Hospitality and Kindness in Health Care

Here was the headline in the Valley News up here in the Upper Valley (central NH/VT) that caught my eye today. Having had multiple experiences at DH (Dartmouth Hitchcock Hospital, now Dartmouth Health) these past few months, and obviously years (all 3 of our kids were born there), I started thinking about the reasons they cite for this freeze on accepting new patients.

For context, there's a "thing" out there these days that we have to support health care workers no matter what the circumstances. And so many of us do. And we should continue to do so. In the early months of the pandemic, a great example of this was hundreds of Boloco customers tossing $60,000 into a GoFundMe account, no questions asked, which allowed Boloco to deliver over $100,000 worth of meals to hospitals throughout New England. That was more than 20,000 hard-working health care workers served. It was fun, to be honest.... selfishly it felt good to contribute even in the smallest of ways.

While the people we encountered at the hospitals were kind in those circumstances (delivering food), showing up as a patient often doesn't yield the same behaviors. It almost feels like Jekyll and Hyde. The same gentleman who graciously welcomes us with piping hot burritos is now a little more gruff. Dare to question anything that is said - especially if it doesn't make sense to the non-health care human being - and risk being met with a stone cold stare and a rebuttal that makes you feel anything other than cared for.

I'm not sure I necessarily blame the individuals themselves... in fact, I'm sure I don't. No, its the institution, the culture that leadership instills day in and day out that leads to this kind of treatment of patients. DH seems to be suffering more than most.

When I see that DH is putting a freeze on new patients, instead of citing the standard “... a number of factors impacting different locations in different ways, including labor market shortages, challenging recruitment for limited number of primary care physicians, adequate regional housing and varying degrees of pandemic recovery at each site", they could consider adding in ".... and yes, until we can guarantee kindness and humanity in all of our patient interactions, in other words fix our broken service culture, we really don't deserve any new patients."

From my family's admittedly anecdotal experience over the past few months, things really are broken.

At a base level, decent bedside manner of too many of the staff (and this by no means includes ALL staff members, please know how grateful and appreciative we are of those who do their jobs so well despite the broken culture) is painfully absent. Yesterday, for a really, really recent example, my wife went to DH for a relatively simple procedure - the kind that most soon-to-be 50 year olds have to undergo - and it turned out that an adult was supposed to accompany her for her entire visit to the hospital. Neither of us knew this, likely because we had not read all of the admittance instructions, so after I dropped her off I innocently continued on to a speaking engagement at Tuck with plans to return immediately after - even then, I knew I would wait at least an hour or more before she was ready to be discharged. Not long after I got back on the road, Maggie called me letting them know that they would not sedate her for the procedure unless I returned to the hospital and stayed put. I could not leave or she would have to undergo the procedure with no drugs whatsoever. She decided I should not leave the professor and 60 students hanging so I continued on and she was ready to, shall we say, rough it. Not fun to think about, a policy totally not in the best interest of the patient. Not a lot of time to worry about it in the moment either.

When I returned to the hospital an hour or so later, I was admittedly frustrated and asked them if they could now sedate her since she had just gone in and I was now there. With no emotion, the answer was no. It was too late. I asked the woman when this policy was implemented, because having had my own colonoscopy down at Mass General I did not remember having Maggie required to stick around. When Maggie had melanoma surgery 2 months ago at Sloane Kettering they did not make me stick around. Why then at DH? It turns out, I was told impatiently, that a patient had once said they were going to get a ride home and lied... and apparently got into a car accident driving themselves home. And voila... the vice tightens. For the 99% of us who are being honest about having a ride home, its the other 1% that dictates policy... and while there's an argument it is for the safety of the driving community at large, the reality is that its to cover the hospitals a&*, which is exactly what the not-so-happy lady at the desk told me. "Liability", she said. I left and hung out for the next hour in the hallway, making sure to remind her as I exited that my frustration was not with her personally but with a system that gets in the way of treating people with kindness, empathy, and doesn't even put the patient's best interest front and center.

