Average Care at a Typical Hospital on an Ordinary Sunday in August

The Bike Path:

On a warm and sunny August Sunday, I was rollerblading with my kids on the Shining Sea Bikeway. On mile nine on the trip, I hit a tree root, went flying, and landed on my shoulder.  I could tell immediately that something was wrong — I couldn’t move my arm and was in the worst pain of my life. Feeling for my left shoulder, it was obvious that I had dislocated it. What happened next was that I received some of the best care of my life – unfortunately it was not from our healthcare system.

As I was lying on the bike path, nearly everyone stopped and asked how they could help. A pediatric nephrologist offered to pop my shoulder back into place. I declined. This wonderful couple on a two-person reclining bike stopped and insisted on pedaling me to the hospital. We were far from the road and knew that calling an ambulance was not straightforward. So I sat with my left arm dangling, in excruciating pain, while David rode the bike to Falmouth Hospital. It was a 20 minute ride finishing with a very steep hill. David apologized after each bump on the road as he heard me swear and wince.

The Emergency Room:

We finally made it to the ER, and, ironically, it was then that my care stopped being so wonderful.

It started off well enough – a triage nurse saw me walking in holding my arm, in distress.  She got me a wheelchair and brought me into triage. I explained what happened, gave my name, date of birth and described the pain as the worst of my life.  I was then shuttled to registration, where I was asked to repeat all the same information.  It felt surreal: I had moved all of 10 feet and yet somehow my information hadn’t followed me. The registration person asked me question after question.   Initially, the same ones: name, address, phone #, etc.  Then, my Social Security number (presumably so they could go after me if I didn’t pay my bill), my primary care physician’s name, his address, his phone #, my insurance status, my insurance #, my insurance card, my emergency contact, their address and phone #, etc. etc. etc.

I told her I was in excruciating pain and needed help.  A few more questions, she said.  She needed the complete registration.

I was wheeled to radiology and sat in a hallway for what felt like forever, groaning in pain. I couldn’t find a comfortable position. Six or seven people walked by – and as they heard me groan, they would look down and walk faster.  The x-ray technologist avoided eye contact.  It was hard — I was right outside her room.  Finally, I asked a passerby if she could help.  Caught by surprise (I must have sounded human), she stopped.  She looked at me.  She then went into the x-ray suite.  A few minutes later, a second technologist came out, saw my arm, and was the first to acknowledge that my arm looked painful.  He told me the ER was pretty quiet and he would get me in right away.

One of the ways we measure quality of emergency department care is to examine the proportion of patients with a fracture who receive pain medications within 60 minutes. While I don’t know who came up with 60 minutes, it wasn’t anyone with first-hand experience sitting in a waiting room in excruciating pain.  Even though I did not have a fracture, my injury was comparable – and I was getting pretty close to 60 minutes when I was wheeled from the x-ray suite back out to the waiting room. I hadn’t been assigned a room, I was told.  Still no pain medicine.  How much longer before I could be seen, I asked? No one seemed to know.  When I was eventually wheeled back to the treatment area, I was told I had to wait for a physician before I could get pain medication. How soon, I asked? No one knew.  The ER doc actually came pretty quickly — he ordered some morphine and things became better.  He was very good at what he did – he manipulated my shoulder and while it was insanely painful, I knew it had to be done. My shoulder popped back in quickly with amazing relief.

The Lessons Learned:

The rest of the time in the ER was uneventful. As I sat on my gurney awaiting the results of the repeat x-ray, I sent out a Tweet. I described the experience as wonderful people, awful system.

1) People who work in hospitals can be wonderful:  One could ask if the people there really had been so wonderful.  Why didn’t the triage nurse take me back right away and skip parts of registration (or at least express sympathy for my pain)? Why couldn’t the registration person wait for the minute details? Why did all those people look away when they heard me groan? I can’t imagine walking by somebody groaning in pain and ignoring them.  Except I probably have.  In the hospital.  And why do we do that? Why do we leave our humanity at the door when we arrive to work?  I assume we just get desensitized to suffering.

