Both Sides Now - Part I

What’s on Your Shoes Reveals What’s in Your Heart.

The cultural divide is immense. Whether officer versus enlisted man, manufacturer or service industry versus governmental oversight agency, or physician versus health care administrator, the distrust and friction are instinctive. Life’s experience bolsters that skepticism.

This blog won’t help to heal those feelings. Rather, it crudely illustrates the distance between healthcare workers on the front line and healthcare management. In Part II, I will speak to the other side—what effective administration should look like and how healthy organizations can build a bridge based on trust and respect over a shared mission. It requires each of us to do what we do best while sharing the best interests of patient care. It is far too rare a case.

I can illustrate the problem of administrators with two presentations that speak for themselves. The first is a graph showing the relative growth between physicians and health care administrators between 1975 and 2010.

The number of physicians in the United States grew 150%, keeping in step with population growth, while the number of healthcare administrators increased 3,200% for that same period. A staggering development.

Medicine is not unique in this. A graph of teachers versus administrators in our school systems would appear much the same. Governmental agencies have pursued this structure for years.

The question is: Is health care or education better off because of this shift? This question is necessary because this evolution has greatly influenced cost and performance. With so many managers, does our health care system function better now than in 1980? Is the health care experience for patients and providers better now than in 1980?

Most of us would say it isn’t.

Healthcare is complicated. Every element is complicated, from how it’s delivered to how it’s paid for to what it feels like for the patient and family. Community hospitals are increasingly rare. Large corporations, whether major hospital chains, insurance-owned and operated chains, or large private or public equity investment firms, have added cost and complexity while increasing the distance between decision-makers and the problem.

The result is one in which compliance and career priorities trump mission. It’s not personal, and that’s the problem. A critical connection has been lost.

While this graph extends only to 2009, the trend has continued.

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The second presentation is a blog I didn’t write, though I wish I had. Dr. Vinay Prasad is a hematology and oncology physician and a Professor in the Department of Epidemiology and Biostatistics at the University of California, San Francisco. He often posts on Sensible Medicine, which I enjoy for its unabashed frankness and disregard for what is politically correct. I think he was having a difficult day. I’ve been there.

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Blood, shit, piss and pus

There are two groups of workers at hospitals and medical centers. There are those of us who, at times in our daily work, come into contact with blood, shit, piss and pus and there are those who don't.

The first time I put my hand in blood was when I was a medical student and didn't see the pooling puddle on the patient’s bed. The last time I came into contact with piss was on rounds in the last month. I carefully judged the color and volume sitting in the bag, and I noticed, too late, that some had leaked onto the floor.

My friend David became a neurosurgeon, and I remember seeing his clogs in the hallway of his home during his residency. They were caked in blood and coated with bits of broken skull like flakes of sea salt.

I remember the first time pus splattered on my scrubs—during an I&D in the ER as a resident at the VA. The patient immediately felt better, and I went to change my top. The smell lingered until I went home to shower.

Blood, shit, piss and pus. Doctors, nurses, technicians, mid-levels, janitors and more come into contact with these fluids during our work.

When you step in these fluids you can't work from home. When you wash these off your clothes you are always a pragmatist. You can't cling to unrealistic idealism when you touch these fluids. You have to abandon being neurotic when your job routinely risks exposing you to these things.

I appreciate the many people who keep the hospital running who never encounter these fluids. We couldn't do it without the ancillary services. At the same time, I am concerned by the growth of the hospital admins. Increasingly, there are more and more employees who don't touch these liquids.

I am troubled when a recent college graduate who has never had blood on their sleeve, locks me out of EPIC so I can complete my annual research ethics module.

I am annoyed when someone who hasn't changed their shirt when it gets stained with pus tells me that I can't get an inpatient PET CT on my patient with transformed lymphoma.

I get irritated when a laboratory cancer researcher who hasn't stepped in piss tells me that antibody drug conjugates save so many lives while my patient has neuropathy so bad he uses a wheelchair.

When my nurse, who has already had COVID, declined the COVID vaccine, I didn't think twice. That's her decision and I was fine with it. When the administrator told her she has to stay at home, even when she felt well, and, instead, I would have to work short-staffed, I knew he has never touched these fluids.

When I get an email from an admin telling me I have to reschedule shifts until I complete my annual respirator fit test — and I am the only one of the two of us who gets coughed on — I am not happy.

Blood, shit, piss and pus. For some of us, it defines our work. I appreciate the folks that help me who don't come into contact with these fluids, but too many don't. Too many of them follow rules blindly. Rules set by other groups of people who don't touch these fluids. They are building an empire of people who don't touch these things. They, at times, stand between me and doing what I think is best for my patient. My patience wears thin.

But remember one thing, someday you will need someone to touch your blood, your shit, your piss, your pus and that day you won't like it if I am off duty completing my annual respiratory fit test.

Vinay Prasad MD

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From Blog Comments:

You missed Puke.

One of the most inspirational moments in my training occurred while working as an EMT before college. I watched a nurse clean up a man who had fallen out of the back of a pickup truck onto the road the night before- never missed by his fellow drinkers. The stink of hours old blood and shit that a lot of beer and a closed head injury produced didn’t phase that nurse in the least. Still my hero.

Why refit the mask if there have been no changes in the face shape or hair?

You left out snot and spit.

I want to thank the environmental services personnel who clean the hospital rooms. We’re screwed without you. You don’t get paid enough. Thank you.

In the wound clinic, I applied sterile maggots to wounds for debridement and cleaned stool out of sacral decubitus. The nursing staff who held the patients for me took the brunt.

There are two kinds of people- those who shower before work and those who shower after.

We need DOGE for healthcare.

My colleagues were negotiating a contract. Three physicians and four administrators were in the room, with the administrators lamenting the bottom line as justification for a poor contract. One of the physicians slowly, methodically pointed to each one in the room as he counted the administrators and then the physicians. “I think I have diagnosed the problem with the bottom line.”

I’m a better person for having touched blood, pus, vomit, urine, and stool.

In my field of work before medicine, bloated outside bureaucracies wedged their way into the productivity chain, slowing things down and increasing costs—all under the guise of keeping everyone safe or in compliance. None accepted any accountability for the consequences.

Does full-on expectoration unexpectedly shooting out of a tracheostomy tube count?

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My Conclusion:

Pournelle's Iron Law of Bureaucracy states that in any bureaucratic organization, there will be two kinds of people: Those who are devoted to the organization's goals. Examples are dedicated classroom teachers in an educational bureaucracy, hands-on health care providers, or many engineers, launch technicians, and scientists at NASA.

Secondly, there will be those dedicated to the organizational bureaucracy itself. Examples include many of the education system's administrators, professors, teachers' union officials, and NASA headquarters staff.

The Iron Law states that the second group will gain and maintain control of the organization in every case. It will write the rules and control promotions within the organization. Those dedicated to the goals the bureaucracy is supposed to accomplish have less and less influence and sometimes are eliminated entirely.

This is what has occurred in corporate medicine.

This blog is more difficult to write as I have transitioned from provider to administrator. Fearing I’ve become my enemy in the instant that I preach.

It’s humbling.

Tim Powell MD