The Other Side of the Bed Shortage

I am spending my day on the other side of the hospital bed shortage. I am sitting with my sister in the nursing home where she is spending the final days of her life. She waited seven months in a hospital bed for this space to become available.
Around us, all is peaceful. People down the hall are playing BINGO. The lady across the corridor has visitors for her birthday. It’s a far cry from the hospital because it’s quiet.

A hospital is a noisy place, day and night. During the day, there are so many people: nurses, doctors, technicians, dieticians. There is all the activity that comes with them. There are also announcements: codes, visiting hours, when the coffee shop is open. There are serious conversations at bedsides and few private spaces. Everyone seems to be hooked up to at least one machine. There are, however, about 12 – 20% percent of patients who are not hooked up and who do not have conversations. These are the people waiting for a quiet space in a nursing home or palliative care or long term care.

Reading articles about Emergency Room wait times or hospital bed shortages, one is given the impression that patients do not want to leave their hospital bed. However, this is not true. Most of them, much like my sister, are relieved to have been moved to a quieter setting. “I’m glad not to be a bed blocker anymore,” my sister says when I first see her in her new home, “I don’t need all the bells and whistles.”

My sister likes this setting in many other ways. She has a view of the Nova Scotia countryside outside her window. There are sitting rooms throughout the residence, with televisions and plants and books – quiet, cozy corners of a type not seen in hospitals. There is a full recreational program and food my sister enjoys. There are two cats.

“The cats are good,” my sister says, “They keep down the mice. You can’t have cats in a hospital.”

“Don’t tell me there are mice in hospitals,” I reply.

“Okay, I won’t,” says my sister who was a nurse, “but you know that’s the kind of thing the doctors never want to hear.”

She goes on to speak about the guilt she had felt when she was “taking up a bed”. She considered that maybe it was because she had been a nurse. She remembered how exasperated she and her colleagues had felt about long term care patients in acute care beds. She hopes she was not too much trouble to the staff when she was still in hospital.

As a child psychiatrist, I have not had to wrestle with bed shortages as other doctors have. Everyone agrees that there is a significant need for long term care beds, but it does seem as though much of the advocacy for these beds comes from the acute care side of the occasion. It comes from the concern that patients are receiving their care not from the relative comfort of a hospital room, but from such places as the corridor of the Emergency Room or closets or any space that can be found. We would all agree that these are not good places to receive acute medical care.

But there is a need for us to be aware that there is also better care available to those patients like my sister who don’t need an acute care bed, but who cannot be comfortably cared for without significant nursing and home care support. People like my sister do not have a lot of energy for advocacy, nor do their families, but it’s important to remember them.

Our lives are important at every stage.

(These are the 2 cats who live at the nursing home. This picture is from Facebook.)

Bill 41 – More Questions

Last week, Dr. Del Dhanoa, a radiologist from Northern Ontario, asked some questions that I decided to answer as another blog since they continue the series I have been working on. The questions also spark further debate about whether the Minister of Health and Long Term Care has completely explained his vision of health care in Ontario, given the degree of change being undertaken in Bill 41.

This is the first question:

“What are your thoughts about Hospital CEOs and Boards? Will they eventually go by the wayside like British Columbia because the LHINs (and Minister) have much more direct control over Hospitals with Bill 41? A Hospital Board Director told me that she/he was ready to hand in his/her resignation after reading Bill 210/41. They feel like they no longer serve a purpose and, after all, their time is largely volunteer based.”

I served on the Board of my hospital when I was the President of the Medical Staff. What is most impressive about hospital boards is how deeply they draw into the fabric of the community in which they are located. My main clinical appointment is at the Royal Ottawa Mental Health Centre, a psychiatric hospital in Ottawa. The members of our hospital Board of Trustees include prominent local lawyers, very senior civil servants, patient advocates – all very busy people who volunteer their time to ensure that the citizens of Ottawa have access to the best possible mental health care. They are all volunteers and commit a significant amount of time to the work of the hospital. They have a vision for how the community can best be served that is grounded in the reality of the advantages and disadvantages of living in the national capital and its region. Bill 41 would add another lens to that vision and, unfortunately, it seems to be a lens that could override some of the most important decisions they make.

In the narrative leading up to his question, Dr. Dhanoa mentions the reaction of one of his hospital’s Board Directors. My husband had served on the board of a local Ottawa hospital and he too believes Bill 41 as an interference that that was unneeded. He spoke of the fact that every new directive or initiative from government just added time to board and committee meetings since one often had to work patient needs and priorities around them. For example, governments have had many interventions over the years to improve wait times, as if doctors and hospitals were not already working hard to do this. Really, does the Minister believe we are trying to increase wait times? Or decrease access? Doctors and hospital boards hear concerns directly from patients and can tailor a local response to their concerns.