What was remarkable was that there were people who were able to break out of that trap.  When I was able to engage someone as a person, they responded.  The woman who stopped when I asked for help.  The second x-ray technologist who expressed sympathy for my pain.  The ER physician who took care of my shoulder quickly when he realized the severity of my pain.  It is the job of healthcare leaders to create a culture where we retain our humanity despite the constant exposure to patients who are suffering.  It’s clearly possible and several people showed it at Falmouth.  And yet, too few healthcare organizations appear to have those kinds of leaders.

2) We have a lousy system.  There were so many reminders in my short visit to the ER.  Asking someone in excruciating pain to repeat demographic information and wait for their insurance information to come up on the computer?  Even when I pleaded with her, she blew it off, reassuring me insurance information was important.  Because that’s how we do business in healthcare.  Making sure I was insured was much more important than making sure I was treated quickly.

When telling this story to colleagues, one person even defended it.  Asking people to wait in pain is fine, she said, because registration information is valuable.  Really? That’s the tradeoff? We can’t design a system where some of the information is obtained when the pain is better? There was no way to take my credit card as collateral and let me go on my way?  Can we really not design a better flow so that patients with severe pain get relief without waiting needlessly? There were so many little opportunities to make my process faster, but it was clear that there was no reason for the hospital to invest in those changes.  No one holds them accountable.  In most industries, the payer holds the provider of poor services accountable.  Not in healthcare.

Not an extraordinary story:

The biggest lesson for me was that this was not an extraordinary story at all.  When I told my story to colleagues the next day, no one was surprised. We accept that when we walk into a hospital, we give up being people and become patients.  We stop receiving care, the way I did on the bike path.  Instead, we receive services. And when you are in pain, the difference between care and services is stark.

People in healthcare get upset when they are compared to other industries, but on this one, it’s tempting.  So many companies have figured out how to do flow better.  How to keep their employees engaged and sensitized and not burnt out.  But in healthcare, we underinvest in that.  Companies spend vast amount of time studying flow and thinking about how to ensure that customers get the services they need quickly.  In healthcare, it’s considered a luxury and most organizations do very little.

Part of the reason our acceptance of mediocrity is particularly frustrating is that this is what care looks like in the most expensive system in the world.  If we, as a society, chronically under-funded healthcare services, one could understand the lousy service we often provide our patients.  I could live with being parked in the x-ray waiting area, ignored — if I knew that we were instead spending precious societal resources on education and research and building roads and bridges.  But that’s not our story. We spend an enormous amount of money, and accept mediocre service in return.

Now that we are measuring patient experience and ER wait times as quality measures, I wondered how Falmouth hospital did.  Out of curiosity, I looked up its ratings. They are fine.  Average. This is not an outlier hospital. My experience was not an outlier experience. And that is the biggest disappointment of all.

Ashish Jha, MD, MPH is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence where this post originally appeared.. He is also the Senior Editor-in-Chief for Healthcare: The Journal of Delivery Science and Innovation.

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25 replies »

  1. Mine was excruciating! I dislocated my rib without knowing it, I thought it was a heart attack! I was unable to breathe or move…I had no idea it was possible to dislocate one’s rib until I googled and found out that thousands of people had been searching for the same information!

  2. Healthcare is a service industry. The service being provided is improved well being through the treatment of discomfort, illness and disfunction. The only difference between health care and any other service industry (e.g., hospitality) is the high value society places on it. Yet, we as customers allow providers, up and down the system – incl. doctors, to treat us to exceptionally poor customer service whether we’re in the ER or just visiting the clinic. If Ashish were checking into a hotel and got the same service he got in the ER, he would no doubt head straight for the competition. Unfortunately there’s a lack of viable alternatives, particularly for emergency care.

    Without competition and accountability, healthcare service providers will continue to provide poor customer experiences. In fact, the laws of economics dictate that they will only provide the minimum service necessary to achieve explicit and measurable targets – nothing more. You get the behavior you reward. Doctors and others within the system are not immune to these forces and assuming they are is counterproductive.

