Volume 2  Number 10  October 6, 2005
Second Opinions

Hospital Helper, Part I

Hospital, derived from the Latin possessive, hospitalis, "of a guest," is the origin of our words hospitality and hospice. In the Middle Ages hospitals were charitable institutions for the poor, children, the aged or infirm. Aside from the common definition in Webster, "an institution where the sick or injured are given medical or surgical care," the word, prophetically perhaps, is also used to describe "a repair shop for specified small objects [clock hospital]".

Through the late 19th Century hospitals were often regarded as a place in which to die (not "die for"). Thanks to the miracles of cardiac, transplant, and minimally invasive surgery, joint replacement, intensive care units, and the machinery of life support, hospitals have basked in the gleam of medical progress and the reflected glory of TV series such as E.R. Lately, however, with the advent of consumer-driven demand and the information explosion ignited by the Internet, a darker view of hospitals has emerged. Some angry observers, having been through the rigors of hospitalization, have compared their experiences to banishment to a penal colony, a sort of hygienic Gulag where living people are turned into faceless patients clothed in sleeveless sacs open in the back, trapped in a narrow bed, their bodies attached to wires or tubes, fed foul food, often denied use of a toilet. These institutionalized unfortunates - so the descriptions go - live in an island universe, their confinement punctuated by unannounced visits of variously uniformed personnel, occasionally identified as nurses, PA's, aides, transporters, doctors, interns, and cleaning people.

Experiencing Patienthood

The psychodynamics of this identity change from person to patient have changed little since the 1950's, when the sociologist Erving Goffman in his classic book, "Asylums" detailed life inside a mental institution. Dr. Goffman observed a kind of psychological contamination occurring on admission. Normally, people can maintain their personal privacy by keeping thoughts of their bodies and their illnesses, to themselves. In an institution like a hospital, "…these territories of the self are violated," he wrote. "The boundary that the individual places between his being and the environment is invaded, and the embodiments of the self profaned."

A story is told by Jane G. two mornings after abdominal surgery when a group of white-coated strangers, sauntered into her room while she was half asleep, and without a word, pulled back the covers exposing her down to her pubic hair. Mrs. G, 45, weak from surgery managed to exclaim, "Well, are you having a nice day too, folks?" The audience of 20-something strangers headed by a gray-haired docent, staring at her exposed belly with detached curiosity, ignored her attempt at humor. After a protracted silence, the older doctor abruptly turned to her and asked, "Have you passed gas yet?" Mrs. G, a mother, a trained nurse and owner of a small specialty shop exclaimed, "Can you imagine, those were his first words to me, in front of everyone. I tell him, 'No, I never do that unless I'm in an elevator.' And he looks at me as if he's offended!"

Thankfully, we have entered a more enlightened era when such bedside teaching with its attendant patient abuse is a rarity. Since at least the early 1980's, medical schools and hospitals have worked at giving doctors classes in bedside manner while including patient representatives on staff.

Hospitals Have Problems Too

Hospitals have their own tales of woe: Oppressive regulations, falling demand, tight budgets, personnel problems, and especially shortages of trained nurses running at 15 percent to 30 percent in some areas of the country. It is not surprising that in a nationwide survey of 2,000 adults conducted by Harvard University, and the Federal Agency for Healthcare Research and Quality, 55 percent of those surveyed said they were dissatisfied with the quality of health care, up from 44 percent in 2000; 40 percent said the quality of care had gotten worse... "The point is that when they talk about quality of health care, patients mean something entirely different than experts do," said Dr. Drew Altman, President of the Kaiser Foundation. "They're not talking about numbers or outcomes but about their own human experience, which is a combination of cost, paperwork and what I'll call the hassle factor, the impersonal nature of the care."

The good news is that the national average length of in patient hospital stays has dropped by over 40%, from 7.8 days in 1970 to 4.8 days in 2003, more than half that decline occurring since 1990. In 1970 a third of patients were hospitalized more than 8 days, while last year only 16% were confined that long. Much of this considerable reduction in hospital stay has resulted from the explosive growth of outpatient surgical centers, as well as stringent new rules imposed by HMO's and other insurers. Even more important is the realization by physicians that prolonged hospitalization for cardiac, postoperative, and many acute patients can be counterproductive by actually imperiling patient health. Frightening examples of the dangers of unnecessarily prolonged hospitalization include increased chances for medical errors and the alarming growth of hospital-acquired infections, about which more later.

Some Remarks on Patient Rights

Over 35 million Americans, one in eight, will undergo hospitalization this year. Most of these, of course, will be patients with repeat admissions, primarily for chronic conditions such as cancer, heart, lung, and kidney disease, problems seen predominantly in the older age group, particularly those over 60. But even if your individual chance of being hospitalized is less than the national average, as we have recently learned to our collective dismay, there's no harm in being prepared for stormy weather.

