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I Aten’t Dead

I am torn between being disappointed at how poorly hospitals work and being amazed that they work at all.

There are two hundred different very specialized professions all trying to help the same set of people. As difficult as medicine is – and goodness knows it is difficult – maybe about half of the resources of hospitals and the people inside them are devoted to anything remotely medical, and the other half are devoted to the near-impossible enterprise of synchronizing these hundreds of different professions into providing something that looks vaguely like coordinated care.

Everyone’s time is so expensive that the system can’t afford to let them waste precious moments figuring out what they’re doing. So pretty much everyone looks at a computer system that tells them what they’re doing, does it, and then enters what they did into the computer system, along with what that implies for other people. The computer system then updates itself and tells other people to react to what the first group of people did.

This happens. A patient tells the nurse that he feels short of breath. The nurse places an order in the computer for a doctor to evaluate the patient. The doctor reads the computer system, evaluates the patient, and places an order for the nurse to draw blood to send to the lab. The nurse draws blood and places an order for the lab to test the blood. The lab tests the blood and places an order in the computer for a doctor to read the lab results. The doctor (who may be a totally different person from the first doctor in this story) reads the lab results, diagnoses pneumonia, and places an order for the pharmacy to send pneumonia medication. The pharmacist sends the pneumonia medication and places an order for the nurse to give it to the patient. The nurse (who, again, may be a totally different nurse) gives it to the patient, who tells the nurse he feels much better. The nurse places an order for a doctor to evaluate the patient. The doctor (who by this point may be a third doctor) says it looks like his pneumonia is gone and places an order for the case manager to discharge the patient. The case manager finds somewhere for the patient to go and places an order for big burly guys to wheel the patient to the door. The big burly guys wheel the patient to the door and place an order for an ambulance to come pick the patient up and bring him to the nursing home.

(because – and sorry for the interjection – it is always a nursing home. One of the first things I have learned is that, of the 1000 different places you can send patients when they improve, 999 are euphemisms for “nursing home”. If you are old, and a doctor tells you “Don’t worry, we’re not sending you to a nursing home, we’re sending you to a rehabiliation hospital/skilled care facility/group care institution/convalescent center/ANYTHING ELSE A DOCTOR SAYS TO AN ELDERLY PERSON”, be aware that these are just different ways of saying “nursing home”)

But getting back to the point – that’s ten orders just in this ludicrously simple example. At each of those steps, someone who has no idea who the patient is and might never have anything to do with him outside this single five minute interaction has total responsibility for patient care. At each of those steps, someone can use the computer wrong, place the order for the wrong patient, or accidentally forget the order and leave the patient sitting out in the corridor for twelve hours.

And every single one of those steps is a horrendously busy person who has received five orders at the same time, all of which are marked “HIGHEST PRIORITY” and who are operating on four hours sleep, and each of whom hates everyone at every other level because they keep giving them more work to do. And they are orbited by consultants, specialists, subspecialists, subsubspecialists, subsubsubspecialists, The Guy Who Knows Everything About The Protein Biochemistry Of One Tiny Part Of The Gall Bladder And Nothing About Anything Else, respiratory therapists, speech therapists, physical therapists, chaplains, Bessie The Adorable Pet Therapy Dog, social workers, People Whose Entire Job Is Sitting Next To Suicidal People And Making Sure They Don’t Kill Themselves, nurse assistants, nurse assistant assistants, nurse assistant assistant assistants, businessmen who overuse the phrase ‘patient-centered’, dieticians, pharmacists, and me.

My job as an intern is to navigate this bureaucracy. I’m with an attending – an experienced, prestigious doctor – who doesn’t want to waste any time. He just wants to go “Someone tell me what’s going on with the patient in room 824” and have someone answer “They have such and such a history and these lab results” so he can say “Yup, I use my massive medical expertise to diagnose that as Disease X, give them this and this and this intervention and then give them a repeat scan” and then move on to the next patient.

