A Startling Insider’s Look at What Happens to Patients Who Stay in the Luxury Suites of a Prestigious Hospital
Last week, thehealthcareblog.com (THCB) asked if they could put up my post about the hospital building boom below where I ask “Can we Afford the Waterfalls”– and all of the other hotel-like amenities that new hospitals are beginning to offer. Do we really need grand pianos, valet parking and all-private rooms—especially in hospitals that don’t yet have electronic medical records? (See my original post here)
Quite a few readers at THCB commented, with a number voting “yes” for the
amenities. But one young doctor said “no”—and then offered this startling insider’s view of the care patients do and don’t receive on the luxury floor of one prestigious hospital:
“Maggie’s right-on regarding the disconnect between hospital frills and quality of care…
“I completed my training in a certain prestigious Boston hospital not
too long ago, and the joke among the medical house staff was that the
expensive private floor was "dónde no hay doctor" ("where there is no
doctor"…named after the famous 3rd-world medical manual).
The other joke was "thank god the [expensive private-room floor] is
located near a hospital."
“Patients paying for the extra space, fine dining, and hardwood
paneling routinely got the very worst nursing care in the entire
hospital. I can’t tell you how many times I was called to evaluate
these unfortunate rich folks whose nurses had drugged them into a
stupor and, because the floors were so quiet, user-unfriendly, and
locked, no passing house staff had noticed their shabby treatment. God
help you if you code…nobody knew where the resuscitation equipment
was hidden behind all that wood paneling.
Where’s the chart? Who knows? Where’s the nurse? Checking her email.
Why weren’t vital signs documented overnight? Well doctor, this is the
expensive floor and we don’t want to wake up these entitled patients.
Why didn’t you call us for this dangerous rhythm on telemetry? I’m not
a cardiac nurse.
“I think there is a simple structural reason for the egregious nursing:
the expensive floor accounts for a small share of the hospital’s beds.
Therefore it can’t be as specialized as other floors…so the nurses
are more frequently caring for patients outside their areas of
expertise. No cardiac nurses. No neuro/seizure nurses. No oncology
nurses. Just nurses (usually ex-surgical) who wanted to cash in for a
couple of years before retirement.
“As an attending, I basically forbid patients under my care from
staying on such floors unless they really aren’t very sick. My
understanding is that the cardiac surgery department at Columbia has a
similar policy…after all, they have to publicly report their
mortality rates. But seriously, ask your friends who’ve trained in
hospitals with such units. I guarantee my experience isn’t unique.
“There’s a larger point here about the nature of health care quality
and patients’ ability to evaluate it. Private rooms and nice furniture
impress laypeople, but they have nothing to do with hard outcomes…and
in my experience, they tend to cover up some pretty shoddy care.”
Another reader offered this insight: “Waterfalls and pianos, if they
were a symptom of a focus on care, would be naturals. There’s no doubt
about their calming influence.
“I fear, though, that instead they’re trappings of care, emperor’s
clothing of care, simulacrum intended to imply care. That we’re trying
to trick patients into thinking they’ve had a great experience instead
of, oh, say, actually giving them a great experience is a symptom of
this self-centered age in which how we feel about something is more
important than the thing itself. We FEEL cared for, ok. WERE we?
Probably not so much.
“I’d like to see a return to the idea that care isn’t a product, but rather an intentional act."
Finally, if you haven’t read reader’s comments on this question on
Healthbeat, scroll down and find comments on both “Are We Willing To
Accept a Two-Tier System?” here and “Hospital Building Boom: Can We
Afford the Waterfalls” here. I’ll bet Bev. M.D. would agree with that
last comment about the “emperor’s clothing of care.”
Bostondoc’s account of the care provided to patients in private rooms is, indeed, scary.
I wonder, however, how typical it is or is it a failure of management. I note that airlines usually put their most experienced flight attendants in the first class section, and the first class attendant is responsible for serving considerably fewer passengers than attendants working in the economy class section. Hotels and cruise ships have standard rooms, junior suites, and full suites all on the same floor. Certain hotel floors have additional services like free breakfast, lounges, etc.