Here is Dr. Dhanoa’s second point:

“The language in Bill 41 is pretty clear. The Minister can act to change Hospital mandates in the “public interest” and this includes activities that decrease Hospital length of stay. As you know, LOS is the basic currency describing the activities in hospitals: from the Emergency Department to the wards, to the lab and the medical imaging department. Everything in hospitals is based on LOS.

So, really, Bill 41 gives the Minister a lot of power to change the way medicine is practiced in all of Ontario’s Hospitals to meet the LOS metric. While on the outside that sounds great, I have many reservations on how that will play out in Ontario especially when physician input is ignored.”

I think that Dr. Dhanoa makes his own point very well and underlines how important it is for physicians to sit on and participate in their hospital boards because it is one important way in which we have input into how health care is delivered. Having said this, it was the decision of Premier Wynne’s predecessor to stop physicians from having a vote on hospital boards under the changes the Liberal government made to the Public Hospital Act in 2010. Doctors realized then that their input was being marginalized by the Liberal government in Ontario.

The problem with ignoring the input of doctors is that we spend all day every day working to integrate patients’ health care. Integration is the goal of Bill 41. Why ignore the concerns of those who actually understand how this might be achieved?

Bill 41 and Hospital Physicians

This installment on Bill 41 comes after a longer review of the Ontario Hospital Association’s backgrounder on Bill 210 released earlier this year. They have not published anything specific to Bill 41.

My personal concern about Bill 41 is based on my alarm over the extraordinary amount of control the government feels it needs over what doctors, agencies, hospitals and LHINs are trying to do locally to look after patients. This is the fourth time I have written about Bill 41 and the longer I look the more alarmed I become. What on earth makes the Toronto-based Ministry of Health and Long Term Care (MOHLTC) believe it has the answers to how health care must be organized in regions so different and so remote from each other that many of the citizens in one have never been to another?

The concerns about Bill 41 for doctors in hospitals are around these parts of Bill 41:

1.       Expanded Ministerial Authority over Hospitals

2.       LHIN Functions and Governance

3.       Home and Community Care

4.       Public Health

Let’s begin with the Expansion of the Minister’s authority over hospitals. Any time the government feels a need to expand its legal authority, it’s important to examine why their moral authority has not been effective in driving change. What Bill 41 really does is allow the Minister to override the decisions of local hospital boards, setting directives and standards. Having served on my hospital’s board in my capacity as President of the Medical Staff Association, I can state that our hospitals in Ontario are well-governed, put patients first and that their boards are populated by local experts who have the best interests of the patients and population at heart. The Minister has not given one reason why he needs to interfere with this. The doctors in a hospital can presently raise concerns with a Board through the Chief of Medical Staff or the President of the Medical Staff and their opinions are sought out and seriously considered. This is very different from doctors’ experience with government. Further authority for the Minister over hospitals is not good for either hospitals or the physicians who work in them.

Secondly, let’s consider how the changes in Local Health Integration Network’s (LHIN) functions and governance could affect hospital physicians. The bill expands the list of health service providers to include family health teams, hospices and “any other person or entity set out in regulations”. Some family health teams and hospices are hospital-based and all of those are staffed by physicians, so these doctors will be affected. In fact, it is important to remember how many primary care physicians provide hospital services. We tend to think of consultants being affiliated with hospitals but many hospital emergency rooms, operating rooms, wards and other services depend on family physicians to provide care. Many Emergency Rooms in smaller communities only remain open because their dedicated medical staff provide extra coverage. They don’t need Bill 41 to tell them what needs to happen.

What I find most concerning about this section on LHIN functions and governance is that the Health Professional Advisory Committee, which all LHINs must have at present, becomes discretionary under Bill 41. When LHINs were first introduced by the Liberals in 2006, the Health Professionals Advisory Committees were criticized as providing too little direct physician input into local health decisions. Now LHINs will have an option of excluding this group altogether. Why is there this need to exclude doctors from all healthcare decision-making?

As for home and community care and public health, all physicians must access these services for their patients and this includes hospital physicians. As a physician, I depend on community services for my most disabled patients. These services need more front line staff and a better capacity to deliver service in a timely fashion, not this extra bureaucracy that will tie up caregivers with paperwork.