My job is to write down all the information he wants and get it for him, then write down all the stuff he wants done and do it for him. This generally involves entering orders into the computer, then begging people to do them, then calling them to see if they were done on time, then wailing and gnashing my teeth when they were not. It’s noticing that a patient who was supposed to have had a CT scan ten hours ago is sitting in the corridor looking lost and somewhat un-scanned and trying to figure out where something went wrong and how it can be corrected and if necessary threatening that I will have my attending yell at whoever is responsible.

Basically I am a secretary, but a secretary with enough medical knowledge that when my attending says “Order some piperacillin” I won’t spell it “pie bear on ceiling” or ask whether it is some kind of exotic fruit. Enough medical knowledge that if someone gets left out in front of a CT for ten hours, I know when to say “do the CT scan now because it’s the right thing to do” versus “do the CT scan now or she will probably die”.

Sometimes I get sent to take medical histories and examinations from people. They are never glad to see me. They usually say something like “I’m in constant pain and I can’t breathe and I just answered these exact same questions for the paramedics and the emergency room doctors, do I really have to do it again?” And I say “Yes” and then ask them How Long The Symptoms Have Lasted and Whether They Smoke Cigarettes because those are the rules.

If you are entering medical residency and want to prepare for it, practice reciting the following phrase: “I don’t know the answer to that question, but I will page my senior resident and he will get back to you.” I keep getting paged by nurses with questions like “Your patient in room 315 has critically low potassium, please advise.” And I went through medical school and I know stuff about low potassium and I have clever ideas for what to do and probably in over 80% of cases those ideas would not kill the patient. But “over 80%” is not enough so each time I have to find my senior, who is extremely busy and hates getting paged exactly as much as everyone else, and ask him a stupid question I already know the answer to. A lot of my job seems to be a totally useless middleman in between patients and nurses who have questions and senior doctors who have answers, but I’m learning a lot and one day I hope to bring my “ideas that will not kill the patient” ratio up to the 90% or so which is considered acceptable.

I have already helped, in a little tiny way, keep some people safe and healthy. It’s not always very dramatic. A few days ago I was looking at some numbers on a chart, and I was like “Hey, in medical school when I memorized this number, it was a much bigger number, and here on the chart it’s a very small number. That sounds like the sort of thing we should do something about.” The woman for whom that number represented the amount of blood cells in her body was probably happy I noticed. And today we had a Rapid Response, ie the kind of thing where everyone is running around waving defibrillator paddles and overusing the word “stat”, and I was yelled at to get some blood from the blood bank, and I successfully got some blood from the blood bank even though this required an entire phone call and two different operations on the computer.

And I have already made mistakes. I’m pretty sure I gave an elderly woman an unnecessary CT scan she had already had two or three days before, which probably cost a few hundred dollars. I came very close to ordering a medical procedure for the wrong person, although luckily it was caught beforehand. I made some mistake in ordering a guy’s coagulation status checked that made him stay in hospital an extra day until the check could be repeated.

And I’ve already had one patient die. He died today. It wasn’t my fault. He was brain-dead and hooked up to a ventilator, and the family chose my first week on the job to pull the plug. Palliative care patients are the easiest patients ever, and my job was limited to listening to his heart and lungs once a day or so and nodding sagely and telling the family that The End Was Getting Near. The last day I saw him, I leaned in to his chest to listen to his heart, and saw he was wearing a necklace that said “Whosoever Dies Wearing This Scapular Shall Not Suffer Eternal Fire – The Promise Of The Blessed Virgin”. Within about a second I had three major thoughts:

1. “And here I am, trying to cultivate virtue and avoid vice, LIKE A TOTAL CHUMP!

2. “Is this, like, a legendary artifact? Should I be trying to steal it?”

3. “Wait, if people believe this works, why do they wait until someone’s on their death bed to put it on them? What if someone gets hit by a car? Struck by a meteorite? What kind of person has a necklace that saves them from eternal damnation, but only wears it on special occasions?”

