A few weeks ago, at 6:30 AM, I was rushed to the hospital, Palm Beach Gardens Medical Center, to be specific in shock, barely conscious, with an irregular heartbeat. While I was not feeling well, we live close to the hospital and my wife and I decided it was faster and safe for her to drive me to the ER.

I collapsed at the door, the ER staff acted swiftly and within a short time I was in stable condition. I had a mild cold earlier the prior day and didn’t keep down my dinner the night before. Despite those symptoms, I wasn’t feeling terribly ill and went to bed at the normal time. As the night wore on, it was clear, something was going on as I had grown very weak.

Once stable and with the return of lab results, the conclusion was the root causes of my problem was a infection (yes, I had a moderately high fever) and dehydration — (this combination triggered the cardiac and related problems.

Given my condition and age it was decided to admit me. I was assigned to the hospitalist group but told a bed might not be available for some hours.

It was at this point that things started to go off the rail. I noticed the original bag of fluid given to rehydrate me was empty. Given my prior experience with dehydration and in the absence of lab studies to the contrary, a second bag of fluids to further rehydrate me was in order. I was told by the ER nurse, they were not authorized to “hang” a second bag, since I was now officially an admitted patient. I was told and it was later confirmed, that the responsibility shifted to the inpatient physician of record. It was now mid-morning, and on inquiring about the availablilty of my newly assigned physician, I was told he wouldn’t be available to see me until about 5:00PM

Needless to say, lying around still dehydrated and have been given nothing more than a Tylenol to handle the fever resulting from the infection receiving no further treatment for the better part of a day made no sense.

The ER physician with a little prompting started additional fluids. The ER staff noting they were violating hospital policy. An anti-biotic was not provided.

Hours later, I was moved to a room. The nurse handling my admission quickly noted the “violation” and

apologetically explained she was to remove the second bag of fluids. I suggest rather than doing something that couldn’t be deemed good patient care, that she call the hospitalist and get his approval and at the same time inquire about starting antibiotics. The hospitalist authorized continuing the fluids and starting antibiotic therapy. I laid there wondering what would have happened to me if I were not a knowledgeable patient and the rules were followed by all these well-meaning people.

Now, this is just the beginning of my experience at PBGMC. But, before continuing, I want to be clear, this is not a PBGMC story but a Florida medicine story. I have lived in PBG for more than ten years, have been to the hospital on other occasions and made a few visits to area Emergency Rooms. I have also been coming to Florida for over 30 years and have had observed and participated in the care of several family members at other hospitals. While, the perfect hospital is indeed a rarity anywhere, the hospital and medical practices in Palm Beach County leaves a great deal to be desired.

The absence of an anchor medical school, academic medical center and dedicated teaching hospitals for so many decades clearly plays a part in this but the problems run far deeper. There is no diminishing the import of the recent graduation of the first FAU Medical School class and the establishment of residency training programs at area hospitals but these new educational initiatives need to prove themselves, mature, and permeate the existing hospital and medical culture which desperately needs changing.

In many respects there has been great improvement in Florida medicine. Most noticeable is the decision of well- educated and trained physicians to practice in South Florida. This has not historically been true. Also, while the shift from community owned and controlled not for profits hospitals to for profit, for profit hospital owned by publically traded companies, has generally been frowned upon in most parts of the country, given the size of area hospitals, the difficulty of recruiting and retaining talented leaders , seasonal volume fluctuations and other factors, the changes of ownership has generally been a good influence. The standardized systems has been an important step forward for most of these hospitals.

Now, the administration of antibiotic therapy and continued rehydration were good decisions it is far from the end of my story. Upon finally meeting my hospitalist, I learned he had already arranged for two specialists to see me — a pulmonologist/(breathing specialist) and infectious disease specialist. I was more than a little surprised frankly believing the accurate reading of my chest X-rays and the expertise of a well- trained internist were sufficient to care for me. This was an easy conclusion to reach since the X-rays showed no pneumonia or bronchitis or anything else of significance. The decision to bring in consultants suggested economic factors trumped clinical ones. To make matters worse, one of the consultants roused me from my sleep at 11:00PM. They both took an appropriate history and routine physical exam — their conclusions were not surprisingly, not special going on but a profound upper respiratory infection (sinusitis) accompanied by dehydration, no change in therapy was in order.

