The Speculist: Managing Scarcity


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Managing Scarcity

Our saga continues.

I finally got out of the hospital FIVE HOURS after the doctor said I was good to go. It didn't matter that much, I suppose. I went from lying in a hospital bed with fluids being pumped into me to lying on the couch at home sipping Gatorade.

It could be argued that all sides of the health care debate agree that there is a scarcity of medical care. In fact, the whole health care debate may just hinge on the question of whether the government or the market represents the most efficient and humane principal source of distribution of care -- although the more ideological proponents on either side would likely insist that their positions are simply right, and that efficiency and / or humanitarian concerns -- while addressed better by their approach, anyway -- are simply not the issue. But assuming that at least a some part of the debate has to do with how best to handle scarcity, I'm left with wondering what that five-hour wait implies.

If the current scarcity is one of hospital beds, if there was a queue of people waiting behind me to be admitted to the hospital, then scarcity was managed poorly. Some kind of just-in-time, out-with-the-old / in-with-the-new mechanism would be called for in such a case. I could have been out of the room ten minutes after the doctor said I could go. Even if it takes an hour to properly clean and sanitize a hospital room before admitting the next patient, they could have had the next person in the queue lying in that bed well within two hours.

If the current scarcity is one of attention, if the nurses were simply too busy attending to patients whose condition was more serious than mine -- and being set for discharge, I am obviously the lowest priority for attention -- then scarcity was handled exactly right. Deal with the sickest first, the less sick next, the well* last.

In my case, it turns out that the major scarcity at fault was one of communication. The nurse explained as she was checking me out that although the doctor noted that I was to be discharged in his "diary" -- I wasn't given a clear explanation of what that was, but I assume its some informal log the doctor keeps on each patient -- he did not copy the instruction over to his orders. She had to get verification from him over the phone to let me go. Something similar happened the previous day when the doctor told me in the morning that nurses were going to "advance" my diet to see if I could start holding down food, but I was not given even ice chips until that afternoon.

I spent years working on process improvement in the telecom business, so this is a very familiar story. Was the error the doctor's? It certainly sounds like it when the nurses tell the story...but then it would, wouldn't it? I thought the irritating practice of having to write all the same medical information down multiple times was something inflicted especially on patients, but maybe not. Perhaps the doctors are only sharing with us a small sample of what they have to deal with. Fortunately, in this case, the delayed instructions had to do with giving food to someone who probably wasn't all that ready for it and then letting him out of the hospital when he was just fine staying there a while longer. It's just scary to consider what can happen when the instructions that get delayed are of a more urgent nature.

The current debate about healthcare notwithstanding, I don't think that any of the three scarcities listed is primarily a problem with the distribution channel. Neither side of the debate is really pushing ideas for creating more beds, more attention, or more communication (or, ideally, better communication). Why don't we work on those problems? The more health care that is available, the better off we'll be whatever distribution channel we use.

To quote one of my favorite authors on this subject:

I would guess that fewer than 20% of the problems that doctors routinely encounter account for 80% (or more) of the time they spend with patients, and that many of these would be good candidates for automating. Offloading 80% of the tasks doctors currently perform would be the equivalent of having five times as many doctors on hand to apply their expertise to the treatment and prevention of illness. The total amount of medical care available would increase geometrically. And, since the vast majority of this care would be automated, the total cost of care would plummet.

Essentially, we're talking about applying Moore's Law to medical care. Increase the amount of care available by an order of magnitude or two, decrease the cost by the same margins, and what is the right model for providing universal health care?

I don't know.

The problem is, neither does anybody else. And our leaders, far from considering these possibilities, have entrenched positions that assume scarcity as a permanent feature of the world, rather than a problem that we should only have to deal with for a few more decades. Unfortunately, how long we will have to wait until we reach an era of virtually unlimited medical care is pretty much in their hands. The longer it takes them to see the possibilities, the longer they will continue to waste all of our time with politics as usual.

