In one case, I was asked to do something quickly that should not be done quickly - at least not by a dietitian as inexperienced as I am - to satisfy the requirements of an insurance company. In another case, something that should have been done quickly was not, to "save money" for the hospital. These two episodes occured just in the last month in a small hospital. During the same month there have been other episodes, not so directly related to money, but which could be traced back to money demands indirectly - related to time pressures and what is or is not considered important by practitioners and management.
1. Pregnant woman with gallstones, pancreatitis caused by gallstones, gestational diabetes. The doctors didn't want to operate on the gallbladder because of the baby, and didn't want to do a c-section to take the baby because the woman was only at 32 weeks. She couldn't eat anything by mouth except about 200 calories of juice, because she'd throw anything else up. The doctors elected to send her home on TPN (feeding sugar, protein and fat directly into the blood). The doctor hadn't gotten the routine labs until several days had elapsed, so just before she was scheduled to go home it was found she had high triglycerides. This meant the TPN she'd been on had to be changed and a new low-fat mix had to be calculated. I was asked to do a 5-minute rush job of recommending a new TPN mix because if she didn't get discharged within a certain window, she'd have to stay over the weekend, and the insurance wouldn't pay for it. But there are a lot of ramifications of changing the mix of nutrients, and 5 minutes isn't enough time to look through her chart, find out how she's been doing, and think through the ramifications of what I should recommend. In this case, there was no medical reason for the speedy Rx - just the insurance company's payment schedule. I did it slower than they wanted to me, but faster than I was comfortable with, the patient went out the door, and I felt I'd compromised on care because I was afraid to buck the pressure.
2. Followed up on a patient recovering from surgery, on TPN (not one I'd recommended). Found she had a "critically low" phosphorus - this means she's in danger of death, basically, because of effects on the heart. The doctor had seen the low phosphorus in the morning and written an order for a new TPN mix with additional phosphorus - but the old mix was still running. Why? Because the hospital's protocol is to let each bag of TPN mix run out before starting a new order - to save money. I told the nurse, but she could not immediately start the new order - she had to call the pharmacy to check it out; pharmacy then had to page the doctor to get an order to run a separate phosphorus IV. All of which took, probably, close to an hour. Meanwhile, the patient was sick and sweaty and had been for many hours. I left at that point, because there was nothing I could do - the next time I saw the nurse, she was running down the hall - things had evidently gone to hell in a handbasket. I don't know what happened to the patient.
There are a lot of problems with the way hospital medicine is organized - increasing time pressures, problems with training, increasing fragmentation of knowledge, problems of communication between disciplines - no one, starting from scratch, would come up with a system like this. I think I will be leaving it soon.
Les