There is much more that I could write about being in the hospital, but do you really want to read about hospital food and sleep deprivation?  My guess is probably not.  So, let’s talk about something really fun – hospital bills.  OK, maybe it’s not that fun, but it sure is worth talking about.
 There are two sets of bills – those from the medical professionals for their services and those for the hospital for the room, equipment, staffing, medications, laboratory work and so forth.  It would be nice to give you more detail on the exact charges, but the information sent from my insurance company really didn’t provide any specifics.  All I can tell you was that (so far), there were 9 charges from the hospital, and 16 charges from the medical group.  The hospital was reimbursed $1,637 for its services and the medical group was reimbursed $6,269 for its services.  I should hasten to point out that the procedure that I underwent involved seven hours of very technical and sensitive intervention by a team of caregivers.
 Now, as you might imagine, working for the Medical University, I have a range of health insurance options from which to choose.  I participate in our preferred provider plan, MUSC Options, which means that I pay favorable rates for using services within the Medical University system.  It doesn’t mean that the Medical University got a better deal on my care, however.  In fact, the insurance company paid only 36 percent of the hospital charges and 27 percent of the physician charges.
 So, I ask you, how many other businesses are there in which the people who pay for services cover only about a third or less of the sticker price?  Maybe there are some, but I have a hard time thinking of any.  The problem is that this is the good news in health care reimbursement – I had insurance.  About one in five patients have no insurance, and more often than not, the providers of care end up collecting little or no money from these patients.
 If you wanted to design a crazy reimbursement system, you couldn’t do much better than the one that we tolerate in the United States.
 

I would like to write a detailed account of my overnight stay in the hospital, but as I was happily sedated for a fair portion of the experience, there are a lot of blanks in my memory.  There are a lot of blanks in my memory even when I am not sedated, but that’s another story.
 At any rate, one of the impressions that managed to stay preserved in my brain was the extent to which good medical care depends upon good nursing care. I had excellent nurses taking care of me, and I was very impressed by their knowledge and experience.  Nursing is hard work and I am sure that even the most dedicated nurses must feel underappreciated at times.  They work long shifts and many have to handle the disruption of night and weekend schedules while raising families.  It is no wonder that we are facing a nursing shortage – there are many easier ways to make a living. 
I was reminded about these impressions the other day at an event that marked the 125th anniversary of the MUSC College of Nursing.  Dean Stuart and her colleagues have done a wonderful job building upon the long tradition of high quality nursing education here.  The College has become a true leader in the field, with the development of on-line curricula and building a state-of-the-art clinical simulation laboratory.
One of the fund-raisers for the college to build these innovative programs is the sale of a white silicone wristband that reads “NURSESTRONG.”  I have worn my wristband now for a couple of weeks and it is a good daily reminder of how much I owe the nurses who took care of me.  If you want to purchase your own wristband and support the College of Nursing, please contact Denise Ciccarelli at ciccarel@musc.edu or 792-8421.  It is a nice way for patients and their families to thank the nurses who inspire us all.

OK, enough about informed consent.  Let’s talk about the experience of being a patient.  There is no better place to begin than to say that I received excellent care.  I hope that I was not getting special treatment – at least that was my goal.  Most of the people who took care of me during my overnight hospitalization had never met me before.  If they were told that I was the President of the Medical University, they seemed not to be too impressed by that.  I honestly felt that they were giving me the same attentive care that they give to all of their patients – nothing more, nothing less.

 What struck me from virtually the moment I checked in was that being a patient is a very anxiety provoking experience.  Even if you are a doctor and know pretty much what is coming, it is a scary event.  Maybe it is even more frightening if you are a doctor.   The first thing that happens is that you take off all of your clothes and personal possessions.  There is a certain loss of identity in doing this – you immediately make the transition from your personal style and choices of adornment to the standard issue, and not very private, garments of the hospital.  I have never served in the military, but I would guess that the experience of taking off your civilian clothes and putting on a uniform must be a similar feeling.  On the other hand, at least one can take pride in a military uniform, whereas it is hard to take pride in a hospital gown.  It seems high time that we got some more interesting threads for our patients to wear.