    • The usual laws of economics do not apply to healthcare.Most so called expert health economists agree on this point.We physicians,who actually treat patients are well aware of this.
      Dr Jha’s experience is very similar to that which occurs in ERs in Canada.The difference being that the actual total cost of care in their single payor health system is about one third, versus the US.

      • Any exceptions to the laws of economics are due to lack of competition and government involvement. However, you still get the behavior you reward. No one, including doctors, are immune to this principle. Without the proper metrics and incentives in place, customer service will suffer.

        • The problem with your theory about a lack of competition and government involvement creating the problem is that is actually what has created much of the mess. Hospitals are not hotels and they are not widget factories but corporations have tried to run them as such for decades, beginning with the HMO model controlling access, limiting physician discretion, rewarding physicians for mediocrity and non-testing (bonuses for NOT practicing medicine because it was cheaper for the corporation that way) — all with the aim of maximizing profits and no thought to the reality that people are not fenders on the assembly line at GM.

          • As I said, you get the behavior you reward. To improve the overall customer experience, there needs to be more appropriately aligned incentives and ways to measure the desired results. The fact that badly structured programs have failed in the past does not invalidate this fundamental principle.

  3. What is amazing about this article is not that the ER proved to be a typical ER, but that a physician actually was surprised about his experience in such an ER. Who should know better about the day-to-day inanities of an ER than physicians?

    But let’s be fair: Emergency Medicine does a very good job of saving lives in true emergencies (such as in cases of catastrophic trauma); where ER’s fail is in the delivery of the easy stuff. Truly, what could be easier for an ER than the swift management of pain caused by the obviousness of a relocated shoulder in an otherwise healthy adult? Could someone have at least provided an ice pack? What is even more sobering is that the patient was a physician! Perhaps this gives a better idea how it feels to be a person outside the system. Imagine what happens to the those who cannot articulate what happened to them with the competence of a physician. Chilling.

    Only physicians can fix these problems; it’s a convenience to blame it on process or hospital administration — the truth is physicians have the power but for years have been abrogating both the professional and moral high ground to corporations and government. Two glaring examples are that they have been shamefully silent about the war on abortion rights and unethical legislation mandating trans vaginal ultrasounds prior to abortions — when all physicians know those U/S’s are medically unnecessary thereby making them medical unethical. The list is long proving such silence.

    I don’t wish any physician a trip to the ER but I would like to see them recover their voice.

  4. What you encountered was just another business process, however this business process was not built to deliver healthcare. It was built to deliver money to the bank. Somehow I don’t think this process was designed by doctors.

    If it were built to deliver healthcare, it would be as simple as giving you a temporary ID to gather information, providing triage and initial treatment, then gathering the billing information and connecting your temporary ID.

    This is what happens when management, driven by profits, bonuses and insurance regulations, makes decisions about business processes.

  5. Wow. I think it’s really unfortunate that you had to be on the other side of the coin. But since you did have that ‘real world’ experience, I hope maybe you yourself will be able to make small changes or adjustments in the system or with the way people are treated in general.
    Everyone can make a difference, great or small. It starts with our individual selves, right?!

    Loving Life,
    Jeanie Ash
    “Freedom to Work at Home, Happy to Keep Family First”

  6. I’m pleased to report there are hospitals that are getting it right. I recently sustained an open calcaneus fracture after falling off a ladder. While I’m sure the ambulance, EMTs and the exposed bone probably got more attention than your arrival via recumbent bike, I was administered pain meds within fifteen minutes of arrival. And while I was repeatedly asked my name, address, emergency contact info, etc., no one asked for my insurance until right before I was sent up for surgery.

    On the downside, the ER attending was shockingly numb to the pain he inflicted–and this is from someone with an exceedingly high tolerance for pain. When I first arrived, I heard unnerving screams of pain from the other examination rooms. I mentally discounted these patients as being “whiners.” And then the Attending came for me. It took a while because I was at a Level I Trauma Center, I had been stabilized, and there were other patients ahead of me. Not a problem. But right as the pain meds began to wear off, the Attending began to debride the fracture–without any local anesthetic or any additional pain meds. As the Attending used retractors to expose the bone and cut away skin, I screamed in agony. And I realized then my fellow patients weren’t, in fact, “whiners.”

