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Let's be careful about nostalgia for the "good old days" of medical practice. Keep in mind that standardizing medical care process has done more to get physici

Let's be careful about nostalgia for the "good old days" of medical practice. Keep in mind that standardizing medical care process has done more to get physicians to WASH THEIR HANDS than all kinds of exhortations about relationships, partnerships, and healing. And washing hands has, since Semmelweis's discoveries 150 years ago, been known as the easiest way to promote healing that medical people don't do. Why do the overnight shift of nurses take vital signs every four hours? So they catch rapid unexpected changes in patient conditions more quickly. Put more crudely, so they don't accidentally leave a corpse in a bed for the next shift. Having to write, or type, the patient's blood pressure into a log is a way to help the overnight nursing shift remember to pay detailed attention to each patient, at least for a few moments. If their instructions were "stop at each door and listen for the patient breathing" those nurses might well miss important changes. Hospital care these days is not only about the towering figure of the heroic superhuman doctor, Harvard Medical School lore to the contrary notwithstanding. It's about all the folks who look after patients, from the community primary care doctor to the RN, to the chaplain, to the "hospitalist" physician, to the person who cleans up, to the person who maintains all the electronic gear. The challenge is getting all these people to cooperate with the patient and for the patient's benefit. The superhuman healer approach to medicine demands superhuman people to be doctors. They aren't, any more than the rest of us are. They have to sleep, and to eat, and to see many patients. So, a good hospital needs to be organized like a good company: where each person's skills and passion complement the others, and gets an extraordinary result from a collection of ordinary people. The buzzword for that is "synergy." Good discipline--good and predictable process--is part of synergy. And, at the end of all that excellent care on our behalf, each and every one of us will become a corpse. A nineteen-year-old with a broken leg can be cured. A 90-year-old with cancer and pneumonia, not so much. It doesn't matter how towering a figure the doctor is, or how kind the nurse is. A radical move in medicine would be to come to terms with death as a natural part of life rather than as a failure of the system.

