Apparently I’m not the only one looking at how we can do things differently in healthcare. On the surface, the efforts at Henry Ford West are very inspiring. However, in this article at least, I find the dots are poorly connected between the obvious costs associated with this approach to healthcare and their simplistic explanation as to why this will work. Cobblestone streets and cooking demonstration may nominally improve the health of the surrounding community but the decision to build this medical Shangrila were motivated by other factors. Bloomfield Hills offers a notably more profitable payer mix than inner city Detroit where the original Henry Ford Hospital is located. I can hardly blame them for expanding into this more lucrative market. In fact, you could argue that the only way to save the mothership was to build this satellite hospital. The resulting cost shifting and expansion into new payer classes should not be ignored simply because the lobby looks nice and the food tastes good.
Here’s an interesting article on Patient Hotels in Sweden.
My wife and I recently went to an exclusively new restaurant in town called L’Hopital. I’d heard that L’Hopital was on the cutting edge but no one would explain why. “You’ll just have to try it yourself, we don’t want to ruin the experience,” replied my friends when I asked what was so unique about their meal. They seemed to stifle a laugh as they said it and when I invited them to join me, they politely declined. “It’s the kind of place where you really only go once. You’ll see.”
My wife and I arrived in the lobby of the restaurant. There were no reservations. Others come in after us and were seated before us. I thought about asking why this was happening but didn’t want to be rude and potentially get on the maitre d’s bad side. Who knows how long we’d have to wait then? Just as we were about to leave our name was called and we were escorted to a table.
We were ushered into a very modern dining room with sleek lines. The waiter was very polite and told us the chef would be out shortly. The chef? Really? This must be a very special place, indeed. As we worked our way through the bread basket, we saw the chef approach. He asked us about our food preferences as well as any allergies and left unexpectedly when another waiter pulled at his arm.
The waiter returned shortly and apologized that the chef was pulled away but assured us that the chef was working on a meal that reflected our preferences. I asked for more bread and we settled in – a good meal of this caliber was certainly worth the wait. Thirty minutes later, I was beginning to get impatient when the chef reappeared. He had more questions for us. Would we prefer a salad or soup? Do we prefer steak or seafood as a main entree? Asparagus or Spinach? When the chef had completed the second round of questions, he again disappeared into the kitchen. Another thirty minutes went by and we summoned the waiter. Where was the food?
“Oh, your salad was finished almost twenty minutes ago, the main entree just came out of the oven and dessert should be served in ten minutes,” said the waiter.
I pointed with incredulity at our empty table as the waiter described this culinary parade. “Where is this food that you speak of?”
The waiter looked quizzically at me and then knowingly smiled as he realized we had never been there before. “Sir, at L’Hopital we will be very attentive to your needs but you will never see the food. It remains in the kitchen for the duration of the meal. When the entire meal has been plated, pictures will be taken of each entree for you to review. Are you ready to see the pictures? They may be ready for viewing?”
We nodded reluctantly as we tried to understand this bizarre restaurant. Perhaps the pictures would provide some solace, some closure, a souvenir of sorts. The chef reappeared with a silver platter covered by an elaborately decorated silver dome. With great flourish, he removed the dome to reveal a stack of pictures resting on an otherwise empty plate. Sure enough, each course had been photographed and a small description in tiny font was barely visible at the bottom of each picture. The food certainly looked beautiful and my wife asked the chef to describe how he cooked the steak and what seasonings he used.
“Oh, lets just say it’s meat that comes from a cow. Then I marinated it in a sauce that you couldn’t make at home, then I put it on the fire. When it got hot enough, I took it off the fire. That’s basically all I can tell you. The rest is too complicated for you to really understand,” the chef said apologetically. Still hungry, I started to slide the pictures into my pocket and we got up to leave.
“Oh, sir, please understand that you cannot remove those pictures from the restaurant,” the chef politely said in a gentle but chiding tone.
