hoped to become, however I am much closer to that person. I don’t think I would have been molded as well, had I had a less demanding task.
I love being a physician. Partly it is the privilege of making someone well. It’s a great feeling. I can go home and feel good about myself, most of the time. Partly it’s the privilege of working with collegues whom I can truly say are outstanding people. I suspect folks in the marine corp feel the same way. There are some things worth doing. There are some things worth being. I am grateful to be a physician. It’s an incredible high.
And now. I will log off.
Cole,
I don’t take back a word of it. I think it is factual. The people I’ve known who have made it through medical school are a serious cut above the rest of us intellectually, and show stamina and ability under duress that would unglue the average person in short order. I have no “vested” interest in this view. It does not apply to me or anyone in my family. It’s simply what I’ve observed being in reasonably close contact with this community. I also never suggested the demands are a blank-check excuse for rudeness. I just find tiresome folks taking potshots at a group that for the most part are extraordinary folks we really need and doing more than the best they can in a dysfunctional system. Most of all, rudeness is much more evident among consumers of their services.
Yesterday, I did an eight hour surgery. Afterwards, I came home and went to bed at 8:00. I did manage to read a half of a chapter of one of the Chronicles of Narnia to my kids before collapsing.
Tonight, I missed my son’s first tee-ball game. I wasn’t even on call, and the ER called me because they had a bar brawler with a mandible fracture. No one else would take it. No insurance of course. I have done hundreds of thousands worth of free surgery. I wouldn’t mind being able to deduct the lost income. After all, I am still paying off medical debt nine years after graduating.
I participated in my first medical malpractice trial recently, not my own, but one of the other local surgeons. Really an excellent surgeon who had a bad outcome. I talked to him today. He “won” but he said he had no idea how much energy it would end up sapping from him.
But I love my job. I perform miracles every day. I have traveled the world doing surgeries on kids with cleft deformities and other problems. But I would add that absolutely everyone not in the medical field is totally clueless on what it takes. (That doesn’t include our Clueless.)
Back on topic: A story told to me by a internist from Arkansas at a Christian Medical and Dental Association meeting. He states that several years ago he got a call from the ER at 3AM to come in and admit an alcoholic in DT’s. (No insurance, of course.) Now, the 3 AM calls are the worst. There will be no getting back to bed, so the whole day will be miserable. When the internist got to the ER, the drunk was reeking of his own vomit. But instead of despising this “lowlife”, the internist saw the face of Jesus. With the help of the ER nurses, they got him cleaned up and admitted and stabilized.
I have always been ticked off for being told that story. No longer am I free not to see the face of Jesus in all the “lowlife’s” that I am called to take care of. How can one be discourteous to our good Lord?
Clueless and robroy,
I’d be interested to hear both your perspectives on the proposal to shorten the mandated 80 hour week for residents. The last I heard they were talking about 56 hours a week or mandated nap times. I’m pretty sure they were going to exempt surgery from this (at least I HOPE). Do you think this sort of thing will help or hinder in the long run?
Albany* #13: This article wasn’t about tort reform or the educational requirements of doctors, but of some of the discourtesies caused by any level of hospital staff. I have several dozen friends who are physicians, I also have a few friends who are university professors of nursing. I have looked into the tired eyes of a surgeon giving the status report of a close friend after eleven continuous hours of a miraculous surgical procedure that saved her life. I also appreciate the care I received from corpsman, military doctors and nurses when I was in the service. I have total admiration for transplant ICU nurses who can keep track of a patient’s dozen metered medication dosages at once. The reason I jumped on your post was that by making such a broad statement, you were dismissing those cases where there are problems. I could present many other examples of discourtesies I personally observed in hospitals. In everyone’s lives and everyone’s profession or vocation there is some room for improvement. I’m sure it is more than one percent.
Cole,
Agreed. But I think the flow of the posts changed the topic. I’ve certainly seen the “skip in the step” of doctors all but disappear over the last 20 years. Getting remedial about their attitudes is akin to “blaming the victim.”
#15
There are two issues here. One is a justice issue. Under the current rules, many residents end up being paid less than minimum wage where their time paid by the hour. This is excused on the grounds that this is “education” rather than work. On these grounds it seems reasonable that if you aren’t going to increase the pay (and since the source of funding comes in part from the government this is more likely to decrease, rather than increase) one should decrease the work. In addition, the culture has changed. I was 23 when I began training. I lived in the rat infested house staff apartments accross the street from Johns Hopkins, walked to work, and was unmarried. Long hours did not negatively impact my family life, since I did not have one. Now, however, beginning residents are usually 28-33, are married, often with children, and are trying to pay for a townhouse. Also, many residents have high debt, and some moonlight to pay this off. So, for all these reasons, reducing time on the job helps, especially if you can’t increase pay.
The other issue is simply pragmatics. As it is, most new attendings have an incredibly steep learning curve when they go into practice. Not only is it necessary to suddenly master all the finanacial aspects of a small business (which they never teach you in medical school) but the amount of work beginning attendings are expected to do, greatly increases. I have noticed that folks graduating today are either unwilling or unable to cope with the learning curve. I think, mostly (physically) unable. This results in incresing numbers of physicians simply curtailing their practices. The medical specialists in my hospital who take call and can be counted to come in at night, are overwhelmingly over 50. (I think this is less true of surgical specialties). The under 40’s tend to simply limit their practices to outpatient only/no medicaid/pediatrics or uninsured, or else they become hospitalists only (subsidized by their hospitals). Their evaluations are a good deal less thorough. There are, of course, many reasons for this; the younger physicians have higher debt. They have younger children. They are resentful and many feel that they have been betrayed by an older generation. But I think simple stamina is part of it. And stamina is something that develops in response to the need for it.
#18, so (if I’m reading you correctly) residency as it currently stands in the US doesn’t adequately prepare attending physicians in 3 to 7+ years of roughly 80 hour weeks. Therefore, reducing the hours further will only increase the problem unless residency is lengthened considerably, or somehow streamlined and made VASTLY more efficient and topical (no/reduced scut, etc).
Residents are basically used as cheap labor to compensate for the fact that university hospitals have a disproportunate share of uninsured and medicaid who are unusually ill. This is the only reason that the federal government subsidizes residents. It is payback to the universities.
There are some things that residents need to/ought to know that are not helpful in terms of making the care of the uninsured cheaper. For example how to run a small business. How to bill. How to deal with malpractice issues.
In addition, there is the practical matter of getting enough practice on procedure (cardiac caths, operations etc. There is essentially no instruction on small business matters, because, after all that is not (really) why the resident is at the program. The resident is there as a cheap substitute for a physicians assistant or a nurse practitioner. The practical education of teaching diagnostics or performing surgery is done on the fly, and attending physicians are not paid to teach. Most attendings teach because they like teaching, and like being around residents. (Attendings support themselves either by research grants or by clinical revenues, and are paid a good deal less than those in private practice).
So no. Reducing the hours further will simply increase the problem unless money is freed up (either by not paying the residents – who already graduate up to 300,000 in debt) or by insurance/government finding new revenues.
I