Demystifying Medicine One Month at a Time

Category: throughput (Page 1 of 2)

The Evolution of Hospitals

I-love-Lucy-assembly-line-300x223Once upon a time, a hospital was a place you went if you were sick. Doctors would (ideally) figure out what was wrong, offer treatment, and you would convalesce.

The longer you stayed in a hospital, the more the hospital could charge you (your insurance, really — if you had it).

This all changed in 1983, with the advent of the DRG system (it stands for Diagnosis-Related Group). Almost overnight, the incentives for hospitals changed. With DRG payment, the hospital would get one ‘bundled’ payment for the whole hospitalization based on the patient’s diagnosis. Average length of stay for hospitalized patients went from thirty days (imagine: a month(!) in a hospital). Hospital executives saw the need to minimize length of stay — depending on the payment for each diagnosis, there would be an inflection point when a patient staying beyond a certain number of days would result in financial loss.

‘Throughput’ became the term of art. (Like widgets on an assembly line.)

Now the average time someone spends in a hospital is a little more than four days. (Of course, for mothers with normal births, this is even less — about 2 days. Many surgeries that used to necessitate several days in the hospital are now done on an outpatient basis. Length of stay in those situations: zero.)

A recent essay on this topic in the New York Times by Dr. Abigail Zuger brought back memories for me. I once had a teacher tell me, “No one should ever need to be in a hospital. Except for some cardiac conditions that require immediate care, the only people winding up in hospitals are frail elders, and those with social problems and no place to go — the mentally ill, the destitute, the homeless.” I remember feeling a bit shocked by this, but as I reflected on it, I realized he had a point. I should start with the assumption, he told me, “that almost no one really needs to be there and they’re better off at home.”

The modern condition leads us to keep people in hospitals for as short a duration as possible. But something is clearly lost. As Dr. Zuger writes:

Hospitals were where you stayed when you were too sick to survive at home; now you go home anyway, cobbling together your own nursing services from friends, relatives and drop-in professionals.

Patients often go home feeling brutalized by all the blood draws, hospital food, and lack of sleep. Rare is the patient who says, “I feel better now — can I go home?” Often we send them home before they feel ready.

It sounds a bit cruel, and like there’s a perverse incentive at play. But keeping people in the hospital is also inherently risky. Hospitalization can cause infections, loss of muscle and coordination (especially in older folks), falls, and delirium. So getting people out as quickly as possible is in many ways the right thing to do.

The truth, however, probably lies somewhere in the middle.

Royal Midwives

Way to go, Princess Kate!

284074C400000578-0-The_unsung_heroines_of_the_Royal_birth_were_midwives_Arona_Ahmed-m-8_1430602563133Not only did the Duchess of Cambridge deliver a beautiful, healthy baby girl, she should be a role model for the way she went about it.

Princess Kate had a well-thought-out birth plan. During the delivery of her first child, she developed a rapport with two midwives — favoring a lower likelihood of medical intervention during the labor and delivery. This time around, she chose to go with the midwives in the initial phase, having developed trust in them, with the hope that they could see her through the entire labor.

The princess reportedly used no anesthetics (“epidural” or otherwise) and had a natural childbirth after laboring in hospital only a little more than two and a half hours.

Good to know there’s surgical backup in case the labor didn’t progress or became medically complicated. But things went well, and Kate was able to do it her way — because she’d clearly stated what she wanted. In the case of childbirth, she wanted it to be as natural as possible — without medications or interventions.

Kudos to the princess and the midwives who attended to her. Article (one of many, just google away) here.


The trend-spotting New York Times published a front-pager about the growth of urgent care clinics nationwide.

These are the places that are often referred to as “minor emergency rooms,” or “doc-in-a-box” outfits. Their value proposition is simple: You don’t need an appointment. The costs are “reasonable,” and much more transparent than usual medical care at a doctor’s office, emergency room, or hospital. Best of all: they can treat a majority of acute conditions and have you in and out in under an hour. No ER can make that claim. Heck, not many doctors’ offices can make that claim.First-Aid-Kit

As the article makes clear, urgent care centers have one tremendous advantage over emergency departments: they can cherry pick patients. ERs are required by a federal law called EMTALA (1986) to see and stabilize every patient, regardless of their ability to pay. Urgent cares have no such obligation. And they don’t take Medicaid. To be seen, you must have either private insurance or pay cash.

Seeing a money-making opportunity, big money (i.e. Wall Street, health insurers, hospital chains) are investing big in urgent care centers.

Naturally, skimming the straightforward acute cases out of the medical morass makes some unhappy. The article quotes one physician:

“The relationship I have with my patients and the comprehensiveness of care I provide to them is important,” said Dr. Robert L. Wergin, a family physician in Milford, Neb., and the president-elect of the American Academy of Family Physicians. “While there is a role for these centers, if I were sick I’d rather see my regular doctor, and I hope my patients feel that way.”

As a doctor, I very much see Dr. Wergin’s point of view. I believe in the importance of a relationship with a doctor (or, heck, a ‘Medical Home‘) over the long term. But as a patient and ‘consumer,’ I can certainly see the value in a place that can handle acute stuff on a walk-in, cash basis. My own patients who try to see me for minor maladies are often disappointed to find I’m not available for same day appointments much of the time.

