A letter from a hospitalized patient to a hospital CEO

We are at a pivotal moment in health care. It’s changing so rapidly even the people leading the change can barely keep up. One of the biggest paradigm shifts over the last decade is the focus on quality over quantity. Improving the health care experience and patient satisfaction are also being talked about in boardrooms across the country (largely due to the link with reimbursements, but still unthinkable a few years ago).

As someone who has worked up and down the East Coast in a variety of different settings — from large academic centers to more rural hospitals — I have found the broad challenges to be the same everywhere you go. Unfortunately it’s also been my experience that hospital leaders often lose the forest for the trees, and are overly focused on unnecessarily complex solutions to simple problems.

I’ve treated thousands of hospitalized medical patients over the years, and with my interest in quality improvement and improving the patient experience, I’ve noticed very similar patterns in what our suffering patients report back to us as their best and worst feelings towards the hospital. While I don’t presume to be putting words into anybody’s mouth, here’s what I suspect a letter would look like from a large majority of patients who are hospitalized in America:

Dear hospital CEO,

Thank you for asking me about my hospital experience during my recent bout of pneumonia. Overall I found the commitment and dedication of the frontline staff to be highly commendable. Their sincerity and professionalism was without question. However, I would like to point out a few observations (in fact, I will list them to make it easier to read).

1. I spent a lot of time in the emergency room waiting for my hospital bed. I know how busy it was and I’m sure everyone was doing their best, but I wanted to mention this. It’s very noisy down there and sometimes felt a little too overwhelming for me (it’s my first time in hospital).

2. There was a lot of confusion when I was admitted about my medication list. The ED and the hospital doctor both had different lists, neither of which was my actual one. I’m sorry I couldn’t remember my exact medication regimen, I’m on several different pills, but is there a better way to get an accurate list — perhaps directly from my primary care doctor or pharmacy? This nearly resulted in a small medication error on my second hospital day.

3. The nurses that saw me on the medical floor were great, but I noticed they were fixated on their computer screens and pushing around their carts more than they were looking at me or other patients! One nurse remarked to me that she agreed completely with my sentiments and proceeded to tell me all about the enormous data entry tasks that nurses now have to do. While I can’t comment on that, my mother was a nurse and my vision of a good nurse was always one who was with their patient at the bedside, talking to them regularly, consoling, and trying their best to make their sick patients feel better. I’m sure things have changed over the years, but I do hope nurses still have time to be nurses.

4. I thought the doctors were very good. Maybe a bit rushed, but again I know how busy they are. One thing though, I was seen by several different doctors in the mornings — the intern, resident, attending, and then other specialists. All of them asked me the same questions and did the exact same examination. I was confused at first with who was in charge, but got it after a bit (some of the doctors also said opposing things to me, which needed to be clarified).

5. I found it very difficult to sleep at night. On my first night, my roommate kept calling out, and on the second night, there was a lot of commotion outside. Also, when I was already getting better, did the nursing assistant really need to wake me up at 3 a.m. to check my blood pressure? Just a thought. I’m sure I don’t need to tell you, but sleep and a good rest is one of the most important things the human body needs, and it’s especially true when we are sick. It should go without saying that hospitals should be calm, quiet and comfortable places.

6. I had two tests done which required me to be NPO. On the morning of each test, nobody could tell me what time the test would be. Have you ever been NPO before? I can tell you, it’s not pleasant. It would be good to have at least some idea how long it will last!

7. A couple of the scans I had, nobody told me beforehand what they were for. A transporter just walked into my room and announced he was taking me downstairs. There were also a couple of occasions where a phlebotomist suddenly showed up during the afternoon to take blood. I’m an educated person, and it would have been good to know the reasons why.

8. My family was extremely concerned about me, and asked on a couple of occasions roughly when the doctor would be around to speak with them. The nurse gave them an 8-hour window! Is this normal?

