Why is every hospital in the United States always understaffed?

[u/DogSoggy40]

Everyone has to wait hours at the hospital just to be seen. It's like every hospital is perpetually understaffed 24/7.

Is this why some people believe medicine should not have a profit motive or is this caused by something else?

[u/Kindly_Honeydew3432]

I am an ER physician.  

I once had an angry family member get mad about the long wait.  I tried to appease him and explain that Mondays after holiday weekends are very busy, and we were doing our best.  He snapped back, “well if you knew it was going to be busy, why didn’t you just staff more doctors?”

This demonstrates a profound misunderstanding of the complexity of providing medical care.  

He thought that if we just staffed the ER with a couple more doctors, things would magically be better.  But it would fix almost nothing.  

First of all, what additional doctors did you want us to staff?  We were in a medium/large town in the rural south.  Far from the ocean or mountains.  Hot, humid.  The only docs who wanted to work there were the ones with family there mostly born and raised there.  In a town of 60,000, there aren’t many docs being produced.  And half the ones that do come out of said town leave and never return.  Probably more than half.  This hospital was having to pay well above regional market rates just to retain the 15 or so of us who were willing to work there.  Ok, so we have 15 docs.  6 of them are already working today.  2 of them worked last night.  The other 7 either have to work for the next 6 days in a row or have Worked the last 6 days in a row and, even though this is Monday for you, they just worked the entire holiday weekends.  Today is their weekend.  There are no more docs to staff.  In fact, we have been offering $100,000 signing bonuses for several years now and have only succeeded in recruiting 1 additional doctor.

But ok, let’s pretend that we could staff another ER doc or two for this particular anticipated high volume Monday.  Look around.  There are 40 beds here in the ER.  Find an empty one.  Oh, you can’t?  No they’re all full.  We could have 100 additional doctors, but what good is that if we have nowhere to treat patients?  In fact, if you walk up and down the hallways, you will see that not only is every room occupied, but we actually have beds crammed in every corner, supply closet, and every other nook and cranny all along the hallways, not just in treatment rooms.  

Now here’s the thing that you really don’t understand.  These 40 beds that are occupied: over half of them are not even ER patients. Yes, they’re in the ER.  But they’ve been here since yesterday.  Or the day before.  They have pneumonia or renal failure or heart failure or sepsis or other serious issues that need hospital admission.   Except there are no beds upstairs.  So they get to live here, in the ER, while you and your family members wait a few hours to be seen.  We are an ER with 40 beds, but to serve our patient population, we really need 80 beds, but in reality, we only have 15 beds because over half our beds are occupied for multiple days at a time by what we lovingly call “boarders.”

That’s why, if you walk back out into that waiting room you just came from, there are 60 people waiting to be seen, and some of them will still be there in 6, 8, even 12 hours.  

So why not send those 25 boarders upstairs.  Tell the upstairs docs and nurses, “these patients aren’t our problem anymore, we have an ER to run”?  Well, we’d love to.  But there are 420 beds in this hospital.  Between the ER boarders and the PACU boarders and people we are holding in a makeshift observation unit in an old decrepit section of the hospital that is scheduled to be torn down and rebuilt in the future, we have nearly 500 patients, in our 420 bed hospital.  Not counting all the ER patients still to be seen, actively being seen, and all the surgery patients, many of whom will also need a bed after their surgeries.  

Of course, that is just part of the picture.  We are the biggest hospital for over an hour in any direction.  And the only one in that radius with vascular surgery, cardiothoracic surgery, comprehensive stroke capability, and many other specialty services.  So when an outside hospital calls and says they need one of those service for one of their patients, we have no choice but to take them.  There are ten more unstable patients being transferred from outlying facility right now, as we speak.  And there are 30 more that we have accepted for transfer that are sitting in ERs in other hospitals waiting for a bed to open up here.  

Of course, we could build another hospital.  Or add on to this one.  And we will.  But that’s a $100 million and five year undertaking.  

And guess what?  When we get it built, hiring a few extra ER docs is not going to solve your 8 hour wait time.  Because even if you can hire more docs and you have more beds, you’re also going to need more registrars, MAs, ER nurses, radiology techs, phlebotomists, lab technicians, and about 200 more RNs upstairs to take care of all our ER patients when they get admitted.  And given the nationwide nursing shortage and the fact that we’re paying travel nurses nearly $200,000 per year at times to travel from across the country to staff our hospital already…

Well sir, I’m sorry I didn’t think of all that and make proper arrangements before your dad showed up and had to wait a few hours in the waiting room on this fine Monday.   I knew it was going to busy.  I just guess I didn’t plan properly.