Most importantly to all doctors who work in hospitals, all of us do see ourselves as being community physicians as well – after all, the hospitals where we work are in the communities where we live and are part of the fabric of our towns and cities. Hospitals and their medical staff contribute to the prosperity of towns and cities. Doctors care deeply about the prosperity of their communities and the quality of care provided by hospitals. Bill 41, with its need to bring greater control over health and health care decisions, is insulting doctors by giving the impression that these measures are necessary. The doctors in my community are working very hard to ensure that our care addresses patients’ needs. Many of us are volunteers on hospital boards, hospital committees, LHIN committees and Health Professional Advisory Committees. Is the Minister suggesting that we should stop? That’s what it feels like.

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Book Review: Stir

Stir: My Broken Brain and The Meals That Brought Me Home is a cross between a memoir and a cookbook. The theme, however, is not one that many can relate to, although the book will help the reader understand what it’s like to live recovering from a brain injury. At age 28, Jessica Fechtor was on a treadmill when an aneurysm in her brain burst. This is her account of how her favourite recipes helped her to recover.

As a physician, I was particularly struck by Ms. Fechtor’s accounts of her encounters with the health care system. These were certainly a stark reminder that, even in the United States, care is not always what it could be. Consider this description of an occupational therapy assessment:

‘ “How did you bathe before you got sick?” The healthy, unterrified version of myself would have realized that all of this “before you got sick” business was just standard language. The therapist had probably been taught to ask the same things in exactly the same way of each of her patients, many of whom – unlike me – had limited mobility before whatever had landed them in the hospital, orhad suffered debilitating physical or cognitive deficits. But hadn’t she read my file? And if she had, and she still thought these questions applied, was I worse off than I knew? Panic crept along the back of my neck.

‘ “I got into the shower. I washed my hair.” My throat was so tight that it hurt to talk. Why was I speaking in the past tense?

‘ “Can you show me how?” she asked. I lifted both my hands and wiggled my fingers around. She scribbled another something down. Silent tears had begun to squeeze out from the corners of my eyes. I wiped at them with the back of my hand.’ (Page 143)

As well as this interaction, the account of a hospitalization when Ms. Fechtor develops a fever after surgery would leave anyone with concerns about health care. In other words, this is not a book for the fainthearted. Having said this, the book also describes how the health care system comes back after a worrisome encounter and goes on to deliver topnotch care. It is this kind of honesty that characterizes the best memoirs.

Leaving the health memoir to consider the recipes, their integration into the text is extremely powerful. As one reads why certain recipes are chosen, the reader realizes in no uncertain terms that food facilitates health and healing. Ms. Fechtor traces the origins of some recipes to her childhood, others to her travels, but all of the recipes are linked to her own life. It is because of this connection that the food becomes an elixir for her.

Think about this for a moment. Think of the foods that you want when you’re not well. Food, preparing food, sharing a meal are linked to healing and comfort in all cultures. Fechtor’s memoir reminds us of this, and tells us in particular how the recipes she cooked, and that others cooked for her, helped her to recover. Food is not just about nourishing the body; it is about nourishing the spirit and this nourishment is linked inextricably to recovery.

An example to illustrate this idea could be chicken soup. Many people have a chicken soup recipe in their family that is felt to be almost a magic remedy. This book does have a recipe for chicken soup – and its history in Ms. Fechtor’s family. She also provides the secret to producing a clear broth, but I’ll let you discover that for yourself. If you’d like to get a feeling for Ms. Fechtor’s writing, you can find it on her blog. You can also find some of the recipes there. Why not find one and think about the food you like when you’re not feeling well? I made the pumpkin bread.

(Note: I read the first hardcover edition of the book published in 2015 by Penguin.)

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Living the Dream

I have not written in about ten days. I have been busy living a dream. On May 2, I began a new job as the Director of Youth Psychiatry at The Royal. This is truly a dream come true for me: to provide guidance to the best team of mental health professionals and to consider how to address the mental health needs of the 16 – 18 year olds in Eastern Ontario.

As I embark on this challenge, I am buoyed by the good wishes of my colleagues. I have worked with many of the staff for fourteen years and their dedication to patients has always been inspiring to me. If it were not, it would have been impossible for me to even consider this new job. The staff go above and beyond their normal duties to ensure that patients get the best care and that their families understand that care.

In the few days since I started this job, I have found myself looking for extra hours in the day and extra weeks in the calendar. I do not quite realize that I’m going to have to give up some of my patient hours to get this new job done. As I set about managing my time, I thought, “I cannot give up the Thursday clinic” and “I’ll still be able to do Dialectical Behaviour Therapy”. “Are you still going to be able to see me?” is the most common question I hear from my patients. Everyone who knows me knows that I will not just drop anyone so the last question is easy to answer, but some clinical commitments will have to change – I almost get it.

