Cloudy Dispositions

I was in medical school when I first learned that the VA healthcare system is viewed by some veterans as a branch of Extended Stay America. This is in contrast to the way medicine is practiced in most non-government hospitals, where care resembled retail in that residents' duties mostly revolved around thoroughput and turnover.

During the backlash against managed care the media liked to sensationalize cases of "drive by deliveries" and other instances in which patients complained that they had been sent home too early, times when they felt they had been pushed out like so many widgets on a conveyor belt.

But I would argue that doctors have no choice: every night scores - maybe hundreds -of people came through the emergency room. Perhaps a dozen of them sick enough to require admission into the hospital for more intensive care and monitoring needed hospital beds - beds which had hopefully been vacated by patients going home that day. But like a hotel, hospitals can be out of rooms, in which case patients hang around in the emergency room, even in the hallways. With more and more hospitals closing down and fewer beds available countrywide, this is the forward pressure driving medicine.

I love the medical terminology that makes hospitals seem like an elite club that you're "admitted" to. Similarly, the term we use for the eventuality that the patient will leave the hospital, "discharge", conjures images of doctors jettisoning their patients from the front door at the first opportunity. I can't deny that overworked as we are, our priority as residents is to get patients out of the hospital and off our service as soon as possible, if only to cut down on the workload. At the VA, though, typical patient stays are longer, up to twice as long. Because it's a government hospital, there isn't the financial incentive to move patients through. Because of the population, often homeless, sometimes married and usually coming from long distances away, a lot of people don't have places to go when they're not sick enough to be an inpatient but too sick for independent living.

The VA is a place where patients regularly stay in the hospital because they don't have a ride home. My chief resident likes to tell the story of the vet who came into the hospital with three pieces of luggage, saying that he had pneumonia and needed to be admitted. Later on they discovered that he had been kicked out of the house by his wife and needed somewhere to stay.

Just last week I saw in the ED a chronically ill patient whose chief complaint was incontinence. Rather, I should say that the chief complaint of the patients wife was that he was incontinent. He himself didn't have any pain, nausea or fever. In fact, when I walked in to examine him he was sitting up reading a book.

Cardiac surgery has been my first rotation with multiple patients who've had triple digit hospital stays, though, and this isn't because of any patient issues. It's because of the VA health care system which doesn't have enough rehabilitation facilities. More on this later.