9. I know it’s a cliché — but the food! I’m not saying we need to have gourmet 5-star food, but I wasn’t a fan. Sorry, but you did ask me what I thought.

10. When I was discharged, the whole process seemed to happen very abruptly. I think we need to be more thorough and go through all the medications and follow-up very carefully. It’d also help if all the appointments were made for me. And while we are on the subject, on my second day in hospital, someone called my family at home and started talking about my “admission status” and when I was going to be leaving. This was before anyone even knew what was wrong with me! More tact please, my family got a bit worked up.

Having given you this list, I still want to tell you that the doctors and nurses did a pretty awesome job. I’m very grateful for that and understand that a hospital is not a hotel. Although you asked me honestly what could improve, that doesn’t mean I didn’t overall receive an excellent service. For that I thank you and your hospital’s dedicated staff.

Yours sincerely,

A medical patient in America

Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.

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  • Ladyimacbeth

    What that patient needs is a hotel.

    I’m not surprised someone would complain that the ER is too noisy. We had a patient complain to management because we were too noisy and woke them up. Guess why we were noisy? Someone was dying. It’s called a code blue. People run. Noise is made. So sorry for the inconvenience.

    We also had a patient or two put a note on their door saying do not disturb. Patients who do that need to realize that staff are going to document that they refused their q 4 hr vitals, assessment or whatever. Hope it all works out for them.

  • Suzi Q 38

    I hate hospitals.
    If you get out of there alive, you are lucky.

  • medicontheedge

    That CEO cares only about the numbers.

  • querywoman

    I have had pneumonia twice in the past two years. The first time, I got 8 days in the medical jail. The 2nd time, I got 2 days.
    I did not have the same lousy experiences.

  • emmabee

    A medical patient in America? Someone who says they were ‘in hospital’? I think not. That would be a medical patient in the UK, or Australia. Otherwise, loved this letter. I spent a month ‘in hospital’ myself three years ago and everything this letter says aligns perfectly with my experiences during that trying time, especially the part about being awakened in the wee hours to have blood pressure checked or worse, drawn by nurses who were not good at it.

    Thank goodness I got out of there in one piece. It wasn’t easy and being rushed out meant the inexperienced resident who removed my staples messed up one of them so that I had to go to a different ED about an hour after I arrived back home, with extreme bleeding. I was on Coumadin for heaven’s sake.

    • Ladyimacbeth

      They check your vitals in the wee hours of the morning because the physician orders vitals every certain number of hours. Patients can and do deteriorate. I worked on a stroke unit and had to wake patients up in the middle of the night to do neuro assessments, and sometimes these assessments led to the patient being rushed for scans as they had had a bleed. Had I not awakened these patients, we wouldn’t have known until hours later. Trust me, staff would much rather let the patients sleep, but if we ignored vitals and assessments to let the patient sleep it would come at a big cost to patient safety.

      They draw your labs early in the morning (we usually started drawing them around 4:30-5:00) so the results will be back by the time the physicians rounded. The reason you probably had people who weren’t good at drawing labs is that the turnover is very high. Working on the floor is not worth the stress, so many of the good ones leave.

      Most nurses and physicians have been patients, too. We understand the inconveniences can be frustrating. When I was a patient in the hospital, I had arterial blood gases drawn on me at 2:30 in the morning and vitals around the clock. Sure, being awakened sucks, but I was glad they intervened in my best interests.

      • JR DNR

        It only takes 24 hours without sleep for someone to begin hallucinating.

        Those who hallucinate in the ICU have a very high chance of death within the next year.

        Sleep is critically important for patients and needs to be a higher priority.

  • AnonDoc

    While I agree that it must be frustrating to wait for the doctor’s visit, it is not very practical for the doctor, who is seeing 30+ patients in the hospital and may also be seeing a full clinic during the day to call every family member if they cannot be present during rounds. If you have questions and cannot be present, write them down and have the patient ask, or ask the nurse because they are present for rounds and usually have an idea of what is going on. Maybe if you are very nice, the doc may call you after rounds a couple days, but expecting it is rediculous!

