There is a serious issue with the flow of information in healthcare, (or at least in the U.S, I never worked elsewhere to know if it's any different). But If you find something during your shift which will be important to know later on, it will certainly be lost as soon as you are off for a few days, or even as soon as a new nurse comes on. To think of a somewhat crude example, if you find out that it is much easier to obtain a blood sample from the veins on the left arm of a patients vs the right, many nurses will still stick the right arm countless times hoping to get something.
And you can leave a chart note about things like that or speak about it during report, but for the most part few people will think "hm, I wonder what everybody else had to deal with." They are probably too busy handling a thousand different things happening all at once. And, even if that is not the case, from what I observed it's simply not part of how things are done. And very often patients will get (justifiably) angry, saying "I've been complaining of x thing for days!" or some version of that. I think it would be much better for both patients and healthcare staff alike if there was a greater emphasis placed on focusing on the series of successes and failures that happen over the course of someone's care, not just seeing it as a single shift or a single problem happening in some isolated point in time.
I once had a week as a patient at the Mayo Clinic in Scottsdale AZ. There were many remarkable aspects of care there versus the impossible mess out here in the other world.
But the single most significant aspect of care at Mayo Clinic is that the doctors and nurses and techs get to read your chart before seeing you.
That's it. You write something in the chart, it doesn't get tossed. It might not get parsed completely, but the essential info is there. And the staff does not get penalized for reading it.
(The other big reveal for me at Mayo was the sheer scale and throughput of the system. Healthcare at Mayo did not cost more than healthcare in my small town. It. Cost. The. Same.
It took six months to get in, I had a week, then it was someone else's turn. I presume that the high paying "celebrity" customers can get seen more regularly. So it's not perfect. But holy cow I wish it were easier for healthcare professionals to do their job.)
The Mayo Clinic (/ˈmeɪjoʊ/) is a nonprofit American academic medical center focused on integrated health care, education, and research. It employs over 4,500 physicians and scientists, along with another 58,400 administrative and allied health staff, across three major campuses: Rochester, Minnesota; Jacksonville, Florida; and Phoenix/Scottsdale, Arizona. The practice specializes in treating difficult cases through tertiary care and destination medicine. It is home to the top-15 ranked Mayo Clinic Alix School of Medicine in addition to many of the highest regarded residency education programs in the United States. It spends over $660 million a year on research and has more than 3,000 full-time research personnel.
Mayo Clinic has ranked number one in the United States for seven consecutive years in U.S. News & World Report's Best Hospitals Honor Roll, maintaining a position at or near the top for more than 35 years.
That's why they are number one. Because they actually use checklists.
Hospital systems are the same way. Moronic, scared management that is fine with these kinds of problems as long as the dough keeps coming in, ignorant of the fact that more dough would roll in (in addition to better health outcomes, which of course is not their first priority) if they would just focus on quality.
Good managers probably already do this, but healthcare has a very short supply of such people. It would be great if this type of improvement were the standard across the board. Let's say, for example, that you have latex and non-latex foley catheters mixed in the same bin in a supply closet. Your patients with latex allergies have gotten a latex catheter put in more than once and it now becomes a problem. Well, someone notices the issue, sends it up to someone above and now there is a new guideline to place the different catheters at least 3 feet apart, or something to that effect. It almost sounds silly, but people would be surprised how many of these mistakes happen over and over again due to equally silly reasons / lack of basic prevention.
That sounds like it’s the same in any sector? Especially IT.
Things like date are pretty commonly messed up. I've also had doctors and nurses put their own, incorrect, interpretation on information I've given them when they repeat it to others. When I say "my child wasn't eating and drinking normally and had half of what they normally do throughout the day", it's incorrect to say "the patient didn't eat or drink all day". That's the type of shit that can look really bad if it's recorded and looked at later. But it's like nobody cares if they record things correctly.
I've also had trouble with people not doing anything with important information. Like maybe you should slow down on the morphine and oxy if the patient is answering fewer basic questions correctly than when they came out of surgery. But it's OK if they can't tell you their own birth date - just give them more and later order a CT ro check for a stroke. Sorry guys, but it should be pretty obvious you're putting them into a opium stupor...
But with some people definitely only ask 1 question per email.
I am not knowledgeable or qualified enough to weigh in on this, but it's something I've heard cited by multiple friends in the field.
As much as I hated doing 24-28 hour shifts on inpatient services, continuity of care does matter and errors do occur in handover.
You have to keep in mind that medicine between 12am and 6am is what we call “keep people alive.” 6am to 12pm after an overnight is for handover.
You’re not trying to diagnose a new illness overnight or make changes in management, your job is to deal with acute overnight concerns only. Furthermore, you’re supported by services such as RACE (an in hospital emergency response team) so you’re not dealing with critically ill patients alone. If you’re on a surgical service and need to go to the OR, staff/fellow + senior residents come in to help.
Acute care services where you’re seeing new/undifferentiated patients and need to be on your game, such as ER and radiology, tend to limit shifts to 8-12 hours.
This is how the Stockholm syndrome feels. I manage a few T.A. in the university, and they barely can think after a 6 hours of teaching (two consecutive classrooms, with like half an hour of rest in each one for the students, and perhaps another informal half an hour in the middle). Sometimes they have to speak in the blackboard, sometime grade informal take home exercises, sometimes reply questions on the spot, and they get very tired. So we have a strict 6 hours per day rule. And if they make a mistake, nobody dies!
On-call medicine is so rote as to not require much, if any, thinking. Ward medicine is far less intellectually challenging than teaching.
Patients who are active/critical are not managed by a single tired resident overnight.
It looks like a random accident, but it's one of the silly mistakes that are more common when someone has worked 12 or 24 hours straight and has no checklists.
 I tried looking for the case, because the details matter, but most of the recent news are about a case where it apparently was intentional https://www-telam-com-ar.translate.goog/notas/202208/602435-...
Nursing errors (i.e. administering the wrong dose) can certainly kill people. They also don’t / shouldn’t work 24 hours shifts (infrequently a nurse might work a double due to emergent staffing requirements, this is a systems issue though and not by design).
There are both technological (EMR and ordering systems) and human safeguards (nurses and pharmacy) protecting against “silly mistakes” by physicians.
Once again, resident physicians’ roles overnights are no where near as mission critical as a nurse.
You also identified a key point in why 24 hour resident call shifts are safe - we have checklists.
If I order the wrong med on the wrong patient on an overnight call shift this will be flagged by the nurse who’s checklist includes verifying order accuracy. This is especially true of medications that can have life threatening complications (e.g. insulin, potassium, hypertonic saline).
Please also note I’m only talking about places I’ve trained (US and Canada) where all of these systems exist. I cannot comment on other countries where the infrastructure is different, perhaps this is more of an issue in Argentina than it is here.
It depends a lot on the hospital. There are good hospitals and bad hospitals.
There was a recent strike of the residents doctors in the capital of Argentina. https://www-lanacion-com-ar.translate.goog/sociedad/no-llega...
> By contract, [...], a resident has to serve eight hours a day, Monday through Friday, and do eight 24-hour shifts per month.
> “We work shifts of more than eight hours, which can reach 15 or more and with guards that are also on weekends. There are colleagues who work 40 hours straight,"
(The last one is a quote of one of the union leaders, so it may be a corner case.)
If it were so automatic and repetitive, it would be easy to pass the information to the next medic and have normal length shifts.
