Tuesday, May 26, 2015


Life flows from warmth to a chill but sometime the chill can get sandwiched between the warmth, like a low pressure between two highs and stay stationary, as in this case; a patient caught between the extremes of human-created double jeopardy- between a hospital and a rehabilitation center.

A fellow I know lived an active life. He happened to find the unfortunate uneven step on the roadside that felled him onto a concrete slab. The slab was not hurt but the man’s skin needed the eye of the needle as it thread through some layers of epidermis and a staple gun to keep the thicker gashes closed. With repaired bones, stitched and stapled skin he went on to receive inpatient rehabilitative services in a facility that boasted the best services in town. “Living healthier lives” the banner claimed.
Unrelated image from Internet 

The facility was clean, almost immaculate; starch white floors with rubberized marked walking paths in its hallways, food served on glassy clean trays, and all care givers dressed in pure white. The only thing that marred the white was an occasional black stethoscope draped around the neck. The plenary focus seemed to impress and exude cleanliness a virtue of godliness as a means to faster, quicker and better recovery from the ill-gotten misfortunes of living impetuously. 

Yet in almost a whisper the hallways had a story to tell, a strange one at that. None of the infirmed denizens of this famed and storied facility seemed to be bipedal. They were all rolling along in their wheelchairs. Some with their legs firmly planted on the foot rests and others with one or both sticking out in front like the bow of the boat parting the air at any obstruction in front for careful clean passage.

The personnel seemed happy and cheerful. The infirmed seemed content too. This did seem like a Shangri-La of rehab facilities after all, just as advertised. Or was it?

I asked…

“How come, none of the patients were ambulatory?”

That caught the woman in the white starched uniform by surprise. “Ah, well, when they are ambulatory, we discharge them.” She replied with an imprint of discomfort in her voice .
Wow, I thought…what a concept of rehab. Bring the patient to the edge of their ambulatory ability and boom, ‘off you go!’

I learnt the secret later from a slightly verbose worker, “Well you see,” he opined as his head turned to look quickly at both sides like Regan in The Exorcist, “we do not want anyone to fall accidentally and hurt themselves. So we have a strict policy to allow full ambulation in the rehab rooms when they are with the therapists, that way, no fall, no lawsuits!” He finished.

“How long do most of the patients stay in the facility?” I asked.

“Oh, anywhere from two to four weeks,” he replied.

“And how many hours of therapy does each patient get?”

“Usually the therapy lasts 45 minutes, because most tire quickly and that is twice a day on alternate days otherwise once a day.”

“The rest of the time…”

“They are in their rooms in bed, being monitored by closed circuit TVs. If they need to go to the bathroom or shower they are given full assistance.” He smiled, “after all, safety is no accident, is our motto!” He added, “Keeps the lawyers away!”

So here was care driven through the eyes of the policy-makers with one eye on litigation risk, and the other on padding the bottom-line rather than true benefit of patient’s care. The staff was happy and well paid and the patients were content, watching TV and being served with no effort required. The only thing missing was real advancement in the patient’s abilities. One might wonder how many of these “discharged patients" would find their way back to the hospitals from falls related to atrophied skills. But those statistics are difficult to come by. Those statistics are only meaningful in readmission rates. So why not rehab the stitched patients for 4 weeks and then discharge. Ah the cynic in me is loath to deliver the benefit of doubt easily.

Rehabilitation 2.0 is the nuanced version of dotting the “I”s and crossing the “T”s for reimbursement checks, for longer duration of stays and for confining the patients from progressing rapidly towards optimal health. Place the metric in the wrong cubicle and what you will get is more quantified nonsense. But it makes people happy! It makes the deliverers of such care wealthy and it makes the pundits gloat with certainty how they have “streamlined” the system for outcomes.

What a system the system has spawned!

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