The next step is improving the process and connections beyond the hospital walls. My parents are meeting with or just finished a meeting with mom’s surgeon as I typed. Last week when I spoke with the surgeon, I asked if I could be dialed into the discussion. He didn’t have a speaker phone. I asked if my parents brought their iPhones could he use that speaker phone. The response “I’ve never done a consult like that. I don’t know how I would make it work.”

Didn’t doctors play the telephone game as kids? What don’t you understand about the fact that not having everyone hear the same thing at the same time decreases the accuracy of the information exchange?

Mistakes do happen but the evidence on whether patients are actually harmed more is mixed at best. In my experience, the short leashes and close supervision may actually make patients safer by creating important redundancies (at the cost of efficiency) compared to other times of the year.

Thanks for another fantastic and insightful post Bob.

The physicians and nurses who cared for my mom were beyond reproach (with the exception of one overzealous cardiologist who needed her consciousness rearranged, which I was only too happy to do, when it came to the topics of intubation and resuscitation).

But, as I noted in my comments on Ashish Jha’s recent personal hospital experience (https://thehealthcareblog.com/blog/2013/08/14/average-care-at-a-typical-hospital-on-an-ordinary-sunday/), I think we miss an important and potentially unmatched quality improvement opportunity if we don’t encourage people to use social media to put pressure on the health care system. For too long, health care providers have gotten the benefit of the doubt, been given a pass on both poor behavior and poorly rendered care. What if the family of Josie King had been able to raise a social media ruckus about what was happening to their daughter (http://www.josieking.org/Home) at the vaunted Johns Hopkins Hospital in 2001?

In my recent reading experience, social media types in health care institutions want to use social media as a way to “communicate” with patients, extol the virtues of their institutions, and highlight their new products and services. This is all another way of saying social media is the next vehicle for optimizing payer mix and maximizing reimbursement. That’s not good enough.

The reality remains that in an culture where there is deep (and often justified) suspicion of corporate interests (and that’s mostly what a large hospital or health system is), there is no reason to exempt medical care providers from feeling the immediate sting of negative trending. It might be the easiest and most efficient way for US health care consumers to send the message that the system stinks (except for the most savvy), that health reform has made it only slightly less smelly, and that health care providers churn excuses faster than farmers churn milk into butter.

The point you raise regarding reimbursement is a subset of a far larger issue in healthcare: should better care be paid better, regardless of the reason (time of year, better staffing, better training)? Here too, alas, the answer is: it’s complicated. The evidence that differential payment makes a difference in healthcare is underwhelming, though it’s certainly being tried, as part of today’s kitchen-sink approach to improving quality, safety, and efficiency. The problems with so-called “pay for performance” are many: healthcare people are motivated by more than money (as are NPR people); we’re not very good at measuring quality; and very large determinants of outcomes have nothing to do with the quality of care. In fact, if we’re not careful, a payment system can easily cause hospitals to shy away from taking poor patients, or those with limited social supports — since they are more likely to have worse outcomes.

One final point that adds yet one more wrinkle. When it comes to training doctors, nobody has come up with a better idea than having trainees actually begin taking care of patients, with supervision. There are ways of doing it better and safer (practicing on simulators, for example), but the bottom line is that there is that we all benefit from having trainees work on real patients. We all want experienced doctors, yet there is no way to get to your 100th case without somehow going through your first.

Thanks again. My best to you and your family — I’m a great admirer of your work and your tweets were really special.

I am also amused by that phrase “July interns.” Do hospitals reduce their billings in July, because of staff inexperience and mistakes? We had some similar instances which, given my mother’s more dire results, are painful to recall now. But necessary.

I have an idea: reduce the costs that are billed in July and August, on the idea that everybody seems to know that the level of care is not as good. This will provide hospitals with an incentive to improve care to earn more money.