Ward call for residents generally works like this:
I have an inpatient list of 15-20 patients I’m covering overnight, some of them I likely know as I’m often part of one of the relevant day teams (unless I’m flying in from another clinical service to help out).
I start by receiving handover from one of the day team members. We sit down together (or by phone) and go patient by patient on the list asking what their reason for admission is, any labs/results I need to follow up on from the day (e.g. patient A had a fever and a cough, we ordered a chest X-ray if it shows pneumonia start antibiotics), patient specific management plans (e.g. patient B may have a seizure overnight, he’s known for this and if it happens give drug Y.) and any patients that I specifically need to see (e.g. patient C was complaining of some belly pain this morning but has been fine the rest of the day, eyeball him in the evening and make sure nothing is brewing).
I then write these action items and notes down (either on paper or in an EMR patient list) for my shift and carry out the relevant actions from 5pm to ~10pm.
Between 5pm and ~10pm I’m following things up and seeing any patients I need to see. Depending on my service I may be taking ED/inpatient consults but that’s not the point here so I won’t get into that.
At 10pm I do what’s called “tuck in rounds” and call up to the nursing station and ask if any of the nurses have issues they want me to address. Often this is something like morning labs that haven’t been ordered, laxative orders, etc. If there are any patients I’m worried about (uncommon on routine inpatient wards) I will pop my head in the room to make sure everything is alright. Cumulatively, the evening usually represents 1-2 hours of active work (again disregarding consults because that workflow is very different).
After that, and until the next morning, I am either asleep in a call room bed or at home. I will only be practicing medicine if there is an overnight issue that needs addressing (e.g. a patient is short of breath, their heart rate is elevated, decreased level of consciousness). These acute ward issues are beaten into every physician from the beginning of medical school and we follow very routine diagnostic workups (i.e. CBC, lytes, glucose, VBG), many of which are codified in algorithms such as ACLS.
If a patient is really unstable I call the RACE/code team (an in-house service to deal with unstable issues staffed by an ICU trainee, RT, and ICU nurse with advanced training) who assume care while I provide support and context as the home service/MRP resident.
This is a very safe system. It is really hard to kill an inpatient with a medical error in an acute setting.
Now let’s pretend I handed over to a night resident starting at 11pm. Two potential sources for error arise:
1. We would go over the same process of “running the list” and discussing patients, except now it’s second hand information I’m relating (versus my initial handover was from the primary team/MRP who knows the patient intimately). Broken telephone / forgotten action items becomes more likely.
2. An acute situation happens overnight and the 3rd shift person alerts the RACE service, except now the resident from the home team/MRP has never actually met the patient (you don’t go round and familiarize yourself with sleeping patients) and has no idea what they’ve been like all day except from what I’ve told them. This creates a huge problem because now they’re reading through the chart/notes to make sure this is a new symptom and not something I forgot to tell them about, they’re also reading the chart to see if there were any action items I addressed in my evening shift that didn’t merit handover but may be related to the acute concern. Whereas with the same resident on a 16-24 hour shift you have a much better understanding of the patients and their unique circumstances.
Many, many, many studies have shown medical errors happen a lot more due to handover than physician fatigue. You can argue that we should have better systems/IT in place to make handover safer, but we do not. Even places with systems like Epic/Cerner, it takes too much effort to maintain the handover list with accuracy and direct verbal communication remains the mainstay.
Furthermore, it’s important to keep in mind that dealing with ward issues between 12am and 7am is also pretty uncommon unless there is a late admission or someone that’s active, but that’s atypical. On-call is for emergency coverage not active medical practice.
Even outside the medical field, it seems like most humans are pretty bad about both writing down and consulting notes. Even worse for the notes written by another human. We really aren't particularly good at transferring knowledge / experience and it takes a lot of effort to do a good job of it, so most people don't even make much of an effort.
This really seems like a problem that still needs a lot more attention, especially in critical places like hospitals and really any long term crisis response situation where there is important knowledge gained over time with a (poorly handled) hand-off to successors.
I had some exposure to formalized incident management at a previous job. There, I learned a few formalities and practices that seemed valuable, especially assigning a single coordinator to be responsible for continuity of information and coordination between many independent actors over a long period. The coordinator role had explicit hand off to their successor where the stated purpose was to transfer important working knowledge and prevent the kind of problems you (and the article) describe.
With patient documentation specifically, what I would really love to have is a simple search mechanism for patient notes. This still wouldn’t solve the problem of getting everyone to capture the right information. But assuming the information is there, and I'm having a real hard time sticking that right arm, I would love to be able to search for "arm", "blood draw," "stick" and see what pops up. I hope it's not something I missed entirely, but I have never used an EMR with such a feature.
Years ago I saw a talk by a VA (US veteran's health care) thoracic surgeon, who was trying to entice tech folk to address the following problem. A surgeon is both team manager and skilled technician. When heads down in the technician role, the management role suffers for lack of attention. Especially severely at the VA, which did randomized staffing of operating teams, so you don't get the "group mind" and practiced gap filling of team which stays together. So surgeons would say "do X", and being distracted, not notice the order was dropped, and then proceed assuming X had happened, with regrettable results. The VA surgeon envisioned a voice system which noted the request, waited, and then whispered a nudge in someone's ear "did we do X?".
If the info were somehow magically there when needed, it would be used, right?
I would start with "sticky note on the relevant machine" type interventions first.
To let my imagination run a little wilder, I tried to think of what a system like that would be in practice, and how it relates to the problems that we currently face with the systems we already have. As much as it would be interesting to have all that information available through some sort of AR, there are really three important things that I would like to see about a patient: code status, vital signs and how they get up from bed.
It's really crazy to me how even the simplest of stuff is buried in a chart or EMR. Most do show the patients code status easily, but quite often it is in a small little font beside not-quite-as-relevant stuff like their marital status and what type of insurance they have. Why isn't this in big bold red letters in every room and in every chart as soon as you open up a document? Even for vital signs you have to click through two or three different things to get the information you need (but thank goodness I get to see some stuff right away, like that ICD-10 code for unspecified follow up for dietary counseling!)
One thing I think a lot of people may also not realize is how little information a nurse often has to go off of when walking into a room. If I am answering a call light for a patient who is not one my assigned ones, and they are screaming that they need to go to the bathroom yesterday, and you see them with both feet planted on the floor ready to get up, you have a quick second to think about a few different things. 1) How alert is this patient? 2) How mobile are they, do we need two people in the room? 3) Is this someone with a massive diabetic ulcer who wasn't supposed to be putting any pressure on that heel at all and they are about to do just that? Of course, you can look at the whiteboard, but you better pray that it's updated haha.
So, going back to the AR stuff. If I could have a snapshot of all this information as soon as I walked into a room, it would be a life saver, especially for situations like the above.
My home country the Netherlands is very different. My father had a stroke quite recently and spent some time in a very modern hospital where they are applying some of the latest insights for patient care. So, he was obviously hooked up to lots of equipment and intensely monitored. However, this hospital has separate rooms for all patients. Reason: it's best for the patients and helps them recover more quickly. Basically, more privacy for the patients and less restless nights. There are no TVs in these rooms. Instead patients are issued ipads with entertainment options and access to various things like indicating dietary preferences. Nurses carry ipads as well. Everything is digital. There are no paper charts in sight anywhere.
