Why I hate hospitals
for my patients (continuation of fellows series)
As long as I have been a doctor, I have realized that hospitals are bad for patients. In addition to the known iatrogenic complications such as infections and clots, the thing that bothers most is the debility.
When I was a fellow, my first month of service was with Dr. Hait (our Institute’s inaugural leader, a brilliant scientist).
During our rounds, he told me something that seemed so simple and yet so profound. “The longer the patient stays [in the hospital], the longer [the patient] stays [in the hospital].” It took a while to understand it. But the way I see it now is, the longer the patient stays in the hospital (bed), the more they lose their function, and the more complications that follow, leading to even longer hospitalizations.
The longer the patient stays here, the longer they will stay here
William N. Hait, MD, PhD, and my first attending on service
This has led me on a quest to prevent hospitalizations, and when they do happen, to minimize the duration of hospitalization. It has become trickier, though. We have made some progress, and some challenges remain.
In the past two decades since that conversation, we have prevented many routine hospitalizations. For example, with robotic surgery, prostate cancer patients are discharged after radical prostatectomy the same day or the next day. With pre-op optimization processes, the duration of hospitalization is less than 7 days for many major surgeries.
For medical patients, we can have patients seen and evaluated in the outpatient setting the same day, and prevent hospitalization.
This implies that those patients who are admitted are likely to be sicker (or have other health and social considerations that make caring for them as an outpatient difficult).
In that context, this advice becomes more important.
Being in bed leads to loss of muscle mass, and each day a patient stays in bed, it makes it harder to get out of bed the next day. This is what I believe and tell my trainees:
“If I take a 20 year old (often pointing my student) and put them in this bed for a week, they will go back to their pre-hospitalization function within a week or two; If I take someone in their 40s-50s (pointing at myself), it will take 3-4 weeks with a lot of effort. Someone in their 70s and 80s, it would take them 2-3 months, if there are no complications.
There is a psychological effect of being horizontal vs vertical.
This was something my psychiatry attending taught me during the 3rd year of medical school. He asked a simple question, “What do you think the patients do the other 23 and 1/2 hours you are not in the room?”
It’s an important question to consider as those who are horizontal are looking at the TV or their ceiling or reflecting on their situation, worrying about the future.
Every time I have said the second part out loud, I have gotten a reaction from patients and families. I think it is because it resonates. They feel the distress of being in the hospital, in the hospital bed. Patients do have a lot of time just being in bed. As human beings, the scary things are always on our minds, and it takes a lot of effort to keep those fears down.
Most times when I say the second part out loud, I open the door for the patient and family to tell me about their worries and fears.
Every time I say the first thing out loud, it is in the context of trying to have the patient be more active. Jokingly, I add, “If I had it my way, I would remove the bed at 10 am and not return it until 8 pm” as a way to encourage movement.
These two statements bring both body and mind together (physical and emotional health).
I hope that as you go on your journey as attending physicians, you will develop your own way to encourage your patients’ physical and emotional health.
Please develop a plan for the prevention of hospitalization in your new position. When you do have to hospitalize patients, try to minimize their hospitalization to the absolute minimum by thinking of all the possible reasons the discharge would be difficult on the first day, and start working on it.
Biren Saraiya MD