So you or a loved one has been admitted to a teaching hospital. While this is not an ideal situation, there are some things you need to know before being hospitalized or spending time with someone who is hospitalized. Consider this your peek “behind the curtain” to what really goes on during the 23 hours and 45 minutes that you are not seeing your doctor. Also consider this a therapeutic post for me to process some of the crazy stuff I see every day. Here we go. First things first….
A Hospital is a Huge Living Organism
Hospitals famously never close and never sleep.Large hospitals provide a huge amount of jobs to the local community and healthcare makes up around one sixth of the total GDP of the United States. At my hospital, it is estimated that 10,000 people per day show up for work. Another larger hospital in town is estimated to average 30,000 people per day for weekday operations. Between the care that needs to be provided, support staff, and ancillary services, a hospital becomes a mini city of its own. Add in all of the associated Subways, flower shops, Walgreens, and pizza places and you have a mini economy.
If you are a patient in such a hospital, fear not. Though 10,000 people may go to work in the hospital every day, in reality there are only a few hundred that really matter to you. These men and women are the movers and shakers of hospital healthcare: surgeons, attending physicians, chief residents, etc. These people have schedules catered around their wishes and influence not only on your care, but also hospital policy as a whole. In general, the various pieces of the elaborate healthcare machine don’t move until directed to do so. More on this later.
Concepts like “day” and “night” don’t matter in my hospital because it is a windowless, rundown pile of sadness. The best way to tell time is by the regular nursing shift change. Promptly at 7am the entire hospital comes to a screeching halt while all of the various units and floors go through their signout procedure from the night before. Promptly at 7:30am pagers and phones around the hospital begin to ring with questions from nursing staff regarding meds, orders, and whether the patient has pooped. This will be repeated again at 7pm (or 3pm and 11pm, if the hospital runs three shifts).
It is important to look at clocks frequently while in the hospital, because there is a distortion of the time space continuum once you step inside. It is also important to think happy thoughts and remember that you are a nice person. Each hospital has a culture that is somewhat pervasive….it works its way into the walls and infects newcomers. These are not often productive thoughts. For example, many times every single person in a hospital will claim to be excessively busy. While many people work many long hours, I can promise you that the administrative secretaries eating their regularly scheduled noon lunch in the cafeteria are not busy, but they have to act like it to fit in. While they certainly do work hard, they also arrive 4 full hours after the surgery team, and leave earlier too. Another silly idea is that you are somehow the only intelligent person in a hospital full of idiots. Each nursing floor tends to think of themselves as the best floor in the hospital, each medical team thinks of themselves as the best doctors, and everyone thinks the Emergency Department is dumb. While some people have a reputation for being somewhat dim, generally everyone is about on the same level. With that in mind, we need to talk about the characters in the hospital
These People Are Super Important to You as a Patient
Way before the crack of dawn, the first workers will begin to arrive. These are primarily surgeons, surgical residents, and the hardworking people who need to cook breakfast for 5,000 people before 7:30am. The surgeons and their residents will wait until the reasonable hour of 5am before waking their patients and asking the same questions to everyone (in pain? Eating? Pooping? Chest pain?). At around 7am the day nurses arrive and perform their intricate signout procedure. As a patient, this morning time is super important. You need to talk to your nurses and doctors before rounds. It might be chaotic, and you might be seen by any combination of the following people, but this is the ideal time to have your wishes be heard. These people include
1- Your Nurse. This person will be most closely involved in your care, and she has the number for the doctor. She can get you food, pillows, blankets, take your blood pressure, give you meds, walk you to the bathroom, and give you a bath. Please treat this person well. They have a grueling, tiring job and receive no appreciation.
2-The Medical Student. This person is in the unique position of desperately wanting to help but having absolutely no idea how to do it. You can ask them for anything, but they will need to ask permission before they give it to you. Even if it’s a cup of ice, they will probably page their resident and make sure. They have lots of time to listen to your concerns and help, so take advantage of this. Medical students can be identified by their short white coats, youthful appearance, and the look on someone’s face when they are perpetually lost.
3- The Resident. This person is an actual doctor, but still getting some supervision. They will do 90% of the work in your care. They also have 25 other patients and absolutely no time to spare. If you are mean to them they will hate you. If you look funny they will hate you. Actually, residents mostly hate everybody and everything. If you are surprisingly pleasant to them they may take a liking to you and move you to the top of the list. I mostly see residents as blurs, since they are always doing 5 things at once and answering pages.
4- The Attending Physician. This is the older doctor you see maybe once per day. He is ultimately in charge of everything that happens to you, but depending on the situation may be more or less involved in your care. When he comes by and sees you with the team, that means we are rounding on all of our patients, and now is your single best moment to make magic happen. Finally share your secrets (“I’ve smoked crack cocaine for 20 years”) or the thing that is really bothering you today (“I haven’t pooped this month”). If you don’t do it now, you will have to wait for tomorrow. This is one of those “movers and shakers” in the hospital, because anything you ask that the resident doesn’t know or is unsure about will have to go through the attending. Also, sometimes the resident will have his plans disrupted by an attending with different plans.
Medical students are usually found bobbing around in the wake of attending physicians, furiously jotting notes.
Let’s say you are in the hospital. In my hospital there’s a better than even chance that you are faking your illness, but let’s say you legitimately have pancreatitis. You will not be able to eat anything for several days, and your belly hurts badly. You push your “I Need Something” button and a young nurse comes in. You ask her to please give more pain medicine, but there is nothing she can give. She tells you she will ask the doctor.
You would think this is a simple process that involves a quick phone call, or perhaps a message on the computer, but it actually is an intricate system. My best analogy is that it would be playing with one of those trampoline tarps from grade school. You know…one of these.
In the middle of the tarp is a pile of numbers and letters. To communicate effectively, you need to maneuver the tarp in such a way that the pile of letters in the middle communicates to the doctor on the other side of the tarp.
So the nurse will page the resident, who will call back sometime this week. The resident may send his med student to evaluate the patient. The med student will not know what to do. The resident will come and evaluate the patient. The patient will finally talk with the resident and maybe get some additional medicine. The resident then needs to put the order in the computer and sign it, at which point the nurse needs to check the computer, see the order, obtain the medicine from the magic minifridge, and bring it to the patient. You can see how many places provide opportunities for this communication to break down. This, in a nutshell, is why nothing ever gets done in the hospital.
To make this even more complicated, every single thing needs to be documented in an archaic computer system so that if something does go wrong and the hospital is sued, they can theoretically document every second of your hospital stay.
“Why should I even go to the hospital? This is terrible!”
Well here lies the great paradox of the teaching hospital. Our inefficiency and the ignorance of the trainee (med student and resident) make sure that mistakes will happen, but introduce so much redundancy that the quality and outcome of your care ends up being really good. This is why six people walk into your room one by one each morning to ask if you pooped yet. This is why we agonize over medication doses, past medical records, and treatment options. From medical students who offer fresh, ignorant perspective to experienced supervising docs able to spot subtleties and guide treatment in difficult cases, the entire medical team provides really great care. And right now, it’s the only way we can train new docs to take care of us when we get old.
That is all. Thanks for reading!