The rooms were modern, clean, and clearly optimized for making patient handling easy and straightforward. What struck me was the attention to detail and level of pragmatism in this. For example, my father's room had wall mounted hangers for folding chairs. These are for visitors. And when they are folded they are not in the way. The room had a whiteboard and a locked cabinet for medication and supplies. The doors are sliding. So, it's easy to move things in and out. Like beds, wheel chairs, equipment, trolleys. Etc. And so on. Just a really well designed and thought through design and architecture. Well managed and efficient.
BTW. This is not a private hospital: my country has a mandatory private insurance system: they can't reject people, people must be insured, and they can switch insurer. So, insurers mainly compete on quality care. Miserable patients and inefficient hospitals are bad for business and they are working to fix any issues there with hospitals. Which is why everyone, rich or poor, gets the same quality treatment in this hospital. It's way better than the private insurance I pay for in Germany. Way cheaper too. My German insurance is about 5x the price. I've been in a hospital here a few times and they can learn a thing or two about efficiency there.
I have lived in two countries with very unfair healthcare systems. High income people get "health insurance" (whatever that term really means!) from their employer. They use it a LOT. Way too much. And their "health insurance" covers most of the cost. The number of times that I have seen high income people see a medical doctor for a runny nose (light head cold) stuns me. What an incredible waste of medical resources! As someone fortunate enough to have this "health insurance" at various times in my life, I am constantly saying "no" when doctors try to over-prescribe all manner of medicines. Obviously, they know my insurance will pay 100%!
The #1 duty of a public healthcare system absolutely must be "acute need". Everything else is second priority, else they go bankrupt. It's rough. I don't know a better solution.
Crazy idea: What if there was a kind of public auction system where people in the queue could set a price to sell their position? As long as it was fair and transparent, I might be OK with it.
1. "Almost every patient has delusions and nightmares" I personally felt "off" when visiting my father. The sounds, smells, lights and constant buzz of activity all contributed to a feeling of being in a surreal dreamworld. Lack of sleep contributes. I can't imagine what my father experiencing.
2. Food was HORRIBLE. One meal was a low quality hamburger on a plain, white bread bun with a slice of "american cheese", fries, iceberg lettuce salad with a couple of slices of cucumber and a single slice of tomato, a container of apple sauce and glass of milk. Lots of salad dressing and ketchup. They wouldn't let us bring better food into the ICU and my dad didn't want to "make waves".
3. Family is critical. My father got better care because I, or my brother, was there to act on his behalf. Having obnoxious family members is worse than having none from what I saw.
My father's cardiologist was explaining the procedure he was about to perform and my sister and mother were so upset they just flooded him with irrelevant questions and questions that he had already answered. I kept trying to get them to stop talking over top the surgeon and actually listen to the answers he was giving. He finally asked me if I could "socialize this with your family" so he could return to the operating room.
This articulates very well what I've usually felt when dealing with doctors. It's like the story of a programmer finding that his code outputs 5 when it should be 4, and then adding...
if(return_value == 5):
return_value = 4
Stumbling in a hangover to appointments on "work days" and giving everyone the same diagnosis as the last (and likely whatever sickness they themselves had recently). Also giving everyone fluids and an ativan so the patient says - "i feel much better doc".
It's kind of an open secret that the ER just gives a diagnosis of dehydration, provides fluids and ativan to get the pipe rolling and charge $4k a pop. Sure they might catch a case of undiagnosed covid, rsv or something else from time to time.
Also I'm not kidding but I would LOVE such a show.
Chicago MD has some of the aspects you mention, especially overloaded, drug abuse, blame, police interactions.
New Amsterdam attacks it by the main character trying to solve the problems and running into bureaucracy.
People really don't understand the dire and primitive state of current medicine.
We are in the dark ages. We don't know why most drugs work; we have some notional idea but it's often an after-the-fact fiction that we tell. We don't know what causes the majority of diseases. In many cases we don't have treatments for the underlying problems, we only have treatments for symptoms.
If you want to see House MD, then tell your congresspeople and senators to invest in funding medical research so we can one day maybe leave the dark ages.
What you should want is curious and creative _researchers_, but precise and totally unimaginative clinical staff. Those are often the same person. See the problem? You want protocols applied down to the last detail. You want nothing left out of standard operating procedure. That's what kills patients in practice.
You might mean creativity in the sense of "let's have guys who think about the right things, and search for rare diagnoses and analyze stuff to see what could work, like Dr House". But that simply can't be done in practice. You can't be testing for every rare thing, because the tail of low probability diagnoses is much too long! And believe me, you _really_ don't want creative doctors around...
Sorry, this is not acceptable. The only time I’ve gotten decent medical care for my chronic issues was when I was making enough money to pay for a doctor who only worked fee for service. He would troubleshoot things like an engineer, because he was a former engineer. He improved the quality of my life immeasurably.
I think there’s a difference between “evidence-based” and using only 100% manualized protocols. If medical science was better and actually had answers for everything, sure, let’s stick to the manuals. But medical knowledge isn’t even close to being that thorough. Clinicians need to be able to think on their feet when they look in the manual and there’s nothing there. Otherwise, you’re failing patients.
GP orders test. I go to a test center to get the blood drawn. They have couriers taking samples to labs a few times per day.
12-15h a day, 6 days a week with not even a lunch break? You're sorely mistaken. It takes an expert to follow clinical workflows.
I am a bit biased because I have several medical professionals in my family, but a common refrain is definitely that most doctors/nurses aren't going to be that engaged and helpful, and are more of a input/output device to navigate rather than someone you want to completely defer to.
The only medical practitioners I've found willing to be more curious and to take a more holistic approach are naturopaths. I have had some notable improvements in my chronic health issues working with them, though I am a little uncomfortable with them given their general openness to things that seem pretty questionable to me (like homeopathy).
Since you’ve used a slightly fancy Unicode character: I found U+00B0 DEGREE SIGN unpleasant here, and it took a brief bit of thought to understand. (A capital N would probably have helped a little, but the degree sign is still disconcerting.) The character you want is №, U+2116 NUMERO SIGN. If you happen to be using a Compose key, `Compose N o`.
For less fancy options, “#” and “number ” would both be better choices and easier to read than “n°”.
To the best of my knowledge, I have never come across “n°” before. “№” plenty, “#” plenty, “No. ” plenty, “no. ” a few times, but not “n°” with a lowercase n.
Looking through <https://en.wikipedia.org/wiki/Numero_sign#Usages>… hmm, French AZERTY? I see now that it does have ° readily accessible.
I think another aspect that made it harder for me to recognise immediately was the lack of a full stop; I’d probably have recognised “n° 1” a bit faster. (I’d write “№ 1” rather than “№1”, though personally I’d go fancy with NARROW NO-BREAK SPACE, but that’s ’cos I enjoy doing crazy things like that.)
P.S. I live in Australia. Similar Anglocentrism to the USA in language, though less pronounced in matters of culture.
Yeah, I'm not really looking for doctors to demonstrate creativity (although House does), so I don't think I'm asking for anything at odds with evidence-based medicine. What I'm saying is that I think you need to get to the bottom of what's actually happening (i.e. why is the program outputting 5 when it should be 4) before you can know what evidence-based medicine to apply in a "precise and totally unimaginative clinical" way to actually fix the problem. As a patient, it just feels like the system, and therefore the doctors in the system, lack the curiosity to figure out what's actually happening. We often get the treatment for the most common issue even though it doesn't quite fit the real issue, or the common issue seems to just be a downstream effect of the real issue.
