Visiting my family member: A tale of two facilities

Recently, a member of my family was involuntarily admitted to the psychiatric unit of a major teaching hospital in New York City and remained there for two and a half weeks.  During that time, the unit kept him safe and provided medication for mood stabilization and thinking.  After seeing my family member, my first priority was to talk with the attending physician and care team.

Evidently, the attending doesn’t like to talk to families or visit patients daily, but the nurse manager assured me he was supervising the care provided by the first year resident.

“Well then, I assume he’s not billing for visits under the teaching physician rules.”

The attending appeared, annoyed, three minutes later.  You can read about the teaching physician rules for E/M and psychiatry services, and both require more than “supervision.”

I checked in, voluntarily and without restrictions, need for supervision or care, to a  newly opened nearby Hyatt hotel.  At check in, I asked to see the general manager, to let him know that I had a sick family member and that I might need help during my stay.  He gave me his name, direct phone number, and email, and said to call when needed. Why was it easier to see the general manager at the Hyatt than to see the attending physician for a ten minute meeting about an involuntarily admitted psychiatric patient?

At the Hyatt, the young staff greeted me with a smile when I returned from the hospital, looked me in the eye, and asked after me and my family member.  One security guard at the hospital welcomed me upon my arrival, although I visited twice daily for many days.  The nurse manager and social worker interacted with me in a professional way when I was able to see them, which was infrequent.  Most of the staff avoided eye contact and responded to requests with as few words as possible.  There were many of them, and they appeared to be busy maintaining the electronic medical record.

I never saw anything spilled or dirty at the Hyatt, so I don’t know how staff there would have responded.  But the ice/water machine in the activity room on the unit leaked every day, at every visit.  The staff would drop a bed sheet or towel to contain the moisture: it seemed like a tripping hazard to me.  After that bed sheet had soaked up the water, was it laundered and put on my family member’s bed?

The clean lobby at the Hyatt was a stunning contrast to the activity room, where I sat with my loved one.  I didn’t lean my elbows on the tables, which always had crumbs or leftover food or were sticky.  The floor was dirty. Occasionally, I saw someone empty the over flowing trash.

Some patients wore scrubs instead of street clothes, confusing other patients.

“Nurse, can you help me.”

Often the young patients did help.

“Here, I’ll get some water.”

“I’ll ask the nurse for a blanket.”

Going out to the nurse’s station and asking for help may or may not have elicited a response. I did need help at the Hyatt with my wireless connection, a few hours prior to giving a coding webinar.  My email to the general manager provided an instant response.  No one at the hospital provided an email address.  A few calls were returned.

I arrived in NYC on short notice, for a room rate of $359/night before taxes and the inevitable Jacob Javits Convention Center fee.  My family member arrived at the teaching hospital on short notice, insurance paying four or five times my day rate.  Not a fair comparison?  The cost of doctors, nurses, medications, food and security on an involuntary floor?  And my loved one was safe and received the needed chemical treatment.  True.

But couldn’t the hospital be clean?  What does it cost to smile, welcome, be available to answer questions?  Is it too expensive to treat a grieving family member with compassion and humanity?  And, if that is how I’m treated, how are they treating my loved one when I am not there to watch? And how are they treating the homeless patient who has no one visiting or asking questions?

Betsy Nicoletti is president, Medical Practice Consulting and author of Auditing Physician Services. She blogs at Nicoletti Notes.

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  • PrimaryCareDoc

    Just want to make sure I’m reading this correctly. The author appears to be comparing the Hyatt to a locked psych ward in NYC. Is that right? And she can’t understand why the locked psych ward is not as pleasant as the Hilton? And she can’t understand why the attending physician on the locked psych ward didn’t give her his contact information, unlike the manager of the swanky Hyatt?

    And she is some kind of medical practice consultant???

    • Dr. Drake Ramoray

      You forgot the part where she was suprised that the attending was put off by meeting with her when her initial contact with the physician amounted essentially to accusing him/her of fraud.

      • betsynicoletti

        I never use the f**** word in polite company. I simply observe that the attending did not see the patient most days and observe that this does not follow the teaching physician rules. And, I certainly did not name the attending or facility.

        • Guest

          “Well then, I assume he’s not billing for visits under the teaching physician rules.”

          The attending appeared, annoyed, three minutes later. You can read about the teaching physician rules for E/M and psychiatry services, and both require more than “supervision.”
          ===============================

          You insinuated to hospital staff, in a very passive-aggressive manner, that if the attending didn’t promptly comply with your demand for a chat, you were perfectly happy to accuse him of fraud.

          That’s not really a great approach for dealing with anyone.

          • betsynicoletti

            What would you have done? I am sincerely interested in your reply.

          • Jason Simpson

            “I simply observe that the attending did not see the patient most days and observe that this does not follow the teaching physician rules.”

            How do you know this? Were you at bedside 24 hours a day, 7 days a week?

          • betsynicoletti

            The attending him/herself told me that in our meeting.

          • Guest

            Did s/he admit to the insurance fraud you were accusing him/her of, though?

          • Patricia

            That’s a dumb question.

          • Suzi Q 38

            I would not have made that comment if I wanted my loved one to receive good care in my absence.
            You were not wrong to say it, but it was not good judgement.

          • Suzi Q 38

            I would have quit arguing with people that could not or would not give you what you needed and wanted.

            I would have called in the nurse/patient navigator or social worker.
            If none existed, a manager or nursing director of some sort.
            The nurses, if you ask them nicely, will tell you the schedule of your loved one’s doctor.

            Mine always did. I just sat their with a book, and waited for h/her.

          • Patricia

            So the hospital staff can approach the patients’ families in anyway they want because they are tired and overworked, right? AND they can bill for skipping meetings with patients. Yet a knowledgeable family member tries to get this appointment by pointing out that there are rules for billing. What should she have said that would be approved by you? Because the docs are the gatekeepers here, they have a huge responsibility (an ETHICAL one) to manage these situations; and do so with grace. How sad that they may choose to take out their frustrations with the system on the patient and patient’s family.