Clearly there's a lot more at stake here than whether some guy has to wait a few extra hours before checking out of the hospital. But speaking as an old process guy, and whether addressing the problem from the standpoint of individual annoyances or what to do with society as a whole, I think we will make much more progress addressing scarcity on the supply end than the distribution end.

* A day later I'm still not feeling all that hot, but "well" from their standpoint


Phil; Your post overlooks a primary driver of hospital (and medical treatment generally) process - a hospital's purpose. A fundamental stipulation of any discussion of health care is that doctors are - and will continue to be - the gatekeepers of treatment. Leaving aside for the moment my axe-grinding regarding the AMA's deliberate constraint on medical school MD programs and recognition of non-US academics, the fact remains that hospitals exist for the convience and benefit of the doctors who staff them (and often as not own them as well), not the rest of the hospital's staff and certainly not the patients. Any discussion of "process improvement" that doesn't stipulate that reality will simply fail. Doctors almost never enter patient treatment orders directly into the patient's chart - the cynic in me being certain this is a liability avoidance technique, but dictates those orders and treatment synopses to a transcription service of some description instead. This results in nursing staff having to enter telephonic order confirmations into the chart themselves for any sort of time sensitive matter (like your release). Necessarily, this occurs as the nurse's priority sequence demands.

Also, patients are released from hospital when the doctor can no longer make money from further treatment, not when the patient is "well". I would bet a substantial sum of money that somewhere in your release orders are words to the effect: "continue treatment under supervision of personal physician"; eg; you ain't well yet, but there's nothing more we (the doctor) can really charge you for further, so get out (as soon as I've made an effort to make it as difficult as possible for you to sue me over any of this you decide you don't like)!

As long as medical treatment is obtained via the existing doctor-controlled gatekeeper structure, the relative availability of some treatment option (scarcity) isn't the controlling issue. And to be fair, as long as MD's are held liable in the present fashion, they pretty much have to restrict access to treatment options out of professional self-defense.

Your professional expertise highlights a measurable improvement in patient care, but fails to take sufficiently into account the nature of the structure your (admittedly beneficial) change would affect. Ever played pick up sticks (or what's that game where each player takes turn pulling out a stick until the structure collapses)? Modern medical infrastructure is complexly structured in mostly non-obvious ways; any attempt at alteration (no matter how badly seemingly needed) poses the real risk of catastrophic unintended consequence (and is why the recent health care legislation is such egregious hubris). I agree we need to make more readily available all the potential new treatments we all read about and hope for faster please, but I really don't see how we get there from here without spending way too much time in way worse along the way.

Glad to read of your improvement; don't go for the chili-mac w/ cheese just yet, right? :)

AMA ... a membership organization with membership something like 15% of physicians? I've never been a member in 40 years.

Perhaps you mean the AAMC that approves medical colleges?

Perhaps you mean the laws of the State you live in?

Perhaps you mean your insurance company that will not pay the hospital you were in for any more care and any more staff? And all of the free care they must absorb by Federal law?

And perhaps you think that health care is some kind of
utility you are entitled to whenever and however you want it, and that someone else is always responsible for it.

I wish you well in the years to come, for wishes are what you will be getting.

Will -
1. I have never felt that a hospital's processes actually existed for my benefit, and attending surgeon. In this day of the (externally) mandated EMR, I am instead asked/told to do it their way, despite prior patterns, etc. The discharge delay is a prlblem with the billing peolpe and the nurses, IF the doc actually writes/authorizes/"inputs" the orders...the dictated stuff comes later and does not impact timeliness of discharge.
2. As to paragraph 2 - those of us trained and in the field prior to capitation and the 1982-3 Medicare reforms (DRGs...) remember well the admits for workups - "the Bowel Run of the Stars..."House of God"...but now we are at the mercy of the insuror you chose/were belabored by - they run the game, and we try to keep you from getting hurt by their priorities, not ours.
3. The real key is in your correct comments about liability - see the rising c-section rates in the current literature and popular press - and unintended consequences. Current reform tries, recent and historical, are awash in same, to all parties detriment.

