We can all probably recognize Zombie Healthcare, whether we’ve experienced it firsthand or with friends, family, or loved ones. You go into a clinic or urgent care or emergency center. Perhaps someone greets you without eye contact. “Insurance and ID,” they say. You hand them your cards even though you know they have them on file and nothing has changed since your last visit. Or if you are uninsured, you’re given a bunch of forms to fill out to determine your “eligibility” for services or discounted care. Or maybe you’ve never been to this particular place before. In any case, you are going to be asked to hand over your information, the things that they need to let you in the door. Personnel might speak to you in that kind of roboticized voice that sounds distanced and impersonal, without inflection. They ask you numerous questions as if reading off a checklist—not curious at all about the answer. If you say “Um”, or hesitate to answer, they repeat the question loudly or just answer it for you and move on. You wait—a long time. Things are sometimes done to you—labs, x-rays, other tests. People may be technically courteous, but no one really says why things are happening in plain language that’s understandable. You’re told everything’s fine. Your symptoms are not a big deal. “Nothing serious.” (Variations on this include: “It’s just a virus.” “It’s probably nothing.” Or “You don’t have x,y,z condition.”) You leave without answers. Or you are told you do have some condition but you might not really understand what it is; you’re given prescriptions but you’re not sure what for or why. You leave feeling underwhelmed and unsatisfied. But what can you do? That’s healthcare.
And that’s when things go relatively well, not counting medical errors, complications of procedures, or just plain rude or dismissive staff. Or your insurance is not covering your prescription and you have to wait for the pharmacist to “call your doctor.” And then there are hospital stays—in which so many encounters with various staff members can leave one dizzyingly confused as to what exactly is going on or has just happened at any given moment.
To be honest, I think this kind of Zombie Healthcare is more common than we might think. And I’m a medical doctor myself.
Dr. Mark Vonnegut has been a general pediatrician in his own private practice for forty years. We interviewed him recently on the Current Affairs podcast. In his recent book The Heart of Caring: A Life in Pediatrics, he uses the term Zombie Healthcare specifically in the context of burned out healthcare workers. Workers may just go through the motions of their work, leaving patients feeling neglected and unheard. Zombies are just about the last kind of people any of us would want taking care of us—or trying to heal or comfort us—when we are ill. Burnout, Vonnegut says, comes from having to do things to patients that don’t help them, things that even harm them. Such duties include burdensome paperwork or justifications required by insurances; “action plans” and questionnaires, mandated by insurance or institutions, that may not be beneficial to patients; or work habits centered on making one’s practice more “efficient” or “revenue enhancing” (seeing more patients per hour, or creating pointless procedures to charge more for a visit). In other words, these duties are all about anything other than the human being in need of care and empathy and time. It’s also about “feeling powerless and unable to help patients,” “like a cog in a machine.” People who are burned out, he writes, should not really be taking care of patients. But with record numbers of healthcare workers either leaving the field (especially in light of the pandemic) or remaining despite burnout, it seems most of us are going to encounter some degree of Zombie Healthcare. This is not the way that healthcare should be. As a practicing pediatrician, I once felt like “a cog” in the healthcare machine. It’s a terrible feeling. One feels ashamed to be a prominent representative of such a dysfunctional system, one that forces clinicians to prioritize insurance or institutional mandates rather than the human needs of patients.
I recall an episode of Zombie Healthcare from about a decade ago. I arrived to a check-up appointment well ahead of time, as instructed. I ended up waiting nearly an hour to see the doctor. The office staff admitted the delay was due to the doctor having been on call overnight at the hospital; that’s why she was running late. That was bad news to me. I feared the doctor would be a in a foul mood since it was unlikely to have been her choice to come see a patient in clinic after a long night on call. My fears were correct. The doctor arrived. Her blue eyes were cold as ice, and bloodshot. She expressed the standard pleasantries but in an unfeeling way. She scrolled through my medical history, which was fairly unremarkable, yet she felt the need to comment: “What a mess.” She said that out loud. Stunned, I didn’t say anything back to her. I left the visit feeling angry she she had been so cold. I thought about complaining but decided not to. I reasoned: the system functioned to create this situation, which practically guaranteed she would be perform poorly. If I complained, it would lead to some “patient satisfaction” problem for her, and I didn’t think it was worth it in the end.