          • Suzi Q 38

            I agree.

      • Patricia

        Let’s be honest here…what IS it then if he is billing for something he did NOT do? The problem is that many patients are educated around these issues and the medical world does not like it. But it’s good to shine a light. You guys are directing your pissy, whinny, know it all comments in the wrong direction. You need to police yourselves and address the issues the author has brought up. You are supposed to be leaders. Not just clap each other on the back with every nasty come-back you post. It’s pathetic. And scary actually.

    • betsynicoletti

      No, I didn’t forget that. I just wonder that no one at the hospital smiled, welcomed, sympathized, returned phone calls or talked with me. Is that too much to expect? If my family member was admitted with cancer, would the response have been the same?

      • PrimaryCareDoc

        Maybe because they’re really, really overworked and busy taking care of actual patients, rather than trying to soothe the fragile feelings of a family member who seems very quick to assume to worst of them.

        • betsynicoletti

          I can’t tell what your objection is? That I think the staff should behave with humanity? That I think it might be helpful if they talked to the person who will be doing the caregiving after discharge? Is that not part of care? Honestly, if it had been your loved one, you would have objected. I have worked in healthcare my entire professional life, and I understand that the demands are never ending and can be unreasonable. My complaints were not unreasonable.

          • PrimaryCareDoc

            My objection is that you are comparing apples and oranges. You are comparing a locked psych ward with a $400 a night hotel. Yes, that is unreasonable. A hospital is not a hotel. It’s a place where very sick people go to receive life saving medical treatment. That has to be the first priority. Not nagging overworked nurses and doctors to smile at family members. Not bitching about the state of the rec room.

            And really, why are you complaining that some patients were wearing scrubs? It’s very possible that they are homeless and their street clothes were not salvageable. What do you expect them to be given to wear?

          • Guest

            The complaint about the scrubs floored me as well. Not all patients in a locked ward have checked in with well-packed suitcases full of clean smart-casual street clothes, and unlike the case for guests of the Hyatt there isn’t a full arcade of designer boutiques for them to beef up their wardrobe from.

          • betsynicoletti

            I wasn’t complaining about the scrubs but the lack of nursing response. There’s a difference.

          • Patricia

            How ridiculous. If any of you people are in the medical field I would expect you to have an ounce of critical thinking skills. She said the scubs on patients was *confusing* to the others. She is giving valuable feedback. She was not saying that people without clothes should go shopping in the hospital boutique (really? you said that?) But what are some alternatives? Can you all use your bright and excellent minds to come up with something that would address these concerns rather than be defensive?

          • http://www.facebook.com/kate.curry.3950 Kate Curry

            She’s comparing attitudes.

          • Patricia

            A hospital ward should take some lessons from a hotel biz. Why not? What is happening is not working. And the author is not stupid, she knows the differences. And ultimately what she wanted was “connection”; a smile, acknowledgement. She also wanted to hold the doc in charge accountable to what he is billing for. Those things don’t cost money.

        • Patricia

          Your response is typical of what the problem is here. You have no right to put this judgement on a person who has gone through a traumatic experience. And your condescension is poison. “Fragile feelings” really? My impression of this author is that she was not assuming the worst; she was advocating for her family member. And if she didn’t who would? Certainly not the doc who didn’t want to show up for his “ten minute” visit. How is this teaching the next generation of doctors. You guys are really passing on some toxic stuff.

        • Suzi Q 38

          Overworked comes with the territory.
          Your job is no exception to the rule.
          I have a friend that is a lawyer, another that is an accountant. They work more than 60 hours a week. They get paid a salary. They bring work home. They travel on behalf of their companies.
          The work appears to be never-ending.

          Yes, yours is even more stressful. You have choices. if it is horrible, do something else.
          Change your life. You have the power.
          Ask yourself what you want and give it to yourself if possible.

      • Suzi Q 38

        You make a good point.
        Your presence will increase the chances of running into the attending doctor. If the doctor does not have a good bedside manner, ask your loved one if he likes his doctor.
        Maybe his answer will surprise you.

  • maria

    I find it cold how the people to attack this woman going through obvious pain and grief are both in the medical field. Have you forgotten the human aspect of your profession? Have you forgotten that this is not the only field where you are super busy attending real needs? It’s sad to see that humans, expecially in the medical field can become so de-sensitized. Show a little compassion…even if you are so busy attending real problems.

    • southerndoc1

      Anyone who works on an in-patient psych unit in a major metropolitan area has been cursed at, spat upon, slapped, kicked more times than they can remember. It’s not their choice to be forced to spend hours fighting with a worthless EMR. It’s not their choice that the budget for equipment repair and trash removal has been cut once again. What is their choice is to continue to work with some of the most difficult patients in the medical system.
      Rather than a snotty comparison with a $400/night hotel room, maybe some simple gratitude would have been more appropriate.

      • betsynicoletti

        Maybe they could “chose” to say hello to a family member. Maybe they could “chose” to smile, look a person in the eye. Does that cost something?

      • Patricia

        Why blame the patients or their families here? I wish people in this field would quite whining, accept how the situation is and then TRY TO MAKE IT BETTER. Analyze why it’s a broken system and get to work. Invite community members in to help. You can’t expect the patients or family members to just shut up and take your crap because your lives are so hard. That’s sort of hard to swallow if your family member has just been admitted to a psych ward, involuntarily.

        • southerndoc1

          Wasn’t blaming patients or families at all. Just pointing out that the staff on in-patient psych units are some of the most dedicated health care workers around, doing an incredibly tough job day after day. We should all thank them. That’s my crap, take it or leave it.

