Saturday, November 02, 2013

the love of money is the root of bad patient care

I've been an ER nurse for an eternity.  Seen a lot of changes.  Seen a lot of changes with our doctor group.

When I started in the ER our docs weren't board certified ER docs, they were internal medicine.  As a nurse group, we had a great relationship with them.  They respected us, valued our opinion and because of that we gave really great care.  The doctors back then worked for the hospital.

Down the road they decided to form a group and contract with the hospital.  Thats when the changes began. Eventually they started hiring only board certified ER docs which is as it should be.

These two changes - the group separating and contracting with the hospital, hiring ER docs only, changed our ER.

This is only my perspective but when they formed their own group, it changed them.  It seemed to become more about the money.  When you contract with someone, you have to make the contractee happy.
What makes the hospital happy? Happy patients. Getting them to come back. Making money for the hospital.  Using the hospitals high tech equipment.

What makes a patient happy? Obviously, they want to feel better.  They want you to calm their fears that something awful is wrong with them.  They expect you to do things for them: run tests, relieve their pain, reassure them.

Now in this day and age, making them feel better takes the form of relieving any kind of discomfort RIGHT NOW.  Pain 4/10 here's some dilaudid.  Hint of nausea, zofran.  IV for everybody.  The days of giving you an ODT zofran, a vicodin and letting you drink water are gone.  More complex interventions make the patient happy, the more interventions the higher the level of care, the higher payment for the doctor and the hospital.  There is a money incentive to do excessive testing, over the top treatment.  Thats what our doctor group does these days. I realize that this is the norm in ERs across the country.  Is this kind of care good for the patient?

The other change, the coming of board certified ER docs changed it too.  Having worked in a hospital on call that trains ER docs, I saw the difference from our ER.  The docs separated themselves into their own area, having little interaction with the nurses other than around patient care. There wasn't the collaboration like at my hospital.  Basically the nurses were task monkeys.  They were there to carry out the doctors orders, their opinion wasn't sought out.

So that happened at our hospital too.  The docs and nurses no longer collaborate with each other like we used to.  It has affected patient care.

Then in the last couple of years, anticipating decreased reimbursement, our docs decided to start hiring PAs and went with the pit boss model.  The PAs see all the patients and collaborate with the staff doc.  PAs are a lot cheaper to employ, allowing that profit and salary to be maintained by the docs.

The introduction of the PAs has had a negative impact on our ER.  PAs, at least in our ER, are not collaborators.  They collaberate with the doctor and thats about it.  They have not been receieved well by the nurses, further alienating the relationship between the docs and nurses.  Once again, all of this has affected patient care.  Not in a positive way.

The point of this blog post: As money becomes more and more the center of medicine, the best care for the patient falls by the wayside, replaced by the pursuit of profit.


KeltCindy said...

Some things should just never be commodified: medicine, education, other public goods/services, etc. *Sighing* Just bone weary of the commodification and relentless drive for profit evident EVERYWHERE. Costs lives and sanity--in every conceivable way.

This crap is going to continue, until it can't (won't be long). Then we're in for below third-world standards of everything.

Hate to be so doom and gloom, but the obscene commodification of health care in the U.S. is part and parcel of the eventual collapse we're in for.


Take care, Ms. Madness. Absolutely LOVE your blog (been following for years).


Anonymous said...

OP I agree with what you said. One more money related issue that drives this whole mess is one dirty word: lawyers. Lawyers and lawsuits drive the CYA machine in medicine. Have a headache? get a Ct scan. Why? because in the infinitesimal chance that there is a bleed or tumor, ordering every test know to medicine will CYA in court. We need to find a way to police docs and keep them accountable, but not in a court of law with the sharks prosecuting poor treatment of hangnails like we have now.

Ann Onny said...
This comment has been removed by the author.
Ann Onny said...

Thanks for this post. Nothing presented here is new, but until now I hadn't seen it presented so simply and elegantly.

I agree with the previous commenter, Cindy, about commodification of public resources, and I, too, am a longtime reader who never comments.

I would like to go a bit further, and suggest that capitalism (and let's face it, this country is a capitalocracy, not a democracy - it's government to the highest bidder and, with very few exceptions, always has been)....*ahem* Capitalism dooms things. It ruins. It corrupts. It reduces. It degrades.

I realize this is a very unpopular sentiment, and I risk being dismissed as some kind of Occupy hippie, but I believe it in my heart to be true. There is a special something (GREED?) that accompanies capitalist systems that just slays the parts that are good and sound and functional as and, dare I say, beautiful. It is the destroyer of worlds - and this post is such a perfect example of such degradation.

All this is not to say that I'm some kind of crazy communist, or even a socialist. The truth is, I don't know what the hell kind of system would work better than what we have now. I just wish we were capable of inserting some kind of checks against the human weaknesses that ruin it for everyone. I think discussions about income and earnings caps are very interesting, and just last week I heard a conversation about limiting CEO compensation to something within a certain margin of a company's lowest earners. For example, barring the McDonald's CEO from earning more than, say, 30 times minimum wage, and thus creating an incentive for corporate management to increase wages for its poorest employees. Years ago I read an article about how the tax law has changed from what it was in the 1920s, and about what might happen if the government instituted wage caps. What if we could define "enough"? How much more would left over to improve the living conditions for everyone else who's not at the top? A lot? A little? Would it really make us less competitive as a nation? Would it really help to elevate people out of poverty? I wish our society was more interested in this kind of dialogue than in the crap they broadcast as TV nowadays.

If anyone is interested, two other items appearing this week seem relevant to this discussion: one is a piece in the NEJM about a possible med school bubble and the relationship between med school debt and rising health care costs; the other is a write up in New Scientist about a study by a mathematician suggesting that civil and political violence is cyclical in nature and the U.S. is overdue for a period of civic unrest.

Unknown said...

Interesting book I read awhile back called "The Rape of Emergency Medicine"

Once I read it I saw this behavior in nearly every private hospital I have worked at so far. Only the big public hospital I work at now is the exception.

I have learned the number of interventions & tests that makes the money it's the KIND of tests and interventions. A bedside ultrasound followed up by a CT to confirm findings is a norm at some ERs.

The more money a group makes for the hospital the more political power they have in the boardroom and over the CEO & CFO of a hospital.

Think on it.

Unknown said...

I am inclined to agree. The heart of good patient care should be service - proper, professional service. Yet even those who go through this for a purchase should get their money's worth. Basic morality. If your doctors and nurses aren't being up to the task, then you should notify authorities and legal counsels immediately.

Greg @ Taylor Medical Consulting

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