Surviving America’s Industrial Manufacturing

"We see the hospital as a factory and our hospitalist group as an assembly line that is in the business of manufacturing perfect discharges.”1 These words are not hyperbole. They are the exact words written by David J. Yu, MD, MBA, Medicare & DSNP Medical Director, Presbyterian Health Plan, Albuquerque NM. Yu cites the work of management guru W. Edwards Deming as a major authority for this approach to patient care. Deming's business principles have been given much of the credit for Japan's industrial revival after World War Two…Theory is not practice. Ever since management and business school "experts” took charge of health care in the 1970s and 1980s not only have medical costs not decreased they have skyrocketed. There was no health care crisis in the 1970s and 1980s.2 It was manufactured by the medical industrial complex composed of hospitals, insurance companies and drug companies for their own financial gain.” Arthur H. Gale, MD, The Hospital as a Factory and the Physician as an Assembly Line Worker, Missouri Medicine, 2016

I recently spent 12 days in a large hospital in the state of Virginia and 16 days in a rehabilitation center in the same state. I had contracted COVID and went to the emergency room on July 3 at the suggestion of a doctor at a walk-in clinic. An EKG screening showed that I had atrial fibrillation and I was admitted to the hospital for observation and treatment. Another illness (colon cancer) reared its head and I ultimately went into hypovolemic shock and required emergency surgery to remove a tumor, clean up infected lymph nodes, and generally repair my insides. I now have colon cancer with liver metastasis in addition to prostate cancer with metastasis which has traveled to portions of my skeletal system.

You might say I've "doubled my pleasure and doubled my fun.” Hey! You have to have a sense of humor about these matters.

The hospital care system is, in fact, an industrial, assembly line operation. Because of this, doctors and nurses do not have time to develop relationships or spend a lot of time with patients. Doctors must make rounds that allow maybe 5-10 minute of time with the patient. Floor nurses are overworked having to respond to calls from different patients and they must prioritize those calls based on critical need. Wait times for assistance from a nurse can feel like a long time when you are sick.

"The time that the health professional has with the patient, and the time spent communicating with the next health professional in the chain (often a significant part of the overall cost of a distinct episode of care) is now rationed to that which is deemed essential. This hinders professionals' ability to establish a significant therapeutic relationship with the patient. Concerns that may arise with the patient that are not easily quantified, and consequently not documented, may also be lost.” Medical Journal of Australia. iMaking cars and making health care: a critical review, Sarah Winch and Amanda J. Henderson, 2009.

Total Quality Madness

The hospital system has become a depersonalized manufacturing process based on Total Quality Management (TQM), or some form of quality control, deriving from Toyota's Lean Engineering or Just in Time (JIT) manufacturing popularized in the 1980's and 1990's. Health care these days is truly an industrial manufacturing process which is tied in many cases to Medicare requirements and billing. TQM/Quality Control Practices are supposed to "manufacture” increased customer/patient satisfaction but the hospital experience made me feel like I was little more than a damaged automobile traveling the assembly line and being worked on by different mechanics.

TQM is described as this:

"Total quality management (TQM) is an administration attitude of uninterruptedly refining the quality of the goods/services/processes by concentrating on the customers' (patients') requirements and anticipations to augment consumer (patient) contentment stable performance. Successful TQM implementation leads to improved organizational performance success.” Journal of Dental and Medical Research, Significance of total quality management practices in improving quality of services delivered by medical and dental hospitals, Devika Kanade, Shailendrakumar Kale, 2021.

If the goal is to improve the organization's quality/patient manufacturing process, a baseline of measurements must be created. It is likely that unmeasurable metrics; for example, wellness, family access, intangible mental states are too nebulous to measure, as opposed to surgical procedures performed (every procedure aligns to a numerical code), exiting the patient in x amount of time from the hospital, recovering fees from the US government/patients, etc.

"The continued equating of quantity with quality and the redesign of work processes leads to continued fragmentation of health care work, loss of autonomy for the health professions, and a potential increase in hospital misadventure. The very act of breaking up an episode of care into a number of steps that may, or may not, add value to the overall process allows for parts to become lost. Of particular concern is the appraising of value so that perceived non-valuable aspects of care can be discounted.” Medical Journal of Australia, Making cars and making health care: a critical review, Sarah Winch and Amanda J Henderson, 2009.

How can a healthcare system that views patients as pieces of a manufacturing process be personal or caring? It can't. Doctors and nurses are not to blame. In TQM, Lean Engineering or JIT, time is of the essence in producing a product, or patient exit, before your competitors can. Hospitals are pushing the notion that they are more competitive than other health care systems nearby in the state of Virginia.

How do you measure competitiveness: How many patients did you see today? How many calls did you make for patients "on the floor.” What was the amount of time you spent with the patient and how does that correlate to TQM? How many patients live or die? How many patients do you push out the door?