          • Patricia

            I think you need to stop holding health care workers in psych wards in major cities as separate people from the rest of the world. People deal with hardships on the job every single day. I am not putting the health care workers down but I am not going to laud them either, not above everyone else. There are good ones and bad ones; just like teachers. They are in a position to seriously make a situation for the patient and family either a good one or a bad one. THAT is something that should be taken into account here. THAT is what underlies the message in the original article.

    • PrimaryCareDoc

      And I find it cold that people can’t understand that those in the medical field, especially those doing inpatient psych in a major city, have chosen to devote themselves to healing the sick. That is our vocation. We can be polite and empathic while doing it, but our utmost goal is not to provide “service with a smile.”

      Medicine is not the hospitality industry. Why is that so hard to understand.

      • Guest

        Because honestly, it seems nowadays to be filled with insensitive, burned out rude jerks, and that doesn’t serve patients well either. My experience as a patient (and being the parent of a patient) completely changed my approach as a physician.

        I am much more conscientious about looking people in the eye and not at the computer. I speak slowly and deliberately, even when rushed for time. I always smile even when I’m not in the mood. These sound like very minor, even silly, touches, but they made a huge difference to me when I was on the other side.

        Just my 0.02. I empathize with this author being frustrated with her experience. Healthcare sucks, and rather than attacking her we could acknowledge that she’s right. It’s awful to be a patient or a family member of a patient.

        • azmd

          But she’s not right. I agree that healthcare is filled with burned-out workers and that people are stressed, and rushed, and errors are made. It’s a dispiriting experience to be a patient, or a patient’s parent.

          However, the writer above is complaining that she arrived at the hospital, demanded that the doctor be paged to speak to her on the spot, made veiled threats about insurance fraud when he wasn’t, and then got a chilly reception from the staff for the remainder of her family member’s stay. She is also wondering why the nurse manager and the social worker did not meet with her as often as she would have liked, not to mention making misleading statements about whether meeting with families is billable (it isn’t).

          It’s one thing to acknowledge that patients or their families are right when they have legitimate complaints. But that does not mean that we should acknowledge all complaints as justified, when they are based on unrealistic expectations of what the present system is set up to provide. Our healthcare system is just barely set up to provide adequate care for patients. Hyatt-level attention to the needs of patient’s families is beyond the scope of what can be reasonably expected.

          • betsynicoletti

            I did not demand that the doctor be paged. I asked that the doctor attend the one (one!) meeting with me and my family member while planning for discharge.

            It is true that meeting with family members is not reimburseable by most insurances. If the patient is present then the clinician may use time to document the service and bill for it based on time. Most other meetings are part of the pre and post work of a hospital service. This is an unreasonable burden on physicians, particularly if a family member wants frequent meetings and and has excessive needs.

          • azmd

            Oh, OK.. I got the impression from the way you wrote the piece that you had arrived on the unit and on your first day insisted on a personal meeting with the attending. I agree that it’s reasonable to meet at least once during a hospitalization.

          • Patricia

            You have completely missed the point. And to say the author ‘isn’t right’ makes me laugh. She IS right, it’s her opinion, her opinion is right for her. You could wise up and start understanding that there are some serious problems here. And it doesn’t have to do with the Hyatt. She thinks that hospitals should be as clean as a hotel! Shouldn’t they at least? (And it’s not that hotels are necessarily all that clean). And that staff should be engaging in human connection.

          • betsynicoletti

            No, I didn’t demand that the doctor be paged on the spot. I saw the attending for one meeting in a 17 day stay. Is that unreasonable? Is it okay to only talk to a first year resident for the entire admission?

        • betsynicoletti

          Thank you. There is so much pressure on doctors, nurses and healthcare professionals.

      • Patricia

        I call B*** S*** on this statement. You should really take a break. You are not the all-saving doctor from the days of old. I have come across wonderful people in the medical field and horrible ones. You should police yourselves and makes sure you provide a comprehensive experience that treats the family as a whole. Building rapport is an important part of that. Nobody was saying you should provide hours of your time with a family member, but if you ignore these issues, then you are being ignorant.

        • azmd

          Please explain why, in a system where we barely have enough time to care for the patient, and where there is NO reimbursement for meeting with family members, it is even remotely reasonable for a family to expect that a “comprehensive experience that treats the family as a whole” should be created by individual doctors?

          It’s certainly a laudable goal for our healthcare delivery system to strive for. I would encourage you to engage yourself in public policy with an aim towards trying to effect change. Angry rants against individual practitioners in the current system does exactly zero to move the debate in a positive direction or create changes..

          • Patricia

            I think you do protest too much. If you read through the author’s original post and other’s that agreed with her you will see that they were not the angry ranting ones. Also my suggestions were not for or aimed at individual doctors per se but to point out that *your* anger is misdirected and causes patient harm (remember the old: do no harm?) Although doctors had enjoyed a lengthy disconnection from the outcomes of their own behaviors that time is pretty much over. So, you can get on board with how it is, or change how it’s going to be. Please don’t tell me to do public policy work; you have no idea what it is I do or don’t do. My point is that if you are all going to complain the way you do, you should know you sound like whiny malcontents and that *you* yourselves should take ownership and provide leadership in changing the situation. You know, rather than rant yourselves at poor patients who have the audacity to be.um..human. Humans with problems. But oh yeah, I forgot, you are the humans with the big problems…

          • PrimaryCareDoc

            The author of this piece was NOT the patient.

          • Patricia

            Yes, that is plain to see. Extrapolate a little.

          • Patricia

            Oh, and as far as getting reimbursed…wow, that’s almost pitiful. Imagine how the masses get along with so much of their time not being reimbursed. OR getting overcharged by doctor’s offices (hmm…$500/hour? Seriously?). It’s a high horse you are riding on; and frightening that you deal with the mentally ill.

          • PrimaryCareDoc

            You work for free, then? It’s not a matter of free time being reimbursed. It’s being reimbursed for work done. Physicians are not paid an annual or hourly salary. They can only bill for work done, and the vast majority of stuff like talking to relatives, paperwork, etc are not reimbursed.