“Why not? Wasn’t this our meal?” my wife asked incredulously.
“Technically, yes, and you can request the photos in writing and we will send you copies within two weeks but they cannot be taken home tonight,” explained the chef.
All common sense seemed to be lost at this point and we started to stand up again when the waiter appeared with several papers. “Please sign here and here, sir,” he said politely.
“What’s this?” I asked.
“Your bill, sir.” I looked down at a cryptic receipt with undecipherable scribbles adjacent to shockingly high prices. The total at the bottom was more than we had spent on groceries in the past two months.
“I don’t have this kind of money, we can’t pay this tonight!” I exclaimed.
“Oh sir,” the waiter said laughingly, “we rarely have people pay us in full. You can pay us in installments. Just sign here and we will happily send you the papers in the mail. Please have a pleasant night and be sure to tell others to come visit us at L’Hopital.”
I’m often disappointed by the discharge instructions that I print out to send home with patients. They are canned summaries of particular diagnoses which often do not begin to describe the specific illnesses of the patient. Furthermore, they are often burdensome in length and detail. I think many patients look at the pages of information that vaguely apply to their situation and either throw them out or stuff them in a file, never to be read again.
So what’s wrong with the way that we do discharge instructions in the ED? Here are a few thoughts.
We give the discharge instructions as we are rushing the patient out the door. It’s ironic that patients complain the most about long waits with little explanation about what’s happening and we shrug our shoulders – that’s just how it is, right? Then at the very end of the visit we suddenly release a deluge of paperwork that explains their condition then lists all of the vague reasons for return.
I myself am guilty of putting painfully general instructions for return. “If you have a return of abdominal pain, vomiting or high fever or if you have any other concerns, return immediately to the ED.” ANY OTHE R CONCERNS? Do I really mean that? If they are concerned that they are not able to finish their sandwich at lunch because of fullness in their stomach, do I really want the to return immediately? What if they start sneezing or coughing? What if they sprain their ankle in the parking lot?
How many times have I given those instructions to patients who are still having abdominal pain when they leave? What are they thinking as they read this on the way out the door? Should they just go right up to the front and check back in? Would I welcome them back to be seen again if they followed the directions that I just gave them?
I might not say it but I’d be thinking “Use some common sense. I didn’t really mean to return for any concern. I know you still have abdominal pain, but is it actually any different? Your coughing has nothing to do with your abdominal pain. Your ankle pain may be a concern but does not require a return visit to the ED.”
So if I know these instructions are ridiculous and the patient does as well than why do I still write it out? Who am I speaking to? The simple answer is the unseen lawyer and jury that always are lurking in the corners of a doctor’s mind. Do these vague statements actually provide legal protection if a patient goes home and develops an appendicitis that ruptures? Probably not.
I guess I’m also writing to the occasional patient who:
a. Reads the instructions
b. Follows them
c. Does not have the common sense to return of their own volition without explicit instruction to do so
Every time I write this, I feel foolish but it provides some small semblance of reassurance that I have covered for unexpected events. It is probably false comfort and it almost certainly is not the best way to approach the patients. Ultimately, it erodes my relationship with the patient because at the moment of departure I hand them information that may not apply to them specifically, often gives detailed information that obstructs the most important points, and is shrouded in this vague cloak of legal protection that encourages patients to ignore common sense.
We need to do this better.
For most people, this painting depicts the heart of medicine. Many doctors and patients today may wistfully yearn for this interaction between the doctor and his young patient. But why is that so? What is conveyed in these dark brushstrokes that has spoken to so many for over 100 years? Even as technology and research have dramatically enhanced our ability to heal, many would say that the doctor patient relationship has been severely compromised. As a practicing Emergency Medicine Physician, I want to start a dialogue with my colleagues as well as with patients regarding the practice of medicine. More specifically, I will express some of my frustrations as well as explore potential solutions as we examine the state of medicine together.