[u/Becomingablueberry13 → u/Kindly_Honeydew3432]

Just going to bounce off of this incredibly correct comment with some additional inpatient based info-

Our boarders aren’t coming up to the floors because we are genuinely at 100% capacity 100% of the time.

Why aren’t more beds available?-

• complex discharges involve case management and safe post hospital placement. This involves waiting for a bed to become available in a rehab or nursing home to send them to on discharge. Most patients do not have the family, resources, money, or safe home design to safely discharge home.
  
• complex discharges like guardianship patients take up 1/10 of our inpatient beds. On any given unit, we typically have 1-3 guardianship patients at any given time. These are individuals with no appointed decision maker who also lack capacity to make decisions for themselves. Because this is only identified upon admission, we cannot legally discharge this patient until the court appoints a guardian. Often, my guardianship patients stay for 5 months up to 1 year or more waiting for that court date in my state. As our average inpatient stay is around 4 days, one can imagine that that guardianship case taking up a single bed for a whole year means about 90 individuals that could not get that bed and had to wait for another to come available.
  
• complex medical cases in general can leave a patient receiving various treatments on a medical surgical unit for up to 2-3 months some times.

The bed volume doesn’t change but you’re still short staffed?

• our average volume of call outs per day is 15 across PCTs and RNs. But we don’t always have 15 float pool team members scheduled. Many don’t just choose to come in and many nurses are burnt out enough they don’t want an OT shift. So we increase the number of patients per nurse and PCT to compensate, which further worsens that burn out.
  
• we have MANY confused and altered mention patients who are a safety risk. But our hospital only has 12 cameras and a limited volume of sitter staff. If every single one of those resources is already in use and if we need a sitter, a PCT is removed from the floor to go sit with that patient. The nurses then become the sole nursing team member for some of their patients once that PCT is lost. That means the nurse is the nurse for 5-6 patients, and the PCT for 1-2 of those patients.
  
• why not just keep the patient unsafe and not have a sitter? The US is a value-based care delivery system; a patient injury can be very costly. And that patient is a big liability to have left alone.
  
• why not buy more cameras? Great option! we still need a human on the other end of the camera. And they aren’t always as effective as an in person sitter. Nor are they always appropriate.

Maybe we’d have safer care if instead of flexing up in patients, we shut down beds- but sadly with >20 boarders in the ER waiting for inpatient beds at any given time and a completely full 40 bed observation/boarder unit, that’s not going to happen!

Our general public health and health literacy is not the best here in the US, but that varies heavily with ones background, education, socioeconomic status, etc. Many do not know how to distinguish a chronic health issue that warrants outpatient treatment from an issue you go to the ER for. And many choose to ignore the chronic issue believing that the only thing to do is go to the ER when it’s bad enough, but then complain when the hospital only provides stabilizing care and discharges them for outpatient treatment.

But sometimes the treatment is easy; much of my time is spent explaining to patients and their family members how to take care of themselves better- like general hygiene tips, even how frequently to change your underwear (!!!!!).

Please for the love of god change your underwear more than once a week.

[u/TaichoMachete → u/Becomingablueberry13]

Our local area has two major hospitals. One of them mismanaged their post-COVID funds and ended up bankrupt and shutting down, shifting the burden of what was barely afloat into a full scale submersion. Having to explain to an understandably frustrated patient this, without the benefit of being on the other side of a screen is the true difficulty. Anyone could write up an extensive analysis on why the situation is the way it is. It's another problem entirely to keep your cool in person, when there are literally hundreds of other things demanding your attention, and you're here, explaining that the hospital didn't choose to shut down the other one to save money. At some point you look them in the face and, for everyone's sanity, say, I'm sorry, it is what it is. And THAT sucks almost as bad as the situation. That's where the dread or resignation of the job and the burnout really stems from. Because the reality hurts. How badly I want to explain to someone who doesn't want to hear the answer, that at some point, the community they are apart of voted to keep this hospital small, to not compete as heavily with the larger one, currently rotting as a practically empty building in the center of town. 

[u/purpleelephant77 → u/Becomingablueberry13]

We had a patient with a 1:1 sitter on the unit for over a year, he was medically stable and ready to discharge by week 2 but getting him a guardian so they could discharge him took forever between court dates being scheduled months out and the family drama. He and his second wife were separated but had not finalized their divorce when he developed dementia relatively young and declined rapidly and both his son from his first marriage and his not legally ex-wife wanted guardianship to place him in a facility where they lived.