And then after about ten seconds, during which I was trying to remain very solemn-looking, as if I found the patient’s heart sounds extremely interesting in a detached medical way, I thought “Wasn’t there something I used to do when I found something fascinating and bizarre like this? Somewhere I would record things back when I wasn’t working sixteen hour days, six to seven days a week? Didn’t I have some kind of a blog? I should find that and write about stuff there.”

But don’t expect too much more out of me in the near future.

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43 Responses to I Aten’t Dead

  1. St. Rev says:

    Clearly, the economic planning problems involved in hospital management could be solved by implementing a prediction market in patient diagnoses.

  2. Very true to my lay experience of hospitals (derived from dating nurses and watching family members die, not necessarily at the same time).

    I’m hoping that the demographic crisis of the Boomers dying will force fixes, but that’s probably wildly over-optimistic.

  3. suntzuanime says:

    Yeah, when I was in the hospital recently (thankfully for nothing permanently damaging) I got the sense of being a pinball bouncing around in some inhuman and overcomplicated machine where instead of a bell ringing out when you hit a bumper instead you had to repeat your name and date of birth.

    I was pretty fed up by the end and gave the lady whose job it was to get me to sign a consent to be treated form a hard time. Now I feel bad. (If you are wondering why I was signing a consent to be treated form at the end of my treatment, well, so was I. Scott probably is not.)

  4. The saying goes: “Those those who talk do not know, who know do not talk”

    Thank you taking the time from your insane schedule to defy that aphorism. This kind of inside info is fascinating.

  5. Doug S. says:

    Bessie The Adorable Pet Therapy Dog

    I want pictures.

  6. Doug S. says:

    Reading that job description makes me think “Someone should make a video game out of this.”

    • Pthagnar says:

      they did, back in the 90s! Theme Hospital is all about managing the pinball table of hospital administration.

  7. Charles Beard says:

    My parents gave me that necklace when I was seven or eight and I wore it constantly (to the point of being legitimately scared if one broke in the shower) until my sophomore year in college.

    Obviously, I didn’t lose my faith, but I realized “wearing a magical talisman out of fear” didn’t jive with the “I’m supposed to love Jesus” stuff I think I believed in every other aspect of life.

  8. BlindMind says:

    I love this blog, most everything on here is fascinating, I may not always agree with it, but whatever I find, I can be assured that it will be well reasoned and supported. Thank you for taking the time out of your extremely busy day to share your experiences and thought’s with us.

  9. Two thoughts:

    1. Either there’s a type in the title of this blog post, or I’m missing a joke
    2. Can anyone report on whether hospitals in other countries are this insane? In Korea, I had a very pleasant experience with a Korean hospital from the patient’s side, but I don’t know what the hospital looked from the doctor’s side.

    • I’m betting that everyone is too busy and expensive to be allowed time to think about what they’re doing is a *very* intractable problem once it sets in.

    • Karl says:

      I’ve only been in the system as a patient in Canada, but based on my experiences it was better than this description. For a broken leg, one nurse and one doctor did almost everything, for two very severe asthma attacks it was one nurse each time, and in all cases there was essentially no waiting involved except for after treatment to see if it actually worked. If it was struck with something more complicated and less life threatening I’m sure I’d get a chance to see the crazy side of our own hospitals though.

    • Gareth Rees says:

      Either there’s a typo in the title of this blog post, or I’m missing a joke

      Yes, it should say “I ATE’NT DEAD” (note position of apostrophe).

    • Deiseach says:

      Re: title of blog post – Granny Weatherwax 🙂

    • Earnest Peer says:

      German hospitals don’t have a terribly good reputation, at least in Germany, but I don’t think they’re as horrendous as this.

    • Randy M says:

      Well for that matter I’d wonder what it is like in other states/areas of the US. There is the same insurance system & federal regulations, but state regulations, population density, local demographics, financial status of the hospital, etc. can probably vary from place to place within the US, although it sounds like other commenters here find this fits their experience.

    • MugaSofer says:

      The title is a Discworld reference – it’s the signature handmade sign used by witch (and book protagonist) Granny Weatherwax during jaunts out of her body, to avoid being mistaken for a corpse.