I see no reason why a cardiac patient, for example, couldn’t be in a cardiac section staffed by cardiac nurses but with a mix of private and semi-private rooms, especially in an academic medical center or regional center of excellence that handles many cardiac cases. The same is true for cancer patients. If nurses are unresponsive or incompetent in serving any patient, whether in a private or semi-private room, management should hear about it and take corrective action. It’s not rocket science.
Well articulated response. I have worked in 2 hospitals with upgraded units, one a major academic medical center well familiar to all, and description above is spot on. The “amenity” floors are more like a living room than a ward, and staff attitude is commensurate with the surroundings–lax and passive. Funny, just like described above, care was frowned upon by all the docs.
The original post rings true–as do Brad F’s comments. I always appreciate comments from people who actually work inside the health care industry. They know, better than anyone else, what is going on–and why.
And of course the patients who choose these upgraded surroundings choose them because they don’t want to feel that they are in a hospital. They don’t want someone waking them in the middle of the night checking on them. They don’t want to see resuscitation equipment.
In other words, probably some, if not many of them, are in denial, pretending that they are not seriously ill, trying to go with their lives as they normally do (conducting business on their wireless laptops, etc.) . . .
This might or might not be good, depending on the disease, and just how sick they are.
Barry–
I’m afraid that the difference between an experienced stewardess and a cardiac nurse is too great for the analogy to hold.
And, as the poster explained: “the expensive floor accounts for a small share of the hospital’s beds. Therefore it can’t be as specialized as other floors…so the nurses are more frequently caring for patients outside their areas of expertise.”
As for putting the cardiac patients on this floor in private rooms in the cardiac unit, they don’t want to be on a floor of mixed private and semi-private rooms with lots of people coming and going, lights on during the night when their neighbors are being cared for (instead of being drugged.)
Maggie,
Not likely. It is all about money and the exclusivity of the private room in my experience. One thing that did not come up here or in the THCB posts, is the need to provide these types of wards for benefactors. Board members, CEOs, celebs, sheiks, and a host of others go home feeling pampered and continue to donate money and wings. I do see it quite frequently unfortunately. There is a good ROI from these floors, and hospitals have good reason to keep them. It is always heartening to watch the hospital C-suite folks make their “rounds.”
Bostondoc-
I thought your post was great. Particularly the “donde no hay doctor” line.
In the interest of full disclosure, I should mention that I work with 1199SEIU, helping Boston’s hospital workers join together as a union.
…And so it will come as little surprise that I agree with many of your statements. The “Mahogany Floors” of institutions like the MGH (which I’m guessing is what you were describing, though I might be wrong), are a symptom of a larger problem: The emphasis of cosmetically making it appear as though care is being delivered, while profit motives undermine the quality of care:
1. There is the tendency to improve the appearance of rooms (not just in the private floors), while paying inadequate wages to service and technical workers in the hospitals;
2. There is a tendency to ignore the labor shortage and short staffing that this creates, because the inadequacy of staffing isn’t immediately visible to a patient or their families;
3. And, having learned that labor shortages caused by low wages haven’t caused a downturn in business, many hospitals throughout the U.S. then make short-staffing a deliberate part of their business plan.
What you wrote really speaks to why those of us in the healthcare union movement got into it in the first place. Without the protection of having joined together, far too few healthcare workers feel safe to tell the kind of stories that you just told.
And when those stories aren’t told, the issues are invisible.
