One morning I found a note on my desk from my secretary. It said:
The Medical Director at St X would like an appointment with you to check that everything is going well for you at St X.
It wasn’t unusual to get a ‘summon’ from the Medical Director of these private hospitals. Usually, it is a low-key chat to make sure that the private surgeons working there are not having issues with the operating theatre equipment or staff, and that they have no complaints about ward care of their patients. It was just over 2 years since I have started bringing patients into St X for my surgical lists so I was expecting an invitation from the MD sooner or later.
I asked my secretary to shorten my next St X operating list, and arrange an appointment with the MD afterwards around 5pm for me.
This was the conversation:
MD: Hi Dr T, thanks for taking the time to see us. So, how’s everything going?
Me: Great. I have had no problems, the theatres are great, the nurses on the ward are helpful, my patients have had no complaints. They are liking the private rooms and….
MD: (Nodding vigorously and leaning forward to cut me off). Well, I want to talk to you about Mrs Y.
Me: Oh? Is she causing problems with the staff?
Mrs Y was a patient of mine on the surgical ward whom I had just admitted two weeks ago. She was a teacher in her late 50’s who sustained severe spinal injuries when she was a teenager and is now wheelchair bound. Mrs Y was also a long term insulin dependent diabetic who unfortunately had severe ketoacidosis last year and ended up in ICU, ventilated for 2 months. During her illness, they didn’t look after her pressure areas so she ended up with severe grade IV pressure sores over both the ischium and sacrum by the time she was transferred out of ICU. She was then discharged from hospital with this problem as no one wanted to deal with it whilst she was an inpatient. Mrs Y went back to teaching, and spent hours every day in her chair. When her blood sugars started to deteriorate and her family doctor noticed an unpleasant smell during one of her visits, it led to the discovery of her persistent pressure sores. By the time she came into my office, she was hyperglycaemic, septic with infection as both pressure sores were wide and deep enough for me to put two fists in each. I could see her ischial bone at the base of one, and the rectum at the base of the other, and because she was incontinent from her spinal injury, the wounds were severely contaminated with faeces as she sat in the wheelchair in her soiled diapers. Understandably, both her and her husband were by now, agitated and frustrated with unhelpful medical staff and hospitals.
I admitted her into St X, because it was a large tertiary private hospital with all specialties on hand. She required an urgent endocrinology review, infectious disease input, a general surgical procedure to divert her faecal output via a temporary colostomy, dressings and pressure care. Needless to say, she started to improve within 7 days. She required intensive nursing care with four times a day dressing change (to prevent accumulation of pus that was continually exudating from the wound) and two hourly turns to prevent development of new pressure sores while she was bed bound.
Mrs Y, at the beginning of the week, cranky from feeling ill and hating being bed bound, was not the best compliant patient. She was a teacher after all and did not like being told what to do. She was also a little distrustful of the nursing staff as it was poor nursing care in ICU which resulted in her current problems. However, after seeing herself improve over a week, she became the most pleasant and grateful patient on the ward. She helped the staff by setting an alarm clock and turning herself so that all the nurses had to do was to pop their heads into her room and check that she was in a different position. She also changed her own colostomy bags so that the staff didn’t have to deal with this particularly unpleasant job. The nurses told me that they enjoyed looking after Mrs Y.
I was rather surprised that the MD had brought her up in our meeting.
MD: No no, nothing like that at all. (He cleared his throat awkwardly). Patients like Mrs Y, well, we find it hard to accommodate them in this hospital.
Me: I know, I know, spinal patients should really be in dedicated spinal units, but there are no private spinal facilities for these patients. Mrs Y has been paying her private health insurance for over 30 years, so she didn’t want to go to a public hospital; she wanted to be looked after in a private hospital.
MD: We understand that, but private health funds in general don’t pay us very much for looking after patients like her. She requires intensive nursing care so we actually don’t get any profit for such a heavy nursing load.
Me: (Speechless for a second) So, let me get this right. You don’t want patients like Mrs Y because her admission doesn’t generate enough profit for the hospital?
MD: I just wanted to make you aware of this, so that you will remember in the future not to bring patients like her into our hospital. We would prefer day surgery patients, but if you feel strongly about keeping them overnight, we are more than happy to accommodate that. As for Mrs Y, I believe you are planning to keep her in hospital for a while?
Me: Yes. At least 3 months.
Both Mrs Y and I had a long discussion about this. She had agreed to take a whole semester out of teaching and come into hospital to have her sores treated properly. This meant bed rest with appropriate pressure care, no sitting in her wheelchair and regular dressings. I had explained to her in depth that if we could make her overall health better, these sores may heal without intervention. If not, they may need an operation. However, even with an operation, she will need to be off the surgical wounds for 6 weeks before she could sit on them. She knew she was in for the long haul, because she didn’t just bring her suitcase when she checked into the hospital, she also brought her Nespresso machine. According to Mrs Y, 3 months was a long time to go without good coffee.
I watched the MD’s face cringe.
Me: I can’t rush the healing process, and I have to wait for the infection to settle.
MD: Maybe you can find a little operation for her so that we can get a little more money out of her health fund during her stay?
Me: But she doesn’t need an operation. She just needs dressings.
MD: We are probably going to lose money if she stays that long.
Me: Would you like me to transfer her to the public hospital? (The MD looked up at me with surprise and a glint of hope in his eyes). I could just say to Mrs Y that St X doesn’t want you here because they are unable to make a profit out of your stay. They think you should really be in a public hospital despite the fact you have paid your private health premiums for the last 30 years…..
MD: No, no. (He started to clear his throat again). There is no need for that. I suppose since we are a hospital affiliated with the church, we can show charity by letting her stay her for a while.
Me: Righto. Is that all? (I started to get up to leave).
MD: But, (he stopped me turning towards the door), if you do a few more of your cosmetic cases here at St X’s, it may compensate for her stay.
He stood up and reached out to shake my hand.
Me: Well, I cancelled two breast augmentations this afternoon because of this meeting. I have transferred them to my lists at another hospital tomorrow.
I ignored his hand, turned to open the door, and walked out of his office without a backward glance.
Mrs Y stayed for the full 3 months and went back to teaching full time, sitting in her wheelchair with a beautifully healed bottom.