Wednesday, July 11, 2012

Good hospital/Bad hospital

Several years ago, back when I was working in the Emergency Department, I had a rather fascinating encounter with a patient's wife.  It was late in the evening on a Friday....a generally bad time to come in to the ER....and she had brought her husband in with a large cut on his arm.  He needed stitches for sure, but the place was hopping that night, and so she, her husband, and her two small children had been stuck in the waiting room for several hours.  After some time, she had come in asking me when someone was going to come get him.  At that point, I think they still had 4 or 5 people ahead of them, and I let her know.  

She (fairly understandably) flipped out.  

As I tried to calm her down, she started to lecture me about how long they had been waiting....and then proceeded to let me know that this wait had come after she had driven her husband over an hour and a half to get there.  "You are SUPPOSED to be the best hospital in the country" she raged.  "How can you be if you make patients wait so long????".

Now I had the "why am I waiting so long" conversation with literally thousands of patients in my time in the ER, but something really struck me about this poor woman's frustration.  She had brought her husband to a hospital that was supposed to be the best (this particular hospital bounces around the top 5 in the country pretty routinely), but not for what he needed done that night.  What he needed was a simple set of stitches, the likes of which nearly any doctor in the country could have done.  When I took a look at her address, I realized she had driven by at least five different hospitals with ERs to get to ours.  Most likely any one of them would have gotten her faster service with the same quality of care.  In fact, within the next few years, three of them would devise marketing strategies around publicizing that fact.  The problem is, this woman had confused "the best" with "good at everything".  

When it comes to hospitals, that's just not true.

Given my professional experience, I was unsurprised  to see Time reporting that not one of the 17 best hospitals (according to US News and World Report) made the consumer reports list of safest hospitals.  

There's a couple reasons for this, some good and some bad:
  1. Best hospitals tend to be large teaching hospitals.  Large teaching hospitals have a lot of residents. Residents can be a little dicey.
  2. Best hospitals tend to see huge numbers of patients.  This can complicate things.
  3. Best hospitals tend to see cases other hospitals can't help.  Almost all of your top hospitals will have higher mortality rates than smaller community hospitals.  Why?  Because unless you're literally DOA, the first thing a small hospital will do with a really sick patient is to ship them off to a hospital with a good intensive care unit.  The top hospitals almost never transfer their patients.
  4. Best hospitals are ranked in large part on how they treat the toughest cases.  The more unique your condition, or the worse your risk factors, the more selective you need to be.  The more routine your complaint, the more a top hospital can actually work against're going to be one of many, and nothing makes you stand out.
  5. Large medical centers, specifically in urban settings, give away a lot of free care to a lot of high risk populations.  These patients are unlikely to do well in any setting, and can skew the data tremendously.  Location counts.
There's constant strife over how to accurately rank hospitals, because professionals skew hospital rankings in the direction of valuing medical uniqueness.  Patients on the other hand, tend to value things like "comfort of chairs in the waiting room" nearly as high as they do "physician competence".  Patient's also claim to want things that they don't really....for example nearly everyone says they value physician competence over bedside manner, yet patient's routinely rate physicians with good bedside manner higher than those with good technical skill.  Patient's receiving appropriate care also file plenty of complaints if it wasn't the care they expected.  No hospital ranking is going to hit every part of the hospital equally regardless of who ranks it, and every department can have a bad day.   

I don't have a lot of answers to these issues, but it's important to keep them in mind when you hear ideas for improvement.  While the Time article got a bit too political for my taste, it is true that patients can only make informed decisions if the information they have is what they think it is.


  1. There's constant strife over how to accurately rank hospitals, because professionals skew hospital rankings in the direction of valuing medical uniqueness. Patients on the other hand, tend to value things like "comfort of chairs in the waiting room" nearly as high as they do "physician competence".

    Kind of like the big name universities renowned for the billions in grant money brought in by famous professors while the poor slunky undergrad student wonders why all her "professors" are first year grad students with heavy foreign accents.

  2. And the best hospital is most likely to have a long line of customers at the door of the ER.

    While the mediocre hospitals are less likely to have such a line.

    (In my area, there is a chain of hospitals which advertise that their ER-acceptance process always includes short waits for a doctor. It's a hospital-chain connected to a med school. So I assume that they have lots of residents on-staff. And I infer that they have a rapid-triage process, with a sort into one of many second-stage waiting rooms...but I found it amusing that the billboards and radio ads would promise a max of 30 minutes before seeing a doctor.)

    1. The good part of the "doctor in 30 minutes thing" is, if used correctly, it does cut out one annoying part of the wait. Basically, what used to happen is patients could sit forever, then finally see a doctor, then find out they needed a CT/MRI/Xray before anyone could do anything else, which was a whole new set of waiting. Seeing an MD up front often does nothing more than get these tests ordered faster....which can literally cut hours off your stay. It's basically a scheme to combine wait times....but it works out pretty well for everyone.

      The other problem with best hospitals is that they tend to be centrally located, so many accident victims wind up there. We had this problem whenever big events took place in the city....get dehydrated at the fireworks display? You're certainly not driving to the suburbs!

  3. I forwarded this widely, and someone wrote back wondering if any of this was useful for ranking churches...

    1. Interesting thought.....I'll have to ponder that.

      Your comment made me realize though...we recently used similar logic to pick a town to buy a house in. It's definitely got some broader applications.