A failure to communicate

In the movie, Cool Hand Luke, a character delivers a famous line, “What we have here is a failure to communicate.”

That pretty much sums up how health care in Nova Scotia operates.

In my experience with hospitals they are so staunchly hierarchical in their organizational structure that they seem almost feudal. Administrators, specialists and surgeons are lords of the manor. Regular doctors are the lower ranks of nobility and everyone else is a serf. Nurses are a little higher up among the serfs, but not noticeably so.

Because of this feudal structure communication flows one way: down hill. There seems to be little back-and-forth. At our hospital on those rare occasions when administrators are seen in the facility, staff suck in their breath and head for cover. As one person said, “It’s never good when they show up.”

Staff know that when administrators are in hospital there is: a problem, a new set of regulations and rules, or a VIP visit. It seems there is a disconnect between administration and operation. Even doctors are frustrated by the yoke of administration they toil under. As one doctor, not associated with the hospital, told me, it is less about practicing medicine and more about procedures. When you look at a community like Yarmouth, Nova Scotia (population 7,200), which lost six family doctors in the 13 months between October 2009 and November 2010, you have to wonder is it because something is lacking in the community or is it the working conditions? Communications play an important role in how people feel about their work. I find most health care workers love what they do, but hate the regime they work in.

A juvenile palliative care doctor in Vancouver told me, “Having worked in health care most of my life I know how the odds are stacked against you, I have always told people that hospitals are run ENTIRELY for the convenience and use of the staff, patients are always in the way, troublesome, or problematic.”

Given how little attention administrators and some doctors paid to what we had to say, I have to wonder how many mistakes are made because some people are too sure of what they think they know.

* When our family member was admitted, we were given a white three-ring binder and asked to fill out several pages of information, which included a brief biography of the patient, patient likes and dislikes, preferences for care (male or female nurses), favourite foods, religion, etc. There were sections for various departments in the hospital so if the patient or family had questions we could write them here and get an answer back. It seemed a good idea in case you missed seeing someone during their shift. Seven weeks later at a meeting with the team in charge of the patient’s case, they said, “any time you have a question ask us.” We replied, “we have and you haven’t.” We showed them the binder and not one of the 10-people in the room claimed to know anything about it. Information that hadn’t reached the floor.

* I shouldn’t have been surprised. This is a facility where people don’t know their colleagues. In a conversation with one woman she said, “I’m sorry, I don’t know who that is.” I pointed to an office 30 feet from her desk. “The woman who works there.”

* Given how the system is set up, I worry about the potential for misdiagnosis. Doctors do their rounds early in the morning when it’s convenient for them. It is not so convenient for the patients who may be under the effects of medication. This is a type of communication that doesn’t seem to be factored into the doctors’ observations.

* I found hospitals so focus on the current issue that brought the patient into care that they ignore pre-existing conditions. In our case, the patient went 10 days without medicine for those pre-existing conditions. We foolishly assumed that a hospital patient would receive all of their normal medications. Not so! The doctors over-looked this and for ten days forgot to administer them. This is a problem with being on a doctor rotation; if one person isn’t as detailed in their notes, things get missed. Or if, as happened with us, doctors don’t read charts, things get missed.

* Then there were times when we did see a doctor we could question. She would walk out and never return. We didn’t know if she had checked into our concern or ignored it. We also had difficulty learning test results. It could take days to find anyone “authorized” to provide an answer.

* Once, having gone a week without seeing a doctor, I left a written list of questions. Staff were aghast at this affront and asked if I was sure I wanted to do this. Yes. I later learned this was considered so extraordinary that the vice president of medicine was informed. The doctor on rotation that week didn’t see any problem and answered them at his leisure. We had the patient covered 12 hours a day, what happens to others who only have visitors for an hour or so? Do you ever get answers?

* A striking example of the hospital’s “failure to communicate” occurred when a feeding tube was installed in the patient’s abdomen. Medical unit nurses prepared the patient by removing a feeding tube from the nose. The patient was then placed on a gurney and taken the 50 feet to the X-ray department where the procedure is done. The first thing the nurses there do to prep the patient is insert a tube down the patient’s nose! I said to the nurses, “They just removed a nose tube.” The X-ray department nurses said, “They always do that, we don’t know why.” I asked if anyone had mentioned it to them? No one knew. I spoke with the chief RN on duty in the medical unit to see if she understood this situation. “They have never told us that. They should be telling us, not you.” This hospital has been open for 19 years and people working less than 100 feet from each other have never discussed prep procedures! This is hurtful and disrespectful to the patient, and costly to the system.

After we were discharged I spoke with an RN from the hospital. When she learned our patient had been on doctor rotation she said, “Oh. So you fell through the cracks.” Obviously, the staff know the rotation doesn’t work, but administration won’t admit that. I suppose they worry about legal liability.

From my anecdotal observations gained during nine months on the floor, it seems that patients who are attended by their own doctors recovered and were released more quickly than those on the rotation. I wonder if the constant communications from their own doctor helped speed things along and avoid the medical limbo the bulk of patients find themselves in? I wonder if anyone has studied this?