It doesn't have to be this way. When we had to transfer from DH for Maggie's melanoma because DH was so backed up that it took 3 months to even get a malignant diagnosis (or any communication whatsoever that something was amiss) and then they couldn't schedule her surgery for an additional 2 months due to staffing shortages, with encouragement from some DH insiders, we scouted for better options. Memorial Sloane Kettering in NYC took us in. Every step of that experience on our two trips down there was, I can't believe I'm saying this, delightful. People were kind, at every desk, they listened, they took extra time to answer questions, even our likely dumb questions. Questions they've been asked and had to answer for decades over and over again. I have no idea why JetBlue treats me on average better than American, or why Starbucks treats me nicer than Dunkin Donuts, but its not because the individuals themselves are better or worse... its because of the culture of the institution they work for either pushes them to be their best human selves or not. And at MSK, they seem to be more frequently at their best, while at DH not so much.

Getting culture right is one of the hardest leadership tasks out there. There's no magic button to fix it. But the first thing that needs to be done is acknowledge the problem. Loudly. Publicly. Get on your hands and knees and investigate the issues at the ground level... in the trenches. And slowly but surely, one voice at a time, start including all employees in the process of improvement, knowing the journey to getting better - just like most severely sick patients - will never be a straight-line up and to the right.

I had an MRI a couple of weeks at DH myself - on a very quiet Saturday which was really quite relaxing. When the woman came to get me, I asked if I could use the restroom before the 40-minute, don't-move-a-muscle scan. She said while beginning our brisk tour of a few hallways "that's what you were supposed to do before I came to get you." We kept walking and it was clear no bathroom was going to intercept my entering that very large MRI machine I could now see. Right as she motioned for me to lie down on the flat table that goes inside the MRI machine, I asked again if I could go because I really felt, well, I had to. "We'll have to go all the way back", she said, zero emotion. She turned and I followed. I did my business and laid down and meditated for the next 30 minutes, of which a decent portion was making sure I didn't feel a need to share with her what I thought about her customer service... and I didn't. Onward, I thought.

Until yesterday with Maggie. Until today's headline in the VN. And of course looking back a few months at the debacle that was my wife's melanoma diagnosis and the poor way she was handled by some (emphasis on some, not all!) of the people she encountered making her feel she needed to take her health elsewhere. Let's not mention the time - oh hell, let's do it - when we transferred from Mass General Hospital to DH midway through Maggie's 3rd pregnancy with our son Bo in 2013. With placenta previa making it a complicated pregnancy, MGH had scheduled the delivery for July 19 that summer. But DH had another idea... they apparently understood due dates better than MGH and pushed Bo's due date back a week. They knew better. The C-Section was re-scheduled for July 26 instead of the 19th. Imagine our horror when the ambulances had to show up in the middle of the night on July 24 as Maggie went into early labor. I don't think there was a scarier moment in my life or Maggie's or our daughters seeing the blood in our bed and the concerned faces of the first responders. Maggie lost so much blood in the ensuing 60 minutes. I remembered the doctors sternness and arrogance (you know arrogance when you see it) when we questioned changing the due date... "you are saying MGH was wrong? You are saying you have better data than they did? Should we call MGH and let them know?" I literally asked her those questions because I was curious and surprised that two hospitals could have such differing opinions. I wasn't implying that DH was worse than MGH, or vice versa, but I needed to reconcile what I was hearing. But... it was clearly insulting to the doctor that we were even questioning her at all. So we pulled back and let things take their course. It turns out she was wrong. And we are so grateful that Bo was born a healthy baby boy 3 weeks early, but wow is that not the way we want our kids to enter the world. Anyone can be wrong, but to be wrong with arrogance and a dismissive attitude is what really stuck in our minds even years later.

There's my riff. Nobody really reads this blog anyway, so its mostly to myself 😅. But it felt good to get it out. My primary doctor is still at MGH in Boston. I love so many of the docs and nurses and staff who I know personally at DH... I know they have their hearts in the right place, I know they are excellent at what they do. But the culture needs a redo from the top down. Yes, that's a big task... herculean... but its not a big task to take the first step which is to publicly accept that reality. In our too-judgmental society, it does take courage to make such admissions, but only then will the good work of building a positive, healthy culture begin.