Wednesday, September 25, 2013

This Is a Hospital, Not a Hotel

"You have to realize that this is a hospital, not a hotel," was my standard response to the "hospitality" criticisms offered by the parents of my patients (I am a retired pediatric cardiologist).

Apparently this attitude no longer applies.  In a NY Times Sunday Review article entitled "Is This a Hospital or a Hotel?" (Sep 22)  Dr. Elisabeth Rosenthal analyzes the new approach that hospitals are taking.  The chief executive of a new hospital opening next year "exulted" in saying: "You feel like you could be at the Marriott."  The hospital "business" has become extremely competitive, for better or worse, and hospitals are improving their bottom line, not by increasing quality of medical care, but by increasing the quality of "hotel" services - such as hiring "celebrity chefs" to provide special menus, including quality wines.  Major hospital systems are averaging $4.5 million annually in advertising alone! Dr. Rosenthal points out that reducing the rate of medication error is not what "sells" beds. More and more it has become amenities, amenities, and amenities.  She goes on to point out that the Henry Ford health system in Michigan recently hired a hotel executive to run its newest hospital, located in the upscale city of Bloomfield.

Believe it or not, a hospital is a business with a bottom line.  Yes, most are "non-profit," but what does that actually mean.  Nothing.  It is a complex operation that pays its executives well, with the CEO's of major hospital systems easily earning seven figure incomes, not to mention the associated perks.  Many have a horde of vice-presidents (I recently counted the number of VP's of a major New York hospital system and was quite astounded when I reached 70 and hadn't finished yet!)  Yet these hospitals are extraordinarily dependent on government subsidies and, as Dr. Rosenthal indicates, this striving for luxury may be adding to the already vast cost ($2.7 trillion) of the nation's health care.

Hospitals want (and need) patient-dollars (i.e. government or insurance dollars).  They are in competition with each other and will do what it takes to bring in patients.  Dr. Rosenthal's article concludes with her description of the VIP rooms at the hospital where she trained.  "Though the views were spectacular, the cardiac arrest team could not get there as quickly as it could to the regular wards.  We called it 'a hotel near a major teaching hospital.'"

Going into a hospital? Assess re-admission rates, infection rates, mortality and morbidity rates for various procedures.  Marketing should not be what "sells" hospitals - success of outcome is what should "sell" hospitals. "You have to realize that this is a hospital, not a hotel!"

Tuesday, September 17, 2013

When Does a Fetus First Experience Pain

An extraordinary discussion is taking place as to when a fetus first feels pain.  At issue is whether pain can be felt prior to 24 weeks of fetal age.  Does it really make a difference?  If one is in favor of abortion, does the fact that that the fetus reacts to pain really matter?  If so, should those performing abortions actually anesthetize the fetus prior to aborting it?  Should the fetus be "put to sleep," so to speak, before the abortive procedure?

Now there is absolutely no consensus as to the exact time when fetal neuronal development matures to the point where pain can be experienced.  Moreover, if one argues that pain can first be manifest at, lets say, 24 weeks, there are invariably going to be fetuses that may have developed this ability sometime before that age, and others sometime after - just as a newborn babies vary in development.  Some babies can sit up at six months, others somewhat earlier, still others somewhat later.  One cannot pinpoint such things!

Believe it or not, there are still those who believe that eight-day old boys undergoing circumcision require no anesthesia as they are "too immature to feel pain."  The circumcision is performed nevertheless - without anesthesia.

For those who oppose abortion the decision is easy.  Whether a fetus does or does not experience pain is not an issue.  Abortion is wrong.  For those who are pro-choice - should it matter?  In a properly performed abortion, any pain that the fetus may feel would be extremely short-lived.  Is this enough to precede the operation with anesthesia?

Doesn't it seem strange to have to anesthetize a fetus prior to aborting it?  

Tuesday, September 10, 2013

Rivera or "Ree-vey-rah."

A recent story on National Public Radio featured an interview with a superintendent of schools (I do not remember his city) whose surname was Rivera.  I do not remember his first name, but I recall quite clearly that when he spoke, his American English was totally accent-free.  Now I don't know how he pronounces his name, but I'll bet he pronounces it the way I would, or most English-speakers would - the way you would - that is without a Latino inflection or accent.  The reporter of the piece, however, constantly referred to Mr. Rivera as Mr. "Ree-vey-raah" reading his surname with a distinct Latino accent in a way that the name would be pronounced in a Spanish-speaking country.  The reporter, by the way, who, judging by his surname (also not specifically remembered), had a Latino background,  spoke perfect accent-free English, giving a Latino accent only to the name "Rivera" and to his own name in his narration of the piece.

I have never heard reporters pronounce Irish names with an Irish brogue, or Scottish names with a Scottish burr, or German names as they would be pronounced in a German-speaking country, etc.  But this is not the first time that I've noted the exception made for Latino names when uttered by Latino reporters speaking accent-free American English.

I seriously doubt that Mr. Rivera, or other English-speaking native-born Americans with names such as Fernandez or Morales, would actually prefer to have their names voiced as they would be in their ancestral Spanish-speaking countries.

But, maybe they do!  And if so, "mea culpa" (pronounce this in the original Latin manner, please).

Nurse Practitioners Good - Physicians Bad

An internal investigation by the Department of Veterans Affairs has found that one of its hospitals in Jackson, Miss., did not have enough doctors in its primary care unit, resulting in nurse practitioners’ handling far too many patients, numerous complaints about delayed care and repeated violations of federal rules on prescribing narcotics.
The investigation found no evidence that care had been compromised in the primary care unit, the vital first stop for many patients. But it concluded that there were enough problems “to suggest there may be quality of care issues that require further review,” a copy of the investigators’ report says.
These were the leading paragraphs from an article in the Sep 9 NY Times about major problems affecting a VA hospital in Mississippi.  Further along the article goes on to describe other concerns, particularly those regarding a radiologist (a physician, by the way - not a nurse practitioner!) who misread multiple X-rays and CT scans.  A large number of patients will now have to be recalled for re-evaluation.  
With this real issue of medial malpractice, not to mention, complete physician incompetence displayed by the radiologist, I was astonished to see that the opening paragraphs deal not with this horror, but with the fact that many patients, in the absence of an adequate number of physicians in the primary care area, actually had to see nurse practitioners!!  God, how bad is that!!  But then the reporter informs us that there was "no evidence of that care had been compromised....."  Is that supposed to be a surprise??  
This Blog has always been a strong supporter of nurse practitioners.  They are well trained and extremely capable.  It is wrong for the NY Times to highlight primary care by nurse practitioners as a "failure" of care in its initial description of the problems of this hospital.  Care by nurse practitioners can easily be equal to (and sometimes even exceed) that of a primary care physician!!  The major issue of poor quality of care at this VA center wasn't in the area of primary care, but the physician-radiologist - the MD, not the NP!