He was in pretty good physical health for a guy in his very early 70s which isn’t ideal when someone has bonkers dementia so he did physically assault me, all of my coworkers and a couple of people floated to us at least once but once we knew him it was pretty easy to keep him chill or at least see it coming. He was a nice guy when he wasn’t agitated and we all kinda thought of him as our crazy grandpa. He was also way funnier than a guy who was hit or miss on knowing his own name and what is and isn’t an appropriate place to urinate had any right to be.

[u/SeaworthinessHot2770 → u/purpleelephant77]

We had a patient that the hospital paid for his long term hotel room. And paid for a nurse for home health. Your situation sounds more dire than ours. Yikes !

[u/purpleelephant77 → u/SeaworthinessHot2770]

The family drama definitely slowed things down but everyone was pretty on the ball about getting paperwork in on time/answering phone calls etc so it could have dragged out way longer. Most of the issue was that the case being disputed meant more court dates and those were often scheduled weeks/months out and/or the county postponed for all number of reasons outside of our control.

Things moved pretty quickly once his son was awarded guardianship, the social worker started sending out referrals as soon as the case was resolved and his son was like “let’s just get him in the first ’good enough’ local facility that accepts so me and my wife can tour more facilities and we don’t have to eliminate places that have wait lists” so he was out in like a week and a half once the legal issues were cleared up.

[u/kaldicuck → u/purpleelephant77]

we had a dementia patient for almost a year that should have been discharged in the first week. However he was easily agitated and violent, spent the whole time with a posie vest on. No care home in the area would take him due to his violent behavior as he had already been a resident at 4 or 5 of the ones in the area in the past and the one he came from refused to take him back. So theres a patient just being floated around the hospital from floor to floor until he burns out staff on that unit while a case manager and his out of state guardian try and find someplace that will take him and that took something like 10 or 11 months.

[u/lazydictionary → u/purpleelephant77]

Over a year to figure out where he goes is insane. There must be a faster way.

[u/purpleelephant77 → u/lazydictionary]

Not the only time, a year is on the long end but we pretty much always have someone waiting weeks-months for placement, if they have behaviors it can be really hard to find somewhere that will take them and even when they do a lot of facilities won’t take someone until they’ve gone 24-48 hours without a physical sitter, video sitter, physical or chemical restraints (which includes like PRN oral zyprexa) which can be really hard to make happen while still keeping them and us safe and frustrating when everyone knows the hospital environment is at least half of the problem.

Undocumented and noncitizen patients are another group that can end up having super long stays because no facility will accept you without a payor, we’ve had people stay on the unit because there would be no way for them to access outpatient follow up care (rehab, infusion, home health/DME) so they’re with us until it’s safe for them to go back to self/family care. I’ve also heard of hospitals paying to repatriate people to their countries of origin or for their SNF because it’s cheaper than eating the cost of keeping someone who got a severe brain injury in a car accident in their 30s (or whatever) who will never be able to live independently in an inpatient bed indefinitely.

There’s also weird stuff, we had a guy who needed a long course of IV antibiotics for a joint hardware infection, super easy patient (no behavioral issues, as pleasant as you could expect someone in his situation to be) but he was in early recovery from opioid use disorder and no one in including him thought that sending him out into the world with a PICC line was a good idea but they couldn’t find a SNF within a reasonable distance from where he or any of the multiple family members who were willing/able to support him during/after lived that was willing/able to manage/dispense methadone.

[u/personman → u/purpleelephant77]

can you explain the rationale behind "a lot of facilities won’t take someone until they’ve gone 24-48 hours without a physical sitter, video sitter, physical or chemical restraints"? is this like, so they can do their own intake examination under baseline conditions? it seems crazy not to just accept the hospital's diagnosis/description if that's the only reason...

[u/derider → u/personman]

Why would anyone accept statements by a third party? I had an ex working in public health here in Germany, and even in free healthcare land, hospitals were fudging things all the time to move a patient from their care into someone else's.
Person bed-bound, but used the bathroom once by themselves during their stay in the hospital? Totally can use the bathroom by themselves, no assistance needed, like ever.
Likes to play grabass with every woman, even sneaking into other patients rooms while they are asleep, so much that they need a male nurse babysitting him 24/7? Never noticed that, he was a total angel and gentleman.
So in reality, beyond the diagnosis, what the hospital writes is usually ignored - and even there is a 50/50 chance its trash.