            When you do your work for free, get back to me.

          • Patricia

            You know…again, it is really hard to feel sympathetic to that: talking to relatives you can’t get reimbursed for? You have to manage it as if it does though. And, yeah, I have done so much work for free. There are people who must do work for free…the guy who does landscaping certainly doesn’t get reimbursed for talking to the customer and answering phone calls in the evening (and yes, I know people like this -working class people, who don’t make near what I am sure you docs do). Imagine how a family would feel if you actually told them that: I don’t get reimbursed to talk to you so, you know, I’m just going to ignore you now.

          • Guest

            After reading this thread I am convinced that physicians are frustrated because their once noble, exalted profession is now one where they neither receive much respect nor great sums of money. They are controlled at the threat of dismissal (by corp med or a hospital), threat of malpractice, threat of patient loss, threat of overwork and burnout. The glory days of medicine are long gone, and any time there is a complaint currently physicians feel “Why the f**k am I still doing this?”

            I don’t blame them.

          • Patricia

            Well this is probably true; however only they can save the essence of their profession. And yet…you can’t ignore the bad rap that medical professionals get for their callous and paternalistic treatment of families and patients. It’s not a new problem. It probably stems from the word “glory” in “glory days”.
            Also, what about the hoards upon hoards of people who work hard and have to deal with being unappreciated and underpaid? Join the crowd. It’s where you belong. And you know, maybe that would help the profession.

          • Suzi Q 38

            I agree, but at least act like you give a care.
            Yes, I could go on and on about how their job once was.
            Suffice to say that the past is the past.
            Those days are gone.

          • Suzi Q 38

            You don’t work for free. You get paid a fairly good salary, and you deserve it.
            Some jobs take extra work.
            Seeing a family member when you can is part of the job. If you need to, arrange to do it when you see the patient.
            People in other careers do more than they are paid for too.

          • Guest

            The hotel manager is nice to people because that’s what he’s paid for – that’s ALL he’s paid for. That’s his primary function. Wait till he’s off the clock and THEN demand he lick your boots, without getting paid for it, see how far you get THEN.

          • Patricia

            You have it a little bit wrong here. But that’s okay. You are in attack mode. A hotel manager must work hard to both be polite and courteous to clients as well as staff. She must keep the hotel running properly. I doubt that you could even truly discuss the reimbursement issue; she would probably laugh at you. Do you realize how much work in the REAL world is done without reimbursement? People just do it, and do it because it’s necessary. Welcome to the real world. Also why don’t we get into salaries and lifestyles….

          • Suzi Q 38

            I think that a meeting with a advocate for the patient and/or family member is reasonable.
            No, I would not have made the snide comment about the appropriate billing, but that is already done.
            I believe you get a lot more being nice.
            At times, though nice gets thrown out the window when you have not received adequate care.

  • Guest

    A non-physician complaining that the service and amenities in a big city teaching hospital’s locked psych ward don’t match those available at “a newly opened nearby Hyatt hotel” was never going to go down well on a medical blog inhabited by real live practicing doctors.

    Maybe a hospitality industry blog would have provided a ‘friendlier’ audience for such a piece.

    • betsynicoletti

      But I didn’t complain about the care, did I? I said the family member got the needed chemical treatment in a safe environment. Friendly audience isn’t the point. Isn’t part of caring for a sick patient talking to caregivers and family members? Doesn’t that increase the positive outcome and decrease the chance of readmission? Isn’t that why CPT developed the Transitional Care Management codes?
      Is it wrong to expect a hospital to be clean?
      Maybe this has hit a little close to home.
      And, I have to ask again. If the family member was being treated for cancer, would the experience have been the same?

      • Guest

        “I never saw anything spilled or dirty at the Hyatt, so I don’t know how staff there would have responded. The clean lobby at the Hyatt was a stunning contrast to the activity room, where I sat with my loved one. ”

        Well. Maybe (just maybe) the Hyatt attracts a tidier calibre of clientele? Doesn’t have a city-full of involuntary psych patients hanging out in it all hours? Prioritises maid service over medical expertise?

        • betsynicoletti

          No, you aren’t going to seriously suggest that it is the fault of the patients that the the floor wasn’t swept or the tables washed? Why? Because they are psychiatric patients they shouldn’t have a clean floor? Would you say the same thing in the OR? All those dirty gun shot wound patients don’t deserve a clean operating room?
          What do medical expertise and housekeeping have to do with one another?

          • Guest

            “What do medical expertise and housekeeping have to do with one another?”

            I don’t know. You’re the one complaining that the maid service in an inner-city locked psych ward’s activity room is inferior to a 4-star hotel’s lobby.
            PROTIP: I expect their room service meals aren’t as prettily presented either.

          • PrimaryCareDoc

            Exactly!

          • betsynicoletti

            How about a Pediatric ward? Or a nursing home? Those types of patients don’t always keep a clean and tidy space. Can we excuse dirty because it is a psychiatric unit?

          • Suzi Q 38

            These places aren’t the best places as far as cleanliness.
            I guess you can complain.
            Or you can do what I did. Volunteer.

            Yes, actually roll up your sleeves and help out instead of complaining everyday to “the walls.”

            In the later years of my FIL’s life, he got harder to care for. We placed him in a nursing home after caring for him at home for 7 or 8 years. I was in my mid 30′s at the time that we first moved him home.

            When we did place him, the nursing facility was fairly clean, but not perfect. Mistakes were made, and misunderstandings occurred.

            I came to visit on Mondays, Wednesdays, and Fridays. My husband came to visit on Tuesdays and Thursdays. The kids would help out from age 10. They would pour the drinks for everyone at my FIL’s table, and help out with the other patients. The would help wipe down the tables after lunch.

            When they could drive, part of the deal was that our daughter had to stop by on Saturdays and our son on Sundays. During the summer months they volunteered for several hours a day, two days a week each.