Patient protection is embodied in Federal Law Better Health Care for All Americans, enacted in March 1998. All plans sponsored by the Federal government and most private health plans have adopted these principals. Moreover, most States, private and Government agencies have published similar guidelines.

But don't let 65.9 million hits on the Google search string "Patient Rights" give you a false sense of security. Many of these "rights" are simply pious clichés, testimony to regulatory enshrinement of common sense, for example, the right to a "Choice of Provider," your right to "Access to Emergency Services," your right to "Participate in Treatment Decisions" the right not to be discriminated against, the right to privacy (exquisitely defined), the right to complain and appeal, etc. etc.

Suggested Add-On Rights

One has to search long and hard to find legal documents describing such obvious rights as:

  1. The right to exchange immediately the demeaning hospital gown for your own nightgown, pajamas, and robe. You also have the right to a bedside commode, with assistance, if you cannot make it to the bathroom.
  2. The right to refuse any nauseating meals offered you, along with the parallel right of ordering your own meals brought in from outside - or in extreme cases reported - walking out of the hospital and going to the pizza parlor or Chinese takeout across the street. Item: The hospital earns a negotiated daily (per diem) rate from Medicare and most insurers, between $1,000-$2,000 a day for your care and feeding. Compare that with $200-$300 per day at The Hilton.
  3. Other specific rights of refusal:
    1. Multiple venepuntures for tests during a single day because an intern or attending suffers afterthoughts following the writing of morning orders.
    2. An IV line or an oxygen tube or other apparatus attached long after the need for them exists. (For courtesy, and if you're in bad straights, I suggest consulting your doctor first on this one.)
    3. Not to be awakened at night for sleeping pills.
    4. Not to be taken anywhere else in the hospital without being told first where you're going, what you're going for, and who ordered the trip.
    5. You cannot be forced or coerced into taking any medication, including injectables with which you are unfamiliar or about which you are concerned. Item: make sure you are properly identified before you receive medications or are transported anywhere. Believe it or not, this is still among the most prevalent and egregious hospital errors.
  4. General right of refusal includes your right to challenge any treatment, diagnostic test, specific therapy, or other procedure of which you have no knowledge or have any unanswered questions. Remember these magic words which Must be obeyed when uttered: "I Refuse this (service)", otherwise you may be manipulated or bamboozled into passivity and acceptance.

While this list of Rights has the aroma of a diktat, it merely expresses a common sense approach to be applied whenever you have concerns, misgivings, or queries. If followed mindlessly and without tact, it may be counterproductive, irritating physician and staff, and possibly imperiling your survival. Still, in a reasonable universe, hospital staffs should be compelled to treat patients with exceeding respect and calm consideration. Nothing can justify inconsiderate treatment of patients, people who find themselves sick in a strange environment, and absolutely dependent on the kindness, let alone competence, of strangers.

Being Discharged

Some final words. Remember to retrieve your medications before discharge (your personal supply will most likely have been taken from you on admission).

You cannot be discharged from a hospital if your caregivers think you need a personality transplant. Moreover, you cannot be discharged absent reasonable medical judgment that you are well enough to leave. This latter rule is fortified by the malpractice statutes. Furthermore, you may request further hospitalization if you do not feel well enough to be discharged or transferred. The Federal Government has established a rule whereby all Medicare and Medicaid patients, before discharge, must be told their right to demand further inpatient care, if they sincerely feel they are not well enough to leave. Fortunately, this issue rarely comes up. On the other side, remember the hospital is not really a prison. You cannot be kept there against your wishes for a single hour, nor can you be prevented from leaving on the basis of an unpaid bill. You can fire your doctor or walk out the door any time you are fed up with your treatment or for any compelling personal issue. In this case the hospital quite reasonably requires you to sign a release stating that you are leaving AMA (against medical advice).

On balance, however, nothing beats good rapport between you, the staff and your doctors, interns, and residents, which should be a health-restoring experience. You can be assertive, yet stay as pleasant and cooperative about your hospitalization as you expect your caregivers to be. Never forget, you are the paying customer, and have the right to demand the best medical care available.

Between hospitalizations, or instead of them, remember to eat a sensible diet, (stay away from fat, salt, and sugar, or anything that tastes good), exercise 3 hours a day, get 10 hours sleep, take adequate fluids, choose your genes wisely, and most important of all, don't forget to floss.

Martin F. Sturman, MD, FACP

Copyright 2005, Mathemedics, Inc.

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