Vonnegut also warns against care that is “abysmally bad,” care that he has seen his friends and family members receive. Care that he describes as “incurious, unscientific, and indifferent.” And it’s not simply an issue of bad intent or performance on the part of healthcare workers (yes, I’m sure there are some healthcare workers that just aren’t able to do a good job on a given day, for whatever reason). The problem is systemic. For example, the time scarcity that is imposed on healthcare workers, particularly doctors, means that there’s always a rush to see patients. The rush is relative—a patient visit can be scheduled to last anywhere from 10 minutes in a busy primary care practice to 1 hour or more in a specialty clinic. But that time scarcity always encourages certain behavior, whether it’s taking shortcuts (typing while one talks to a patient), ordering more tests or specialty consults instead of spending more time with the patient to figure out what’s going on, or just in general being hurried. As Danielle Ofri, an internal medicine physician and writer, puts it:
“In the pressurized world of contemporary outpatient medicine, there is simply no time to think. With every patient, we race to cover the bare minimum, sprinting in subsistence-level intellectual mode because that’s all that’s sustainable. We harbor a fear of anything ‘atypical’ popping up. I dread symptoms that don’t add up, test results that are contradictory, patients who bring in bagfuls of herbal supplements with instructions to ‘ask your doctor.’ If I can’t spring to a conclusion in a minute flat, I’ll never keep up. God help me if their medical history includes [something obscure or complicated]. … If it requires thinking, I’m sunk.
This is an embarrassing admission for a field that prides itself on intellectual rigor. But with the frenetic pace of medicine today, there’s no time or space (or reimbursement) for cogitation. We end up overordering tests because it feels more workable in the moment. We overrefer to specialists because we don’t have the mental bandwidth to integrate confounding data. Beyond the financial waste, modern medical practice is a Petri dish for medical error, patient harm, and physician burnout. There’s no surer way of grinding down committed clinicians than forcing them to practice the cookbook medicine we’ve always derided.”
Ofri is exactly right. When I first started practicing general pediatrics, I was struck by how little time there was to think about the situation at hand. Many patients are healthy and their routine check-ups go smoothly and quickly. To some degree, one does get “faster” with experience. Common conditions being common (sore throats, ear infections, skin eruptions, diarrhea), you see a lot of the same things on a given day, and these visits become routine as well. But you never know what’s going to happen with a given patient, and a patient is only simple from a medical standpoint until they’re not. Some patients require significantly more time and thought than the system allots. Maybe their symptoms are not entirely clear. Maybe there is a challenging social situation impacting the whole case, and that adds a layer of complexity. Maybe one needs to think about the case more, or talk to another doctor about it, or refresh one’s memory on the diagnostic possibilities. Maybe it’s late in the day, and one has decision fatigue, and so a situation takes longer than it would have earlier in the day, when one’s thinking is fresh. Whatever the case, the system is simply not built for you to have time for extra deliberation. Time scarcity is an insane condition under which to practice medicine. As the saying goes in medicine, “Patient care takes as long as patient care takes.” In other words, you cannot put a time stamp on care. Yet the system will never let you take the time you need. You can take your time, of course. But you will pay a price. You will spend the rest of your day trying to make up for lost time. You will stay late doing charts. You will give some other patient less time than they deserve, or make another patient wait, to make up for a complicated patient earlier in the day. And everyone around you—from front office staff to medical assistants to lab techs to social workers in your clinic—must also deal with this time scarcity and with patients’ and their families’ rightful frustration with this rushed system. And that’s just one example of how the system promotes bad care by design. Ultimately, whatever you call it, bad medical care is dangerous. And as Vonnegut argues, most of us are defenseless against it. (This is why I believe that all patients need an advocate—either a family member or a friend—with them at clinic visits or hospital stays.)
In early March 2020, around the “start”1 of the pandemic in the U.S, my mother came down with a runny nose and cough. A few days into the illness, she went to her primary care doctors’ (PCP) office, where she saw her doctor’s nurse practitioner. My mother was told she had a virus and was sent home with an inhaler. However, a couple of days later, about a week into the illness, she developed a fever, headache, and worsening cough. My mother understands that a fever in an elderly person is not to be taken lightly. She decided to go to the emergency room, which I agreed was a good idea. The timing and nature of her symptoms concerned me: a new fever several days into a “viral” type of illness raises concern for a bacterial infection. Perhaps a sinus infection or a bacterial pneumonia? Or something else?