            They were “pros.”

            The staff respected us because one of us saw him almost everyday. If they were short staffed, our kids would volunteer to do what they could.

            My FIL was well taken care of, partially because we were always around.

            If there was a problem, I just let the charge nurse know. She took care of almost everything.

            Anyway, arrange to move him closer to your home if you want things done a certain way.

          • Guest

            I think she should move him into her room at the Hyatt and care for him there.

          • Suzi Q 38

            That is an option.

          • Patricia

            Wow…way to attack the vulnerable person here. What is your problem? WHY can’t people try to work on solutions rather than berate someone who dared to complain about poor conditions and lack of physician involvement on a psych ward?

          • Patricia

            But it sounds like you did complain. And it’s amazing what you did for your father in law. However to expect everyone to do that as a response to poor conditions is not realistic. You sound like you have a lot of reinforcing elements that had made it possible for you to do that. Not everyone does.

          • Suzi Q 38

            Thank you.
            Yes, it is not an option for some people, but anything is possible.
            As far as reinforcing elements that made it possible…our decision to just give it a try.
            He did not spend down all of his assets and give it away to us. We instead used the money from the sale of his house to hire him good care.
            We had a nurse come in 6-8 hours a day, 3 days a week. He went to adult day care two days a week.
            We took care of him ourselves nights and weekends.
            This continued for 7-8 years, until he became older and harder to care for.
            It was not easy, but we did it.
            No, I do not suggest it for everyone.
            Keep in mind that it is an option.
            It is cheaper than a nursing home at $4-6K a month.
            I just found that if you want things a certain way, sometimes you have to do it yourself, or pay extra for a certain level of care.

          • Patricia

            I appreciate your thoughtfulness with this subject. I can imagine that if the responsible person was single, or low-income, etc, without resources it would be more difficult. And with mental health issues, I can imagine it is even more difficult. We are subject to medical oversight and insurance requirements as well as legal ones… It is truly difficult to navigate the system. AND it would be great if practitioners saw themselves as partners with the family rather than individual capitalistic-based form-fillers who have no humane responsibilities. (And when I compare myself to your situation, I cannot see how it would work out taking care of my mother, in the same way).
            Good points!

          • Suzi Q 38

            I really think that the physicians and other health professionals at least start out with good intentions.
            I just think that the job and all of the people that they have to please (including the patient), wears them down.
            Also, the stress to make the right decisions and medically treat the patients correctly must be huge.
            I imagine in psychiatry, patients are difficult to treat at times. If they are in a locked ward, they are dangerous. Turn your back on them and you may be physically in danger.
            The family member that lives out of town is at a disadvantage. H/she has only a limited amount of time to get the right care for their loved one.

            As a family, we made some important financial decisions for my FIL. Some people have no money to work with at all, others are not willing to “part with it.’
            They live with the parent for 3 or so years prior to their admission to a nursing facility, then spend down all of the parent’s bank accounts and other possessions, then admit them to a qualified nursing home that accepts medicaid/medicare.

            I think too, the spouse is allowed to keep the couple’s home and still admit their spouse to a nursing facility.

            When you do this, you are left with whatever.
            There is little control.

            My friends that are nurses did say that they kept certain patients that had frequent visitors fairly clean. They did not want confrontations with the patient’s families.

            In my case, the confrontations and the fact that my FIL paid cash every month for his nursing home didn’t matter.

            I figured that if I utilized social services, rehabilitation centers, stroke clubs, home health nurses, and doctors that made the occasional house call, we could do a better job for far less.

            I kind of think that even long and short term cruises as I aged, would not be a bad idea for moderate nursing care. I would rather be on a cruise than in a nursing home or senior facility.

          • Suzi Q 38

            You could do what I did. My FIL was in a nursing home.
            No one would care for him like I wanted him cared for.
            I tried reminding a nurse to give him a shower.
            She ignored my request. I asked a second nurse…same thing.
            By the third request of yet another nurse, I was livid.
            I finally told the facility to call the attending doctor;
            I was taking him home.
            I had two little kids under the age of 5 and a part-time job. They told me that what I wanted to do was impossible.

            I brought him via ambulance, in a diaper and a total lift. I hired nurses for him until he got strong enough. They bathed him every other day.

            I got the insurance company to transfer him t the best neurology rehabilitation hospital on the west coast. He stayed there for 6 weeks and improved. After he was finished, I found an Army I.D. card. I figured that FIL was a veteran, and got him another 6 weeks at a really good VA Hospital in California.

            When he was done with the two stints in rehab, he could walk with a claw cane and come home again.

            My point is that rather that criticize little stuff,
            focus on the big things. If you don’t like it, move him to another facility. If that facility doesn’t work, then try another one.

            If all else fails and you still don’t like it, complain.
            If nothing works, bring him home yourself.
            Try it.
            This will give you more empathy over what the physicians and caregivers have to deal with everyday, day in and day out.

            It is not so easy.

      • PrimaryCareDoc

        Excellent. When a bunch of people tell you what you’ve written is offensive, attack them by saying that they’re the problem (“maybe this has hit a little close to home”).

        No, maybe what you wrote was just completely off base.

        • Patricia

          Maybe it is the defensive audience of docs that read these blogs. I have noticed the group-think around anything that criticizes how docs might behave.

          • Guest

            I don’t agree with the group-think. The job is hard and getting more difficult to practice, but we shouldn’t lose our humanity. If we do then there’s nothing left.

          • Suzi Q 38

            I agree.
            I am incredulous at the attitude of some of my doctors. I got rid of a couple of them, but decided to complain after I got rid of them.

            I want them to realize that I was not a hypochondriac, and their attitude and decision to minimally treat caused partial paralysis/weakness in both legs for me.
            That when I say something is very wrong and I request help, they should at least take a full MRI of my entire spine. I know insurance companies are PITAS, but they should try and have me try to call the insurance if it is denied.

