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Here’s another of my favorite peeves about being in the hospital. What’s with these hospital gowns that are open down the back so the whole world gets to see your butt hanging out? Where’s the genius that dreamed this gown up? Has he ever worn one? Any patient who has will tell you that these gowns are demeaning.
Next time you’re in a hospital, take a look around. You’ll see patients ambulating with one hand on their IV pole and the other holding their gown together at the back. Alternatively, you’ll find a more dignified brand of patient who’s wearing two hospital gowns. That’s because most nurses are merciful enough to teach their patients to wear one gown so it’s open in the back, and a second one, in reverse so it covers up that airy slit over their rear. In this way, each patient consumes twice as many hospital gowns but still maintains dignity.
So what’s the one thing that no one ever steals while they are in the hospital? Besides a tray of food? A hospital gown! No one wants to see one of those gowns ever again.
I would like to sentence the ugly gown designer to wearing one for a full year. Then we’ll see what he or she comes up with as a new design for inpatient clothing.
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The hardest part about being the hands of the American health care system is waiting. Next time you’re in the doctor’s office (or worse: the Emergency Room), take a look around you: it’s a crowd. The waiting room is really the crucible of suffering embodied in American healthcare.
It would be simple enough if we could predict, months ahead of time, when we are going to need a doctor’s services. Then we could make an appointment in a timely fashion. But the truth is: the more we need a doctor, the less able we’ll be able to make an appointment. We’re damned if we do (nothing’s wrong) and damned if we don’t (something’s really wrong). The heart and soul of medicine is waiting. In fact, the Latin word patiens literally means “he who waits.”
So we wait like the good patients we are. But why? We wait because every doctor is so overburdened cranking out large numbers of patients and trying to keep up with reimbursement that often, by the end of a busy clinic day, the average patient is waiting more than 90 minutes after their scheduled appointment time before being seen by their doctors. Medicine has become a numbers game. The more patients seen in a clinic session, the greater the revenue. The shorter the amount of time with each individual, the greater the revenue. The quicker you make the diagnosis, the greater the revenue. In the end, it’s just a matter of the size of the check that comes in.
As a doctor myself, caught up in this system, do I have any solution? The answer is: no. I gave up when I noticed my nurses would put up a printed clinic schedule for me that allotted twenty minutes for each brand new patient evaluation. These were patients who were seeing me primarily for brain tumors! In other words, if you were a patient newly diagnosed with a brain tumor and were seeing me, as a neurosurgeon, for the very first time, you were allotted twenty minutes in which I was to get a medical history, physical examination, review your labs and x-ray studies and then I was to outline, in a meaningful and compassionate fashion, the risks, benefits and alternatives of major, life-threatening surgery. All of this in twenty minutes! I realized there was no way that I could live with this.
One day, I looked up at Carol, my most trusted senior nurse in the outpatient clinic, and asked:
“How long do I really spend with each new patient on their first visit with me?”
“An hour, at least.”
“Well, maybe we should change our schedule so that we devote an hour for each new patient visit.”
“If you do that,” she said “you’ll only be seeing four new patients in an entire afternoon.”
“Four? That sounds like a pretty puny showing for any clinic, doesn’t it?”
“Well, they sure won’t be happy with you in Billing and Collecting.”
“Well, they’re not too happy with me now, I suspect. So be it.”
Carol and I made a decision that we would dedicate an hour to each new patient and we would be limited, obviously, to evaluating four new patients in an afternoon between 1:00 and 5:00. Suddenly, we had a bunch of satisfied patients and a group of disgruntled bookkeepers. Carol and I created a few simple rules for our clinic. And not only kept our patients happy, but it made us feel like we were trying our best to demonstrate respect for them.
Find yourself a doctor who is dumb and safe
I know that this seems like an odd admonition. But look at it from this perspective: it’s been said that there are only four kinds of physicians in this world:
a) Smart and safe
b) Dumb and safe
c) Smart and dangerous, and
d) Dumb and dangerous
You never want to be the patient of a doctor’s who’s not safe—whether they’re smart or dumb.
The “dumb and dangerous” types are easiest to spot. They are so obvious that they are either weeded out during medical training or they have already self-selected themselves for arenas where their lack of intellect and talent won’t harm anybody. Avoiding dumb and dangerous doctors is fortunately not a big problem for most patients.