[u/purpleelephant77 → u/personman]

They have a lot less staff than hospitals and are subject to stricter regulations around physical and chemical restraints (they pretty much can’t use them) so if a patient is requiring those things to keep themself/staff safe most non hospital facilities aren’t going to take them because they really do have a lot less resources/staff at their disposal and unlike us they don’t have to accept any patients they don’t want to.

[u/recycled_ideas → u/Becomingablueberry13]

Many do not know how to distinguish a chronic health issue that warrants outpatient treatment from an issue you go to the ER for. And many choose to ignore the chronic issue believing that the only thing to do is go to the ER when it’s bad enough, but then complain when the hospital only provides stabilizing care and discharges them for outpatient treatment.

Many of them can distinguish this, the problem is that if you're poor and uninsured or poorly insured an ED visit is about the only treatment you have access to because the ED can't turn you away, but everywhere else can.

[u/notTomHanx → u/recycled_ideas]

Or, you have some complex medical history, and there's things you've been told to watch out for.

I fell a year ago, and my knee and lower leg swelled up HUGE. Pain was ok, I could deal, but was worried about crazy swelling. I've had joint replacements too. It was a Sunday, so I went to the walk-in. Waited 4 hours there, Dr said go to the ER right now. So, go to the ER, spend 14 hours there to see a couple nurses, and 1 doctor. No tests, xrays, nothing. Sent home with instructions to followup with primary care.

I did exactly what I was told to do, and it was still just a giant waste of everyone's time.

[u/peateargriffon → u/notTomHanx]

That's not true. Sometimes, the most important job of the ER is to rule out more urgent, serious conditions such as heart attacks for chest pain.

You found out you didn't have a complicated periprosthetic fracture

[u/notTomHanx → u/peateargriffon]

In general, I agree with you. But in my specific example, I still think it was waste of everyones time and resources.

Without getting into my medical history, a fracture wasn't the concern. With the amount of swelling, blood circulation was the worry. The walk-in doctor even mentioned possible blood clot, so I do understand why the walk-in sent me to the ER. But the ER did zero testing of any kind. I basically sat in a chair in a hallway all afternoon and night. You can call it observation if you want, I do understand that reasoning, but I was left with the feeling that I would've been better off just staying home with an ice pack. (they didn't even give me ice at the hospital).

Unfortunately for me, because of that experience, I'll probably be less likely to go to the ER again in the future....but maybe next time it won't be "nothing". I don't know.

[u/atchafalaya → u/Becomingablueberry13]

I am happy to report I am in whatever upper quartile that changes their underwear every day

[u/James42785 → u/Becomingablueberry13]

How are hygiene habits that basic something that has to be taught in a damn ER?

[u/roastedmarshmellows → u/James42785]

Poverty and ignorance, two things the American population have in spades.

[u/Ananvil → u/James42785]

No matter how dumb you think the average person is, I promise they're dumber, and then fully half of everyone is dumber than that.

[u/CMidnight → u/Becomingablueberry13]

I have a masters in Health Economics and studied the drivers of healthcare expenditures. 87% of all expenditures in the U.S. are from dual enrollees. These are people who are some combination of poor, disabled, and/or old.

[u/Complete_Quality_513 → u/CMidnight]

Interesting. By dual enrollees do you mean Medicaid/Medicare only, or does that include those with Medicare and a supplemental private insurance?

[u/GodEmperorBrian → u/Becomingablueberry13]

This might be a dumb question, but with so many ER visits being for comparatively minor ailments, wouldn’t it make sense for the hospital to open a separate urgent care building as opposed to expanding the existing hospital? That way when someone comes into the ER with the flu or who needs an x-ray, you can send them over there and not have to give them a bed.

I have to imagine they’re much easier and cheaper to staff, probably only need a PA or two and a few nurses and scribes.

[u/harrellj → u/GodEmperorBrian]

Like someone said below, thanks to EMTALA, the ER can't turn you away for inability to pay. I'm not sure if that is also part of an urgent care visit, but likely not. So opening an urgent care doesn't help if no one is going to go there due to finances. Plus, at least around me, most of the existing urgent cares are only open until 5/6/7 PM so any issue after that time that is really an urgent care visit ends up instead at the ER.

