Not long ago, a friend of mine went through the experience of four days in Lenox Hill hospital for elective surgery. Since Lenox Hill, with its Upper East Side address and its upper-crust clientele, is considered one of the sniftier medical hostelries around, I was interested in what her stay was like.
“I had not been in a hospital for a surgical procedure since 1976 with the exception of giving birth to children,” she said. “I was amazed at the difference in tone and quality of care and attitudes. The nursing staff seems to be not as engaged in nursing care as in endless paperwork. A lot of the nursing care that in my experience had been administered by nurses is now done by aides … ” She uses words like “impersonal,” “mechanical” and “sullen” to describe how she was treated.
My friend continued, “Whatever the old definition of a hospital was, it was where a person went when he or she was ill and where the sick person was the point and center of the nursing care, but it is no longer true. The nurses have been transformed into clerks and their opportunity to practice their trade has been severely limited. They roll their eyes when you ask them how much they hate filling out forms in triplicate. They will occasionally tell you that they are not practicing nursing care in the way that they were trained to.”
That’s the patient’s-eye view. Nurses will agree. I interviewed one not long ago who said that she had not given a back rub and massage to a patient in years. Such ministrations are not in the scope of her assigned duties, she said, explaining that she hardly touches a patient these days. Does it matter?
Besides making a sick person feel better, the nurse explained, in the old days nurses picked up clues and small signs and symptoms by giving back rubs, by touching and having the time to talk to the patient. Hands-on nursing is apparently a thing of the past. My patient friend remarked of the quality of care she got at Lenox Hill, “I think you get less bathing, less bedpan assistance. I mean the bedpan will appear, but if you can’t quite pull the whole thing off, they really won’t help you and you end up feeling a little uncared for” by the non-nursing staff. What a charming experience to come out of the operating room and have no one to help you get the bedpan under your rear. My patient friend said the nurses didn’t leave their patients to fend for themselves. “This was not true, interestingly, of the nurses if they happen to be the one who delivers the bedpan.” It was the nonprofessional staff that left patients to fend for themselves.
As nurses no longer draw blood, give injections, measure medications or carry out the doctor’s treatment regimen, concern grows that untrained and-or uncaring staff may injure, maim, endanger, kill or inflict uncalled-for pain on those whose health and welfare has been made their responsibility. The Lenox Hill patient remembers, “I was struck by the level of frustration that the physicians have about the care that their patients are getting. Just the sighs that they would make … those kind of half-apologies. There was a lot of feeling that they have to double-check even simple orders.”
Again, this is hardly a problem unique to Lenox Hill. The significance of Lenox Hill is that if such a superior institution, where the richest and most influential go, has the problem, what must things be like elsewhere? In all likelihood, the care provided at Lenox Hill is markedly better than that which you may expect at other hospitals. Throughout the city and nation, stories are legend of relatives and friends of gravely ill persons coming into hospital or nursing home rooms to see sights like the lunch tray sitting on a table just out of reach of the patient; incapacitated patients unable to feed themselves left without sustenance; patients allowed to dehydrate because no one of the staff had time to sit by the side of the bed and help them sip; patients left in soiled beds; patients left unturned in their beds.
Perhaps none of this matters if the standard measure of medical care is mortality rates and cost. If pain, worry, fear, misery and suffering are of scant importance as long as the person leaves the institution alive, then perhaps my friend’s Lenox Hill experience should be shrugged off. Nevertheless, if you think you may some day be a patient at Lenox Hill or wherever, then what my friend says is worth mulling over: “I get the feeling that the care I got is another version of the loss of pride of work, that the control and tone of what it means to be a caregiver in a hospital has been usurped by the managed-care
people, by administrative financial issues.
“There was so little time that a nurse could have to be with a patient in a room, an elderly patient or, particularly, an in-pain patient. There is no leeway. There is no slack. There is so much paperwork that they have to do.”
Nurses have been converted into middle-management paper shufflers, instead of caregivers. One visiting nurse told me of the paperwork involved when she opens up a new case, typically a seriously ill patient just pushed out of the hospital. (In this era, heart-bypass patients go home in three or four days.) This nurse said that before she so much as touches a bandage she must complete two hours of paperwork with a patient who may be exhausted, who may be in pain, who may not be quite compos mentis. The paperwork includes asking the poor devil to sign no fewer than 12 forms.
What is to be done? One approach, which is characteristic of our era, is to go further in the process of automating patients. Who can say-it may be possible in the near future to build hospital rooms like those self-cleaning Parisian toilet kiosks. We seem to have come fairly close to that with the incubators for neonatology cases and the newest intensive care units. The downside of these I.C.U.’s is that they disorient the patients and induce a specific kind of psychosis, but maybe that’s not too high a price to pay to keep gravely ill people out of the hands of the hospital staff.
The truth on the ground is that one must be very careful about complaining of the treatment or lack thereof accorded a hospital patient. Increasingly, the hospital patient is a hostage. If the family complains or demands better care, once they walk through the automatic sliding doors to their cars, retribution in the form of neglect or harsh handling may be and often is visited on the patient.
Another approach is lawsuits, bills of patient rights, ombudsmen and the other transparent tricks used by lawyers and politicians to make us believe that they are making things better when they are actually making themselves richer. The last thing American medicine needs is another violent shaking up, another set of ill-considered reforms, more paperwork and politics.
In the long run, needless to say, the free market, competition, business, stocks and bonds as the model for medicine has to be abandoned or drastically modified. Instead of injecting more profit motive into medicine, it has to be drained out of it.
Obviously, hospital staff, the bedpan people, to use the title we honor them by, have to be paid more, a lot more. You pay minimum wage, you get minimum service, but there is also the question of dignity, of race and intergroup relations. To the extent that our hospitals are places where black people empty white people’s bedpans and brown people mop up white people’s vomit, things are not going to go well. You can’t buy tender loving care, except by a tender, loving regard for others, something in notably short supply in a society that holds sharp elbows and quick knees in such high regard.
The rich, as we know, live longer than the rest of us, but it should have dawned on them that sooner or later they, too, sicken and have to go to a hospital. They are banking on having their own round-the-clock, private nursing care to make up for the institutional deficiencies. Except it doesn’t infallibly work that way, if you reflect on the hospital deaths of rich people like Andy Warhol. Private nurses seething with tepid indifference and a tenuous dedication to a profession whose ideals they have never internalized don’t give the billionaires the edge they’ve come to think their money ought to buy them.
On second thought, those automated Parisian toilets may be the way to go, and if a patient perishes of neglect inside one, well, flush.