Hospitals: The Good, the Bad and the Ugly

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I recall the hospital in my small town during the time I was growing up. It was St. Joseph's Hospital. The nurses were nuns and from what I could tell in the short time I stayed there after my double hernia operation, they were close to God.

St. Joe's (local name), like all the hospitals of its time, had a unique smell. The hospitals always had a smell that separated them from the real world that I lived in. Back then it was the smell that only comes from something that emits its character in an odor. It was an antiseptic smell. It was a quiet smell. It was a smell of respect in the neighborhood of disease. The focus of the hospital was the care of the patient at all cost. A unique focus. A focus that emitted a unique smell.

The smell of hospitals today is indistinguishable from any strip mall located on a turnpike in New Jersey, Illinois, or California. I've tried to figure this out over this past year in my travels. Not only do I admit patients to my own hospital, but because some people think I have some interesting things to say (fools are everywhere), I get to travel and visit a number of hospitals across the country.

At first, hospitals appear to have no smell at all because there are thousands of special interests within a hospital that emit so many odors that they cancel each other out. By the end of last year, they just smelled like crap to me. Hospitals spend their waking days preparing for yearly inspections from agencies created to survey, approve and accredit hospitals. Unfortunately, dotting the i's and crossing the t's on all the survey points has little to do with patient care.

What I See

Hospitals seem to only care about profitable diseases. One would think that this entire country is filled with only three types of people:

1. Very healthy women having babies


2. People with cancer that need chemotherapy or radiotherapy


3. People with heart disease that need a stent procedure.

I say this because in every hospital I go to, the obstetrics floor, the "I am a Person With Money" Cancer Center and the Invasive Cardiology Wing look like a Ritz-Carlton hotel. When I tour a hospital and the administrator proudly displays these freaks of medical construction, I usually drop out of these tours and check out the rest of the hospital.

Mitch Featherston

First, I look for what is called the Med-Surg floor. This is the floor where people with all kinds of other diseases go. What I usually find are dirty floors, linens piled outside rooms in overflowing bins, nurses who are tired and ignored and patient-to-doctor nursing ratios that approach the population base in the largest province in China.

In one hospital I recently went into, the Orthopaedic Floor had an inadequate number of pain pumps, older continuous passive motion machines, and an anemic physical therapy section that looked like a public toilet in a NYC subway.

In college sports there is a program called Title IX - this means that men's sports cannot get more funding that women's sports. We should have this in hospitals. If funding is given for a particular disease then a percentage must go to the rest of the hospital as well.

Medicine is not a business; Hospitals are.

Hospitals are run by Boards, administrators, and professional businesspeople. Doctors are not businessmen. We all seem to know this. Here's the 411 on something you don't know - medicine is not a business. That's right. You will probably hear every freaking "expert" in the country banter all day long that medicine is a business. No way.

Hospitals are businesses; medicine is a calling. Medicine - which includes doctors, nurses, respiratory therapists, physical therapists, unit clerks, radiology technicians and more - is a world that defies all the rules of economics. Applying the rules of economics to medicine leads to "acceptable" loss of life.

I recall that a number of military strategists used to talk about "acceptable" losses in nuclear warfare. What a concept. Businesses like Pepsi and Microsoft understand acceptable losses. If Pepsi has a division that they spent a lot of money on but is not working, they will sell or close the division. An acceptable loss. In medicine, the acceptable loss rate is zero. The acceptable complication rate is zero. The acceptable death rate is zero.

This does not mean that these things don't occur. It means that, as medical people, we refuse to accept it as a way of life and work to the end to prevent these things from happening.

Businessmen running hospitals accept complication rates. They accept infection rates. They accept death rates. Most of the time it happens way before anyone can figure out it was their doing.

A True Story

I was called recently about a problem in a mid-sized community hospital and asked to give an opinion on the situation. It appears that in this hospital there was a growing joint replacement program and the surgeons were concerned about a large transfusion rate as compared to a neighboring hospital.