    After the debridement, an orthopedic trauma surgeon took over my case and I never saw the Attending again. In the OR, I underwent further wound debridement, which kind of calls into question the point of the first debridement. Happily, the ER Attending was anomaly to otherwise excellent care.

    • In too many situations, other people are “whiners,” until whatever they are whining about happens to you.

  7. Oh how the mighty fall. Interesting when this happens to a “civilian,” it’s just the way it is. When it happens to a doctor, the earth moves.

    Hope you’re feeling better.

  8. Davis,

    several great points. In healthcare, we believe that great leaders are born. The experience of many other industries has been the great leaders are made. While there is surely a lot of variation in innate talent, leadership can be taught and trained.

    Physicians have an ethical responsibility to be leaders who are advocates for patients. if not, if we are nothing more than employees who respond only to financial incentives,then we do not deserve the special place the society still bestows upon us.

    Thanks for the good work you do in this area.

    • Here’s the problem: physicians are predominantly economic actors and have been encouraged to become so by our bizarre reimbursement and litigation systems. Amongst the physicians I have worked with over the past 25 years, there have been 10 talking about their portfolios and currency trading options for every 1 talking about sweating bullets over how to relieve a patient’s suffering.

      And, as for the social idolatry, it’s an inexplicable and almost completely undeserved anachronism to me. After athletes and entertainers, physicians have the highest median wage amongst all US workers. You’d think that all that money would have produced both market efficiency and quality.

  9. Thanks for sharing this important story. Doctors becoming patients or caring for family members demonstrates the gaps between what exists and what it health care can and could be.

    In the end, it is the culture of the organization that makes the care we provide that much more convenient, hassle free, and worry free. That takes leadership as you rightly point out.

    “It is the job of healthcare leaders to create a culture where we retain our humanity despite the constant exposure to patients who are suffering. It’s clearly possible and several people showed it at Falmouth. And yet, too few healthcare organizations appear to have those kinds of leaders.”

    It is because we in health care have failed to train leaders. Until doctors decide that being leaders and change agents and medical schools and residencies decide that leadership skills and training are as important as clinical skills and bedside manner, health care is unlikely to change.




    Hope you feel better soon!


    Davis Liu, MD
    The Thrifty Patient – Vital Insider Tips to Staying Healthy and Saving Money (2012) & also Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America’s Healthcare System
    Blog / Website: http://www.davisliumd.com
    Twitter: @davisliumd

  10. What if I didn’t have insurance information to share with the registration person? Or a credit card for that matter? I do believe care should come first and that people are not looking to “eat and run”- at least not if they can pay what are reasonable fees that will allow them to go back to their life without being more in hock than before they entered. You didn’t mention if you told anyone that you were a physician. I believe you would have certainly been taken better care of. But if I was a person without insurance or credit card, I might have felt diffident about ‘engaging the humanity’ of the healthcare professional as you felt.
    I am not criticizing you- I am a big admirer of your work, if anything- but a system doesn’t run without the people. I don’t like the good people-bad system explanation; it has been used also for the banking or mortgage or housing or other financial disasters- take your pick! All those people walking by were the system.

  11. Ashish, I love your posts. Here is what this post made me think: while our health care system (such as it is), has never been as technologically advanced and as administratively screwed up as it is now, it has likely had a pretty steady stream of good people working in it. A self-selected population of people who want to help (and not incidentally make a pretty good, heavily tax subsidized living). So, if that’s true, what does that tell us about good people working in health care? After all, hasn’t the system evolved to this point on their watch (and that of their predecessors)?