Creativity also has a role for non-critical conditions when standard treatments aren’t working.
I don’t think it is ideal to operate this way though, to be clear. Obviously this could have easily been missed by me or anyone else. But you aren’t arguing that point. You are approaching it from the perspective of minimising the variance in clinical quality. I don’t agree with you that this requires standardising how clinicians are, not just what they do.
But it is just as formulaic as described above. The doctors aren't trying to solve your issue. They're following a flowchart, and if that doesn't work for you, that's your problem, not theirs. Next time, be a better patient.
I've had doctors tell me "Good news! You don't have a problem!" when they were testing me to see if they could explain the problem I have. It's good news for them, because their next step is to tell me to fuck off. It's not good news for me, but apparently they can't tell the difference.
As a clinician, I'd say yes to a bicycle for the mind. But currently, my job is already plenty full with worrying about applying what's known in a correct manner without seeking to break new ground while treating patients, which would be very dangerous and given the odds of success, very stupid. What I'm implying is that the general public has a completely skewed view about what really kills patients in the ICU: mundane infections and "medical errors", which are not really errors at all but in a large majority of cases failures and complications of usual procedures.
> Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care
> Results: Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4.20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37.2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner £18.11 v general practitioner £20.70; adjusted difference £2.33, −£1.62 to £6.28).
I’m not sure where this leaves us, as the cheaper training cost for the nurse is a factor too.
House gets to choose his patients, he pre-rejects any that he doesn't want to deal with or has no ideas about, or no interest in. Real world doctors can't do that. House gets to do basically any test for any cost without having to justify it or argue with insurance, scheduling, resource constraints, practicality or side effects. If he needs an MRI, it's available, if he needs his team to spend all night tonight on blood tests in the lab, they can do that and the lab is there and they have no consequences tomorrow of having no sleep.
House has plot immunity, the worst that happens to any hospital employees as a consequence of his behaviour is the loss of a lot of potential money, or some paperwork or audit. The show never focuses on the life of the patient who has to be on dialysis forever because of House's risky intervention before he knew what was really wrong. House blackmails and barters with and sleeps with the hospital administration to get away with things no real doctor could do.
House and Wilson are named as a play on Holmes and Watson, and the original Sherlock Holmes books were notable because Holmes walked the reader through deducing interesting conclusions by looking at evidence anyone present could see but with a fresh viewpoint, things like the height of scratches on a wall. Recent Sherlock TV shows and films, he's written to magically know things that nobody could know, by means the viewer isn't shown and can't participate in, and presents them as amazing accomplishments to wow the viewer. House is the latter, in an episode I saw recently (Series five, episode 1) he is absent all episode with the usual array of organ failures and suspected pregnancy and suspected cancer, then in the last five minutes he walks in, stabs the patient in the leg, declares she has leprosy because she looked youthful, and walks out. And of course she has leprosy. It's not even good storytelling, it's a background thread for House and Wilson's interpersonal problems and his assistant's own terminal disease diagnosis.
Or to put it another way, you read a blog post about heoric troubleshooting of some tech problem and it's good reading. That's self-selected from someone who had an interesting problem and the time and skills to diagnose it and the luck of it coming to an interesting conclusion. Most troubleshooting is not that, it's mostly the basics over and over, or it's above your skill level or outside your skills, or it might not be but you can't spend time on it, or it comes to a boring conclusion like "we never got to the bottom of it before the system was decommissioned".
In Series 3, Dr Foreman goes to be head diagnostician at another hospital, pulls a House move of risk taking treatment, saves the patient, and gets fired. The dean of medicine tells him the procedures work for 95% of cases, and everyone needs to follow them in all cases because everyone thinks their hunch is in the 5%. It works for House because that's the show.
One widely under realized aspect to healthcare costs in the US (there are many) is the very high number of ICU beds per capita, ~35 per 100,000 people. While it gets a little complicated to compare apples to apples, a reasonable person could say we have 30% more than germany which is the only european contry that is close and double to triple most other nations we are typically compared against like the UK and Canada.
ICU beds are extremely expensive to both build and operate. Also for the lay person the term "bed" has a specific regulatory meaning and does not refer to just the physical existence of the room and bed but means that it is operational with highly regulated amounts of staffing, services and equipment. Each "bed" has costs in the millions to build and equip and operating costs are typically in the neighbood of $10k to $40k per "bed" per day, occupied or not, a large portion being labor.
Quick Google search for "icu beds per capita" finds: https://www.oecd.org/coronavirus/en/data-insights/intensive-...
US: 25.8 / 100K population
Germany: 33.9 / 100K
A lot of patients we manage on the ward or step downs (i.e. pressors on step down, I’m unaware of any ward that will let you run these, very few tolerate central lines) really should be in a full ICU, or at least a high level step down unit like D4ICU at KGH (rather than the hilariously awful AMA units at TOH).
Not even close.
Canada: 12.9 / 100K population (slightly higher than OECD average)
For the record, it is usually better to quote "OECD" than "G20". G20 just means total GDP is large, but GDP per capita can be very low, like India, Indonesia, and China. OECD is always (democratic and) high-income -- high GDP per capita. For example: Nederlands, Norway, and Switzerland are all OECD, but none G20. All are very high income and high human development.
This is not the bed count of units capable of having cardiac support or prolonged ventilation.
I can’t readily find the OECD figure but if you look at ventilator capable beds in Canada the number drops to ~9.7, again inclusive of community/regional hospitals mostly staffed by non-ICU trained physicians which are only equipped for short term ventilation.
Which center in Canada have you trained at where there isn’t constant pressure to offload ICU patients to the ward due to a lack of beds?
Maybe it's the hospital inflation applied to equipment?
The reason they cost so much even if no one is in them is because of what a "bed" means. It isn't the literal bed, it is a unit a treatable/treating capacity. Requiements vary somewhat by jurisdiction but it's going to mean 24/7/365 nursing and attending doctor staff. You can't just call them in when a patient shows up, they need to be scheduled and available. Then ICUs will also need a large cadre of oncall specialists, neurologists, cardiac, laboratory testing staff, and on an on to cover a huge range of possible patient needs. Stocked blood units, stocked medicine units. All those things have costs whether a patient in in the bed or not. Hospitals to a large extent spend an incredible amount of money on capacity. No wants wants to end up in a hospital to have them say, "oops, we didn't expect your spleen to rupture today, Dr. Bob won't be in till next tuesday so you are out of luck, sorry"
Radiology generally needs to have a CT ready to go when there is an ICU. It likely needs an MR too, and staff for running after hours. Portable X-ray and ultrasound, a PACS, a RIS, services contracts and a load of other smaller costs.
That’s several million in hardware costs.
The running cost is huge with MR service contracts alone into the hundreds of thousands per year.
Staffing utterly dwarfs that expense and getting skilled people to work out of hours requires a lot of money, and additional cover for when they sleep.
Staff need to be kept competent with courses and training, certificates and leave to get to these sessions. More money.
The consumables are silly expensive and expire fairly rapidly. Everything needs to be available and a few spares should be present.
Radiology can be a cash cow for day to day operations in a private clinic. But having staffing and equipment that can run 24 hours a day with 100% uptime is a massive cost multiplier.
In case it was unclear, I was being sarcastic in my reply and pointing out the hypocrisy of being offended that "regular people" would have to foot the bill for ICUs - as if they weren't the ones relying on their existence.