In any event, good luck, it isn't a clear liquid unless you hold it up to light and is translucent - and, no, Jack Daniel's is still not a clear liquid.

Doctors almost never enter patient treatment orders directly into the patient's chart - the cynic in me being certain this is a liability avoidance technique, but dictates those orders and treatment synopses to a transcription service of some description instead

Actually, doctors must enter their orders into the chart and the vast majority of orders are placed by them that way. The issue is that often charts are hand written and need to be transcribed into the hospital information system, which is usually left to a unit secretary who is harassed and overworked. Phone orders from physicians are taken, but they are more an exception not the rule.

To suggest that doctors do not enter orders themselves into the chart as a way of avoiding liability is an outrageous display of ignorance. Without some direct order from a physician, PA or NP nothing happens. There is no magical divining of the physician's will by nursing. Orders do not go to some transcription service. You perhaps are thinking of consultation reports which do go to a transcriptionist for printing or entry into a computer system.

Yes the system would work better if knowledgable professionals in nursing and alied health were given the authority to place many of these orders, but then they would be open to the same liability as doctors and they would demand the same compensation appropriate to their share of the responsibility. Doctors do not want to share responsibility as that would mean sharing income as well. Fat chance of that ever happening.

As to hospitals existing for the sole benefit of the physician, that's another cynical display of ignorance. It is certainly a symbiotic relationship, but hospitals often act in ways that are diametrically opposed to the physician's desires.

Doctors almost never enter patient treatment orders directly into the patient's chart - the cynic in me being certain this is a liability avoidance technique, but dictates those orders and treatment synopses to a transcription service of some description instead.

What planet do you live on? Not Earth. Physician orders for hospitalized patients are entered directly on the chart, not dictated to a transcription service. At least that is how my father did it. That's how my wife does it. That's how the doctors that treated my father and mother recently did it. In the latter case, my wife and I got chart access permissions and read them.

Transcription services are used for postoperative notes - surgeons use them in most major hospitals, but even then the postop orders are in the chart, often using standard forms with options selected and qualifications entered.

That said, there is probably some low hanging fruit in doing task analysis to improve procedures. Unfortunately, a recent attempt to do that was stymied by a combination of HIPAA privacy concerns, and the FDA classifying a checklist as a medical device.

Let me preface this response to sagi's comment above by noting that argumentation for it's own sake on another's site is rude. That said; @ sagi:

No, I wasn't refering to (yet another of) the competition in America's own version of the Guild Wars. Even a shallow first pass perusal of the AMA's history makes clear that said organisation is designed from it's foundation as a legal and governmental influence peddling operation:

"1847: Nathan Davis founds the AMA at Academy of Natural Sciences. The Committee on Medical Education, Code of Medical Ethics, and first minimal standards for medical education are created.
1899: AMA Committee on National Legislation is created, the AMA's special interest group. Council on Exhibits educates the public on health. AMA studies tuberculosis, and how to control it, educates the public, and advises the building of government sanitariums. AMA tells local boards of health to pass mandatory smallpox vaccination."

So, again No, I mean the small group of self-determined elites who interfere in virtually every aspect of your apparent occupation and have for the better part of the last two centuries, your personal membership notwithstanding.

The hubris your comment displays is exceeded only by the towering assumption you erect from which to cast aspersions. I specifically noted that the issue of medical treatment generally was a complex one, indeed that it virtually defied even the most simplistic-seeming efforts at its remediation. Yes, this would extend to insurance companies declining to pay all that doctors think their services are worth (to include their support staff and maintenance of their professional infrastructure) and that government regulation is indeed intrusive and imposes costs both direct and otherwise. Thank you for your contributions to the discussion.