            I will say that the patient advocacy has been fair so far. The doctors have to answer some of my questions about my care, and my case will be reviewed by their respective department heads and other medical staff.

            There were two others that were fantastic. I made sure to say so.

          • Suzi Q 38

            They are just sensitive. You would be too if you were criticized everyday.

            I have had to be critical of my physicians lately, as huge mistakes were made in my care, but I have come to realize that at the end of the day, no one tries to harm you medically.
            At times, they are just overworked, distracted, or just plain thinking that you are a hypochondriac or something.

            No excuses for being apathetic, but it happens in all professions.
            The problem is that this profession involves peoples’ lives.
            This is probably why were are so emotionally angry when there are errors in our care.
            It is personal and important to our well-being or health.

        • Guest

          What she did was share her experience and give feedback. You’re the one finding it offensive.

          Medical care cannot be error free. However, it can be courteous, and when we have fallen so far that even a request for courtesy is met with anger and defensiveness then there’s no hope.

          Look in the mirror, doc. Are these comments reflective of the type of physician you aim to be?

          • Guest

            When your primary move is to threaten regulatory action against a medical care giver, you’d better bet they’re going to be on the defensive.

          • Suzi Q 38

            Yes, I would have to agree with that.
            Not a good “first meeting.”
            The snide remark was a bit callous and threatening.
            She could have learned when his attending doctor was generally in, and “planted” herself there.

    • Patricia

      Maybe some people are tired of hearing doctors whining so much about how hard their lives are because of the big bad medical care system. I mean, aren’t you in it for the good of the patient and family? Or maybe it’s just to get awards and get published? Rather than demean and make fun of this author you could use it as a valuable insight of the experience of the ‘other’. That would raise some of you above and beyond, which would provide amazing solutions to the problems the author illustrated.

      • Guest

        “which would provide amazing solutions to the problems the author illustrated.”

        Like it or not, the maid service in a locked psych ward’s activity room is never going to be up to par with the maid service in a posh 5-star hotel lobby.

        • Patricia

          I don’t understand your comment. “Maid service” is a strange term to use in this context.

  • betsynicoletti

    I readily admit that I am complaining now–as I said not about the care–but believe me, I walked on to that unit scared for my loved one and with only an attitude of gratefulness that my family member was safe. You can choose to believe that I arrived with an entitled mentality or a chip on my shoulder, but that is not the case.

    • Dr. Drake Ramoray

      Having very limited exposure to the inpatient lockdown wards short of medical school and the occasional visit as a consultant, I agree with you that usually they are generally intimidating places. I can only imagine what it would be like visiting a family member. The nurses definitely tend to be less warm than say on the OB or oncology floor and the unit is almost universally in the most disrepair in a hospital. I don’t think anyone can readily dispute your grievances with the conditions especially as it pertains to the care of your loved one.

      That being said it does not appear to me that you went about things the right way then, or the way you present the episode in this piece. I would have been livid as well had I been visiting a family member given those conditions (and can understand how you reacted the way you did). If the nurses on the floor were of no help the I would have worked my way up to the nurse manager, and worked on up the supervisory levels. Assuming that your loved one did not appear in any danger I would have similarly insisted if necessary to talk to the attending regarding the case. Similarly if that was unsuccessful I would continue to work up that chain. I certainly would not have brought up adherence to medical coding issues as a way to goad the attending into coming to speak with me. While it certainly brought him to you, the exchange was probably not beneficial to either party. An alternative would have been to contact the patient lliason or patient services should those departments be available at the hospital (they often are at large teaching institutions).

      Lastly, rather than try and compare the conditions on the psychiatric ward to a posh NYC hotel I would have written a thoughtful, well constructed letter to the hospital thanking them for the care that they provided my loved one (I get the gist that they were treated well from an exclusively medical standpoint) but that I had multiple grievances with the condition of the ward as well as other aspects of their care. I would have listed those in a clear and concise manner as well as why I found them acceptable. If I had felt the need to share those conditions, I would have then posted that letter on this blog with any identifying information removed.

      I do have one question though. I have been under the notion that psychiatrists are not required to see inpatients every day as it seems every med staff meeting I attend at my local hospital that they are trying to rewrite the rules in terms of frequency they must be seen (was every other day, then three times a week etc.). Do you have any evidence (hospital bill or such) after the fact that you felt your loved one was being billed for days that that were not seen by the attending? I could certainly see where that could potentially be abused give that the patient’s are seen by a resident (obviously not the same thing) on a daily basis. The teaching hospital environment is a bit different in terms of billing and psychiatry is pretty unique within either system.

      • betsynicoletti

        I wish I had the benefit of your advice while I was in the midst of it. I can see that the comparison with the Hyatt was provocative. You are absolutely right: I am assuming that the attending will bill for all days. The attending him/herself told me directly that he/she was supervising the care, and didn’t make daily visits. It is not my intent to follow up on that.

        I said in my original piece that the nurse manager and social worker interacted in a very professional way. I should have been more generous and said that it was clear that both of them had too much to do. I work in healthcare and so should have been more sympathetic to the strain on the staff. But when it’s your own family member: well, you can imagine.

  • southerndoc1

    Transfer all the patients in the psych unit to the lobby of the Hyatt. Make the Hyatt file a insurance claim for everything they use down to a bottle of water from the mini-bar and wait 90 days for payment. Have half the occupants of the Hyatt be indigent and pay nothing on their bills. Then report back to us.

    • betsynicoletti

      I’ll get right on that.

  • azmd

    As an attending on a locked inpatient unit and as the mother of a child with neurodevelopmental and psychiatric issues, I can empathize with both sides here.