At the risk of sharing some PII, are you willing to share some of the conditions that you set?
It's important to get the right balance around specificity. You need to include some
I used a template document but don't recall where I got it.
No reason. No reason at all. I may change my view on this in a few months however.
I was in a paediatric cardiac ICU when my daughter battled with heart disease for 7 of her 8 month life. Another dad who we got close to in the ICU said the phrase "practising medicine says it all...".
My experience is same same but different. It was during COVID, so we welcomed the nurse change, sad/happy to see one go and welcome another. Paediatric ICUs and their staff, I'd say are top tier in most respects. Parents are involved with most/all decisions, and nurses/drs respect most wishes, don't like your child being disturbed at night for non-100%-necessary stuff? Ask social services (etc) to print out a sign with your wishes and stick it on your room door. May not 100% work, but worth a shot. It did in ours.
Sleep is somewhat respected as this is when babies develop/heal best, unfortunately it's an ICU, and these are sick kids who need 24/7 complex care, so there's sometimes little wiggle room. I attended a conference in Chicago on heart disease and it's outcomes (npcqic.org), and sleep and proper nutrition (not just feeding TPN) are definitely hot topics. I know the NICUs are extra hard on any additional sleep/disturbance other than 100% necessary.
But shoutout to nurses, drs, any medical staff, ICUs are sterile, haunting, traumatic places. I witnessed things I can never forget. They do the same, and have to do it again, and again.
I realize this wasn't your point - and who knows maybe I'm misreading you - but this comment makes me reconsider my view on that. I have a child and having to go through something like what you describe makes me feel sick. Doing that and then having any degree of empathy - sympathy even - for the people involved is a credit to you.
These words are both poetic and heart-wrenching.
One thing that this article touches on, but I think needs to be emphasized even more is that the stark reality is that the only advocate for the patient is the patient themselves, or perhaps a caretaker.
The burden is on me to ask questions about fertility and sperm banking because my oncologist is well... an oncologist not a fertility expert. I have to ensure that every department is communicating with every other department.
Hospitals and physicians are fantastic at solving discrete issues, but the bigger picture is often lost in the chaos. I can do it as a technically adept 34 year old, it's horrifying to think about how someone closer to 80 goes about it.
I had family there to advocate for me, but there's no way in hell I would have been able to advocate for myself. I was literally seeing things around me in the ICU room that didn't exist. My family were probably the only ones that realized that that wasn't the real me.
The hallucinations stopped happening as soon as I was moved to a normal patient room for the rest of my recovery, and I have full working memory of that normal patient room.
To be fair (and this is also true for the article itself), it might be difficult to distinguish cause and effect here. Being moved into less intensive care means that you are more stable which might lead to other issues becoming better in the following days regardless of whether you are in the ICU or not.
The author's dad was being seen by a variety of highly trained specialists all working to treat him, but "people need to sleep" seems to be a recent discovery in the ICU world, and if his family hadn't been there to help, every new nurse would have tried to give him the same medication that gave him a bad reaction, over and over, just because there wasn't an established place to write that (obviously important) information down.
I've read that food with better nutrition than regular hospital food may reduce mortality rates by as much as half . That's such a huge effect that it's shocking that hospital food is just expected to be bad. Everyone says nutrition is vital for health, but hospitals don't seem to care.
I think the root problem is cost-cutting. Management cuts costs until the brink of disaster, and tries to hold it there for as long as possible. This is not a system that strives for the best outcome for patients within reasonable limits of the resources available; this is a system that attempts to extract as much value as possible from the patients, and patient death is only prevented as a means to that ends.
For the average person healthy food usually means food with fewer calories and more micro-nutrients, like eating more broccoli and less white bread.
This study is about malnourished patients who need more calories than they can even digest from an average meal so they need specialized high-calorie foods that are customized for their own metabolism. It's essentially exactly the opposite of what "healthy food" means in any other context.
So it has nothing to do with any narrative about cost cutting and the quality of ingredients used in hospital cafeterias.
But I think that is missing the forest for the trees, what this study showed is that when a patient is left on their own, they consume an inadequate diet that _puts their health at risk_ in a hospital. By a big margin!
I would imagine, though the study didn't show this, that the primary factor in recovery here was having a human (dietician) actually paying attention to your recovery. On intake they put together a plan, and followed up routinely to ensure that the patient has consuming their diet.
The GP's point is valid, hospitals are missing out on a 50% increase in health outcomes because they're letting patients fend for themselves with regard to nutrition. You're right that it isn't as easy as spending $6 per meal vs $3 to buy "better" food. But what it means is that hospitals are failing their patients because they aren't thinking and acting with a holistic eye towards patient outcomes.
Most people just don’t give a shit outside thier immediate responsibility.
Looking at the global view and actually making changes that require persuading other people is a hard and often thankless task.
Many people who do give a shit get this crushed out of them early in their career by the negativity you will face if you try.
Much easier to just accept the status quo.
Occasionally you get a group of people who really care and come together determined not to let things be crappy and they can form an organisation that is significantly more effective for a time. But once the rot of “We can’t fix things” sets in, it’s really really hard to turn things around.
A second major contributor to inertia, is that the initiatives from lower echelons are usually set for failure by the intricacies of bureaucracy. And said bureaucrats are completely unimaginative about what they could do to fix things, because they never leave their office to see what's really happening in the trenches. So yes, in fine the problem is the extreme stupidity stemming from human collective behaviour. Complain, and suddenly _you_ are the problem!
If nothing else, you either take the blood pressure the normal way with a pressure cuff, which is going to wake you up. Or you put an intra arterial catheter, which reads continuously without bothering the patient, but has a small risk of damage to the vessel, infection etc
This is the type of stuff I have a gripe with. Sinecure and fiefdoms of power.
Stanford Healthcare recently installed a system where all alarms/notifications get sent to a hospital assigned device the nurse carries rather blasting in the sleeping patients room as 90%+ are false alarms (aka IV or SpO2 sensors).
The real issue is that hospital technology is outdated and most places don’t have the option for this level of telemetry.
I’ve never been told / instructed my staff to “be near the patient at all times”.
In fact, most places have 1:8 nursing coverage on the ward…
1. I used the possessive “my” in reference to nursing staff for simplicity in writing and clarity to the reader rather than to indicate ownership, we are on a team. This is akin to saying “my goalkeeper wears Nike soccer cleats”.
2. I do not “order nurses around.” I verbally communicate and leave medical orders in the chart that nurses act on. It is not about a power struggle, we are all trying to do our jobs and do what’s right by the patient. I’m grateful when nurses question my medical orders (as long as it’s a positive/educational discussion, which it is 99% of the time) as they catch my mistakes and we all learn together.
If you are concerned that you can’t order nurses around, I strongly suggest reflecting on whether this leadership style is the most conducive to providing quality patient care as this can increase barriers and hostilities in the workplace resulting in communication breakdown and adverse events.
Fiefdoms of power - nursing union not wanting to give up the night shift premium pay when the job description changes to monitoring a screen and half the physical workload vs. day shift.
Again, this started before Covid, the pandemic just highlighted how much these cuts screwed over both healthcare professionals and patients.