candiodari 9y ago
This. Every healthcare system in the world needs to choose. We simply cannot have healthcare for everything, including rare, expensive and/or hopeless diseases (or all 3 at the same time). As long as that's what we demand, healthcare will go wrong. And let's please just stop pretending that this is somehow an America-only problem, caused by whatever (democrats: by not being public conservatives: by public largesse. And yes, despite how it sounds I do think both arguments have merit). True, America has it bad, but healthcare is failing, financially or otherwise everywhere in the developed world [1]. And healthcare in the non-developed world ... well, this was in the newspaper 2 days ago [2]. Healthcare is failing in the developed world for economic reasons. Those are not about to change, so it will get worse unless we figure this thing out with major changes (which ARE going to include limiting treatment). [1] https://www.politico.eu/article/europe-health-care-systems-on-life-support-special-report-drug-pricing-medicines-public-services/ https://www.politico.eu/article/europe-health-care-systems-o... or more specific https://www.theguardian.com/society/2016/aug/16/nhs-cancels-thousands-of-operations-on-the-day-patients-association-study https://www.theguardian.com/society/2016/aug/16/nhs-cancels-... https://www.bloomberg.com/news/articles/2013-01-03/frances-health-care-system-is-going-broke https://www.bloomberg.com/news/articles/2013-01-03/frances-h... and let's just not mention Spain or Greece's health care system. [2] http://deredactie.be/cm/vrtnieuws.francais/Soci%25C3%25A9t%25C3%25A9/1.3151965 http://deredactie.be/cm/vrtnieuws.francais/Soci%25C3%25A9t%2...
- deleted 9y ago
  [deleted]
- gaadd33 9y ago
  Why does [2] have anything to do with this conversation? Maybe google translate missed how it was related to the doctor missing something or the healthcare system not paying for treatment? Can you explain more?
  - candiodari 9y ago
    Well, there was a hospital in India, that when a patient came in feeling unwell in his abdomen and then ... a) somehow this patient developed a ruptured liver and severe trauma to the skull (given that he survived the flight and was conscious we can easily conclude that neither injury was present before the hospital got involved) b) missed that someone at the hospital has removed the heart and kidneys from the patient c) signed off on a "natural causes" death certificate, no mention of what happened to the organs (note that organs for transplant need to be taken out before death occurs, so it's not like they removed them with the family's permission after clinical death) d) refuses to investigate how this happened e) got the government to concur, and actually the government is helping them with d) That's something that got reported last week, and this was a hospital in India, so third world healthcare.
aaavl2821 9y ago
That may be true, but one aspect of the "good old days" (at least in the common cultural imagining of the "good old days") is that you could get more attention from doctors outside of a hospital setting, even at home, and that doctors had more time overall to spend with each patient All the procedures you describe seem like very important improvements in quality of hospital care, but there is (or should be) more to the healthcare conversation than what happens in the hospital
- nitwit005 9y ago
  You can still get a doctor to show up at your house. It just costs a lot, so people don't.
  - jeffwilcox 9y ago
    Sigh, so true. My first job out of college here in Seattle was by a major company that provided 100% coverage for all healthcare, $0 copay; at the time, that included doctors straight to your home, anytime. It was only after we were pushed to HSA plans that I started learning about billing, and that apparently it's basically unheard of to have physicians come to the home. Still feel whiplashed by the change...
pishpash 9y ago
> ... gets an extraordinary result from a collection of ordinary people Of course doctors are ordinary people. The ones that become doctors these days aren't even the brightest in school -- those go into STEM or, god forbid, finance. But if they are ordinary people why are they paid like the superhuman healers that they aren't and still hold themselves as such?
- chimeracoder 9y ago
  > But if they are ordinary people why are they paid like the superhuman healers that they aren't and still hold themselves as such? They're not. The lifetime after-tax expected earnings of a person entering medical school today, after work and operating expenses are taken into account, is probably a lot less than the equivalent figure for the average Hacker News reader. Doctors make nowhere near as much money as people think they do, and that incorrect perception is based on stereotypes that haven't been true for decades.
  - pishpash 9y ago
    I speak of labor cost, so don't include student debt, delayed employment due to training, and taxes as they are kind of irrelevant. Malpractice insurance counts, not sure what other "work and operating expenses" are unique to doctors.
- OliverJones 9y ago
  Many doctors I know opt to work for a practice association and draw a salary, typically in the very low six figures. Why? Their association handles all the huge pain in the neck CYA stuff like electronic medical records, triage, insurance and Medicare billing, malpractice risk management, scheduling. From the practioners' point of view, especially for those who care for people over 65, socialized medicine has already arrived in the US. The rules around care and reimbursement are rigid. You'll get an occasional congresscritter who used to be an obstetrician or dentist claiming it isn't so. But those specialties don't have to try to get paid by Medicare.
paulcole 9y ago
>Why do the overnight shift of nurses take vital signs every four hours? So they catch rapid unexpected changes in patient conditions more quickly. The first sentence of the second paragraph of the article you seemed to have avoided reading says: “Checking things like temperature, blood pressure and respiratory rate every four hours on hospitalized patients has been the standard of care since the 1890s, yet scant data indicates that it helps.”
- mikecsh 9y ago
  > yet scant data indicates that it helps But this is not the case. In the UK, these observations are entered into a proforma by the nursing staff which allows them to calculate a "National Early Warning Score". Based on the patients score, the nurse has to escalate to an appropriate team and the doctor on the appropriate team has to take the referral. Not only does this help identify deteriorating patients, but it helps to fight human factors like "I don't want to call such and such a doctor because they are always rude on the phone so I'll just leave it and hope it gets better" In terms of actual data, we have a national body (NICE) that provides guidelines and recommendations based on appraising the available data and research. For NEWS scores, see: For an overview: https://www.nice.org.uk/guidance/cg50/chapter/1-Guidance#physiological-observations-in-acute-hospital-settings https://www.nice.org.uk/guidance/cg50/chapter/1-Guidance#phy... For the full report and evidence used to compile the guideline: https://www.nice.org.uk/guidance/cg50/evidence/full-guideline-pdf-195219037 https://www.nice.org.uk/guidance/cg50/evidence/full-guidelin...
- OliverJones 9y ago
  If a patient is stable enough that the taking of regular vital signs is nothing but a nuisance, maybe it's time for the patient to leave the acute care hospital and go home or to a rehabilitation facility. Nobody wants patients who don't need acute care services in acute care hospitals. Maybe DNR / palliative-care patients should get a break on the four-hour vital sign gathering. But people start yelling "death panels" when this sort of thing comes up in hospital policy.

candiodari 9y ago

This. Every healthcare system in the world needs to choose. We simply cannot have healthcare for everything, including rare, expensive and/or hopeless diseases (or all 3 at the same time). As long as that's what we demand, healthcare will go wrong. And let's please just stop pretending that this is somehow an America-only problem, caused by whatever (democrats: by not being public conservatives: by public largesse. And yes, despite how it sounds I do think both arguments have merit). True, America has it bad, but healthcare is failing, financially or otherwise everywhere in the developed world [1]. And healthcare in the non-developed world ... well, this was in the newspaper 2 days ago [2]. Healthcare is failing in the developed world for economic reasons. Those are not about to change, so it will get worse unless we figure this thing out with major changes (which ARE going to include limiting treatment). [1] https://www.politico.eu/article/europe-health-care-systems-on-life-support-special-report-drug-pricing-medicines-public-services/ https://www.politico.eu/article/europe-health-care-systems-o... or more specific https://www.theguardian.com/society/2016/aug/16/nhs-cancels-thousands-of-operations-on-the-day-patients-association-study https://www.theguardian.com/society/2016/aug/16/nhs-cancels-... https://www.bloomberg.com/news/articles/2013-01-03/frances-health-care-system-is-going-broke https://www.bloomberg.com/news/articles/2013-01-03/frances-h... and let's just not mention Spain or Greece's health care system. [2] http://deredactie.be/cm/vrtnieuws.francais/Soci%25C3%25A9t%25C3%25A9/1.3151965 http://deredactie.be/cm/vrtnieuws.francais/Soci%25C3%25A9t%2...