On the other hand, the “smart and dangerous” ones are tricky. They’re the most ones difficult for patients to avoid or forego. That’s because so many of the “smart and dangerous” surgeons are considered to be among the very best in their fields. Acclaimed as icons within their profession, they can be quite seductive and charismatic to patients. But these physicians are dangerous because they really do know a lot about their specialty and have demonstrated great proficiency in their surgical skills. But these “smart and dangerous” surgeons like to “push the envelope,” to try the newest techniques, employ the latest devices, and achieve recognition for accepting the most challenging procedures. The “smart and dangerous’ doctors have an insatiable hunger to be in the limelight. No matter how much acclaim they achieve, they need still more. And who pays for the daring feats carried out by the “smart and dangerous” to satisfy their appetites for recognition? Their patients, of course.
A resident colleague of mine in Boston used to plaster posters up on the walls of our on-call room. He had giant photos of fighter jets, cockpits, and the Navy’s Blue Angels jets streaking skyward in formation. He explained to me that the posters reminded him that surgeons were like pilots--fighter jocks. I was puzzled by this analogy. Fighter pilots have to demonstrate true bravery. They practice their craft by exposing themselves to lethal forces. When skill or luck deserts them, they lose their own lives. Maybe some like to think of themselves as heroic fighter pilots but, as surgeons, we never lose our own lives when skill and luck abandon us. When surgeons experience a crash, the patient is the fuselage--the one that crashes and burns. The surgeon gets to eject and walk away from each disaster. Maybe it's a form of courage but I fear it's usually a false bravado.
I often discuss these notions with my medical students and residents. Would they like to be fighter pilots? There are lots of secret grins of bravado. But to carry out the analogy between pilots and surgeons, you really need to take it one step further. Pose the hypothetical question: How willing would you be as a surgeon to forfeit your own life whenever a patient died? In such a context, the surgeon could label him or herself a jet pilot. I ask my medical students to imagine a different, hypothetical world of surgery, where the laws in healthcare require that every unexpected complication experienced by the patient would also have to be recreated in the surgeon who performed the case. So if the patient’s foot were to become infected and gangrenous until a below-the-knee amputation is necessary, then the surgeon’s leg would also be cut off. If infection overwhelmed the patient, then the surgeon would share the same fate. One of my medical students noted: “Such an arrangement would dramatically reduce the number of candidates going into surgery.” And how! I’ve never met a doc who wanted to practice in such a hypothetical world. But try to imagine some of the side effects of such a law of reciprocating injury. Surgeons would exercise the utmost caution in screening and selecting candidates for surgery. Surgeons would only consent those patients with the very highest likelihood of getting through surgery without a hitch. The surgeon’s post-operative vigilance would take on a nerve-wrecking quality as surgical teams would press to eliminate all complications that could befall the patient and, hence, themselves. But think of the profound trust patients could feel knowing that their fate would be shared with their surgeon. Surgery would become a whole different world, wouldn’t it?
A final note about smart and dangerous surgeons. There’s a German proverb that goes: “Too clever is dumb.” Very smart surgeons are often just too clever for anyone’s good. That’s why a physician’s empathy is vital to the practice of safe medicine. It’s compassion that puts the brakes on a doctor and makes him or her prudent. Not brains and training. A keen intellect without a warm heart is a prescription for bad surgical outcomes.
What about the category of physician who is “dumb and safe?” Surprisingly, this is a physician with whom all patients should feel comfortable, secure, and safe. The dumb, safe surgeon is the one who’s aware of intellectual shortcomings; does not attempt procedures that are unknown or unproven. He or she creates elaborate algorithms, checks and balances, redundant mechanisms so that nothing will be missed, nothing will go wrong. This is the kind of doctor who will bring in any number of consulting sub-specialty physicians to assist, ensuring the absolute best advice for the patient. Fortunately, most of our best physicians fall into this category.
