NIR subscribers of long duration are well aware that we believe in first-hand data collection–who will forget the 1999 issue wherein we recounted our participation in the first cat-to-human brain transplant? (It didn’t take….sorry about that, Whiskers) Or last year’s cardiac cath lab beach party ?
In any event, it was time for another field trip, so we decided to see how things might transpire for emergency surgery in the service of addressing an appendix that had ruptured (just for an extra soupcon of challenge). We have thus just spent nine days in what turned out to be a complicated inpatient stay, the details of which will be recounted in excruciating detail in our other publication, GastroPerspective. But there are a couple points that could be made of potential CNS relevance, of which we have chosen just one: Getting rid of Psychiatric hospitals was Really Dumb.
Where did they go?..or, What, they’re gone? Pretty much, save for handfuls of corporate, academic, and and legacy units that are completely unsuited for the scale of the task. We are not just talking about Deinstitutionalization as practiced in the 1970s. That grand experiment in top-down social engineering was billed as a humane advance, but in general, because most states neglected to build a safety net sufficient to the task, or more accurately, did not find an alternate source of funding once the federal government stepped away (not irrelevant to today’s Health Care debate), it turned the chronic schizophrenic population into a nomadic tribe sometimes shipped across state lines by the last municipality that had neither the expertise nor resources to provide them with the comprehensive services they needed. So bus tickets filled in for resources–let them be somebody else’s problem.
But we are also referring to a second-generation culling of inpatient services, from 1995-2005, that was market-driven, not governmentally mandated (again relevant to today’s debate). The first stage had closed many of the huge state hospital ‘snake pits’, the second involved the gradual strangulation of small private psych hospitals and Units by insurors who found it easy and profitable to ‘just say no’, systematically discriminating against Psychiatry, Neurology, and Substance Abuse patients, all of whom tend to be customers without a voice.
What does the Health Care Matrix offer these patients when they, cycling through illnesses that often ebb and flow, hit a point of crisis? For the most part they end up in the ERs and Med/Surg units of community hospitals. Where, after triage, if hospitalization is the only viable option, they are mainstreamed into the larger body of individuals with medico-physical afflictions. Which means the same Unit houses patients with infectious diseases, those recovering from major surgeries, patients in drug withdrawal, those in psychotic decompensation, Alzheimer’s patients with a medical issue, individuals with a toxic delirium, and so on. Because Cardiology and Oncology have been able to define themselves as high-return Cost Centers, those patients sometimes have the luxury of dedicated units, and of course Maternity has a sacrosanct space, because that is a population with PR clout beyond measure. This means that the hospitalists and nursing staff working on Med/Surg units have to function as extraordinarily broad-spectrum clinicians, a feat many pull off to a remarkable degree. But in conversation with some, they admit that the overscaled yet compressed heterogeneity of the populations they have to juggle makes a difficult job doubly so. And it feels like the proverbial Bedlam for many of the patients within it.
So the irony is; as science shifts the practice of medicine towards what in theory is ‘personalized’ and ‘precise’, in many therapeutic areas, economics has driven real world practice to a depersonalized, ever-more-imprecise model, tossing this myriad melange of patients together in the hope that the generalists running these units can somehow figure it out. They do the best they can, but it is like serving as a translator in a Medical Tower of Babel for the 21st Century: There is a price paid by the staff and patients beset by the deluge constantly dumped upon them.