I think the article gets it right. Urgent care is a trend likely to grow at least until the market is saturated. What will keep them afloat is the value they provide, until doctors’ offices (‘medical homes’) can offer truly expanded hours and availability, and come up with more transparent pricing and same day efficiencies.

Doctors and traditionalists will continue to wring their hands over this upstart economic/delivery model, but as the industry moves from cottage to corporate, this is just one more stream in a raging river.

Call Now to Reserve Your Spot in the E.R.

Emergency Rooms are a bellwether of the U.S. Health Care “system.”

I’ve explained in other posts why the E.R. is a tough place to work and a tougher place to be a patient.

Now comes news that some Florida-based hospitals are piloting an E.R. reservation system. The goals are intuitive:

  1. Minimize patient waiting times, thereby
  2. increase patient satisfaction.
  3. Improve the working and waiting environments for staff and patients, and
  4. boast about the new idea, providing the for-profit hospital chain (Tenet) a marketing advantage.

Ding! The old-fashioned way.

All it costs is $9.99. No joke. You have to put the money down on a credit card to reserve your spot, which guarantees that you’ll be seen within fifteen minutes of the appointment time that you are given.

And what If you’re not seen in fifteen minutes? Money back guarantee!

So these hospitals are going to let us reserve a spot in the often horridly long E.R. queue? That’s ten bucks I’d be glad to spend. What’s not to like?

According to the article, the system works well for those whose health situations are not true emergencies. But for those with serious issues like heart attacks or strokes, waiting for your reservation time can be a big mistake.

“Time is tissue,” we are taught in medical school.

Come to think of it, isn’t making an appointment for the E.R. kind of like what you’re supposed to do at your doctor’s office?

If you can make an appointment in the E.R for the same day and be seen in fifteen minutes of that time guaranteed, why bother with a primary care office that makes you wait anywhere from two to six weeks for an appointment with your doctor?

Makes me wonder…

1st Gear Weekends

May is one of my hospital teaching months.

I have the privilege of taking care of patients sick and vulnerable enough to need hospital care. In addition, I have the opportunity to work with medical residents and students, who always teach me new things in exchange for the ‘wisdom and experience’ that I bring to the bargain in acting as their supervising physician.

This one's for the kids. D'oh!

One of the maddening things I’ve noticed about hospitals is that very little gets done on weekends. This is true from the smallest community hospitals to the major teaching meccas.

It doesn’t make any sense.

How can we work in overdrive for five days every week, madly admitting, diagnosing, and discharging patients amidst a flurry of medication, lab testing, radiology, and arranging of follow-up services, only to slow down to a crawl every Friday afternoon?

Let’s look at the airline industry for comparison. Medicine is often compared unfavorably to airlines. Airlines allow price comparisons. Airlines reward loyalty. Airlines have a blame-free culture of safety that says, “We’re all in this together. If one of us goes down, we all do. ” So anyone is empowered to call a safety check when something isn’t right.

Hospitals? Not so much.

Do airlines put their passengers on board planes every weekend only to hold them on the tarmac until Monday morning rolls around? Who would stand for that?

Americans decry how much is spent annually on health care, yet 29% of every week in a hospital runs so slowly that essentially nothing gets done. [With a long weekend, it’s 43%!]

What do I mean by ‘nothing?’

Certainly hospitalized patients get outstanding nursing care around the clock. They get good doctoring and respiratory care, too. They get excellent food service, environmental service (cleanup), and nursing aides who help with many tasks. I don’t mean to disparage any of these folks. They work hard. Medication is dispensed. Heck, some hospital patients even convalesce and start to feel better.

But hospitals aren’t in the convalescence business anymore, at least during the five days of the work week. Those days are a flurry of ultrasounds, radiology tests, physical/occupational therapy assessments, and interventional procedures–like having feeding tubes placed, biopsies done, and elective surgeries performed.

Other industries have figured out how to schedule their employees to optimally meet demand for services on weekends. Airlines. Restaurants. Factories. Retail establishments. Police and firefighters.

Why are hospitals so special?

I admit, I like to have my weekends off like most other people. It’s especially useful for those of us that are parents.

But who is the weekend slowdown really benefiting?

  • Not the patients. They have stay in the hospital longer.
  • Not the hospital. They have a bed that could be used for a newer, sicker patient.
  • Not the doctors or trainees. They are mostly in ‘babysitting’ mode waiting for specialized services that won’t fire up again until Monday.

I’m often told that there’s a shortage of ultrasound technologists in America. Are they to blame? Try getting an ultrasound on a weekend. Cue the tumbleweed.

Radiologists, especially the kind that are good at biospying body parts or putting in invasive catheters safely, are never available past Friday mid-afternoon. Tumbleweed drifts.

I just know if I were a patient (I am), I would be pretty peeved to spend a May weekend in the hospital when I could be home with my family. Oh, did I mention that my diagnosis and plan of care depends on the biopsy or the line getting placed? Crap.

Wait ’til Monday, I guess.

Bonus points and innovation awards to the smarties who can solve this one. Doesn’t seem like rocket science to me. Could be an easy marketing advantage:

Bedrock hospital. Where 24/7 is not just a figure of speech. We figure out what’s wrong and we get you home. Faster than they other guys.

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