Bad Hospital Care: Fragmentation Equals Trouble

When I was working in a small hospital in the city many years ago, nursing administration decided that all nurses were to rotate through all the services. Operating room nurses had to do a shift in emerg and on a general medical ward, for example. The idea was to broaden everyone’s experience, I think. It didn’t work because there was more to great nursing than fundamental skills or what nurses could pick up from inservice lectures. Difficult nursing jobs were familiar to people who had been doing them for years, and that familiarity couldn’t be replaced by experience of a few days or weeks. And patients were seeing a different nurse almost every day.

There have been two similar changes in my own profession. First, disasters or medical mistakes in hospitals got people excited about the ungodly hours trainees had to endure on call, and those shifts were limited so that no resident doctor was ever on duty for more than 24 hours at a stretch. Definitely a good thing for the residents’ peace of mind, but it also increased the number of doctors required on hospital services. More faces, less time (I don’t think there was any reduction in hospital disasters and medical mistakes, by the way). The rise of hospitalists resulted in people’s primary care doctors (family physicians or internists) only visiting them socially if they were in the hospital. Hospitalists pass care of large numbers of people on general medical words back and forth.  The idea is that they make comprehensive notes for each other, although looking at hospital progress notes sometimes makes me wonder about that.

Thing is, these changes affecting doctors haven’t worked very well either. Handing over care may be okay on a surgical or medical subspecialty ward where the care is 95% technical: one specialist can check if the stent is working as well as another. But where the patient’s motivation, confidence, and sense of hope about the future figure in whether he makes it out of the hospital or not, something important disappears when he has to rely on a different face every 48 hours for trusted reassurance, congratulation for small progress, and fine tuning of treatment from one day to the next.

This increased fragmentation of care in hospitals was one of the things that nearly killed my mother-in-law during a recent hospital admission after a fall. The absolutely professionally capable, perfectly well-intentioned, tirelessly hard-working nurses, physiotherapists, doctors, and social workers, who came and went every few days it seemed, couldn’t really get to know her and still do their jobs. Especially on weekends.  So they never saw and got the gist of the big, real picture.  How was she walking before she fell? Why is she on this medication and are the bad effects offset by good ones? Which kind of transfer on and off the toilet is easiest for her? When she has to go to the bathroom, will she ring the bell? How long has she been in the hospital anyway? Frail old people in the hospital can just dwindle for obscure reasons, sometimes because they believed nobody knew them, or cared. The medical record of course reads like nothing went wrong at all.

Well something has gone wrong. Three to five days is not enough time to get to know somebody. At the risk of sounding like Chicken Soup for the Soul or worse, it’s about the relationship. To imagine that a person in trouble in a hospital can be processed by protocol as long as the protocol is comprehensive is just wildly radically nuts. It would be as if we offered looking at perfect oscilloscope pictures of sound waves in place of sitting in a theater listening to an orchestra. The whole meaning and purpose of the thing is gone, and we are presented instead with an idiotic smiling simulacrum, like the kid in the bank ad who gets a cardboard cutout instead of a real working red truck. In place of somebody you know greeting you every morning to reassure that they understand what’s going on and want you to get better, you see a shiny new face asking the same questions you’ve already answered eight times, like somebody starting from scratch.

Administrators who assume that professionals are interchangeable may want to know what’s the problem? You expect some violins playing, some kind of Disneyland magic here? Implied I suppose is the challenge: okay, what is this relationship you want? How do you describe it? How do you train somebody to do it and make sure they’ve done it?  How do you pay for it? What does it weigh, can it be left outside overnight, is it hazardous, and where’s the danger warning label and two-volume instruction and training manual?

The danger that needs labeling is the presumption that the most important thing of all doesn’t exist because it doesn’t lend itself to engineering principles. The care you give someone in a hospital or anywhere else is based on who that person is and on your wanting them to get better, not on completing a set of tick boxes. It takes a fair bit of focused time, the same person-to-person conversation carried on over days or even weeks, to start to understand someone else’s problems. As soon as we presume otherwise, there’s no reason not to dice human interaction into ever smaller pieces until it just disappears.

As usual with my worries about health care, I can’t avoid the big question: What are we supposed to do about it? And as usual the truth is I don’t know. I do what I can to keep my patients away from the hospital where a relationship-dicing chopping block is the first thing you encounter when you go in the door. I also try to get to know the people I care for, and have humane as opposed to technical conversations with them. But you can’t, at least I can’t, come up with ten commandments for how to get the relationship back into medical care. But there are people, like Dr. Dennis McCullough who advocates for “Slow Medicine”, who are beginning to point the way.

Another humane physician, Dr. Abraham Verghese tells in his novel Cutting for Stone of an examiner who asks a medical student a trick question: What kind of care in an emergency situation is administered by ear? The answer is “words of reassurance”. When we need them most, those words carry their healing power only when they come from someone we know well and trust.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 40 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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