    As to the scans, they usually have a purpose, other than the defensive medicine of which you speak. Automatically refusing scans does the patient more harm and makes him/her stick around longer because the scan get cancelled and then has to be re-ordered. The reason that the pt is NPO and has no idea when the scan will take place is that NO ONE knows when it will take place. The radiology/echo/etc department might have some idea that it will take place in the morning or the afternoon, but it completely depends on how fast each scan is and how many STAT emergency scans need to go first. It is very variable

  • azmd

    The doctor’s job is to take care of the patient. That includes examining the patient, talking with the patient, coordinating care with other healthcare workers, reviewing the results of labs, studies, etc, and documenting everything that he or she has done. .

    The doctor is assigned cases based on the assumption that he or she will take approximately 10-15 minutes per patient to do all of this, and do it well. This means that your typical hospitalist has about 30 hospitalized patients to see every day. The hospital does not allow for extra time in the doctor’s day to have separate conversations with family members, chiefly because the hospital cannot bill the patient’s insurance company for extra time talking to family members. If the family is at the bedside when the doctor is examining and speaking with the patient, then most doctors are happy to speak with the family and answer questions.

    Doctors are not “acting like gods” when they are reluctant to have separate conversations with patients family members. They are acting like anyone would who had a high-stress job and was being asked to do extra work by someone who appears not to realize that the work being requested is not part of the worker’s job. It’s as though you stopped a fire fighter who was putting out a fire and asked them to give your first grader a talk about fire safety.

    I agree that things should not be this way. But until your insurance company decides that it is willing to pay for separate conversations with patients’ families, hospitals will continue to not allow doctors time in which to do a lot of that.

    • rbthe4th2

      Do I understand correctly?

      1) Extra questions are work and therefore need to be payable.

      2) That patient family members are the equivalent of 1st graders and that they are an interruption, not a positive one.
      3) That there is an excuse for bad manners?


      • azmd

        Uh…anything that anyone does at work that consumes time is work, right?

        So having separate conversations with family members is of course work. How could it not be? You are at work, you are spending time on a work-related activity, by definition you are doing work. And yes, that work needs to be payable. My employer expects that I will spend my time during my work day doing work that the hospital can bill for.

        I and many other doctors happen to believe that speaking with family members should be an important part of the work we do. Unfortunately, third party payers don’t agree with us on that, and so speaking with family members while we are not in the presence of the patient is not reimbursed.

        Therefore, if you are a hospital employee, the hospital does not budget time in your day to have separate conversations with family members.

        If I spent even 5 minutes a day providing separate updates to family members for each of my patients, I would get home from work an hour later every single day than I already do. And honestly, there is no such thing as a 5 minute update call. I have never once called a family member and not had it take a minimum of 15 minutes, which is understandable, but again, not reimbursable for my employer.

        This is not a reasonable expectation for people to have. But of course they do, because they don’t understand that the healthcare system doesn’t value communication with them. They then blame the doctor for not having time to speak with them, when they really should be looking at their own insurance companies practices.

        I don’t blame either doctors or patients for being unhappy with this system, but blaming the doctors for it is wrong-headed.

        • rbthe4th2

          and where did I blame the doctors? I asked for clarification if I understood correctly. I think all three got the answer, yes, by your statements. Correct?

          • azmd

            Think what you want.

          • rbthe4th2

            You mean that money talks over a patient and what’s best for them? This is why I believe healthcare is a business, nothing more. Bill for that time under a patient consult or a higher level consult if you have to answer questions. I think that would be fair and actually should be allowable because you are spending more time with them. If the care is more complicated, then up code. That answers the business question. Or, tell patients from the AHA, AMA types of groups that these types of discussions are an unreasonable expectation. That way patients will know not to expect them.