Another interesting thing is that I have meetings – more meetings than I ever thought possible, for committees identified only by acronyms or letters. I asked someone today, ”What is the ABC Committee?” You know you are in serious difficulty when the acronym listed as words does not help you understand what a committee does.

The nature of a physician administrator’s work brings a doctor directly into the conflict between the patient and the system, with the necessity that the patient must get the best service and care at the same time as the system improves. Finding the best care often requires the system to be more flexible than is possible. Improving the system often changes many of the elements of care that patients and their families felt were helpful.

Doctors are the one link in the health care system permitted a degree of professional autonomy because of the mechanism by which they work in a hospital. Instead of being employees of a hospital, doctors are appointed to a hospital’s medical staff through a process in which they have privileges for certain activities, such as admitting patients. Balancing professional autonomy with a hospital’s public mandate is a conundrum that a physician administrator has to consider – it’s so much easier to fall back on clinical work.

Having said this, an administrative role such as my new job gives a doctor a chance to facilitate the changes that will improve care. I’ll decrease the paperwork, get electronic prescribing, improve the electronic health record…I’ll make a difference. That is the hope. Even if I don’t understand what my committees do, or how I’m going to do all the clinical work I want to, I know that having this new role is gives me a unique opportunity to help both patients and my local healthcare system. Someone said to me, ”I can see how pleased you are to have this job, you brighten right up when you talk about it.”

I hope that I’ll wake up gently as I begin to realize what I’ve gotten myself into.

 

Hospital or Community?

Everyone in Ottawa is preoccupied with thoughts of a new building for the Civic site of the Ottawa Hospital. The local Member of Parliament and Environment Minister, the Hon. Catherine McKenna, expressed concern that the site chosen on the Central Experimental Farm would destroy valuable agricultural research. As well, the increased size would turn the rest of that green space into the staging area for a large healthcare factory.

As well as the Minister, Kelly Egan, the Ottawa Citizen columnist, decried the lack of true public consultation and raised a point that the planners for a new Ottawa Hospital seem to have overlooked: “hospitals are not the best vehicle to deliver basic health care”.

It is exactly this lack of vision about the function of hospitals in the future that troubles me. So far, the discussion seems not to have considered that there are many who believe that we must move health care away from hospitals, especially basic care. What is basic health care? For most of us, basic health care consists of the minimum health care necessary to prevent illness and to manage chronic disease. For most of us, it is the care delivered by our primary care physician, with some diagnostic tests and pharmacy consultations included. That care is minimal when we are healthy, although even healthy people require greater basic health care at the beginning and end of our lives. The care at the beginning of our lives is mostly preventative while the care we require as we age usually includes some attention to chronic illnesses that we develop.

Chronic illnesses are those with symptoms that wax and wane, becoming acute only periodically. These are illnesses like hypertension, chronic obstructive lung disease, or depression. The people with the most chronic illnesses are older people, and what do older people want for their health care? As the doctor in my family, I have had a lot of experience in health care with the older people in my family. I have a good sense of what they want, and, as I age myself, I am getting an excellent idea of what I don’t want.

I do not want more and bigger hospitals. I do not want to spend my final years in or visiting some healthcare factory. As I have watched older and less healthy family members struggle with chronic illnesses, I realize that their least happy times were when circumstances forced them to be admitted to hospital. Having said this, this is where all of them died, despite their wish to die at home. From visiting many relatives in hospital or in their long term care residences, I know that these views are not unusual. Almost every older person I know feels this way.

The Ottawa Hospital is not necessarily at fault in this situation. One of the most innovative institutions in the country, it has responded to community needs and bears the responsibility of having to be everything our community wants in a university teaching hospital. It provides excellent care by devoted staff and is desperately In need of updating. But how does a community balance the needs of patients and families with the need for health care delivered efficiently?

One agency that certainly seems to be considering what the public wants and needs is MaRS. MaRS Innovation is a not-for-profit organization based in Toronto that seeks to bring medical research to market. You can find out more about this organization from their website but I wanted to show how their analysis of health care transformation affirms the view that care must move away from hospitals and into communities. The infographic (included below) in the description of their Transforming Health event shows how decentralization away from large institutions could transform health care.