After some simple research they found that the other hospital had implemented a product called an OrthoPat. This is a product that allows for the salvage of blood during the hip replacement operation and after hip and knee replacements. This meant that during a hip replacement case blood lost during that surgery was able to be put back into the patient. Over the course of a year this product would save almost 150 blood transfusions over the previous system.

What Happened?

• The surgeon presented the product with all the data to a committee made up of a general surgeon a nurse, and three hospital administrators


• The committee approved the product


• The Chief Financial Officer of the hospital unilaterally vetoed the purchase of this even though he did not have the authority to do so.


• The surgeon spent 3 months complaining to administration about this situation.


• Finally the system was reapproved.


• Two weeks before implementation of the system the surgeon got a call the system could not be implemented.


• The reason for not implementing the system was that the hospital across town that used the system had hospital-based nurse practitioners manage the tubing on the ward.


• Even though this surgeon's hospital has nurse practitioners on staff in multiple capacities in the hospital the Executive Vice President of the hospital, actually an MD at one point in his life, refused to assign this responsibility to one of these nurse practitioners.


• When the surgeon inquired why this could not happen, he only received an e-mail reply saying "this service is not available at this time."


• The product designed to save unnecessary transfusion was stopped from being implemented - again by an administrator.

This is remarkable. A product, known to prevent the need for unnecessary transfusions, was simply not implemented because a single hospital administrator did not want to assign one of the nurse practitioners in the hospital to manage the tubing. I can only assume that he felt that the potential disease transmission that could occur from 150 unnecessary transfusions a year was an acceptable loss. It was acceptable only because it was not in his own operation or in his own family.

I am sure someone who contracted Hepatitis C from one of these transfusions wouldn't think it is very acceptable. I wonder what the hospital will say when a patient who gets sick from one of these unnecessary transfusions, gets an attorney, and sues all of them for this grossly irresponsible behavior.

Not convinced yet?

• Hospitals are owned by stockholders.


• Hospitals judge their quality by standards that have nothing to do with health.


• Many hospitals no longer care for the poor and the underprivileged.


• Hospitals reward physicians that save money at the expense of patient care.


• Hospital administrators have no clue concerning their infection rate.


• Hospitals only order equipment if they either need to market a procedure or are embarrassed into it.


• Hospitals are political in the way they deal with staff. Congress is political. Need I say more?


• Doctors within a hospital have little say or power to bring about change. Patients have no say.

Is there another side? I am sure there is. I am sure across this extraordinarily large country there are hospitals driven to the care of their patients and the communities they serve. Unfortunately, you don't get recognition for doing something right unless you also have an extraordinary Public Relations department.

Hospitals will go out of their way to pass all kinds of state regulatory surveys and parade around their success. All they did in these surveys was dot the "i's" and cross the "t's." Stay out of hospitals if you can. You will probably live longer.

Dr. K.

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Technorati Tags: hospitals, health care, medical practice

Cancer Treatment: Who Profits?

Jamie Beverly

I just finished reading a report published in the NY Times on June 12, 2007 entitled Incentives Limit Any Savings in Treating Cancer by Alex Berenson. When you read things like this you really can get mad about what is going on in American medicine.

There will always be the good, the bad, and the ugly. The biggest problem we have in medicine is figuring out which is which. You are welcome to read this brief article but here is the summary: Boy meets girl, boy marries girl, and they live happily ever after. Oh, I'm sorry, that was the government's view on the state of health care.

The summary is actually the following: You are going to die. You are going to die with no money. Along the way a lot of people already way richer than you will get even more richerer (new word I made up...). What is even more interesting is that since you are going to die relatively quickly, these greedmeisters get to repeat it all over again, and again.

I recall in political science courses in college a phrase "Hard cases make bad law." What I learned was that a legal case presented before the Supreme Court that was difficult to decide and had many twists to it eventually led to a decision by the court that produced bad policy or generated reactive law making in response. No one really wants a hard case to determine policy.

In the same sense, difficult medical conditions make for bad public health policy-making. Let me give you examples. A simple case: If an otherwise healthy person is just starting to get a heart attack and you can give them a medication that prevents the heart attack from getting worse and saves their life then that drug should be approved for use to be given in all these situations regardless of price. Easy Case. Good Policy.