Maggie,
I read your post with great interest. Unfortunately, this has become the way of the world… cashing in on what the rich can afford to bring up the bottom line. Can’t fix the airlines? Just make private jets available to the wealthy so that they don’t have to deal with the travel headaches. Your city doesn’t have a stadium with enough private, indoor boxes for corporate use? Float a half billion dollar bond or let the taxpayers build your NFL or MLB team a new stadium so that the rich can sit in comfort and bring in the big box. And now we see what’s happpening with hospitals as well. Appeal to those who can afford to pay for luxury out of pocket while even those with insurance struggle to pay their medical expenses. I found a healthcare consumer advocate on YouTube who has started an internet based show addressing many of the problems you discuss. Here’s a link to the YouTube video: http://www.youtube.com/watch?v=zHk3pdfzdvI. Keep up the good work.
Michael
In regard to mandates, I thought this was a really outstanding review in this months Heath Affairs. It lends some needed perspective on how feasible implementing a health program such as the Swiss have here in the US.
brad
http://content.healthaffairs.org/cgi/content/abstract/26/6/1612
As an aside, and this has nothing to do with the topic at hand, and more to do with the community that is active here.
I come back daily for the reasons you cite. There is no flaming, people tend to reveal themselves (I think a highly predictive indicator of a good blog), and the dialog is at a sophisticated level. I know that if I post, I will learn from whomever chooses to respond. I hope that does not change as I view this site as a solid resource, as well as an enriching source of new knowledge.
Brad
Barry
Thoughts on budgets:
Like Medicare with patients that exceed usual LOS/DRG expectations, there are outlier payments made to hospitals. For example, a patient with stay of 67 days secondary to respiratory failure of unanticipated nature incurs a huge bill, the bulk of which would never be covered by standard DRG payment. CMS supplements.
Similarly, from an actuarial point of view, a hospital budget, assuming no Katrina-esque or 9/11 tragedies, is predictable in the short-term, give or take. Yes, CFO’s will say one decimal point or 1% error and you are sunk for the year. True. Whether the Feds/State will make up the shortfall and they run in the red is a different story, but they know how things stand from quarter to quarter. Ultimately, the facility must be aware if they are negotiating poor contracts, running inefficiently, or assuming too much liability secondary to charity/bad debt. Compare this to a a Grady in Atlanta (NYT piece was excellent and an eye opener), where it was a combination of both poor funding AND bad mgmt.
So, keeping that in mind, I could envision a “regional oversight board” with teeth that could see and act when things are going off track. If a hospital is legitimately squeezed, support should be built in the system (?? cap and trade with other regions, advances on budgets, subsidies). Either way, I dont think “a cap” is a rate limiting step. As they say, “stuff happens,” and workarounds and safety valves can be built in in the cases of non-malfeasance.
Obviously, this could get complicated, but it is just a thumbnail sketch.
Brad
Tom,
I like that there is a libertarian voice on the blog. Keeps us all honest and gives another point of view. Dont disappear.
I want to relay a story to you. I just got home tonight after a long day at the hospital. I spent some time caring for a sweet 25 yo woman. Graduated from a good college, paid her way, has some serious debts, but clearly has a bright future. She just started a job at a well known business establishment on the UES of NYC this week. Her health benefits kick in in 6 months.
She came to the ER toxic as hell with what I suspect is new onset inflammatory bowel disease. She did not ask for it, it just struck. I had a medical student with me during our discussion (this was eye opening for him as he usually hears about “medicine” only). Anyway, as she was hysterical crying about her financial prospects and bills, here are her two options:
1) remain hospitalized and get her procedures and biopsies done. Receive a massive bill and hope to negotiate a bundled down sum.
2) Leave the hospital, and pay FFS for procedures, etc. She must pay cash on the barrel in the private world, or wait several weeks for our GI clinic.
Oh yeah. Fill prescriptions regardless that are expensive and unwieldy after she is discharged.
Frankly, it broke my heart. All I could think of, and I dont care if you are on the right or left side of the aisle, this is real life, is how the hell did we get to this place.
You might have a snappy retort, and feel free, but your words were not the tonic I was looking for. Somehow, I dont think Jefferson or Adams had this in mind, no less Ike.
Anyway, such is life.
Brad
why must people have their name on hospital buildings!