This becomes particularly interesting given the discharge instructions I was provided included follow up visits with my regular doctor ( a board certified internist) and each of these two specialists. I saw no point in finding out if these were recommendations built into the hospital’s automated discharge protocols or decision of the hospitalist. In either case, economics not care requirements seemed to be the over-riding factor. While pulmonologists and Infectious Disease experts are valuable resource to the community and the economics of these specialties can be challenging follow up office visits were totally unnecessary.

Because of my cardiac history, my cardiologist was notified of my admission. He was off the second day of my hospitalization. The cardiologist covering for him did visit me, assured me he had reviewed my chart carefully and from his perspective he was fine with me being discharged but would visit over the weekend if I was still hospitalized. Frankly, unless there was a change in my condition, those additional visits were similarly unnecessary but additional evidence of the medical practice culture in Palm Beach County.

I recall earlier in the year an article being published in the New York Times about the practice of medicine in South Florida and the uneasiness of New Yorkers (I left New York more than 40 years ago) with their Florida physicians — cardiologists were specifically discussed. The focus was on the astonishment of the New York physicians with what was suggested to their patients by their local physicians. There was also considerable discussion about the magnitude of cardiac testing in comparison to most of the rest the country. I was surprised The Palm Beach Post did not pick up the story given the frequency with which the Post pulls stories from the Times. The Post, which does a superb job in addressing many questionable practices in Palm Beach County and beyond apparently doesn’t have the resources to address medical care issues about which there is so much talk within the area.

I could have drawn from the experiences of other family members at other hospitals — St. Mary’s. Delray Medical Center but thought it best to make the point with my own most recent experience.

A complete critique of the experience would be incomplete without a discussion of the use of hospitalists. Hospitalists have been introduced as new specialists; specializing in the care of hospitalized patients. The thinking was that hospital practice/systems and the diseases that now cause hospitalization have gotten so complex that to expect community based family physicians, with just an occasional hospitalized patient, to properly care for their patients would be unreasonable. While reluctant to defer to hospitalists in the beginning, community based physicians have come to willingly accept them as part of their practices. This acceptance was based on the validity of the aforementioned rationale as well as the economic and life style advantages. The economics of staying in the office are better than visiting one or two patients in the hospital (including no disruption to office hours.) The life style issue, most office based physicians would visit their hospitalized patients at the beginning of the day — very early, or at the end — very late in the day; a clear diminishment of the quality of life.

A major disadvantage to using hospitalist was the lack of familiarity of patient with physician and physician with patient. There is no mechanism for overcoming the first of these limitations. As for the second, communications between hospitalist and personal physician was to bridge that gap. Regrettably, these communications, ideally, on admission, during a patient’s hospitalization and upon discharge rarely occur.

Hospitalist programs vary — in some places, a hospitalist group may work at more than one hospital in the community, they may have primary responsibility for patients in intensive care as well as in all other areas of the hospital, there may be only one on duty, they may have their own office based practice (unlikely given potential competition with the patient’s original personal physician.) These factors all can compromise the quality of care. There is little acceptable justification for a patient to be admitted early in the morning and not being examined by his admitting physicians (a hospitalist) until early evening.

Again using my experience as an example, a less knowledge consumer would likely not have been rehydrated rapidly enough and antibiotics may not have been started for 12 hours. This is not good patient care.

One last word, I was discharged within 36 hours because I knew that the principle antibiotic I was receiving was available in pill form, all I needed was a prescription, the removal of my IV lines and a ride home. The less well informed patient would have been exposed to more than the lack of sleep one experiences with any hospitalization but the exposure to infection, medication errors (yes, my medication was mismanaged) and bigger hospital and doctor bills.

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