    The system that you describe is unfixable, perhaps because the people working in it are too nice, as I posit you were during your care experience. I think that there isn’t enough banging of shoes on the table…by patients or by doctors, nurses, PAs, NPs, janitors of all kinds who have great ideas that are never heard or tried because they’re too nice and the bureaucracy too impenetrable. Funny how I have never heard anyone accuse the late Steve Jobs of being too nice.

    • Vik — thank you for your very helpful comments. I have to believe that it is no longer about good people trying harder. I work in hospital. I try pretty hard. I am not sure I can do any better than these people did for me.

      We have watched the system devolve into one where getting my insurance information was a lot more important to the hospital in treating my pain. Until organizations believe that there is a real cost to mediocre service, I doubt we will see substantial improvement. Maybe that cost comes in the form of banging shoes on the table. I suspect it will have to hit their bottom lines in order to make a difference.

      • Indeed, but my point about banging shoes on the table was meant both literally and metaphorically. A friend of mine recently characterized me as a human Hellfire missle, and, indeed, when sufficiently roused, virtually no one is better at getting the attention of a target audience and of making clear that virtually any act other than the one I want will be treated as provocation. That skill set might have proved useful to you that Sunday afternoon if, say, I had accompanied you to the hospital. All these nice people might have resented my open and clearly relished belligerence on your behalf but you would have gotten far better service and, at the end of the day, that’s what matters. If they resent it, who cares? I don’t.

        The medical care system has grown fat and indolent feeding at the public trough of tax subsidies and direct payments which has bred a sense of entitlement. I point to, as an example, a healthcare executive bragging on LinkedIn’s Healthcare Executives Group that he had now arrived at the point where he was “in line for a million dollar a year hospital CEO job” because he had paid his dues and it was owed to him. What kind of mentality does that leader inculcate in his people? The kind that you faced. Great leaders (few indeed) create great cultures that, in turn, support the work of inspired employees. Health care is a near total failure at this.

        Lastly, maybe the most important banging of shoes is through social media. Maybe we should teach every patient or family member with a smart phone (which is to say nearly every patient or family member) to start using it at the moment of entering the hospital. Rude staff member? Tweet out hospital, employee name, badge number. Insolent physician? Post a video within minutes of the interaction. Get on the hospital’s Facebook page as soon as possible start talking about your issues. On the flip side, give credit where it is due, but I am not a big believer in praising people for doing the expected. Hospitals might get an interesting lesson in the value of quality by becoming the subject relentless negative trending that they will never get from every cockamamie quality reporting scheme we devise.

  12. I spent nearly 12 hours in the ER at one of the top children’s hospitals in the country with my 7 year old 2 weeks ago. Despite no pain or life-threatening injuries, there was a potential risk that she’d been abused (later confirmed negative). It took 5 hours for the attending doc to confirm (after a short 4 minute exam) that she had not been harmed by anyone, but the emotional pain I suffered during that time was the WORST of my life. They all saw me exhausted, sobbing, drained, etc. It was the middle of the night, and during my wait, I saw the attending doc chatting away and joking with other staff. Not sure what procedural event precluded him from coming in before that. He has a daughter, 1 year older than mine. I hope he never has to experience the parental trauma that I did.

  13. This summer I taught my Georgia Tech students at Study Abroad at the University of Oxford and two students had experiences with the NHS. Both reported good quality, caring people, and an overall good experience. Both reported being astounded at being asked for only their name and DOB at the front end, and nothing upon discharge.

    Oh, the course I taught was Healthcare Management.

  14. Thanks for your comment Lynn. I’m sure the pediatric nephrologist was very skilled, but passing was probably the right call.

    Its an interesting question — how do we help people work in environments like EDs and not become numb? I don’t think its impossible. It just has to be a priority for organizations to create the environment where people can be people.

  15. Nothing educates a physician like a little personal experience. Bet you wished you’d let the pediatric nephrologist pop your shoulder back in place when she/he offered. It would have been excruciatingly painful but for a much shorter length of time.

    Way too often the people working in EDs become numb to the suffering in order to function. There are rare folks who find the capacity to balance self preservation and basic human kindness or decency. They mostly work in housekeeping, I find.

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