My Experience

It is likely that were it not for one of the many nurses badgering her colleagues and physicians, I would have bled out. Earlier, another nurse noticed my bleeding and suggested a colonoscopy which I initially refused but I ultimately relented which proved critical to my survival.

My blood pressure nearly hit the deck. As I was wheeled into surgery, I vaguely remember that the nurses in the operating room were incredibly coordinated in their individual tasks akin to a perfect offensive play in US football where all 11 players know their assignments and execute them to near perfection. I uttered something to the surgeon about sewing me up which he was able to honor. Then, the anesthesia took full hold and I was out in the darkness somewhere.

When I awoke I was in the intensive care unit (ICU) being looked after by the nurses. I had a device which allowed me to inject pain killers into my body every few minutes. The time I spent in the ICU was like being trapped n in dense fog bank with a face appearing out of the gloom every now and then. Ultimately, I was moved to a room where I could be safely isolated as I had COVID. The room seemed to me to be at the far end of the hospital. My family could not visit me or even look through plexiglass windows at me. The experience was terrible.

My primary physicians visited with me as much as they could and those visits were most welcomed. My prognosis is not good and so palliative care physicians came to visit and spoke with me about the limited options available to me.

As the hours dragged by, I began to feel like I was, indeed, on an assembly line.

The nurses and their assistants that came with my treatments all had specialties. For example, a different nurse each time would open the door and say, "I'm with Respiratory and I've come to give you your inhaler.” I would take one hit from it and then the nurse would lock it away and leave. At other times someone from Respiratory also would show up to give me a ten minute treatment with a nebulizer. Those treatments could take place at any time of day and night. I received nebulizer treatments sometimes at three o'clock in the morning after being awoken from a sound sleep.

On that note it was impossible to get a decent night's sleep. Nurses would come into the room to administer medications seemingly every four hours. And then blood work was done sometimes three times a day to include the early morning AM hours.

Other nurses would take care of other matters such as changing sheets and bed pan issues. I was not presented with any physical therapy options to be able to get up and walk to the in-room bathroom which I really didn't know was there.

And so I lay there in bed stewing, not watching the junk on television, with a dead cell phone and no options to get out, at least I thought. I did have an in-room phone which I could use to talk with my wife and son.

Is Anyone Out There?

Buzzers seemed to go off repeatedly and not be turned off for sometimes a half hour. And if you needed to call a nurse using a device akin to a remote that controlled the bed, call device and television, it would invariably take what seemed like an eternity for the nurse to arrive. I had little appetite and didn't eat much during those twelve days but no one offered me any alternatives for nutrition.

Perhaps the saddest, and humorous, event happened when I received a Transesophageal echocardiogram (TEE), designed to check out the heart function. They put me to sleep, of course, and when I awoke I was alone in the procedure room. They had put me in a fetal position buttressing me with cushions and tie down straps so that I couldn't really move. I figured it would be a matter of minutes before they came to get me but the "matter of minutes” turned into 20 minutes. I began to yell out, calmly, "Hello, hello, is anyone out there,” (borrowing from Pink Floyd). My shoulder began to cause me some pain and so I kept repeating my words but still, no one came. I could see people walking by so I figured they could hear me. Wrong. So I increased the decibel level until someone opened the door and asked, "What's wrong?” I said my shoulder hurt and I've been stuck in here for 45 minutes with no clue as to what went on during the procedure. I received a sort of "whoops!” look and finally was brought back to my intolerable hospital room having been forgotten.

Escape!

I had no idea how long I would be stuck in the hospital but then on July 15 a nurse came in the room to remove my stitches. She said, "Did you know you are going to be released today to a rehabilitation facility?” I said I had not been told by any one of the news, which I viewed with caution. But I was excited to learn that I'd be off the assembly line. I was scheduled to leave at 4:30 PM that day but as that time rolled around I had not been cleaned up or changed into my street clothes. As the clock struck 5:00 PM, I heard a commotion outside the door. The medical transport driver was reading the nurses the riot act as he was on a tight schedule to pick up other patients. Two males nurses in shirts and ties rushed in and got me all set to get transferred to the rehab facility. Right up to the very end, I was forgotten, like a lost part, that fell off the assembly line.

The rehab facility was like heaven. I got full nights of sleep, physical therapy, decent food and very personalized care. I was up and walking within ten days and doing the little things (making the bed, brushing teeth, shaving, showering) that we all take for granted. My family and grandson were able to visit and it was just great! That went a long way to bolstering my recovery.

A friend from a family of doctors told me that it "it is not safe to get sick in America. It's a crap shoot,” he said.

Another buddy commented that, "I'm not too high on the medical profession. It used to be a vocation but now it is just a job, all process oriented.”

John can be reached at [email protected]. He published a book in 2019 titled Cancer for Jokers, an irreverent, black humor based look at his first cancer diagnosis.