Hospitals operate under the assumption that things have to move faster

I covered one of the chief residents in our hospital for two days recently, seeing more than 40 patients in total. My off-the-cuff remarks on Facebook still apply: “Twenty-two inpatients later, it is time once again to declare my awe and admiration for all who do this work daily: hospitalists, housestaff, nurses, techs, custodial staff (et al., et al.). And, of course, the patients who are — on the other side of the hospital mirror — working harder, in their way, than all of us.”

What’s more, I was struck — not for the first time — by the differences between the hospital and clinic, not just in tone, atmosphere, communication and pace, but in how those things affect medical thinking and decision making.

I am not talking about critical care or emergency medicine, nor about “codes” (cardiac resuscitation), merely because I do not participate in such care regularly. But I think my observations might still apply.

Simply put, the hospital operates under the assumption that things have to move faster. That tempo, I believe, encourages a certain frame of mind: We should treat, do, test. People are sick, we want to make them better, and lab tests and interventions are an avenue to this.

You already see where I’m going, because, if you know me or my blog, you know my bias. If anything, I think we tend to over-order as a health care system … and the scientific literature bears me out.

What would it mean to apply evidence-based medicine to hospital care, in a thorough-going fashion? I mostly do outpatient medicine, and guarantee you that I assume no superiority for the application of evidence-based medicine in that realm. No, much of what we do in clinic is still based on intuition, externalities, unsupported lore, personal preference (not the patient’s, God forbid, but our own as doctors), or some other blend of bias and conviction.

Would it be harder in the hospital to take stock? Would workflow be disrupted?

Or is it just that I am unaccustomed to the hospital, and things are really changing in that direction? What do you think?

Zackary Berger is an internal medicine physician.  He blogs at his self-titled site, Zackary Sholem Berger, and is the author of Talking to Your Doctor: A Patient’s Guide to Communication in the Exam Room and Beyond.

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  • Deceased MD

    It’s all about the money.Not about what makes medical sense.

    • leslie fay

      absolutely. Harder, faster, harder, faster. I am a retired respiratory therapist and I can tell you after almost 40 years that it’s all about your workload. You are always given heavy workloads and you must meet a minimum number. there is no place to enter the number of pt’s you helped by getting them something they need by tracking down an equally overloaded nurse(you can’t give them sugar for their coffee or even just coffee until you are sure what they are allowed to have).

  • Ellan

    I’ve been an ICU nurse for 15 years and over the last 6 or 7 years I feel like we are constantly bombarded with new evidence based practices to adhere to. Joint commission, with all of there core measures, is just one example. Related to the pace and over ordering, even in the ICU this is a problem. Even though most patients do need frequent tests and interventions, there seems like there is a certain point on the patients trajectory towards wellness that we miss and continue to do it simply because the patient is in the ICU. Which brings me to the subject of ICU bed utilization and don’t get me started on that!
    However, my perspective is as a nurse and not as a physician.

    • leslie fay

      ICU bed utilization-always a hot-button issue for me. Never could figure out why a DNR pt. was taking up an ICU bed, except that there was money in there for someone.

      • R.E.B.

        I am a vocal proponent of appropriate, high-value care and eliminating waste in our system. However, it is important to clarify terminology before throwing it around. DNR does not mean do not treat. DNR status is an entirely appropriate designation for an elderly patient who has minimal chance of surviving a cardiac resuscitation. However, there interventions available in the ICU that typically cannot be offered on the medical floor, including vasopressor medications for hypotension/shock and non-invasive positive pressure ventilation for respiratory failure. While an 85 year old with heart failure may have decided quite appropriately to be DNR, in the setting of sepsis from a UTI transiently requiring vasopressors, she should not be denied access to an ICU and therefore access to these life saving medications (unless, of course, it is her wish to avoid ICU level care). Please do not conflate DNR with Do Not treat and perpetuate misconceptions about the myriad of available medical interventions available to patients who decide specifically that cardiac resuscitation is not within their goals of care..

        • leslie fay

          DNR has always meant do not resuscitate, it does not mean do not treat. Obviously there is a big difference between treating a condition that is treatable and a person who has coded from a condition that cannot be reversed.

  • eqvet2015

    If you took an average with the outpatient sector, the speed might come out right. Waiting weeks (rare) to months (more common) to be able to get diagnosis and treatment of major, life-altering illnesses isn’t the solution, either, and that seems to be the norm if your PCP can’t figure it out.

  • medicontheedge

    I am not sure it is about the speed as much as it is the DOING THINGS. Perhaps as a culture we are measuring progress and success and satisfaction by tangible items we can see and touch. As an example: an otherwise healthy kid comes in with a stubbed toe to the ED… instead of just examining it, proclaiming it a simple everyday injury, and advising the patient and family to take care while it heals, we order a battery of x-rays, then put a splint on , a cast shoe, and measure for crutches. Kind of like the idea of a “gift with purchase”… if we did not DO these things, instead of prescribing “tincture of time”, the customer feels like they did not get value for what they spent. Even when they really are not the ones paying for it. It’s all about the Press-Ganey’s man. And sometimes time and rest and observing IS the best treatment. Can’t have that. It can’t be measured.

  • Dike Drummond MD

    The hospital is the most expensive place to offer any care. This financial consideration is what drives the intensity of services and hospital setting. The whole concept of “the right person in the right setting at the right time” with regards to the provision of care means that everyone is focused on doing everything possible as quickly as they can whenever a patient is inside the walls the hospital.

    With organizations taking financial “responsibility” for patient care in the future, I anticipate this will only intensify for one simple reason. The best way to goose your profit margin when you’re paid a flat fee for each patient is to get them in and out of the hospital as quickly as possible.

    If evidence-based studies show that doing things more slowly works better, I would anticipate they would be shifted to an outpatient setting.

    My two cents,

    Dike Drummond MD

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