Sleep is almost impossible with regular check-ups... 30 min or 60 min, don't remember. Excepting the comatose and most medicated(maybe not?), a person's sleep cycle is unable to reach REM when a stranger approaches and fiddles on regular intervals. I would think monitoring from afar(sensors, cameras) would be more beneficial, but I was informed the liability factors preclude such remote monitoring.
edit: to add context, I slept in the room on separate occasions with 2 family members. While tests were not performed, the regular checks were mandated. I was exhausted after my shifts ended.
This makes sense for someone who might be in there for weeks, but I was barely there overnight!
During the night, it would drop to 40 (which is still fine), but sometimes below 30, at which point my heart monitor would blare an alarm, waking me up and scaring the absolute bejesus out of me, raising my heart rate immensely. A nurse would walk in, see that I was fine, and leave again.
This occurred nightly for a few days.
The training doesn't really matter. Context is very important as is caring about doing a good job. You'll find a severe lack of both in hospitals. You eventually have to stand up and defend yourself against bad healthcare... or search endlessly for good healthcare which is terribly difficult to find.
Anecdotally, when I was in the hospital (much more minor, at a much younger age), they kept waking me up at 3am to draw blood and clean and do god knows what, and the light outside my room was constantly on. It felt... at best annoying, at worst, downright jarring and disruptive. It certainly feels like the sleep and rest parts of recovery and care need to be revisited.
After ACL reconstruction surgery many (~30) years ago, I was required to stay overnight due to both the general anaesthesia and the lateness (late afternoon) of the procedure.
I had a similar experience with the nurse coming in every two (2) hours to take my vitals. I was trying to sleep, but she kept waking me up. I groused about wanting to rest, but was informed (direct quote) "this isn't a hotel!"
And it's not. Rather it's a money printing facility for the owners of the health care system that runs the hospital.
Now we've moved back toward "birthing centers" which focus on the mother and the baby; perhaps it is time for something similar to grow across all aspects of care.
And women are still giving birth lying down, fighting gravity, for the doctor’s convenience.
Monday - Friday
- Wake up at 4:30 AM
- Get to hospital by 5AM to start rounding on patients
- Sometimes work inpatient all day sometimes clinic thrown in, but usually not done working until 7 PM, without even a 15 min break or a chance to eat a meal (15 hour day)
- Come home and do about an hour of notes
- At least once per week, wake up in the middle of the night to deliver a patient who asked for that kind of continuity of care.
- Wake up around 5am to be in by 6am to start the day
- Work inpatient, usually without time for a 15min break for food, until 10AM SUNDAY (28 hours shift)
Repeat 49 weeks/year (days of 24/hr shift can vary and she usually gets one weekend off/month). Her average time at the hospital last year was 96 hours/week.
How much confidence do you have that you'd be able to take care of a complicated pregnancy at the end of a 28 hour shift, having not eaten for more than 24 hours, having 10 other patients on your mind, and having had only a couple of hours sleep the night before? It's no wonder to me anymore to me birth outcomes are so bad in understaffed hospitals in poor areas...
But yeah, there's a good reason why suicide rates are so high for doctors...
The limiting factor isn't medical school admissions, it's residency spots. We'd need to increase medicare funding if we want more residency spots.
Even bus and truck drivers have a more sane maximal shifts restrictions.
I have seen administration do some blatantly illegal shit around physicians with COVID, but I don't want to write that up here.
Staffing. Well, what can I say. Patients are there 24/7, staff is obviously not. That staff works in shifts, great realization. I am almost surprised that the author wasn't surprised ICU staff has vacation and sick days.
And finally "The ICU is a good place to not die, but a bad place to recover.". No shit, Sherlock, tgat is basically what an ICU does, stabilizing patients enough to transfer them to a "normal" station for recovery, or, worst case, to a paliative unit if death is the only possible outcome.
Oh, not to forget: "It really makes me think about how the hospital might be organized differently. If the hospital focused less on pure survival, might their patients recover faster?" What makes a emotionally involved amateur think that the people running ICUs, after sometimes years if nit decades of training in that exact field, don't think about this question constantly? And tgat the current state of ICU care represents the current optimal solution?
I am so fed up with articles from people judging things by looking at them from the outside. Mind you, the articke in question here is one of the better ones.
I found this article informative, and not cynical at all. No system is perfect, and so with all of the significant benefits they provide, ICUs have some things they aren’t best for.
> Continuing to say that is reason "you" have to wait for getting a slot and asking whether or not the observed sotuation is actually hood is cynical.
I see you bashing the author, but you haven’t made a coherent argument at all. In fact, I’m not sure if this is even English.
If there’s something op got wrong, help us understand and make it a teaching moment. Just bashing them isn’t productive.
My point of this anecdote vis-a-vis high-agency healthcare systems: I like when I can ask questions to a doctor about their diagnosis and proposed treatment. Yes, I understand they are busy and there is a reasonable limit. I am equally annoyed when this is viewed (in the extreme) as an assault on their authority!
There's lots of levers that could be pulled in the US. Cut down on undergraduate requirements, incentivize large health systems to fund more training (people like to complain that the federal government only funds a fixed number of residency slots, as if a trillion dollar industry is just absolutely helpless to do anything).
Medical care suffers under the bizarre idea that central planning and capacity management will control costs. Meanwhile, costs are spiraling up and up and up. Train more doctors and all the stupid games being played to optimize their utilization start to go away, because it is less worth it when demand is less than supply.
A huge proportion of US physicians are already mediocre; a shocking number are bad. (Source: I am a physician.) Given this, I am concerned that further relaxation of standards in an effort to train more doctors won't lead to better outcomes.
The high standards certainly prevent people who are unable to meet the standars from practicing medicine, but they also prevent people who are able to but see the standards as unreasonably onerous and pursue something else. Some of those could have been great doctors but looked at the steps and said nope, I'm not going to go to med school, then hope I can get a residency, in which case I get to have a hellish schedule and little autonomy for at least three years, and then probably a hellish schedule and little autonomy for many more years.
We don't need better outcomes. We will happily take the existing outcomes but cheaper.
Yes there's no undergraduate major named "premed". There's no need to be pedantic. But US medical schools generally require a 4-year undergraduate degree (BA or BS) and certain coursework (biology and chemistry, among others). 
> will somehow lead to reduced healthcare costs
And yes, I'm saying that if it takes a couple years less to train a doctor - by letting them go directly to medical school after high school and doing the prereq coursework there over maybe 5.5-6 years instead of the current 4 - that will lead to lower healthcare costs. Not sure why that's so controversial of a statement. It's simple supply and demand.
It's "controversial" because you are conflating two issues.
Shortening the path will at most lead to a very minor supply increase at the time it is implemented; the gains don't compound. Without increasing the total number of admission spots (or more critically, residency slots), the overall supply will not be meaningfully increased.
Removing a prerequisite (bachelor's degree; which I point out in another comment is not actually required at many schools) is generally unrelated to the supply of US physicians and this is why you're getting pushback.
> the gains don't compound
You give doctors, on average, an additional 2 years of their life to practice medicine instead of spending them in college on a pointless degree (not to mention, slightly lower college debt when starting out). Multiply that over however many doctors we graduate every year, and it'll add up over time. It's not "compounding" in the mathematical sense of the word, obviously. If you assume that a medical career is about 35 years, that's like an 8% increase in available doctor-years over 35 years (or something like that - the math is a bit handwavy). Without doing literally anything else.
I saw your other comment about degree requirements and I'll respond here. In addition to the consulting website, I also looked at Johns Hopkins and they do have a degree requirement. Thanks for providing that counter-example. I wasn't aware and I'll update my understanding of this.