    I can say from personal experience that it is absolutely true that there is an outpouring of support from the community and from medical providers if you have a family member diagnosed with cancer, but if you have a family member with a mental illness, not so much. If at all. This can be extremely painful and one can feel very alone at times. Over the years this has been a useful insight for me in my work and so I routinely suggest to parents of my young adult patients who are newly (or not so newly) diagnosed, that they consider getting involved with the support groups run by the National Alliance for the Mentally Ill. I also recommend, if resources allow, that parents arrange for counseling for themselves to provide a safe place to vent, to get support, and and to work on coping effectively with their fear and grief.

    As for family visits with the attending, I have a few comments:

    Whether family members mean to or not, they frequently and unconsciously expect the staff taking care of their family member to assume that caretaking role for the family as well. I can honestly say that 90% of my conversations with family members which are intended to be “just ten minutes to answer some questions,” devolve into 20-30 minute conversations in which the family member wishes to share about their own feelings and experiences, or their thoughts about what emotional factors could have led to their child’s illness. It is very hard to gracefully extricate oneself from these “sessions,” especially if they are face to face. Furthermore, hearing about a parents fears and concerns is of limited and only indirect benefit to the patient. It is of course the compassionate thing to do, but we are encouraged to “work smarter” these days and “do more with less” which means staffing has been cut and we have to make difficult decisions about how to spend our time.

    I also hope it does not seem hard-hearted to point out that time spent soothing families is not reimbursed by anyone, since it involves no patient contact. We have some limited ability to bill for meetings that are specifically organized around discharge planning. A meeting immediately after the patient is admitted, when discharge needs are not known, and which does not include the patient, does not meet criteria for transitional care management.

    Furthermore, I am frequently very surprised that family members who would not dream at showing up at an office (of any sort) without an appointment, feel that they can arrive on the unit and request that the doctor be paged to appear immediately for an unscheduled family meeting. Inpatient doctors’ days are filled with scheduled meetings of various sorts as well as emergencies. As with any doctor, it is probably most effective to ask for the phone number for the doctor or the social worker, and leave a message politely requesting a callback to answer some questions about diagnosis and treatment, when the doctor has free time for a phone call. Presumably you would not arrive on a cancer ward and expect to be able to page the oncologist to promptly arrive and answer questions; why would the expectation for a psychiatric specialist be any different?

    Also, as others have said, the tactic of forcing the attending to put in an appearance by (even in a veiled fashion) accusing him of insurance fraud is guaranteed to not only alienate the attending, but also the nursing staff who, unlike the general public, sees how many hours the attending puts in doing very stressful work. If you had the perception that the nursing staff was cold and unsympathetic, one reason may have been that you got off on the wrong foot by making such an outrageous accusation. I can assure you that the nursing manager most likely shared your comments with the entire staff. Additionally, if a family member is overtly aggressive or emotional in his or her interactions with staff, that is generally a red flag that engaging with that family member is likely to be more time-consuming than an overworked staff is able to manage. Our primary obligation is to take safe and compassionate care of our patients; our ability to deliver that care can be jeopardized by lengthy and/or emotional interactions with non-patients. One way to avoid engaging with a potentially emotional family member is to avoid making eye contact or initiating conversation.

    On a final note, with respect to concerns about the cleanliness of the unit compared to the Hyatt: psychiatric patients, unlike medical or surgical patients, are quite ambulatory. They walk around and do things that make messes, like have snacks, or do craft projects, or throw up. This is completely fine, but since housekeeping services are among the first things to be cut when costs are on the line, a psychiatric unit will inevitably be less clean than the Hyatt. And if you are wondering why a psychiatric unit cannot be as profitable as a Hyatt, I would invite you to use your practice management expertise to calculate the deficit that a typical unit runs at assuming the following: Thirty patients, 30% of whom have private insurance ($1300/day), 50% of whom have public insurance ($900/day) and 20% who have no insurance at all ($0/day). Staffing needs: Nine RNs per day, ten techs, two social workers, one unit clerk, two attending psychiatrists and one half of a nurse manager. This is even before other facility wide labor expenses are paid such as housekeeping, dietary, administration, maintenance, tech support and security. And even before infrastructure expenses are paid such as utilities, maintenance, taxes, etc. I hear patients’ families express astonishment that a hospital cannot be profitable on a facility fee of $1300/day. I am amazed that we can even keep our doors open.

    • Patricia

      I think that you make all very good points. However you don’t offer any solutions. I would think that if you had time to answer these posts in detail you might sketch out a few ideas rather than tell the original author how wrong she is.

      1) Because the medical system as it is today is profit driven then she as a consumer has every right to expect that if someone is billing for services, those services are actually performed. This should be done without backlash. It’s not the consumer’s problem that the system is broken.

      2) Transparency. If the physician has ten minutes to talk with a patient’s family, then perhaps you all can come up with some ideas on how to make that happen. How about having someone discuss on admission what the procedures are, what the limitations are, and who to turn to for what. Hand out an easy to read card that illustrates those points. Example: the physician has *X* amount of time to spend with you, since she is attending to all the patients (etc); so please have these sorts of questions ready for her. And say: If you need to talk further, schedule an appointment with our social worker.

      3) How can you be so dismissive of dirty conditions on a ward? It doesn’t matter why it gets that way. And you can make the excuse about funding cuts (that is always the go-to) but how about, again finding solutions. You have to understand how these types of things affect both the patients and their families.

      4) “Red-flagging” family members and patients shows really poor practice as far as creating a healing inclusive atmosphere. I can’t understand why you keep blaming the patients and family rather than the inability of the medical structures (including those who work as physicians, nurses, etc etc) to come up with strategies to make things work and work better. Of course people are emotional and upset in these situations. It seems like some very necessary training needs to happen here.

      I know you are going to argue with me and point out all your experience but you are neglecting the patient and family experience. It’s tiring to hear about doctors whining all the time about their difficult lives. Because really, we all have difficult lives in the changing world. It’s really actually *more* difficult to have to navigate the health care system when you are poor and sick and disadvantaged, and then have to deal with doctors and staff who won’t look you in the eye because they can’t figure out how to talk to upset people in a 10 minute time frame.

