Bigger isn’t Inherently Better (Guest Post)

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One of the secondary effects of obamacare – along with any government takeover of health care – is the decidedly negative and inhumane bureaucraticization inherent in such gargantuan system. The cliched reference to service in such a system being on the level of a visit to a DMV office run by inhabitants of the film “Brazil” being the end result feared by experienced physicians and patients. The idea that bigger hospitals by nature of having greater resources automatically provide better medical care is a false assumption far too ensconced in the minds of politicians and academics invested in the likes of obamacare. My own experience with the recent loss of my son shows how wrongheaded such ideology is.

Texas is in the midst of setting a new mandatory classification system for NICUs that is tied to reimbursement for caring for premature and sick neonates. In the ongoing deliberations, there is a political faction that has been trying to set up a statewide system that would force critically ill infants to be transferred to a few large academically based hospitals, by making it harder for smaller community hospitals to meet the new statewide requirements, under threat of nonpayment for medical services. The concept being that parents do not care how far their children need to go to get the “best” care, and only large, academic hospitals provide such care. Such ideology may not be a problem in states where people live only an hour away from such large institutions, however in a state the size of Texas, many people live as far as 6 to 8 hours from such facilities. When a family is faced with weeks to months of their child being in an ICU so far away, there are great financial, logistic and emotional burdens to carry. It is not easy to leave your child at such a great distance while having to continue working in your home city or town.

Adding to this, is the lack of compassion seen all too often in large medical facilities trying to care for so many patients. I have worked in hospitals large, medium and small as a physician. There is an almost direct link between the size of a hospital and the propensity to rely on protocol thinking in the delivery of patient care. Protocols are not inherently bad, however the tendency to restrict the practice of the art of medicine, as if individual patients are as interchangeable as machine parts, grows more pronounced as a hospital gets larger. From my almost 2 decades of medical practice, I have seen how the slavish devotion to protocol “cookie cutter” medicine degrades medical treatment through lazy medical thinking.

When I have a patient who is dying despite everything that I try to do to save them, I am honest with their parents, and I stay with them until after their child passes. I make sure to tell them how sorry the nurses and I are that we could not heal their child, and try to help them through the grieving process. We handle each death in a manner that gives the greatest possible compassion for the family, and utmost dignity to their child.

When it became obvious that my son was going to die, the large, academic hospital where he had been on a lung transplant list had the machines, medicines and the protocols to provide his painfree death as we withdrew care. What they absolutely did not have was any sense of human compassion in the process. The attending physician was comfortably at home. In fact, there was no physician, not even a resident, on the floor, much less one who came into the room to speak to us. We had to call the physician at home to request withdrawal of care. The nurse assigned to my son actually told me, knowing that I was a critical care physician, that despite over 6 hours of severe CO2 narcosis in a patient with chronic lung disease on a vent, that we just needed to give him another 12 hours of chemical paralysis (he had already had over 4 hours of such with continued worsening of his blood gasses) to see if he could recover. After he had been taken off the vent as we withdrew care, his heart monitor began alarming as he went into asystole. I turned the monitor off, just as I do when I have a patient dying, since there is no reason to add to a family’s anxiety with noxious alarms as their child is dying. However, in this large academic institution, slavish devotion to protocol-driven medical care led the charge nurse to the highly inappropriate decision to come uncaringly into my son’s room to insist the monitor be turned back on because she had to have 60 seconds of monitor-recorded asystole to pronounce time of death. Her rude, uncompassionate demeanor while arguing with me detracted greatly from my son’s dignity while dying, and showed an unimaginable disregard for our family in our time of grief. Were any doctor or nurse working in my unit ever to display such inhuman callousness, they would be fired on the spot.

I share this story not for the purpose of garnering sympathy, but rather to warn of the danger that such a horrible, uncaring manner of providing so-called care will become the norm if the effort to overcentralize control of medical practice is not stopped. I would not wish my experience on my worst enemy, but that is what the future holds if we do not succeed in halting the misguided effort to turn over control of medicine to large government bureaucratic systems.

8 Responses to “Bigger isn’t Inherently Better (Guest Post)”

  1. 1

    another vet

    Sorry for your loss. It seems as though everyone I associate with has, in the last year or two, lost a loved one or knows of someone who has.

    I recently had an experience that fits the theme of what you are talking about. My mom had a mild heart attack around a month ago. The attending cardiologist said her only option was open heart surgery. The surgeon gave her a 75/25 chance of making it. The pulmonologist wasn’t so optimistic. I asked the cardiologist if they could use less invasive means and do it in stages (thinking “out of the box” just like my old 1SG days). He said no and that she would even be at risk with the less invasive means, a position he changed. The surgeon came back and decided to send my mom to another hospital where they have a world renowned noninvasive cardiologist who decided to do everything in stages. He put in a stent that took her left main from 70% clogged to 100% open. A few days later he used a balloon to fully open her aortic valve. Both procedures lasted all of a half an hour apiece. She went home the next day. Hopefully he’ll be able to put in a TAVR within the next few weeks. She is not completely out of the woodwork yet, but is no doubt in a lot better position than had they followed protocol thinking as you called it. And to think that the first hospital she was in is a good hospital. One can only imagine how bad the VA hospitals really are given they are government controlled. One of my cousin’s wife is a nurse and warned us when this happened that with Obamacare the robotic way of doing things was going become more common.