Well, my mother spent several hours in the ER (her neighbor, himself a medical doctor, went with her for support), where she had extensive lab work done along with a chest x-ray. A “friendly” doctor (her words) told her she was fine and that everything came out “normal” and that she just had “a virus.” She was sent home. But her symptoms had been worsening. Her fever continued. She had an intense headache. While fevers and viral illnesses can certainly cause headaches, I was struck by how intense her headache was. I wondered if something else was going on. I got my mother’s login information for the hospital portal and, the next day, checked the labs myself. Everything looked okay—except the sodium level. It was much lower than normal. Low enough that it should have been re-checked before she was sent home to confirm whether it had been a lab error or a true abnormal finding. If the latter, it should have received further evaluation (there are several possible causes of low sodium, and headache is among the symptoms low sodium can cause).
I called her PCP to see if they could order a sodium lab check. But it was the weekend, and they couldn’t. They said she’d have to go back to the ER. So we went. The whole process was repeated. The slew of labs, the chest x-ray—and no, we couldn’t get a COVID test despite my raising the issue with the ER doctor. (COVID tests were only for patients being admitted, I was told. Which made zero sense to me but that was that.) In the end, my mother ended up having what’s called atypical bacterial pneumonia (it did not show up on x-ray and required a CT scan of the chest) with associated hyponatremia (the low sodium was confirmed). It’s fairly textbook—I remember learning about it in medical school. You treat the pneumonia with antibiotics and give the patient some extra salt by mouth and the salt level corrects itself. But it took two expensive ER visits to make this diagnosis because the low sodium level had been missed by the first doctor. And nobody in the ER apologized for the fact that the same facility had sent my mother home the day before with an abnormal lab value that should have been dealt with.
Then there was the prescription error that resulted in my mother receiving half the number of antibiotic pills she needed. This required phone calls to the ER to try to get the prescriber to fix it—and another trip to the pharmacy to get the missing pills. I had to talk to a pharmacist on call in the ER who wanted to change the antibiotic instead of fix the prescription, and only after discussing it with them for several minutes and firmly confronting them (“You are not the prescribing doctor, please just fix the quantity amount”) did I manage to convince them to relent and fix the problem.
Within a day or two my mother’s fever resolved, her headache got better, and she turned a corner. While she recovered from her illness without complications, I think about other ways that it could have gone.
What about the patients who do not have doctor family members to check their labs for them? What about the patients who stay home despite worsening symptoms because they were told multiple times, “you just have a virus.” (Pneumonia can be severe and quite dangerous in the elderly, and with COVID, “just a virus” has taken on new meaning.) What about people who live alone and don’t have others to check on them? What about any number of other complicating factors? To me, overlooking or misinterpreting an abnormal lab value is inexcusable. I don’t know why it happened. But it shouldn’t have happened.
Bad care can happen to anyone. Historian Timothy Snyder wrote about his experience in European and American healthcare systems in Our Malady: Lessons in Liberty from a Hospital Diary. The American experience was notable. Snyder was bothered by the fact that he—a privileged white man with health insurance—received, at times, such shoddy care. His point was not that he should receive care superior to that of anyone else, but that even the most privileged people in society are not protected from bad care. (No one should get bad care, he argues.) On one level, Our Malady is a patient-level indictment of the inhumanity of the U.S. healthcare system. Snyder details the dismissiveness with which he was treated. Snyder didn’t die, but he very well could have. He was already in sepsis (a dangerous infection) by the time he got to a New Haven hospital in late December 2019, his fourth presentation for medical care in less than a month. In between moments of lucidity and fading consciousness, he observes a world of chaos, of actors dismissive of his concerns. He describes distracted physicians performing a spinal tap and dismissing his requests that they review his medical records from the previous hospital visits. He undergoes two surgeries to drain a pocket of infection from his liver. He is discharged with antibiotics and has followed up with a neurologist for persistent tingling in his hands that he’s told may be the result of nerve damage from an exaggerated immune response to the infection.