 The other immediate impression was how quickly one gives over total control to other people.  As a patient, you are in the hands of people who you don’t know very well, and you are in a completely dependent position, even if you are not terribly ill.  Most of us are accustomed to being the conductors of the symphony of our own lives.  Suddenly, there is somebody else choosing the music and conducting the orchestra.  I suppose that one can fight this loss of control, but for me, it was just easy to just be swept along.  Maybe that was because I had complete confidence in the conductor and the musicians in this particular orchestra.

So, let’s get back to the topic of informed consent.  Is it possible that sometimes a patient can be given too much information?  That may seem counterintuitive, but having been on the receiving end of informed consent recently, I am at least wondering whether more is always better when it comes to hearing about potential adverse effects.  The first problem is that it is difficult, if not impossible, to describe all of the potential complications a patient might encounter.  Even if you could describe an exhaustive list of potential problems, some are extremely unlikely (happening at most a few times in thousands of procedures) and may never have occurred in the hands of this particular caregiver.

Must the doctor describe every possible adverse event regardless of how infrequent it might be?  I would argue that a line has to be drawn somewhere, and while one might debate where that line should be drawn, only those events that have a reasonable likelihood of occurring require discussion.   The challenge, of course, is to define what constitutes a reasonable likelihood.  One person’s reasonable likelihood might be another’s rare event.

Second, if the list of potential complications gets quite long, even if the risks of individual complications are quite small, the cumulative impact on the patient may be overwhelming.  Somewhere along the way, information can morph into anxiety, and the patient may shy away from a procedure that offers them clear benefits that far outweigh a long, but highly unlikely list of complications.

As I started thinking about this issue, it occurred to me that even within health care, the expectations about informed consent vary.  I cannot recall, for example, ever having had informed consent administered for treatment by a dentist, although I suspect that oral surgery may require it.  What about outside of health care?  There are many other risky activities for which society does not require the provider to give information or receive consent.  One of our riskiest daily activities is driving in a car, but we do not require car dealers or manufacturers to provide informed consent.  We do not require gun sellers or makers to provide informed consent.  Even exercising in a gym carries with it some risk of injury, but we do not expect informed consent to be administered by the gym owner.

I am not suggesting that we diminish the role of informed consent.  It is an essential part of ethical health care, and I still believe that, generally, the more information that is given to the patient, the better.  Still, I do think that the whole process could be better standardized and we could come up with clear guidelines about what level of risk needs to be discussed.  In the meantime, be forewarned, reading further could be hazardous to your health.

I am not sure whether or not blogs have Prologues.  If they do, are they called Problogs?  At any rate, a little introduction to this blog seems in order.  With blogs, it’s hard to know whether anybody ever reads an introduction, since the natural progression seems to be to read the most current entry and then work backwards.  After a few entries, the introduction would become some sort of long-lost historical record floating unnoticed in dusty cyberspace.

Still, starting with a long-lost historical record seems like a good place to begin this blog.  And since, in all likelihood, it will be unread, we might as well start with a confession:  I don’t know what I am doing here.  Before you think that there is some sort of big existential angst brewing here, let me clarify:  it is unclear to me why I am writing a blog and it is equally unclear to me how one writes a blog.

The simplest answer as to why I am writing a blog is that I was encouraged to do so by colleagues.  It was not an easy sell.  To be honest, writing a blog seems a little vain to me.  What sold me on the value of the blog, or better to say, the potential value of the blog, is that it can be a way to communicate to others some things that they might not otherwise know  – not so much about me personally, but about the amazing things that I see everyday as part of my job as the President of the Medical University of South Carolina.

The tipping point for me to start writing this blog was my recent experience as a patient in our health care system.  I learned a lot that one doesn’t really know as the president of this university and it has changed the way I think about what we do and how we do it.  My first few entries will be focused on those experiences.  Maybe those entries can build up enough momentum to carry me forward into a broader range of topics.

If you are reading this far, my expectations already have been exceeded.  Thanks for visiting this blog and please let me know your thoughts and reactions.