Last comes the physician who is “smart and safe.” Obviously, we would all like to find such a physician but they belong to rare species indeed. In my entire life as a clinician, I’ve only met two or three individuals who fit this category, so there’s little chance of finding one. I don’t number myself amongst these special few. I’m just dumb and safe. And I’m proud of it. I’m honored to be counted among that group. I’m usually able to avoid preventable complications, the ones I can predict might occur. My patients usually do well not because I rely on my smarts but because I am obsessively compulsive. I‘ve had to develop an iron-willed discipline and an elaborate set of ritualized steps to guard against committing errors. For the patient, it is only the outcome, not the means, that matters. So when you go into your surgeon’s office, don’t only look at the diplomas on the walls. Look into their eyes too.
Find one great nurse in the hospital and cherish her
I‘ve heard many a physician say that the nurse is the doctor’s eyes and ears on the patient. That statement is true. Unfortunately, I’ve heard this comment made frequently in court testimony when a doctor is trying to lay blame for his or her negligence on a nurse. My own personal experience is that ninety-nine times out of a hundred the nurse tried to tell the doctor something was amiss, but the physician didn’t listen until it was too late and catastrophe had already stuck.
Nurses are also the heart of Medicine. They are the “final common pathway” for compassion in the hospital. They actually touch the patients, feed them, clean them off, and tuck them into bed. They are the mothers of modern medicine, the hospital’s heart of unconditional love. Patients can rejoice when they are finally in the hands of a caring nurse. Unfortunately, nurses are now becoming such a rare resource that they are being relegated to management positions more than direct patient care, and that has been a terrible loss for both patients and physicians.
Nursing is still, to my mind, the closest we can get to the essence of good medicine, effective healing. Why? Because try to visualize how an attentive, kind nurse makes the experience of illness and pain so much easier to bear. There’s no difference in the physiology between two identical patients undergoing the same surgery. Their sensorial experience recovering from surgery will be identical. But look how dramatically a good or bad nurse can effect how these patients feel emotionally about that experience. The tiny little things a nurse can do--like an ice chip on your tongue when your mouth is dry, or providing fresh clean-smelling pillow case--they change the patient’s outlook, pain, and suffering. It has nothing to do with pharmacology or molecular biology. It demonstrates the inestimable significance of what one human being is able to do for another. So nurses seem to dwell that much closer to the ultimate quality of healing that resides in our individual capacity for compassion.
Stick with the doctor who answers your questions
Every patient has the right to ask any and all questions. And the questions can be plenty stupid. Usually, the “stupid” ones are the best ones. A disturbing number of patients report they never felt they were given time to ask all their questions of their doctor. I hear the patients say: “Well, he seemed to be in a real hurry. I didn’t want to bother him.” Or “I just felt my questions were silly. I was so anxious about the procedure I couldn’t think straight. I was numb at the time.”
One of my attendings at the Massachusetts General Hospital had a rule: the patient could only ask one question of him. As soon as the patient started to take a breath and get up the courage to ask something, this particular surgeon would hold up his hand and say: “Aah, aah, aah! Before you ask me anything, I just want to remind you that you should really carefully consider what question is the most important to you…because you’ll only get one.” Few patients ever asked a question. Who could ever be sure what would be the most important one? If any doctor ever says something like that, slam the examination room door in his or her face and head for the nearest exit.
So what’s my practical advice? Always listen first to what your doctor has to say. Tell him or her that you want some time to think things over. Make a follow-up appointment in two days (unless it’s a life-threatening emergency and you need to be operated upon immediately, in which case there’s not a whole lot of time to ask questions). If the doctor seems put off by your request to come back, get out of the office, and find another surgeon. If the doctor says something like: “Okay. But I have an opening in my surgery schedule this week and I was going to put you into that slot. I won’t be able to do that if you want to come back another time,” run out of the office and find yourself a new surgeon. If he or she says: “Fine. I’ll see you in a couple of days,” then you can head home and make an appointment to come back.
During the two-day hiatus, pull your family circle together. Brainstorm a list of all the questions you can. Put them down on paper. Number them; it doesn’t matter how many of them you have. The more, the better. Leave a space of three or four lines after each question so someone can jot down the doctor’s answers as you plow through your whole list. It is far better to be asking questions before the procedure than afterwards.
What Not to Eat in the Hospital: Everything!
