i devoured this book in a day - it's a literal recount of my residency experience at harborview, Seattle's county hospital! right down to the the names of the "outsized personalities" that make harborview what it is. the author, audrey young was the year ahead of me in training. read this if you want to find out what it was my training was like. (a no brainer clue - it's nothing like gray's anatomy.) from running the medic one radios in the emergency room to sprinting for codes across 6 ICUs and 7 floors, the anecdotes seem as familiar as if they were my own patients - and some of them probably were, since the patients she describes are composite sketches of "frequent fliers" who were familiar to everyone who worked there. also read this if you want a window into how broken our current health care system is and why we need reform - more reform than what's on the table.
I learned that while we were training, 1/6th of the urban public hospitals in the US shut their doors, and in nonurban areas, public hospital closures exceeded 1 in 4.
I remember that Harborview was always open for patients - when we staffed the medic one phone, we were responsible for accepting everyone who came to the hospital by ambulance or by transfer, and we were instructed that we always took everyone with the utmost of politeness. But when Harborview filled - and unlike many private hospitals, who might say they were full even when beds were only 65% capacity because of staffing issues or saving beds for the lucrative elective surgeries to come, when Harborview fills that meant we were working at 110% capacity - it would be curious that other private hospitals that moments earlier had plenty of beds open were suddenly closed to Harborview patients. Because our patients often didn't have insurance.
some of my favorite excerpts:
"Copass ... describes a drinker named Douglas Lightfoot who was routinely delivered to the county ED by the Seattle PD. 'What's important about Mr. Lightfoot is that he pickled his hypothalamus. Which makes him an amphibian. Put him on a warm rock, he gets warm. Put him on a cold rock, he gets cold. When Mr. Lightfoot comes in, you should say, 'How may I help you, sir? Can I get you a warm blanket? Can I get you some hot soup?' Because that's usually what Mr. Lightfoot needs.' ... He warned us not to keep Mr. Lightfoot waiting while we got coffee or composed a Pulitzer-worthy chart note. if something needed doing, we were to handle it politely and efficiently and, when we were done, move on to the next patient. 'The essence of the emergency room can be summed up like this: How quickly can we work, how well can we do?'"
Fleet: "Is the pain focal or cosmic?"
"Fleet told me that the PR dept had consulted him years back on a newfangled logo for the hospital, a blue-green design that showed off the original building's art deco style. That didn't capture the place at all, he told the PR people. If you wanted to represent the hospital, you had to show a guy lying in a gutter in Pioneer Square, and out of the corner of that guy's eye, shining up on the hillside, would be Harborview."
and some cogent analysis:
"the Dartmouth Atlas of Health Care [is] an extensive body of research that showed that systems focused on specialty care are ultimately more expensive and often produce worse health outcomes than systems with a strong primary care focus. But what can Harborview do with this information? The hospital won't expand primary care services as long as they are losing money, and these services are likely to lose money for as long as the market continues to undervalue primary care."
"Clearly, there are occasions in which technological innovations work miracles, but there are also so many instances in which we simply acquiesce to the over-medicalization of our lives, instances in which medical treatment does little to relieve the anguish of disease, aging, or death, let alone improve health... Enormous sums are spilled in the last six months of a person's life. How can it make sense to withohold our spending until there's slittle left to gain, and then blow it all?"
And for all those of you who "don't want to pay for someone else's bill," you already do. "The cost of caring for the uninsured is picked up by everyone else. Based on data compiled from several government databases ... $922 of the typical family health insurance premium in 2005 went to cover the cost of the uninsured. This cost is expected to rise to $1502 per family by 2010. One-twelfth of health insurance fees paid by employers goes to fund care for the uninsured."
"What we should pay attention to is Harborview's novel operational model, its practice of directing "profits" into health care for all, rather than to stockholders or whoever else is occupying the organizational pinnacle. The Harborview model works because all of the staff make sacrifices, including those at the executive and professional levels, and because everybody is working toward something larger than their own financial gain."
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