However, your own source said "a baccalaureate degree...is strongly preferred". So it has to be asked - how many non bachelor's degree holders actually get into med school?
Every US-trained doctor I've had has gotten a bachelor's degree (I read bios when they're available). The ones that don't were foreign-trained. If the number of med school applicants greatly exceeds the spots, I'd imagine nearly all serious applicants are going to get a bachelor's degree to improve their chances. It sounds like you're a doctor - what proportion of people in your class got in without a bachelor's degree?
Source for this? That's surprising to me and a brief Google search tells me the exact opposite.
You really don't understand how reducing the number of years it takes to train a doctor, after they complete high school, will lower healthcare costs? Are you unfamiliar with supply and demand, or the relationship between the cost of production and pricing?
> Every U.S. medical school requires the completion of a four-year degree from an accredited college or university.
However, if we look at the University of Chicago's Pritzker School of Medicine as just a single example  we see the following:
> "A baccalaureate degree is not required but is strongly preferred by the Admissions Committee."
Given that your reference, "Shemmassian Consulting", appears to be low-quality given that it makes categorically false statements, I won't bother to search for other schools. Suffice it to say that I am aware of quite a few, including my own, that do not require 4-year bachelor's degrees.
Finally, I understand supply-and-demand quite well, and I agree that increasing the supply of licensed US physicians may decrease healthcare costs (but it may not, as excess dollars in the system likely will be vacuumed up by administrators). However, this discussion is about decreasing entrance requirements to medical school, which is completely orthogonal.
Agreed, but I would go further and say that if demand by students for the training provided by residency exceeds the demand by hospitals for the work provided by residents, I don't see why residents couldn't pay for their training just as they do for medical school. The whole "residency funding" thing seems like a red herring as an explanation.
To be clear, I'm not saying that medical graduates should have to take on more debt to pay for residency, but rather that the reason this doesn't happen is not obvious according to typical economic reasoning.
The below article on how awful medicine and medical school are was written a decade ago and nothing has gotten better. People really like social status.
Knowing these people, I also get the feeling that if pay were worse / debt was higher they would have pursued alternate careers. If your goal is to make more physicians you don't want to make the job less desirable. There are already paid residency positions that go unfilled every year (not because there arent enough students, but because the students dont want them). I don't know why you think people would pursue positions that they have to pay for.
To your other point on the intense competition: If half the people currently applying to medical school quit applying the quality of your average future doctor would drop.
Had a cousin and a friend (both I would characterize as smart and hard working) take several years after undergrad and eventually “settle” for physicians assistant schools.
Is it? Is there a study demonstrating the correlation to pre med test scores to patient outcomes?
It just strikes me as something that wouldn’t be particularly hard to answer with a detailed study, and probably is a pretty high value question to answer, so I wouldn’t be surprised if there was a study.
Maybe I’ll poke around this weekend
This is the reason: as soon as the medical industry has established a consensus price for some procedure or other item of care, the hospital administration starts to work on figuring out how to do it for the least possible cost. The price has been set in stone, no need for further justification. Medicare or whoever WILL pay that much. The price is fixed so the only knob left to turn is cost, and cost will be reduced all the way down, until service is just above a level so poor that patients would decide to stay home.
I anticipated your argument in my other comment...
For the most part this seems like a sensible and reasonable article communicating what must have been an extremely difficult situation for the author. In case the author reads this: I'm really glad your dad got better and I know everybody working in the hospital appreciated the amount of patience and restraint it seems like you showed in helping him without being that patient family member who goes off the handle about everything. (There are so many of those.)
Many of the issues the author points out are very real - constantly-rotating doctors, attending disregarding consults once the consult leaves the room, the ICU not being set up for anything but bare survival - all of that is totally true from what I understand. I think, if anything, the author fails to understand how systematic and critical those issues are when he says things like this:
> So, digestive issues, hormonal issues, and mental issues all get short shrift. Basically, if there’s an obvious symptom, a consult will come in to try to treat the symptom. Then they’ll take another test in a day or so, see what happens, and go from there. There’s no sense of a scientific method, reasoning from first principles, or even reasoning from similar cases though.
I don't think this is giving the medical practitioners a fair shake here. Doctors do a huge amount of this kind of reasoning and research, even in the ICU. The trouble is often not a lack of reasoning, but a matter of, as with everything else you note, resources. Like you realized, the goal of the ICU is "keep patients alive at all costs, and worry about their comfort once they're able to be alive without our help for a while." Judgments are made with that in mind. It's not that they can't do reasoning about complex problems, it's that spending time on a complex but non-fatal problem means somebody with a potentially fatal problem won't get that time, and that's not what the ICU is for. Anything that can be solved later... will be solved later.
So the real question is not "Why didn't they help this patient with his digestive issues?", it's "Why didn't they move this patient out of the ICU once he reached the point where non-life-threatening digestive issues were relatively of any importance?"
On the plus side, I was surprised at the decent quality of food given to my wife. Steamed vegetables and mid grade proteins with every meal.
After two nights we made the case to be discharged. Everyone, including nurses and family, thought we were crazy to leave so early. Best decision we made and my wife recovered great. With the built in iOS medication reminder app and a blood pressure monitor I was able to manage her just fine.
In my country you don't even stay a single night if everything goes fine. There is no medical need for parents and child to stay at any hospital if there were no complications
Side note: it was surprising how well the "dad chair" served as a place to sleep after being awake for 24 hours.
> It also doesn’t help that dads aren’t the patient after a birth, so they aren’t fed or given a bed.
Yes, and? You're free to go to the cafeteria and buy food or leave and go buy food. And there's usually at least a chair. What do you expect, a Marriott?
So yah, they should be bringing the father food, and there should be a bed for him because the father is critical in having good care for the wife.
Post-intensive care syndrome is something that happens that hardly anyone who hasn't been in an ICU knows about. Even when I was in the ICU the medical team never discussed it with me. My running joke to deal with what happened is that I aged 10 years the 2 weeks I spent there.
This ignores the (I think) very strong possibility that the old people are preferentially selected by the system because, thanks to Medicare, they can _afford_ the ICU. Many people aged less than 65 cannot. Consider the idea that if we had something like "Medicare for all", the population of the ICU would better reflect normal demographics.
That said, as a beneficiary of Medicare I can only be grateful. I had several days in a top-quality hospital and a procedure by a top-quality surgeon, and after all the EOBs had come in, I ended paying out of pocket... nothing at all.
"Americans dying because they can't afford medical care",
"66% of Americans fear they won’t be able to afford health care this year",
"Nearly 46m Americans would be unable to afford quality healthcare in an emergency",
"Nearly 1 in 4 Americans are skipping medical care because of the cost",
and more are easily found. If this doesn't reflect people avoiding hospitals, or leaving early AMA, and thus reducing the number of pre-Medicare patients by some amount, I'd be very surprised.
Meanwhile I wasn't mentally doing that great. When I was finally conscious I started hallucinating and hearing voices. I was hearing insults from the staff that weren't there and felt like everything was done with malicious intent. It was quite traumatic. I actually remembered these delusions for years afterwards and had trouble accepting that it wasn't real. It's only been a recent thing that I've even been able to speak about such experiences without shutting down emotionally. The work that doctors and staff do at ICUs is extremely valuable. But it's definitely not a great place for a vulnerable mind.