What is the problem with hospital food? You’re in the hospital, you’re sick, you’ve been given a thousand different medications that make you nauseous and rob you of your appetite. Everyone’s telling that you need nourishment to heal. What does the hospital do? They figure out a way to create the most bland, tasteless, unappealing, over-cooked food the world has ever seen. Then, just in case, you might be tempted to eat it, they leave it out long enough so it’s stone cold and then have it served up to you by the most surly hospital worker they can find!
Anyone who’s read a magazine or newspaper within the last fifty years knows that nutrition is important to your health and well-being. We’re encouraged to eat fresh vegetables and fruit. Plentiful portions of lean meat. Salad, greens. Doesn’t every hospital know this? Haven’t they heard yet? Don’t they have a nutritionist on staff who could give them some guidance?
I could never recommend hospital fare for anyone who’s trying to get better. It’s got no real nutritional value. The vitamins and minerals have all been cooked out. It’s got no life left in it, so it has no life to lend you. I don’t think hospitals will ever change. They must have to send chefs to some secret culinary school to learn how to make every dish so unappetizing.
I’ve given up trying to change hospital food. Instead, I tell the family to go out and get some healthy, delicious food prepared for take-out and bring it in to the hospital for the patient. Or better yet, whip up three or four great, home-cooked meals, and package them. Warm them up (every hospital floor has a microwave). Start putting some real, genuine, healthy food in your loved one! Oh, and be sure to bring some vitamins and supplements too!
Everyone wants to know about vitamins these days. I usually recommend a good, all-round daily multiple vitamin pill. I also add 1000-3000 mg of ascorbic acid (vitamin C). It’s a co-factor in laying down collagen (the stuff that wounds heal with), and it prevents urinary tract infections by making the urine acidic. Great stuff. I also add 400 units of vitamin E and 25,000 units of beat-carotene, the latter for five consecutive days only. If my surgery has affected joints (like spine surgery), I also encourage my patients to take chondroitin sulfate and glucosamine sulfate supplements. A little baby aspirin or subcutaneous heparin is also good for preventing blood clots from forming in the legs as long as there is no excessive concern about post-operative bleeding. I usually like to order a couple of heaping spoonfuls of fiber (like Metamucil) to help the bowel movements stay loose enough that the patient doesn’t have to strain. If the patient has to have a so-called “solid liquids diet” (an oxymoron), then I’m a great proponent of those wonderful fresh “smoothies” that are chock full of fresh nutrients. Pour in bananas, soy protein, wheat germ, yogurt, carrots, apples, or an entire steak if that’s what you want. If it’s a prolonged spell for your loved one on that kind of a diet, get a high-quality blender in your kitchen at home, and start mass-producing smoothies to bring into the hospital.
The question arises: what is to be done with the hospital food? Well, I wish they’d just stop making it and order out for some real food. Or give it to a food bank so it won’t go to waste. Alternatively, it could be slop for pigs.
Let me say one last but important tip about nutrition during recovery. Every patient who has been through surgery or on any antibiotic should eat at least three to four servings of live culture yogurt a day. The reason is that systemic antibiotics, including even the one or two doses they put in your veins during surgery, wipe out the normal bacteria that live in our bowel and help us to digest our food. When these “helpful,” benign bacteria get knocked off, harmful bacteria can quickly take their place. This can turn into a life-threatening problem if you consider the highly resistant bacteria we have floating around in our hospitals these days. But yogurt comes to the rescue. Yogurt is milk that’s been cultured with live Acidophilus bacteria. These are the “good guy” type of bacteria. So flooding your gut three or four times with bacteria from yogurt can really help keep the bad bugs at bay and help prevent antibiotic-related complications. Remember how your Mom told you yogurt was so good for you?
My last bit of advice about eating after surgery is simple: don’t. Drink. Drink lots of fluids, till you feel like your back teeth are going to float away and you are “peeing like a racehorse.” It takes days after general anesthesia for the bowels to get back to running smoothly. Naturally, many patients give in to their hunger and start wolfing down solid food as soon as they get the nod from their surgeon. Don’t. These patients usually pay for their premature ingestion of solid food with painful abdominal distension, and even nausea and vomiting. So my recommendation is stick to liquids till after you’ve had a couple of bowel movements and you’re passing wind again like a jet turbine. Then ease back into solid foods starting with some simple soups, shakes, and smoothies. You’ll be glad you did.