            I do expect and have asked how to fight for reimbursement for EHR time, phone calls & the like to patients from insurance.

          • azmd

            You are mistaken about what can be billed for. As I said, phone conversations with family members are not reimbursable activities, and as such they are not valued by my employer and time for those phone calls is not budgeted into my day.

            In fact, at my hospital, we are expected to have a formal meeting with the patient and their family once during their hospitalization. There is a special area on my contact sheet for non-reimbursed activities which I check off when I do this. There is no area on which to check off extra phone conversations with family members, I am expected not to have them. In fact, if I routinely stay late talking to patient’s families on the phone, and maybe sometimes don’t answer pages promptly because I am involved in these conversations, I am at risk for being officially labelled “inefficient” and “disruptive” by my employer.

            Again, this is not my preference on how I would like to practice. Thanks for whatever support you are offering for the system to change.

          • rbthe4th2

            Then in all fairness, tell the patient and have them corral all the family members they need and how long you have. Tell them it is a system issue and apologize, but can’t return calls. That at least allows them to go work at the system to get it changed.

            Then there is no expectation on their parts.

          • azmd

            I agree that patients and their families would be better off if they were fully informed about how healthcare reimbursement practices are affecting the care that they receive. But it’s not as simple as “telling the patient.”

            Look at how long it took me to communicate that fact to you. My initial response includes the statement “The hospital does not allow for extra time in the doctor’s day to have separate conversations with family members, chiefly because the hospital cannot bill the patient’s insurance company for extra time talking to family members.”

            This was followed by three responses from you which were fairly hostile and included the following “Bill for that time under a consult or a higher level of care if you have to answer questions.”

            Most doctors, faced with this sort of response from family members, will not persevere as I did with neutral, objective responses providing factual information about billing practices. They will just give in, and on their own time, call the family member but they will feel resentful and stressed, because they are trapped in between competing requirements on the part of their employers on the one hand, and patients’ families on the other.

          • rbthe4th2

            Then why not ask to have that put in some sort of “patients rights” or the like book?

            You interpreted it as hostile. It wasn’t. It was a statement of fact, here is something you can do to fix the problem of not getting paid for it. I didn’t interpret the responses on here from any one as hostile. Data without emotion is simply data.

            You get one obstacle, try and conquer it by doing something another way.

          • azmd

            You know, a patient/family handbook is a really good suggestion and I recently suggested that I be allowed to do a research study at my hospital in which I would write such a handbook, pass it out, and then study the impact on patient family satisfaction survey results.

            Instead I got assigned to study the impact of EMR on physician errors when entering orders. Oh well!

            And in terms of hostility, you may not have intended it that way, but this response does read as hostile…

            “1) Extra questions are work and therefore need to be payable.
            2) That patient family members are the equivalent of 1st graders and that they are an interruption, not a positive one.
            3) That there is an excuse for bad manners?”

          • rbthe4th2

            To save time on the EMR physician orders deal, there is a group called ImprovedX. You may want to see if they have anything.

            #1 is correct as a statement. The complaints were we’re not getting paid to talk to family members. That’s work. We should be paid. Otherwise its our own free time to do it. Unless any of those statements is incorrect, and I’ve seen it repeated several times, its 100% accurate.

            #2 and #3 is because that’s how patients feel about it. Much like there was consternation for how one of the doctors published an article on physician suicide and because we patients didn’t do anything about it, take up our 6 – 10 min. asking after our physician rather than trying to get our problems solved that we/the insurance paid $$$ for, we deserved any bad treatment we got.

            Considering I had a doctor tell me ‘you know I don’t like it when you do that’, II’d say maybe we’re on a little more even terms. I’ve spent time and so has DG (who I don’t see posting a lot any more unfortunately) where we were polite and kind to docs and it only got us stomped on and the brotherhood closing ranks to give us health care that we needed. So now, I just stick to the facts.

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