American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, February 8, 2013

Small hospitals, the bystander effect and a hospital that works well

I just finished another week of hospitalist shifts at a small hospital in Alaska. It was a good week. People worked well together, the patients were well served and seemed to feel good about their care, and, since I had been at this hospital for several weeks, I noticed some of the things that really worked.

The hospital is a member of the "Planetree Alliance," which works with member hospitals to make them more sensitive to how patients experience things, and also works to increase efficiency so energy and money can be directed in the right way. I read some things about this group. Apparently it was started by a woman after she had a terrible dehumanizing hospital experience and now started an organization to make hospitals less unpleasant.

In some places it works, and in others it does not. It sounds like that has to do with whether the nurses are genuinely overextended. Planetree hospitals look better, with fish tanks and waterfalls and nice lounges, and have services like massage and therapeutic touch. Staff members do retreats to help them learn about what patients experience and to absorb the new care model. Some nurses have expressed that they feel like scripted automatons and couldn't possibly be expected to take care of really sick people and also act like day spa hostesses. In my hospital they seemed to be doing fine, and, because it's Alaska, they probably chucked the script but kept the waterfalls and the general attitude.

What I noticed about this hospital is that the doctors work well together (generally) and the nurses take initiative to make sure patients get the care they need. I usually find at least one nurse when I work at a hospital who says something or does something that reveals a deep misunderstanding of human physiology and makes me really nervous to leave a patient in his or her care. The nurses were all good and they acted like members of a team that took care of patients rather than being disgruntled or subservient. This can only come from not having been yelled at by physicians for asking about treatment choices or lab results. The nurses were always busy, but did not seem terribly harried, which bespeaks adequate staffing ratios.

Every morning Monday through Friday I would sit down, as hospitalist, with the social workers, physical therapists, nutritionists and nurse discharge planners and discuss all of my patients and what we needed to achieve success. Because it was a small hospital in a small town, usually somebody at the table knew more about the patient than I did in ways that would explain how the patient came to be so sick and what hurdles they had to jump over in order to get home. They might tell me that the husband had been abusive or that the caregiver was actually a schizophrenic daughter or that the patient had huge financial resources, which opened up many new options. They might know that less than civil behavior was the norm for this patient. They might have stories of how the patient almost died a few years ago and that it is amazing that they are independent and working now.

Since there were lots of Alaskan Native patients, people who had lived there for years would explain to me how their families and culture affected things. Since it was a small hospital we could talk about all of my patients every day and someone would volunteer to take care of details like obtaining expensive medications or contacting caregivers so that I could take care of medical problems and not get overwhelmed (very often).

Nurses also had these Vocera walkie-talkie things so I didn't have to go wandering all over the ward to talk to them, which made me much more likely to be able to come up with a plan that both of us understood.

The fact that this hospital was small was very important in making it good. Small hospitals get a bad rap when it comes to taking care of certain life threatening emergencies. If you have an acute heart attack and need to get an artery opened up pronto to save your life, you want to be right next door to a major metropolitan hospital. Our emergency department flies such patients to the nearest major hospital, which can be achieved in less than an hour, weather permitting. The patients who stay, though, get care from a set of doctors who usually know each other well, are used to working together and are right there when you need them.

Since there are a limited number of specialists available, patients don't usually have a large and unwieldy entourage of physicians confusing the nurses and pharmacists with conflicting orders. It would be nice to have all of those endocrinologists, oncologists, rheumatologists, cardiologists and vascular surgeons (to name a few) available, but for that loss, something is gained in consistency and familiarity. The coordinating hospitalist has to actually think rather than call a specialist for each offending organ, which is good.

I read an article in the New England Journal of Medicine about the "bystander effect" in medical care in a large university medical center.

The bystander effect was coined after a much publicized rape/murder in New York City during which none of a number of people intervened to save a young woman. Psychological studies have investigated what variables make us unable to do the right thing when faced with an event that clearly needs action. Social norms that work in other situations sometimes make us stupid. We assume, in a large group, that someone else is more qualified to act than we are. We pay less attention in places where we are overstimulated.

It's inexcusable, but occasionally toddlers run into traffic unheeded and the injured or ill lie in public, unattended. The author of the article was a specialist helping care for a person in the intensive care unit of a major hospital and noticed that the patient was getting sicker and sicker with nobody out of scores of doctors taking responsibility for making important decisions until the patient nearly died.

He noted that bystander effect researchers have found that when the bystanders are friends, they are more likely to take action. He suggested that fostering friendship among doctors in a setting like that would be good for patient care. I agree, and would add that there might be other good reasons to be friends as well. In my little Alaska hospital I noticed the opposite of a bystander effect. Everyone seemed to have an opinion and told me about it. All of the patients seemed to be being stealthily watched by multiple caregivers all the time. It was very nice.

Another thing I noticed about this hospital was that the doctors were really good. A couple of the internists were the former chief residents of their well-respected training programs. A young anesthesiologist had trained at Harvard and the Mayo Clinic. People were still psyched to take care of patients. I'm not sure how this happened, but I think that a couple of decades ago some good doctors fell in love with the area and decided that they would make it medically excellent. They called their friends and their friends moved there and they trained medical students and medical residents and kept up their enthusiasm for teaching and learning. I think that's what happened. There might be some other factors involved. I'm not entirely sure of the ingredients or how the recipe was put together but the final product is excellent.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health care so expensive?, where this post originally appeared.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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