Consider this observation of Snyder and his wife’s experiences around prenatal and birthing care, comparing the experience in Vienna with that in the U.S.:
“At every step of the pregnancy, right through childbirth, we had the sense, even as foreigners, that the medical system was designed for the child and for us. There was never the creepy moment that one has inside American commercial medicine: when you wonder just why something was done or not done, or why some weird evasive phrase was just uttered, or why a doctor or nurse behaved oddly or slipped away. In the United States, one often has the feeling that there is a hidden logic dictating events, because there is: a logic of profit. In Austria, it was clear that the goal was the welfare of the unborn child. Prenatal visits were mandatory, in exchange for access to the welfare state.”
Snyder’s wife had their second child in the U.S., and that experience was much less comforting. In contrast to the Viennese experience of no medical bills, engaging birthing classes, un-rushed delivery, and the intense four-day postpartum stay in the hospital being taught by nurses how to breastfeed and care for the baby, the U.S. experience was cold, protocolized, rushed, and involved lots of medical bills and statements. Snyder puts it startlingly: “It does no honor to the idea that ‘all men are created equal’ to mandate an unequal start to life.”
Our neighbor, the doctor who had helped my mom during her first ER visit, is actually so jaded with medical care that he completely avoided care after a fall left him with a swollen arm a couple years ago. He refused to get an x-ray. He cited his father’s decline after a fall as his reason for avoiding care: his father had fallen, broken his hip, and then the care and hospitalization for that had resulted in numerous complications that led the man into a downward spiral which resulted in his death. Our neighbor’s is an extreme case to be sure. He had a swollen arm for some time, and he hasn’t regained full function of that limb. But it goes to show how traumatizing healthcare experiences can be.
To be clear, Zombie Healthcare is a systemic problem. I don’t blame healthcare workers in general for Zombie Healthcare. Every day, healthcare workers show up to work in a system that is often hostile to patients and to workers. Every day, workers try to take care of people the best they can. Just as I remember the bad experiences in healthcare, I also remember the good ones (for example, a particularly caring ICU nurse who took care of my father when he was sick many years ago, a specialist I saw who never used a computer in the exam room and always talked to me like I was a person, not just another patient on his schedule). While everyone is responsible for their own actions and for making sure they do their job to the best of their abilities and according to professional standards (I am not arguing that we excuse or overlook incompetence, malpractice, or serious medical errors), the system promotes bad care and indifferent care, and healthcare workers should not have to be superhumans who fight against bad conditions to somehow maintain perfect composure and performance. Furthermore, people can be motivated to act in ways that reflect their best selves, or less than. Unfortunately, our for-profit health insurance system—that which we call “healthcare”—often motivates workers to carry out their jobs in survival mode, and that survival often results in sub-optimal healthcare delivery. We all deserve better than Zombie Healthcare, and healthcare workers deserve better than the working conditions that promote Zombie Healthcare.
The first step toward achieving better conditions, as Vonnegut argues, is to remove the profit motive from healthcare and the artificial scarcity and bureaucracy created by this for-profit system. The competing ideas of what Vonnegut calls “money” or “mission” (to help people) “cannot coexist.” We must enact a single-payer system. We need Medicare for All. But a socialized payment system is only part of the fix.
As Vonnegut puts it, the care of patients has to come first. The goal of healthcare should be to get people better and reduce suffering, period, so that people can enjoy their lives. Doctors, nurses, and all healthcare workers taking care of patients must be given the time and resources needed to properly assess and care for patients, focusing on the concerns patients have. This means we need to adequately fund hospitals and clinics and other facilities throughout the country so that people everywhere can get high-quality care. We could also envision a system in which healthcare is not a transaction made in a particular building (although we could make those buildings beautiful and welcoming and healing). We could have, like many countries, a system of community health workers to interface with people in their homes and communities, to monitor people’s health, educate, and administer public health programs (such as vaccination programs) and direct people to further care when needed. We might also envision public fitness programs and gyms along with public options for food, since lifestyle is an important part of overall health. We can create the system we want, one that would truly promote human health and well-being. But we need to free ourselves from the prison of our for-profit insurance system.
Originally posted by Current Affairs on 2022-04-15 11:20:27