One of my favorite lines to patients is, "A hospital is a dangerous place. You do not want to be there any longer than you have to be." I started using it when I was an internal medicine resident. My reasoning was the problems mainly from hospital acquired problems, mostly infections.
As a resident I saw airman basics from training admitted for things like the Chicken Pox as they could not be sent back to the barracks. We had a few of them develop other infections including Clostridium Difficile and pneumonia from atelactesis. There was even one that developed a deep vein thrombosis.
Hospitals tend to make people feel sick. The environment often causes the problems. They tend to not move around as much. They tend to have pain and not breathe in as much. They often have staff doing things for them they would do themselves at home. The hospital is also an environment where there are other patients with infections around.
There are other contributors. Staff does need to be on top of when catheters are placed so the risk of infection will be lowered. Hand washing and other cleaning techniques play a role in not spreading infections. And when it comes to procedures it is important that efforts are made to not make mistakes.
A recent commentary in The Wall Street Journal by Dr. Marty Makary at Johns Hopkins University addressed ways he thought things could be improved.
One of his first points is the physician everybody may love may not have good skills. It is a problem. Patients and often nurses and even primary care doctors can have a hard time evaluating the true skill of a sub specialist physician. It can be the technical skills that Markary mentions but it can also be the cognitive skills.
I have conversations about care all the time with endoscopy staff and primary care physicians. I learn a lot from the conversations. I also sometimes get uncomfortable when something is told to me that was from a another doctor that I know is outside what is typical care. It is impossible for primary care doctors and nurses to follow the gastroenterology literature like a sub-specialist and they have to rely on us for answers many times which is a significant responsibility.
One suggestion of Markary is to have cameras in the operating room. He specifically mentions the work of Dr. Douglas Rex in the colonoscopy world in improving quality by reviewing videos. I agree with Dr. Markary but it is problematic in a country that has the legal climate in the United States. Even Dr. Rex will admit there is some subjectivity to the studies and that not every study has confirmed changes are always effective based on data.
Another suggestion is having patients be able to participate in documentation. I agree with that as well although he may overestimate many patients' knowledge and interest of their medical history. His example of a dose being corrected is unusual because many patients cannot produce a list of medications they take let alone doses.
The gag orders he speaks of related to internet reviews are a point which should spark interest here. People can go and say what they want about health care facilities and doctors completely anonymously. The data is just about as reliable as a typical comment section on an ADN piece. It is a less than ideal situation and gagging may not be the answer but it may be a place for some regulation.
I recently was speaking with a public relations person for a hospital. They commented to me that they would have gone to a specific physician because they really knew what they were doing. She also mentioned the doctor was not great with interpersonal skills or personal hygiene. I agreed with her on all points. One can only imagine how reviews would break on that physician.
My suggestion would be to have something more like is done by Kaiser. Have patients fill out standardized forms in offices and facilities and then have that data published in some fashion. It is always important to remember patients often do not completely understand the care factor and can be overwhelmed by the "nice" factor.
Markary also believes hospitals should openly report infection and mistake rates. It is not a bad idea since over a long period of time the data would have validity. The concern again would be the legal system which could use the numbers even if they did not apply to an individual case.
One thing Markary does not talk about is how big organizations often have rivalries between departments. He does not speak about how sometimes how sometimes administration or unions can interfere with processes in hospitals. And reviews of cases often end up in front of committees for final action where most of the people on the committee are unfamiliar with the kind of case being reviewed. Unfortunately, there can be varying degrees of interest in actually getting inside the cases and over reliance on one opinion in the room.
There do need to be changes in approach. Those changes need to be followed by legal protections that are already in place for other industries as long as the process is followed. Medicine lags behind in this respect and it explains the frustrations to many patients. Being open is a good deed and is helpful. We need to make sure it is a good deed that does not get punished.