Could my community embrace such a model? Most people I have spoken with acknowledge that sometimes there is no choice but to be admitted to hospital, but do so many clinics have to be in a hospital? Have the planners (both hospital planners and regional planners) spoken to patients and families? Have they heard what I have heard from elderly relatives and friends? These are some of the ideas that I am hearing, and that I am coming to want for my own health care as I age:

  1. Please provide my health care to me at home, as much as possible. I will happily skype my doctor while instruments read my vital signs. If need be, the appropriate health care provider might drop around to my home for more complex tasks like drawing my blood or completing a health exam.
  2. Please make sure it is convenient to get my blood work and other diagnostic tests completed. Some evening hours would be good so that my wife (or daughter, or son, or neighbour) doesn’t have to miss work to look after me.
  3. Please make sure my family doctor gets reports as soon as possible. Giving me a copy might help with that.
  4. It would be nice if my wife (daughter, son, neighbor) could run other errands while I am waiting for my appointment. Could this clinic be in a mall?
  5. Since what I do in hospital most of the day is wait for doctors, could I not do this at home with nursing care?

All of these wishes confirm that there is a desire for more care in our communities, not necessarily a desire for a bigger hospital. As well, when one considers how many people are waiting for long term care, are more hospital beds needed or more long term care beds?

In the interests of full disclosure, I must add that I currently live one kilometre from where the Ottawa Hospital would build a new Civic site and I dread the impact it will have on my neighbourhood.

Like my neighbours, I am distressed at the thought of a huge industrial health complex taking over more of my neighborhood than it already does. Like my neighbours, I understand the importance of the agricultural research at the Central Experimental Farm that will be destroyed if the building is placed on a site there. The Canada Agricultural and Food Museum, and its young visitors, will be affected by such complex development. Is there no concern about that collection of heritage Canadian animals?

But, most importantly, will the public discussions include patient and family consultations?

MaRS

 

 

Follow-Up: 2 Hospital Days

ScutariIn the five days since I wrote about my husband’s experience in hospital, I have heard from over one hundred people who have had similar experiences, either personally or with a family member. You can read about some of their experiences in the comments related to my previous post, as well as on my facebook page. I also received many emails, as did my husband who sent the blog out to a number of his friends.

As I read through many of these accounts of bad food, dirty surroundings and a lack of privacy, I recalled reading the biography of Florence Nightingale when I was 9 years old. While I am not saying the hospital conditions in Ontario today are equivalent to those at the military hospital in Scutari in the nineteenth century, I vividly recalled from that biography that patients in Victorian England dreaded going to hospital because the conditions were worse than the poorhouse. I found myself wondering if our hospital services had reached the point where we were going backwards – back to a time when people did anything not to be admitted to hospital. Read through a few of the comments to my last post and you’ll see that some people are saying just that, that they will do anything to avoid hospitalization.

The question for me, after reading so many insightful comments is: What can ordinary Ontarians – and most of the people commenting were Ontarians – do to help hospitals improve the level of care they provide? What should they request when they lobby or write to politicians? How can they be helpful after a hospitalization, either their own or a family member’s?

Some of those Ontarians who expressed concern were physicians. There is one thing that many physicians can do to improve hospital care if they work in hospitals and that is to be as vigilant as possible about their medical staff meetings and opportunities. I met with Dr. Chris Carruthers a month or so ago. He reminded me that doctors have a lot of influence via their positions on hospital committees and boards but that they often do not bother to attend those meetings or committees. This is something we could change. The physicians and nurses who attend Board and Committee meetings have a unique opportunity to put forward the patients’ and their own point of view.

As a Clinical Director, I ask my patients and their families to fill out my hospital’s surveys, including their impressions of our brand new building. Patient concerns are taken very seriously. I believe that if every patient concerned about the quality of hospital food mentioned it on a survey, change would begin to happen. That is one example but change related to patient experience is necessary in many aspects of hospital life.

An important element in a facility is atmosphere. About one year ago, I moved to an office that was big enough for me to complete my assessments in it. A number of my patients mentioned how much better they like my office than the interview room. They told me that they feel more welcome when they are able to see me in my office. Their comments make me want to do something to make the interview rooms more homey but hospitals have fairly rigid rules about what can be put on the walls in common spaces. I wonder if that’s a completely good thing.

Not wanting to be in hospital is normal but I am still concerned that my last article raised so much negative feedback about the physical attributes of hospital care. With so many people taking time to write about their experiences, I wanted to provide even a couple of small things we could do to improve our hospitals. We can do this. Please let us all know what you would do to improve hospitals. If there is enough interest, it might even be worth having a tweetchat to generate interest and raise awareness with respect to the problem.

Finally, thank you to everyone who read my article and took the time to let me know their experiences. I have learned so much from all of you.