  10. Deiseach says:

    Glad to hear you are surviving in the Great World of Work.

    Interesting that the American hospital system sounds not dissimilar to the Irish one (e.g. sitting around waiting for a test for ten hours) only with a lot more computers involved; do you really diagnose pneumonia by blood test and not by listening for rales with a stethoscope? I feel like my hospital experience is the equivalent of being treated with leeches 🙂

    You never heard of the brown scapular before? IThere are also other colours of scapulars, but the brown one is the most common). You wear it all the time, of course! Your late patient wasn’t wearing a miraculous medal as well? I’m surprised, because they generally go together. Anyway, seeing as he sounds like a co-religionist of mine, thanks for the heads-up that I should pray for his soul.

  11. hamiltonianurst says:

    I like replacing the word “hospitals” in line 1 with “brains”.

  12. Randy M says:

    Thanks for the post, quite interesting especially since I haven’t been in a hospital since my first daughter was born 5 years ago now. I’ll pass it along to my SIL who is in nursing school.

  13. Malcolm says:

    It occurs to me that it might be valuable for you to explicitly note your own guesses (if you have time, ha) each time you’re asked a question but aren’t more than 80% sure, and then crosscheck them with the doctors’ answers, and see which areas you’re missing and study this stuff? I would say “maybe it just comes with experience” but I keep reading stats about needless deaths in hospitals due to physician error, and while some of them are surely due to the insanity of this system, others are likely due to mismatched answers etc.

  14. Anonymous for fear of employment says:

    I had a very similar feeling recently starting a job at a company that organises public policy events in [capital city]. We literally have people whose only job is to find details of people to invite, other people whose sole job is to make slightly different letters for various types of attendee, another whose job it is to double check those letters, another whose job is to send them out…. Plus people who manange the magic database that keeps this all working. (I’m one of the people whose job it is to find people to speak at events.) And thats just the permanent staff, we hire seperate companies for the venues, transort, food, etc.

    I always understood how division of labour worked in the cliched factory example, but it never really occurred to me that the same process would apply to ‘mental labour.’ But apparently it does, and it seems to be very effective.

    [Larger hypothesis: because it has become fashionable to parody corporeate culture (dilbert style) we underestimate how effective such methods of ensuring organisation are.]

  15. Peter says:

    “I am torn between being disappointed at how poorly hospitals work and being amazed that they work at all.”

    I work as a consultant, so I visit a lot of businesses. This is every place.

    • coffeespoons says:

      Not every place. I am working doing accounts stuff at 3 small technology companies. Mostly everything works very well and is very simple.

  16. komponisto says:

    More like this, where you charmingly tell us information about the world to which you have special access!

    (And fewer like the previous post, where I feel that you violate the advice of a great mathematician, G.H. Hardy — and waste a first-class man’s time expressing a majority opinion.)

    • michael vassar says:

      If no first rate men defend majority opinions, only minority opinions will receive first-rate defenses and the majority opinions will systematically appear more wrong than they are. Historically, I think that this probably contributed to communism.

      • komponisto says:

        Hardy’s quote ends with “by definition, there are already plenty of other people to do that”, which suggests that numbers can balance out eloquence. (This seems right to me: an opinion with both numbers and eloquence on its side will seem overwhelmingly compelling, and I don’t think majority opinions that people take the trouble to defend eloquently are typically deserving of such exalted confidence levels.)

        I suppose that my true rejection of the previous post may be that it was dark-artsy, using tone and charm to disguise a fairly banal majority position (“I don’t like math, and this trait is immutable”) as an incisive contrarian stance. (Naturally, this tactic is particularly irksome when one disagrees with the majority position in question, as I do here.) On a deep level which may be hard to explain concisely, it sort of pattern-matches to all kinds of situations where people motivatedly deploy eloquence in support of existing power structures that they themselves benefit from.