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    @another vet:

    Vet, your story is unfortunately all too common. I am glad your mother is recovering, and wish your family the best of luck.

    The sad fact of the matter is that medical practice, despite wonderous technological and pharmaceutical advances, has suffered from a serious watering down of residency training. Book knowledge is of course vitally important in medicine, but the experience of being in the hospital observing the response of patients to treatment regimens is even more important in gaining the experience necessary to recognize when treatment plans must be altered or tailored to a specific individual. The old cliche is “Sometimes patients don’t read the textbook”, which is where the art of practicing medicine is so invaluable. If all patients responded exactly as the textbook indicates, then you wouldn’t need physicians. You could simply type into a computer the patient’s symptoms, labs, and xray results, and have a cookie cutter treatment plan spit out for nurses to implement. Patients are people – someone’s father, mother, sibling or child – and the preference from individuals like Ezekiel Emmanuel to impose centralized protocol treatment mandates regardless of specific patient requirements will result in unnecessary suffering and death.

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    Allow me to be very blunt. It’s not only big hospitals that are mired in their procedures. I’m also going to say that small hospitals can have assholes on the staff also. My mom had a major right hemisphere stroke, sadly we didn’t find her for 12 hours so there was no hope. She did know what was going on and could show some agitation but her vitals were sliding. The IDIOT Neurologist comes in and starts talking about starving mom, she’s getting agitated. Had the dip shit bytch just looked at the vitals she’d see that my mom would be gone in a matter of hours. I came within 2mm of beating the living shit out of her. Sorry for the language but I was and still am just a bit ticked and it’s been 13 years.

  4. 4

    another vet

    @Pete: I don’t think it’s confined to the field of medicine. It’s part of the overall collectivist mentality that is being fostered in this country. Unfortunately with medicine, the stakes are much higher and more immediate for the individual.

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    Upchuck, I am very sorry you had to go through that.

    Individual idiocy on the part of medical personnel can of course be found at all size hospitals, and as you described in your mother’s situation is reprehensible.

    I am very concerned that such desultory, uncaring, inhumane manner of treating patients will increase under the push for more centralized control of the practice of medicine.

  6. 6

    James Raider

    @Pete: #5

    . . . . misguided effort to turn over control of medicine to large government bureaucratic systems.

    Pete, as you point out, bureaucracies cannot “care.” People like Ezekiel Emmanuel are not only misguided, but five minutes listening to him and one realizes he suffers from insecurity and his delusions of grandeur are encased in an ego which might rival that of his former boss.

    BIG government is for those who cannot “do” for themselves and feel a need to be led and instructed on what to think, say and act. Bureaucrats managing and ruling over healthcare will deliver a nightmare which is only beginning. Once the bureaucracy gets a little older, 5 – 10 years down the road, it will make decisions over life and death, applying new thresholds we dare not voice today.


    Please accept my sincere sympathy on the passing of your child, and my best wishes in moving forward, retaining his Spirit close to yours where he will always be.

    If I may grab a passage from “My Self, My Soul” . . . .

    My Soul:
 “Children’s Souls do not die. Each Soul comes into this world with a purpose, and once its journey here concludes, it continues on its journey through a peaceful, loving transition.”

    My Self:
 “Yet from our perspective, it is still a very permanent passing of a Loved one and the pain endures.”

    My Soul:
 “A Loved one, yes, and a Soul to whom you can be grateful for having provided a gift through its brief voyage. It is a powerful gift, although it is understandable that you do not perceive it as such. It is a gift to the Loved ones. It is a gift to the selves of the Loved ones, and a gift to their Souls.

  7. 7

    Scott in Oklahoma

    Pete, I really don’t have much to add to this conversation, but I do want to express my condolences and prayers at the loss of your son.

    As to the huge expansion in medical bureaucracy, I can relate it to the industrial world, going from a Mom & Pop operation where thinking out of the box is the norm and the employees are more concerned with accomplishing the mission than they are “following established procedures”. I don’t fit into the big corporate deal.

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    James and Scott, thank you for your kind words. I got into medicine when my 2nd child was diagnosed with CF, and swore I would never treat patients (or their parents) the way I was treated when he was in the hospital. Nothing makes me angrier than when I see lazy and uncompassionate medical “care” for patients, and is definitely the source of my strident opposition to a government takeover of health care. Patients are people, not a collection of symptoms, and have the right to utmost dignity. The Hippocratic Oath demands physicians act as such. To behave otherwise makes it to easy to become enslaved to insufferable ego, resulting in disdainful arrogance and the denigration of the healing arts.

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