I feel like there is more that could be done in such a situation. e.g. where someone is profoundly hallucinating. I was over-stimulated and noise was making everything worse. If I just had of had a dark room to recover in I probably wouldn't have been traumatized. Maybe even ear plugs or a mask. But I didn't even have that. I'm also kind of surprised by the OPs story because the ICU I was in was like this closed surgical ward filled with medical staff. ICUs don't really seem like a place to have visitors. I get the feeling many people there aren't even going to be conscious. OPs dad is lucky to have had such good family support.
This implies a lack of duty of care which is painfully unfair.
As a counter story to this I have a friend of mine who is a _former_ ICU nurse with a gigantic scar on her forearm.
I much later in our relation found out that the scar is from a patient who basically ripped her forearm biting down on it while she was trying to stop him from tearing out a central line in his own neck.
It's ironic that in trying to stop a patient from having a massive central line bleeding she ended up bleeding herself.
Outside hospitals we fail to realize how disoriented and irrational patients can get when coming out of anesthesia or with certain diseases.
So yeah 'as needed' is absolutely right because everyone is entitled to work in a safe environment.
A UK judge once talked about balancing the “benefits and burdens of treatment” when making medical decisions, I think that’s a good way to think about it. The benefit of ICU care is less chance of deterioration and death - the burden is the pain, medication effects, discomfort, noise, confusion and many other things described in the article.
It would also be less confusing for the family if the doctors could explain their thought process well, but a) not everybody is good at this, b) not every family member can necessarily even understand or remember this when they are distraught and sleep-deprived, and c) the health system (and patients) don’t want to pay for the time - if they paid double, the doc could spend twice as long with them, as happens with boutique / concierge doctors.
Regarding the ICU doc disregarding the consult recommendations- the ICU described sounds like a “closed “ ICU where the intensivist makes the final decision, vs an “open” icu where a hospitalist will often be the one making the final decision regarding care. Either way, it seems obvious that someone has to coordinate the care and decide what’s important right now and what’s not - there are many tests that a consultant may recommend that won’t improve the chances of the patient improving right now, and can be done later on the med-surg floor of the patient survives that long. Many of the consultant recommendations may also be contradictory, someone has to take responsibility for picking and choosing a course of action
[edit: fixed typo]
> we let a 90 yr old with dementia/diatebetes/etc. pass with dignity.
Often it's a 4 week old baby.
For every 1 sophisticated family member, there are 19 unsophisticated ones, who toss a weighted coin and, if it's heads, they decide they want their dying, non-responsive relative - possibly their baby, possibly their mom, etc. - to be kept alive at all costs. I don't know if this is politically toxic as much as it is cultural, and possibly globally cultural.
You needn't use your real name, of course, but for HN to be a community, users need some identity for other users to relate to. Otherwise we may as well have no usernames and no community, and that would be a different kind of forum. https://hn.algolia.com/?sort=byDate&dateRange=all&type=comme...
You are stretching the word often, most people in the ICU are close to the end of their life. A lot of people don't realize but most of the time if you needed to spend weeks in an ICU you are probably not "living" in a dignified way. Almost all ICU doctors/nurses I've talked to would rather have a DNR in their old age than live like that.
My human dignity does depend on whether I have to endure the rest of my life pooping my pants, not remembering my own name, and hooked up to some noisy machine telling my lungs to breathe and my heart to beat.
If I'm in pain, am delirious, and am unable to operate in the world. I've lost my dignity.
What's worse is how much of Medicare's wasted spending goes to harmful treatments.
My point is, what's not sociopolitically allowed is discussing how personal choice as well as normalized systematic issues (e.g., urban food deserts) are killing us, slowly. It's unfashionable to suggest someone's weight is (ultimately) unhealthy. But the USA wants to have its cake and eat it too, literally. That's not working out. It's not sustainable.
Finally, not to get off topic but over the last couple of weeks there's been a thread or two on HN based on acticles suggesting the GDP and similar "classics" economic metrics are hiding underlying social issues. That is, for example, healthcare care contributes to the GDP (or whatever) but that healthcare is for diabetes, opioids, faltering mental health, etc. We're falling apart but not to worry the economy is doing just fine.
It's complicated. But to your point, the fact that some important topics are ofc limits isn't helping. Until that changes the status quo will continue.
The recent push to try to re-frame obesity as healthy, fashionable and sexy seems particularly bizarre and unexplainable. It's the opposite of what happened with cigarettes, which started out as fashionable and healthy, then slowly became known as unhealthy and finally fell out of cultural fashion.
Fair enough. But then what do you suggest we do as an alternative to normalizing diabetes and obesity?
To your point - kinda - about losing weight. Changing behavior isn't any easier when there are too few environmental signals to nudge behavior in a more healthy direction. As humans, we are wired to assume the norm we see around us. How do we reverse the tide when abnormal (and unhealthy) has been normalized? When everywhere you look, there are people just like you?
I do agree. Mental health is important. But a component of that is (dealing with) adversity. I'm certainly not condoning repetitive malicious bullying, but the current climate has outlawed any/all references to traits connected with being unhealthy. At this point there are no social deterrents, are we really better off?
Have we robbed Peter to over-feed Paul?
Of course, obesity is a huge issue (especially in the U.S. compared to many other "developed" countries) that can affect people's lives negatively and causes further medical issues such as diabetes, and ultimately can prevent people from leading a life that is as fulfilling and meaningful as they would have liked.
But we are still dealing with people here, not rats in a laboratory experiment, and I think the issues that directly follow from being obese are already bad enough that it does not help to pile on more shame by treating those people as being "weak-willed" or something of the sort, or denying them basic human dignity and respect for being outside the sacred norm. Do we really have to add artificial negative consequences for being overweight? Does that help those people have a more fulfilling and meaningful life?
I don't think people will just forget the direct negative physical/social consequences of being overweight by not being reminded of them all the time in a moralistic tone (and even just reminding people of such information can be moralizing, depending on the context in which the information is provided).
You might think everyone wants to act in the best interests of their relatives, but of course that's not true. Some people will want to speed the natural process along because that inheritance looks really appealing, and no one is really going to miss the old guy/gal anyway.
Besides, that's not really the problem. The problem is profiteering by insurance companies and the hospitals they (effectively) run for profit, with patient wellbeing as a regrettable requirement they have to put some effort into.
Ever hear of the Obamacare death panels? The ones where doctors would decide if your loved one was too old and shouldn’t get treatment?
Yeah. That’s this.
What it really was that Medicare would pay for consultation with doctors (?) to discuss end of life care and setup living wills and DNRs and such if the person wanted.
That way if something happened and they were taken to the hospital they could be treated the way they wanted to be and not stuck in a coma on a vent for the rest of their life if that was against their wishes.
But the Republicans branded then “death panels” (which for political purposes was brilliant). So the choice of having help making those decisions was removed.
If our society really cared for the elderly, they would be integrated and respected, not segregated and shunned. We do the latter because we fear age, sickness, and death. Fear isn't caring.
In the US. It's perhaps the most striking difference that hit me during my stay overseas. In the Old World we occasionally get people completely panicking about their own death. In the US, seemingly _everyone_ is like that.
That is certainly not true. Traditional societies and non-western societies have far different ways of relating to elders than we do, and even among western societies there are variations.
You could give a lot of people medical treatment with a proper healthcare and tax system. Why don't we try that first?
30? or 21, if you prefer the book ;p