I do object to your presumption of my sense of entitlement not to mention your ability to influence its putative fulfillment (Wishes? Really? 'Cause I've had most of 60 years now to compile quite the list you know.) As it happens, I do think that for the most part (there are a number of possible exceptions to my general viewpoint) medical treatment - and specifically its practitioners - are a form of utility service. How else to describe public health efforts for only one (actually quite complex) example? I suggest there are others but decline to occupy this space with a more comprehensive listing.

As to the sanctity of hospitals (and doctor's relationship to them), let me offer the following analogy by way of illustration. Imagine a structure created solely to house the technology and support mechanisms necessary to correct as many possible different maladies as possible. Imagine further that this special place has a dedicated professional (indeed, several such) available as needed as part of it's fundamental format. Welcome to your auto mechanics garage. Now, what difference is there between your mechanic working on your car and your doctor working on your body as regards their relationship to the facility within which they do these things? Like garages, hospitals exist for the convience of the mechanics that staff (and often own) them, not the "patients".

Thank you for your well wishes.

More generally, I think it worth re-iterating that obtaining more simplified access to, and more direct control over, more advanced forms of medical treatment (whether corrective or enhancing) is a complex and almost certainly disruptive proposition. Far more so than many seem to have fully considered to date. One of the value's I find at The Speculist is the willingness to examine those complexities and consider potential means to cut through them.

In various hospital stays I have noticed that the intake is efficient once you get past the emergency room, but the release process tends to be ragged. Once after a long wait dressed and sitting on the bed, I picked up my case and began walking out, pursued by a nurse, who said I had to be signed out and then go in a wheelchair. Things moved quicker after that.

I wish to thank John Gregg, jim m and ech for their corrections; my experience is obviously much more out of date (when not outright wrong) then I had thought the case. Although I think jim m went a bit far; I never said hospitals exist for the "sole benefit" of doctors. That would be stupid; obviously the other staff and employees (not to mention the patients and external suppliers of goods and services) also benefit, and all of which simultanously work in support of the fundamental purpose I ascribed to a hospital. I also recognise that hospital buracuracy tend to think of the hospital as having equal priority to the doctors on staff, I simply happen to believe that a falsehood. Doctors can function quite successfully without a hospital, the inverse not so much.

I have seen my own current medical chart; it runs to about 9 inches or so in thickness (5 opthalmic surgeries account for about 2/3's of that). While there are a considerable collection of doctor's hand written notes, orders, pictograms, etc, all of that is attached to a transcribed (ie: typewritten) formal record. I also note that much of the hand written portion is in a variety of different handwriting which leads me to observe that an RN, NP or PA "transcribing" a doctors orders, while not a formal service, is in the spirit of my original statement.

Hello Phil -

Please bear in mind as you read this that in addition to holding a B.S.N., I also completed a Master's degree in Engineering Management and Systems Engineering so I, too, am quite interested in processes.

I work in a cardiac unit in a mid-sized hospital in the central part of the U.S. I am sorry you had to wait 5 hours to be discharged - that is TOO LONG! But let me explain to you how that can happen. (And I acknowledge up front that I know nothing about your case - this is just based on what I see every day at my hospital.)

1. The doctor comes in, sees you, decides you can go home, and writes in illegible writing in the chart, "Pt. d/c'd to home." The doctor looks around the nurses' station to tell the nurse who is responsible for you what is going on, does not see the nurse and, because s/he is truly very busy, decides to leave WITHOUT SPEAKING DIRECTLY TO THE NURSE. The nurse, who was in another room taking care of one of his/her 5-9 OTHER PATIENTS, has NO IDEA that the doctor was even on the floor, much less that the doctor has indicated that the patient can go home. The nurse only becomes aware that something has happened when, one to three hours later, the patient hits the call button and asks "What is going on? The doctor was here X hours ago and said I could leave!"

(And, as an aside, please be aware that because the doctors are NOT involved in the discharge process, they have NO IDEA how long it takes to prepare all the paperwork, medication scripts, and discharge instructions that we need to give patients. If the patient is on 20 meds, needs a lot of instruction, etc., it can take 30 minutes to prepare just the paperwork.)