deleted 9y ago
[deleted]
gaadd33 9y ago
Why does [2] have anything to do with this conversation? Maybe google translate missed how it was related to the doctor missing something or the healthcare system not paying for treatment? Can you explain more?
- candiodari 9y ago
  Well, there was a hospital in India, that when a patient came in feeling unwell in his abdomen and then ... a) somehow this patient developed a ruptured liver and severe trauma to the skull (given that he survived the flight and was conscious we can easily conclude that neither injury was present before the hospital got involved) b) missed that someone at the hospital has removed the heart and kidneys from the patient c) signed off on a "natural causes" death certificate, no mention of what happened to the organs (note that organs for transplant need to be taken out before death occurs, so it's not like they removed them with the family's permission after clinical death) d) refuses to investigate how this happened e) got the government to concur, and actually the government is helping them with d) That's something that got reported last week, and this was a hospital in India, so third world healthcare.

aaavl2821 9y ago

That may be true, but one aspect of the "good old days" (at least in the common cultural imagining of the "good old days") is that you could get more attention from doctors outside of a hospital setting, even at home, and that doctors had more time overall to spend with each patient All the procedures you describe seem like very important improvements in quality of hospital care, but there is (or should be) more to the healthcare conversation than what happens in the hospital

nitwit005 9y ago
You can still get a doctor to show up at your house. It just costs a lot, so people don't.
- jeffwilcox 9y ago
  Sigh, so true. My first job out of college here in Seattle was by a major company that provided 100% coverage for all healthcare, $0 copay; at the time, that included doctors straight to your home, anytime. It was only after we were pushed to HSA plans that I started learning about billing, and that apparently it's basically unheard of to have physicians come to the home. Still feel whiplashed by the change...

pishpash 9y ago

> ... gets an extraordinary result from a collection of ordinary people Of course doctors are ordinary people. The ones that become doctors these days aren't even the brightest in school -- those go into STEM or, god forbid, finance. But if they are ordinary people why are they paid like the superhuman healers that they aren't and still hold themselves as such?

chimeracoder 9y ago
> But if they are ordinary people why are they paid like the superhuman healers that they aren't and still hold themselves as such? They're not. The lifetime after-tax expected earnings of a person entering medical school today, after work and operating expenses are taken into account, is probably a lot less than the equivalent figure for the average Hacker News reader. Doctors make nowhere near as much money as people think they do, and that incorrect perception is based on stereotypes that haven't been true for decades.
- pishpash 9y ago
  I speak of labor cost, so don't include student debt, delayed employment due to training, and taxes as they are kind of irrelevant. Malpractice insurance counts, not sure what other "work and operating expenses" are unique to doctors.
OliverJones 9y ago
Many doctors I know opt to work for a practice association and draw a salary, typically in the very low six figures. Why? Their association handles all the huge pain in the neck CYA stuff like electronic medical records, triage, insurance and Medicare billing, malpractice risk management, scheduling. From the practioners' point of view, especially for those who care for people over 65, socialized medicine has already arrived in the US. The rules around care and reimbursement are rigid. You'll get an occasional congresscritter who used to be an obstetrician or dentist claiming it isn't so. But those specialties don't have to try to get paid by Medicare.

paulcole 9y ago

>Why do the overnight shift of nurses take vital signs every four hours? So they catch rapid unexpected changes in patient conditions more quickly. The first sentence of the second paragraph of the article you seemed to have avoided reading says: “Checking things like temperature, blood pressure and respiratory rate every four hours on hospitalized patients has been the standard of care since the 1890s, yet scant data indicates that it helps.”

mikecsh 9y ago
> yet scant data indicates that it helps But this is not the case. In the UK, these observations are entered into a proforma by the nursing staff which allows them to calculate a "National Early Warning Score". Based on the patients score, the nurse has to escalate to an appropriate team and the doctor on the appropriate team has to take the referral. Not only does this help identify deteriorating patients, but it helps to fight human factors like "I don't want to call such and such a doctor because they are always rude on the phone so I'll just leave it and hope it gets better" In terms of actual data, we have a national body (NICE) that provides guidelines and recommendations based on appraising the available data and research. For NEWS scores, see: For an overview: https://www.nice.org.uk/guidance/cg50/chapter/1-Guidance#physiological-observations-in-acute-hospital-settings https://www.nice.org.uk/guidance/cg50/chapter/1-Guidance#phy... For the full report and evidence used to compile the guideline: https://www.nice.org.uk/guidance/cg50/evidence/full-guideline-pdf-195219037 https://www.nice.org.uk/guidance/cg50/evidence/full-guidelin...
OliverJones 9y ago
If a patient is stable enough that the taking of regular vital signs is nothing but a nuisance, maybe it's time for the patient to leave the acute care hospital and go home or to a rehabilitation facility. Nobody wants patients who don't need acute care services in acute care hospitals. Maybe DNR / palliative-care patients should get a break on the four-hour vital sign gathering. But people start yelling "death panels" when this sort of thing comes up in hospital policy.