        • komponisto says:

          (The above should probably be understood mostly as an emotional communication, as opposed to a contribution to formal epistemology designed to be generalized. Just as Jeopardy requires answers to be phrased in the form of a question, the norms of this community as internalized in my mind require that opinions be expressed in the form of epistemological theories that imply them.)

        • Alex says:

          I would guess from Scott’s post that his stance is indeed contrarian within his social group (though not society in general).

          Why/how do you think he should acquire an interest in mathematics?

        • komponisto says:

          Why/how do you think [Scott] should acquire an interest in mathematics?

          I think he should avoid language which suggests that “people interested in mathematics” constitute a separate tribe from him and should regard his interests as lying on a continuum with theirs.

        • Bob Unwin says:

          Agree with Komponisto. Eloquence diverts from the substantive issue. How good at math would non-mathy smart people be if they were much more strongly required to do math to a reasonable level? How much would they enjoy it? The LW community encourages math interest, but not that strongly. (And the math in encourages is quite specific and narrow).

          Case studies: many people have to do math as part of political science, quantitative sociology, psychology (either in stats or in mathematical psychology), epidemiology, computer science, and any part of engineering. My experience is that people in these fields often haven’t much like math in high school. Then at college or grad school there’s some math that they have to learn and to use very frequently. I’ve been impressed at the competence that they achieve. (Not that these people become great mathematicians or have much creativity in math, but they gain competence in non-trivial mathematical ideas and are able to understand the mathematical ideas of more skilled practitioners in their fields).

          Some analogous situations: in the sciences and engineering today, everyone has to have basic coding skills. In many fields, people end up doing LOTS of coding (but maybe a very specific kind of coding). If some smart people just couldn’t enjoy/do coding, this would seem very problematic. But my sense is that people get good enough at coding when it’s utterly required of them.

          Then there are weird cases over a wider range of intellectual ability like haredi males who have to spend studying jewish religious texts. how good do these people get?

  17. Harvey says:

    Not that different from a starting engineering position in a major company, then. Instead of doctors, you have technical specialists that they promoted to management, so they know everything but spend all day in meetings so they never get to use their skills. And instead of patients, you have machines and tooling, each of which has been rebuilt a bit differently so they almost have personalities. And instead of you, they have me, who is running around between six different bosses trying to tackle six engineering problems at once, but doesn’t quite have the clout to really get anything moving on his own but still has all the responsibility of trying.

    If nothing else, I can say the day goes by very quickly.

  18. wallowinmaya says:

    >…back when I wasn’t working sixteen hour days, six to seven days a week?

    Is this statement really true or an exaggeration?

    • Scott Alexander says:

      Was true then. Now I’m down to more like twelve hour days most of the time unless I’m on call.

  19. Ted Seeber says:

    I came here to find out why Euthanasia supporters like your post on dying in hospitals, only to find a question that I as lay Catholic doing the New Evangelization by blogging, can actually answer.

    Scapulars are extremely popular. They’re usually just a couple of bits of felt and a ribbon. They aren’t just worn at the moment of death, normally. Normally they’re worn for YEARS. I even knew a guy who was so fanatical he wouldn’t even take it off for a shower. He was so fanatical that his was actually several of them of different colors sewn together.

    The colors vary, the promises vary, but they’re all what the Catholic Church calls “private revelation”; that is, a vision somebody had of the Blessed Virgin Mary in the last 1800 years or so; starting a good few centuries after her death.

    I’m sure what you witnessed was evidence of a family member whose faith runs more to visions and miracles than to reason and logic.

  20. N says:

    I’m really moved by your article. I’ve spent a lot of time cultivating mindfulness and meditation techniques to help cope with horror. I’d be honored to share some of that with you if you’re interested. In the meanwhile. hold strong – you are working with people who want to create a better world.

  21. Error says:

    I showed this to my partner. She works in a hospital (housekeeping, not medical) and asked me to pass on her sympathies that you must deal with the general omnipresent insanity.

    I’ve heard hospital train wreck stories from her, but the doctor’s perspective is new to me, so this is fascinating.