The most poorly managed institution in modern western society is the hospital. I say this after half a century of steady exposure to hospitals of all sorts. I was a student, resident, fellow, staff member, section chief, department chair, chief of staff, and even a patient. Inertia at all levels was unconquerable. Newton’s first law is everywhere decisive – bodies at rest tend to remain at rest. The modern hospital, of course, should be the best run component of our high tech infrastructure. But the average Holiday Inn is better run than the leading hospital in almost any major city.

Most of what a hospital does is the same as what a hotel does – food, lodging, TV, etc. That part of the business is abysmal in comparison to a hotel. The food is awful, the accommodations dreadful even by the standards of a small business hotel in Japan. The TV carries only a few channels, is old, and very small. Hospitals are only just beginning to offer internet service. The major teaching hospital that I worked at for decades still doesn’t provide their patients with this service. As for Netflix and Amazon video, they are as rare as microbes are common. All this lack of amenities, when 90% of a patient’s day in a hospital is spent sleeping or staring at the ceiling.

Almost everything is lost. Try to find a patient’s chart. When you do it’s twice the size of New York’s Yellow Pages. Pick it up and more pieces of it fall out than the subscription cards in any glitzy magazine. If you really want to hide something put it in the patient’s chart. It will never be found again. The move to electronic records has permanently lost the chart – it’s in the cloud, wherever that is. The ER has created new and innovative ways of losing information while providing the all purpose excuse – a computer glitch or failure. Physicians spend so much time in front of their computers that the patient might as well stay home and email or text his problems to the doctor, thus possibly assuring that his physician might actually see them.

I went through a 2 month course of diagnosis and treatment with a physician who never once touched me. This coming academic year I’m participating in a course for second year medical students entitled History and Physical Examination by Extrasensory Perception. These soon to be physicians will thus be prepared to devote all their time to their computers. Fifteen years ago I went through a medical encounter that was temporarily derailed because a physician neglected to look at a chest x-ray. I’m the one guy in town who you don’t want to fall victim to the medical axom not to proceed without knowing the results of the tests you have ordered. This recitation brings me to the three culprits responsible for the generally subpar level of medical care in the US. Understand that I don’t believe that there was a halcyon age 50 or more years ago. Things back then were screwed up for different reasons.

First the doctor. He, or more commonly she, is the one constant in this rant. I have been telling my students since the prime of the cathode ray tube that medicine is 95% common sense. And right up to the age of CRISPR they have not believed me. By common sense I mean good judgement. While it’s nice to have an encyclopedic knowledge of medicine stored in your brain ready for instant recall, it’s not a requisite for good medical practice. Listening to your patient, doing an appropriate physical exam, and then ordering those tests that will get you in the right direction are the first steps. Medicine is now organized such that it’s easier to order 50 tests than just one. Here’s where good judgement is key. The physician should realize that if 50 tests are ordered at least two or three will be outside of the normal range, even if the patient is Clark Kent. Thus, it’s just as important to know which results should be ignored as it is to realize which require follow-up.

The next step is crucial. Which specialist should be consulted and how should the resulting opinion be used. What typically happens is that the generalist enlists a platoon of consultants and defaults the patient’s care to these various specialists with the unfortunate outcome that no one makes a decision without the concurrence of the rest of the platoon, which in turn results at best in semi-paralysis. As with lab tests, the physician in charge needs to know when to follow the consultant’s advice and when to move on without it. You are very lucky if you have a physician who has the judgement and fortitude to do as I just described.

The second part of this three legged stool of mismanagement is partially the result of the following third leg. The growth of the medical administrative regime has been metastatic. The administrative cart is far in front of the ass it’s supposed to support. Most doctors now work for an organization typically led by an administrator, eg of a hospital. If you want to judge the pecking order just look in the parking lot and see who has the best spot. Also look at the administrative suite and note its spaciousness and decor. A hospital administrator is interested in only one outcome – profit. The only distinction between a for profit and not for profit hospital is that the latter does not pay taxes. Good service and favorable outcomes are desired only to the extent that they generate income. The physician is valued by administration for the same reason. It’s no accident that savvy physicians who want to thrive in this environment get MBAs.

The last culprit is, of course, the government. The rise in medical costs is directly linked and proportional to the degree of governmental involvement. This involvement is now total. When Obamacare passed and the Republicans pledged to repeal and replace it, I said that whatever they came up with would be called Obamacare. Once the federal fox is in the hospital henhouse, he’s there to stay. The biggest reason your doctor seems welded to his computer is the federally mandated rules and regulation to which he must comply. The practice of medicine is now to a very large extent guided by a bureaucracy similar to that established by the Dodd-Frank Act. If you don’t check the right boxes and don’t use the right ICD 10 code you won’t get paid. Currently, there are 68,000 ICD-10-CM codes and 87,000 ICD-10-PCS codes compared to 14,000 ICD-9-CM codes and 4,000 ICD-9-PCS codes previously used. Mama, don’t let your son grow up to be a cowboy. Tell him to become a coder.

Congress is now debating how to fix healthcare (the biggest misnomer in common usage). This is akin to asking Lizzie Borden to make a career in eldercare. Things can always get worse, but pain tolerance can increase in parallel. Thus it’s hard to gauge how much longer the voters will endure the current state of medical mismanagement. Is it a surprise that the number of applicants for each place in an American medical school is below 2 and likely to continue to fall?