Here is a different one: A patient who is 87 with terminal cancer ("C" word) with a life expectancy of six months can be given a $75,000 drug that has a 30% chance of extending their life expectancy an average of three months. That's a hard case. That's a really hard case. What kind of policy can we make from this? Do we treat or not treat based on age? Should $75,000 of Medicare dollars be spent on an 87 year old for a "chance" to live three months?

More importantly, who makes that decision? If you had the money and it was your mother or grandmother, do you buy the drug? Why does it cost that much anyway?

Unfortunately, in the world of cancer treatment, it is these difficult decisions that are more common than the easy ones. This does not mean we can't weed out the rats from basement of cancer care though. Let's go back to the article in the NY Times and look at some issues.

The general thrust of the article was that since Medicare has cut back on the reimbursement to oncologists (non-surgical cancer specialists) then the treatment of these patients was being moved from the comfort and quality of these offices to hospital settings (presumably less personal and caring) as the doctors were claiming that they either broke even or lost money on the treatment of these patients.

The article points out that before the Medicare reimbursement decreased, doctors were making huge profits for giving chemotherapy to anyone at all cost and the financial incentives pushed more chemotherapy treatment.

On one side: This is obviously true. If there is a built-in profit to chemotherapy one time then you double your profit giving it a second time. I can do more math on this but the point is clear. There is no bonus put on spending time with the patient or thinking about their care - only in running more patients through the door.

On the other side, the article refers to the differential between the cost of the drug to the doctor's office and the price that Medicare reimbursed as "profit." I think the NY Times needs a basic lesson in economics.

The money the doctors collected from Medicare is called the gross revenue. The cost of the drug is referred to as a direct cost. The doctor has a ton of other costs to deliver the drug. These include the intravenous, the salary for the chemotherapy nurse, the furniture, the electricity, the malpractice, the receptionist, and the phone bills - the list goes on and on. If you are in a really caring cancer center that also has psychiatric social workers to help you and nurse educators on staff, the costs increase.

The difference between the gross revenues collected from Medicare and ALL these costs is called profit. The article points out that the current Medicare fee schedule pays for 6% above the cost of the drug. I would have to assume that a plate of Twinkies cost more than 6%, let alone all those other services.

Analysis: Somewhere between both sides a negotiated agreement may be possible. A reasonable amount of built-in revenue must be built in but again - who decides what is reasonable? We have serious problems in this situation because we have a lot of difficulty with a multi-tier healthcare system where the rich can get all the cool services and the poor get treated in a dungeon.

This causes doctors to be pitted against patients. While some suggest that we can actually determine a fair market rate or that we need to change the financial incentives there are some pretty darn obvious questions staring right at us: Why in the world do these drugs cost so much, why do we allow the pharmaceutical companies to set ridiculously exhorbitant prices and reap absurdly exhorbitant profits, and why do we allow the insurance companies to dictate who gets treatment?

Forget about pointing to doctors and clinics that make money. Forget about pointing to patients who think they want everything for free because they think it's a right. Try this on for size. The doctors should make money because they are being entrusted with serious questions and issues and the patients should get treated for a heckuva a lot less than they are paying now.

Try some basic arithmetic. I am too busy ranting about this crazy drug-and-insurance-company-controlled system to do it but can someone out there compute this? Add up the yearly gross revenues of the top fifty pharmaceutical companies and top fifty insurance companies in America. Take 10% of that revenue (for example a direct tax on gross revenues of pharmaceuticals and insurance companies) and apply it to a national insurance fund. Would that make a dent in getting the millions of Americans with no health care coverage the proper care they need? Will 15% do it? Will 20% do it?

If we really care about the uninsured or those who do not have proper access to cancer care and all medical care why are we wasting time trying to save nickels with decreased reimbursement to doctors or denying coverage to patients? The drug and insurance companies have been given governmental license to print money at our expense. Isn't it about time we got it back from them?

Get out your calculators.

Dr. K.

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Technorati Tags: cancer, health care