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Curbside Consult with Dr. Jayne 5/13/13

May 13, 2013 Dr. Jayne 1 Comment


I attended a very traditional medical school. We weren’t allowed to actually think about diseases (let alone actual patients) until the second year. Once we had nearly finished the second year coursework and had learned enough about diseases to merit his appearance, one of the more senior members of the clinical faculty would teach.

Dr. Elliott was an extremely well known internal medicine physician who had published enough papers to scare the willies out of all of us. Since we hadn’t met him before, we didn’t know what to expect from his lecture. We quickly figured out that although he looked a little bit like Santa Claus, he wasn’t bearing gifts unless that gift was a personality that was a cross between Dr. House and an extremely grumpy teddy bear.

All the syllabus said about the lecture was the title: “Sick or Not Sick.” Dr. Elliott went up to the podium and started reading a patient case study. At the end, he’d look out over the class and say, “Sick, or Not Sick?” and call on some poor unsuspecting student.

The student would give his or her answer, which was invariably wrong. We were used to reading about diseases, so we figured if the patient in question had anything that sounded like one, they were “sick.” Only after sitting through about 20 minutes of torture did he begin to tell us what he was looking for.

By definition, “sick” was a patient who needed hospital admission. “Not sick” was someone who could be cared for in the ambulatory setting. To second-year students, all of them sounded pretty sick.

Flash forward to today. Probably none of those patient would be classed as “sick” since we’re now discharging patients that are sicker than those we used to admit. Once the length of stay is reached, it’s a race to get them out of the hospital.

The simple black-and-white nature of “Sick or Not Sick” crossed my mind today as I was reading a depressing string of articles. Topics included the 80 percent C-section rate at private hospitals in Brazil; the rise of patient empowerment; the drastic increase in healthcare costs as a portion of our economy; and the rabid competition of hospitals for market share.

I have to mention that I was reading these articles in the frame of mind of someone who is extremely tired of the consumer culture in which we live and just survived an ER shift where no less than three patients threatened to report me to the state board for “denying care” when I was delivering evidence-based practice for viral illnesses. Overlay a couple of articles about how one of the richest people in the world is trying to end polio and improve sanitation around the world with a flashback of the patient who threw her bedazzled iPhone across the room because I had to unplug it to use the outlet for a medical device, and there you have it.

If we want patients to be rational thinkers about their healthcare, they need to be both intellectually and economically engaged. We need to play a black and white game of, “Do I need it to get better or is it a marketing gimmick that will drive up all of our costs?” as we look at hospital initiatives.

I’ve written before about hospitals that post their ER wait times on the Internet or services that allow pre-scheduling of ER visits. Sure, that can increase patient satisfaction. But is it actually going to make me better? Probably not. Would I pay extra out of pocket for it? Probably not. So why is the hospital spending thousands of dollars on IT systems to support it?

Same thing with “dining on demand,” which has been a nightmare at my hospital. Since I started my medical career as a Candy Striper delivering meal trays on a labor and delivery ward, I’ve seen lots of hospital meal trays over a fairly decent period of time and have even partaken of a few myself. Is allowing a patient to order their meals on a touch-screen at the bedside cool? Sure. Does it allow patients to eat when they want? Definitely. Has it improved the quality of the food in proportion to the amount of money it cost to interface the ordering system with the EHR dietary orders and the additional personnel cost needed to operate like a restaurant and make sure it’s all accurate? That’s debatable. Again, will it actually improve my clinical outcomes or is it something we just think we need? Would I rather have a lower nursing ratio or dining on demand? I know what I would choose.

We need to think carefully about cost vs. convenience and quality vs. gimmicks. More are more people are going without healthcare this year than I’ve ever seen. It’s largely due to cost. This is driving hospital revenues down at the same time that costs to lure patients with the latest robots and gadgets are going up.

It’s time to stop the madness. It’s time for all of us – patients, physicians, and administrators – to stop thinking about “me” and start thinking about “we.” Put down the smart phones and stop being self-absorbed and look at the world around you. There’s a difference between “need” and “want” and “what is good for you.” We all need to embrace that difference as quickly as possible.

Have a gimmicky system at your hospital that cost more than it was worth? Are you tired of the tail wagging the dog? E-mail me.


E-mail Dr. Jayne.

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Currently there is "1 comment" on this Article:

  1. Dr. Jayne, I can surely appreciate your point of view; especially given your immediate exposure to some of the nastiness you describe. However, I don’t think the full story is in health systems “choosing” to do these things over other projects that may contribute more to direct patient care. The sad fact of the matter is health systems are not only incented to do these things; but they are practically required to if they care at all about their “quality” scores and the subsequent payment and patient flow that comes from them. HCAHPS is really less about pure quality than it is about “patient experience” and since it is a core part of the hospital VBP program, hospitals need to care about it. If your health system is also a Medicare Advantage plan, they have to care about their STAR measures and 2 of the 5 core components of that program (both MA and PDP) relate more to patient satisfaction than they do to pure quality. I would be the first to submit that culture is probably the biggest thing a health system could fix in improving their experience scores but since that it hard to do, many pursue the incremental gains promised with things like food service improvements, guest wifi, and ER wait time counters. When a patient is asked “was your stay always comfortable and quiet” instead of “did you get well” on their government mandated survey, it’s going to inevitably lead to “improvements” like this.

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