      You all need to re-group and figure out how to manage better and still meet the physical and emotional needs of your patients. Like I said, try involving the patients in setting up realistic expectations for your time instead of pulling the emotionally distant and dismissive doctor thing.

      • betsynicoletti

        Thank you for your comments. It would be unreasonable to expect the attending to talk to a family member every day.

        Does the fact that the illness is psychiatric change our assessment of this? If the patient had sepsis would we think it more reasonable that the attending talk to a family member every day or two, or would the first year attending be enough?

        And on the one day that I did talk with the attending, the attending was very helpful, had great insights, asked important questions. Isn’t that the role of the team leader?

        • Patricia

          Yes! That is the role of a team leader. AND yes, if a patient had a disease like cancer or heart problems the scenarios would be different. I’ve experienced it from both those perspectives with family members.

      • http://www.facebook.com/kate.curry.3950 Kate Curry

        I wish I’d written that. But then, I also think we healthcare workers feel overpowered, defeated, and devalued at this point. I bet many of the people who have made tetchy comments here do try to be receptive, responsive and compassionate.

        • Patricia

          I agree with you Kate. AND I also think that we have to make things better ourselves; we can’t wait for the systems to do it for us because they have no incentive to do so. This includes patients (not all can be of course) to be self-advocating and health care professionals to do the same (and not at the expense of each other!)

    • betsynicoletti

      Thank you for this. I found it very helpful and very much appreciate both the time and the thoughtfulness and honesty.

      • betsynicoletti

        I read this quickly in between other activities, but I want to appreciate your point of view as a parent, and your advice to me. I did receive support from my friends and colleagues (some of whom rescheduled meetings and understood delayed work) but I think your advice about joining a group and counseling is correct, and I’ll follow it.

        And, I do appreciate your perspective from working in the facility.

        • azmd

          You are welcome. It was written in a helpful spirit. It makes me sad to see all of us, physicians and patients being at cross purposes and cross with each other. If we can share honestly what our thoughts and experiences are and can understand each other a little better, maybe that will help.

          • Patricia

            Except that you choose to denigrate and condescend to those who *don’t* share your views when they honestly share. You know the *right* things to say to a vulnerable person and I don’t think that you are being disingenuous; however your other comments make me wonder. Keeping yourself separate in this “know it all” way is getting a lot of support from other docs reading and commenting here.

        • f. lusu

          local NAMI and DBSA groups meet every other week. if you don’t like the facilitator or the group,you can choose a different location or just wait awhile because there can be a big turnover in some of the groups. counseling/therapy might be a much better fit for some people who need more support or don’t feel comfortable in a group setting where they have to participate.

  • http://www.facebook.com/kate.curry.3950 Kate Curry

    Maybe if physicians didn’t swan in and sweep out of healthcare facilities, they’d understand this article better.

    • Guest

      Maybe if non-physicians didn’t swan in and sweep out of locked psych wards, damning them for not being 5-star hotel quality and damning their specialists for not being as ingratiating as people whose ONLY JOB is to be ingratiating are, we’d all be a lot better off.

      • Suzi Q 38

        When I was in the hospital, my room was so filthy that I didn’t want to stay there.
        I left within 30 hours.
        I had just had an anterior Discection of my cervical spine.
        the DRG was 4-5 days.
        I didn’t want to catch a nosocomial infection while I was there.
        I would not have thought to complain to my neurosurgeon, the fellow, or my neurologists.

        Instead, I complained to my acquaintance friend, who was the wife of the CEO of the teaching hospital I was at.
        I told her that it was so dirty!
        I only elaborated slightly, as I think she gets an “earful” most days, and she doesn’t need my whining.

        I told her that the physicians were great, but could he ask the custodians to do their job?

        I also could do without the visiting nurses 24/7.

      • Patricia

        So a family member is a “non-physician” now? And not an important part of the treatment plan? Is this a prison you are talking about?

  • southerndoc1

    Honestly, I think everyone here – the docs and the patient advocates – wants the same things. Doctors don’t like working with stressed out, exhausted, grumpy staff; we don’t like dirty work environments, we don’t like not having time to talk to patients and family.
    I would imagine every physician posting here has butted their head over and over against the bureaucracy that now controls our health care system, and has some scars to show for it. But we’re being realistic: we know we can’t change things. Doctors and staff are as much victims of the system as patients. And so we see red when attacks like this are directed at those who are powerless to improve the situation. If the post had been properly directed at the suits in the executive suite and at the insurance companies, I think the response would have been quite different.

    • Guest

      But she doesn’t interact with the suits or execs, so she voices her frustration with those she DOES interact with. And then gets attacked. A reasonable post like yours gets lost among the hostility. It’s unfortunate.

  • wiseword

    What’s with the “family member” circumlocution, not to mention “loved one”? (That was a funny movie, by the way.) What ever happened to “relatives”? Is there some political incorrectness there?

    • betsynicoletti

      Not that I was aware of. Relative doesn’t sound close enough.

  • southerndoc1

    This seems relevant (from AMA NEWS):

    “Only 3% of executives in a May survey by the Beryl Institute, a patient experience advocacy organization in Bedford, Texas, said physicians or other clinicians held primary responsibility and accountability for addressing the patient experience. Even fewer, 1%, said chief medical officers were in charge, while 14% said chief nursing officers were. The most common form of patient experience leadership was committee, cited by 26% of executives, followed by a dedicated patient experience executive, cited by 22%.”

    • Suzi Q 38

      Are you saying that doctors do not have the most responsibility and accountability for patient care?

      • azmd

        What’s being said is that doctors do not control the patient experience and that increasingly they do not control the circumstances under which they deliver care. This situation is beginning to affect the clinical care of patients, as we have seen from many patient comments and stories.
        Certainly it should be widely accepted at this point that doctors have no control over certain aspects of the patient experience, such as hospital cleanliness.

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