As part of my conclusions, I want to begin with a story. This is a story about my sister, Marcia. I'm very proud of my sister. She was a professor of creative writing and also a very accomplished award-winning poet. In April 2017, she developed severe abdominal pain, nausea, vomiting and bloody diarrhea, and she was admitted to the hospital. She was treated with antibiotics and fluid support but failed to improve. A CT scan of her abdomen revealed small bowel obstruction. My brother, Steven, and I rushed out to New Mexico to be by her side. We arrived at 1:30 PM on a Saturday. Upon arrival, we saw our sister in misery. She had an ashen complexion, and was complaining of abdominal pain. She had a nasogastric tube in place. There was over 1,200 ccs of bile colored fluid in her suction trap consistent with bowel obstruction. She looked very ill. We were anxious to talk to her physician. Would she require surgery? How were her laboratory values? What was her prognosis? Her son, Nick, kept telling us he thought she was going to die. We asked the nurse to page the physician, and learned that he couldn't come to our room for another three hours. He was very busy. He finally arrived at 5 PM and explain that Marcia would continue to undergo nasograstic suction to decompress her bowel. He reported that the surgeons were following her and that she might require surgery with placement of an ileostomy, a drainage bag designed to trap all the material coming from her small bowel. An ileostomy? My sister would never want that. We were very worried. The following day, Sunday, we arrived at 8 AM only to learn the surgeon had rounded at 7 AM and he could not be reached. Our hospice also could not be disturbed because he was very busy. I tried to understand. Yes, they did appear to be very busy. But this was my sister. We asked her nurse, but she had no idea when Marcia's primary physician would be seeing her again. There was a large volume of fluid draining in her suction container that day as well, indicating ongoing obstruction. My sister began to cry. What was going to happen to her, she wondered. She hated the thought of a permanent drainage bag attached to her abdomen. Steve and I had no answers. The next morning, Monday, we arrived at 5:30 AM to be sure that we wouldn't miss the surgeon. We waited and waited. We were afraid to go the cafeteria to eat breakfast because we didn't want to miss the surgical team. While we were sitting at our sister's bedside the nurse assisted Marcia to the bathroom three times to have bowel movements. At 8:45 AM the surgical team arrived. We had been waiting for over three hours. He indicated that his partner felt Marcia would require surgery to leave her small bowl obstruction. I mentioned that Marcia had had three bowl movements. He clearly had no knowledge of these events and had not spoken to the nurse. He appeared surprised and pleased. I also noted that the volume of drainage from the NG tube had decreased by one-half overnight. He was also unaware of this fact. These findings strongly suggested her obstruction had resolved. He smiled and stated let's wait another day and see if she continues to pass stool. Her obstruction may be resolving on its own. After the meeting we tried to encourage our sister, but she again broke down in tears. She was frightened and anxious. She laid in bed appearing week and helpless. My brother and I hugged her and comforted her. I anxiously watched the drainage of the nasogastric tube, praying it would continue to slow down. We also briefly met with our primary care physician. He was unaware of the surgeon's plan, but he was pleased to learn from us that they wanted to observe for another day. The following day we arrived at 6 AM in the hopes of seeing the surgeon. At 7:30 we decided to go to a cafeteria for breakfast. During that 50 minute period, one of the surgeons walked into Marcia's room, said hello, and quickly removed her NG tube. He then told her she would not require surgery. My sister quickly contacted us by phone and we rushed up to her room. Too late. They had vanished. We never saw the surgeons again, and only spoke to the hospice one additional time during our four day visit. For much of the hospitalization, Marcia, Steve and I were left in the dark. Steve and I sat at Marcia's bedside for over 40 hours. And during that time, we interacted with physicians for an estimated 25 minutes, or approximately 1% of our visiting time. The surgeons, and the hospitalists were rushing from patient to patient, from place to place. They didn't have time to talk. We were fellow physicians, and we understood. How would the average patient family member interpret their actions? Was this patient-centered care? As with nearly all health systems, there were also some very big positives. Marcia was very impressed with the quality of the nursing care she received. She found that the nurses, quote, nurses and staff truly were person-centered every step of the way. I was touched every day by the kindness and compassion of every person working behind the scenes at the hospital. And this included housekeepers, patient care coordinators, the people who brought the meals. Not once did I feel treated just like a patient by any of these people. That feeling of being made to feel part of the family will always stay with me, and I believe it's why I got through the experience as well as I did. However, the big problem was communication between the parts of the system and the unavailability of the physicians. We liked Marcia's physicians. And when I saw them I found them friendly and personable. But the system they were working under allowed them minimal time to talk to their patients or to coordinate their care. As compared to nurses, clerks, and other support staff, they seemed to be in the background. The nurses had no idea when the physicians would be present at the bedside. I worry that the unpredictable nature of their work not only interferes with communication, but also is likely to lead to burnout. From the patient's point of view, the system and the providers are seen as one. If the systems are defective, physicians appear harried and distracted. Remember, as the work of Demming emphasized, every system is designed to produce the results it achieves, and it is very clear to us that the systems of delivery in the health system caring for Marcia needed to be improved. And each of you now have all the building blocks to create a patient-centered Healthcare Delivery System. And this is the name I propose to call TPS, or lean adapted to health care. The name can be abbreviated PhDs, emphasizing the fact that everyone working in this system is expected to use the scientific method just like a PhD to continually improve the delivery systems in their hospitals and clinics. And patient-centered emphasizes that the primary focus of the system is to deliver value to the patient. Thank you.