2. In some hospitals, ALL of the doctors involved in the patient's care have to give their OK for the patient to be discharged. It is not uncommon for patients to have 5 doctors involved in their care. That means the nurse has to page all of the doctors, get their ok to discharge, the meds they want the patient to be on, and their discharge instructions.

And please do NOT think that when a nurse pages a doctor that the doctor calls them "right back." I frequently have to page doctors multiple times to get them to call me back. This can take hours. Believe me. Most of the time, it is because the doctors are busy with other patients but sometimes, SOME doctors don't return pages simply because they don't feel like it.

3. In some cases, one doctor says, "Yes, the patient can go home." The consultant doctor says, "No. I need to check something, go see the patient, whatever." The nurse has to wait for that to be resolved.

4. In some cases, the nurse has another patient who is very ill or very labor intensive and the nurse simply cannot get away to do her other work.

5. Finally, I have worked with one or two nurses before who will delay a discharge simply so they don't have to get another admission. It is rare but it does happen and it is always ridiculous.

I suggest the following to improve process flow:

1. Make it a policy that when the attending says a patient can be discharged, then the patient can go home, regardless of what the consultants say. The nurse should NOT have to call everyone involved in the patient's case to get the "ok to discharge" - the attending is responsible for managing the patient's care - he or she is responsible for making sure everyone is on board with the patient's discharge.

2. REQUIRE that all progress notes be typed. There has NEVER been a patient I have cared for whose chart I have not read in detail. I can't stand not knowing exactly what is going on with my patients. The problem is that I CANNOT read most doctors' handwriting. Most of the time, they write things that give nurses clues on what might be coming down the pipe - but we can't read it and here's the big secret: neither can the other doctors. Type everything so everyone can read what is truly important.

3. Most hospitals have computerized/electronic charting. REQUIRE that when a doctor is discharging a patient that the order be entered in the computer, not just written in the progress note. Most of the computer systems used by hospitals have a "flagging" system that will highlight or color the discharge order so the nurse sees it more quickly.

Just some thoughts from someone who does this every day.


I'd be open to the idea of manufactured scarcity if it involved rate-limiting steps. If you saw a five-hour delay at a doctors office or an outpatient facility--where getting the next patient in depends on getting the last patient out--you'd have a better case for wasted resources.

Hospitals correctly allocate resources where progress vs staffing is maximized. Hence, the nurse will have several patients and the transporter may be taking patients to xray or surgery as well as getting them out the door. When the decision has been made to discharge you to home, from the hospital's perspective there are no more rate-limiting steps in the delivery of YOUR care. Attention may get shifted to patients who have procedures, tests, are more ill, etc.

About the only place in a hospital where you will see an effort to "turn and burn" are in places with expensive equipment and/or a greater level of staffing. Think ER, OR, procedure suites (endoscopy, etc) , or specialty units (ICU, etc). The hospital ward is rarely time-sensitive in the same way that these other locations are. On the ward it's mostly a waiting game for the patient to recover to the point where it is safe (or reasonably manageable) for a return to home or rehab.

Although it is creates a colorful image, it's unlikely that another patient is "circling" for a hospital bed to open. Everybody's cynic tells them different things. Mine thinks that if there had been another patient waiting for a spot, the potential of lost charges (for an occupancy day) would have resulted in a more rapid exit.

Sorry you had to wait. I know it is frustrating. My guess is that there was no rush to get you out because hospitals don't view discharging patients to have the same priority as other aspects of patient care.

Handling scarcity is precisely one of the primary things that markets by design excel at.

That makes more sense than some of what I deal with in my field of long term insurance.

Funny, here I was thinking this is one case in which the market is killing us. Consider, for instance, what might happen to the scarcity of physicians if they were guaranteed to have all their education bills paid for, either outright or upon completing their degrees and intern periods. This currently can cost upwards of $150,000 and is a significant barrier to entry. If you want to address the scarcity of doctors, paying for their training would be a good start. The same applies for nurses.

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