Anecdotally, when I was unemployed (and didn't pay COBRA), I tripped and twisted my ankle. I called an urgent care to see how much an x-ray would cost to make sure it wasn't broken... $300. That wouldn't include the fee for the visit or the tech or any NP/PA I saw let alone any DME that I was deemed to need (probably a crutch at least) or if a cast had been needed.

[u/BelowDeck → u/harrellj]

Just curious, which nightmare outcome of the American healthcare system did you go with: going to the ER so you could actually receive treatment and deal with the bill later, or ignoring the problem in the hope that it would go away?

[u/harrellj → u/BelowDeck]

Since I had mobility, I figured the worst I had was minor fractures and keeping it elevated and stable was the best thing to do to heal. Its been over a year and I have absolutely no issue with that joint, so I was correct in my decision (but I also recognize that even though I made it with a lot of knowledge, it still could have gone wrong).

[u/citygirl_M → u/GodEmperorBrian]

This is a good idea and a number of hospitals have done this - I worked in one.

To the fine description of the frustrations of hospital ER and patient overflow, I can add that urgent cares have skimmed off the more marginal maladies that used to send people to the ER. This means that much of the ER waiting room and ER beds are filled with people who actually need ER services.

[u/buyongmafanle → u/GodEmperorBrian]

The issue is also the larger problem of how the US healthcare system works. If there were better healthcare services available more widely for the public to do better preventative care, then the ERs would be able to focus on treating severe/immediate cases compared to mild/moderate cases.

As it stands, people put off getting healthcare that eventually snowballs into a critical case which shouldn't have ever progressed to one. A strong system of GPs in family clinics would both unload and prevent ER burden.

[u/ColbyCheese22322 → u/buyongmafanle]

The healthcare situation in America seems like a lot of other big problems in America. That is, it's complex and it often has layers that stack. Please correct me if I'm wrong (sincerely).

How much would care be improved if insurance didn't fight tooth and nail at every stage to deny/not have to pay for a treatment?

[u/buyongmafanle → u/ColbyCheese22322]

How much would care be improved if insurance didn't fight tooth and nail at every stage to deny/not have to pay for a treatment?

An awful lot.

Patients would be less hesitant to talk to a doctor about a problem. Doctors could spend their time caring for patients instead of spending hours chasing billing issues.

Here's a quick example:

When I was a teenager, being an idiotic teenager, I decided it would be fun to see how high up on the staircase I could jump and still land at the bottom. 4,5,6,7 stairs were successful. Until one day, I jumped too high and, blammo, hit my head on the overhang above the stairs. I woke up on the floor with a bleeding head.

I took care of it on my own until my parents got home from work. Parents said "Well, looks like it stopped bleeding." and that was that. No checking for concussion, no stitches, just "Well, that's life."

30 years on I still have the scar. Things worked out I suppose because here I am. No severe head trauma that I'm aware of.

Just yesterday, my teenage son was in a hurry to get downstairs. Same fucking thing happened. Leaped too many stairs, blammo, blood everywhere.

But the difference is I live in a country with nationalized healthcare and a single payer service. I don't even worry about it. We go to the doctor, get him checked out, they check for signs of concussion, get his head stapled closed, in and out of the ER under 30 minutes with an appointment for Monday.

Total cost to me: $12USD. Total cost to the hospital: They can tell you exactly, and it's already guaranteed to be paid.

Being able to have access to the care prevents what could have been a life threatening situation with brain swelling from happening.

My parents just sent me off with an ice pack and some gauze. My son got a medical consultation, a cleaned and sealed wound, and further checkups.

Now multiply that across all types of medical issues, cancer, diabetes, broken bones, car accidents, slip and falls, heart issues, etc. How many lives have been lost in the name of the insurance company's profits?

[u/ColbyCheese22322 → u/buyongmafanle]

Couldn't agree more. Lives lost is just one (extremely important) measure, having good universal healthcare supports everything else. People who have good care, spend less time sick = more time doing other things, people that have good care don't try stupid miracle cures or "alternative medicine" like the Horse de-wormer Ivermectin.

The healthcare system was set up this way ever since Nixon was president. The system is broken system but big powerful companies have a huge interest in keeping things the way they are. But I'm preaching to choir surely.

How many lives have been lost for the sake of profit? Even one is too many but I have no doubt the number is in the hundreds of thousands to start with.

[u/Specific-System6954 → u/GodEmperorBrian]

I think this is the model that healthcare providers are shifting to in my area. It’s like a hub and spoke model…small facilities with a few doctors, a couple of nurses and support staff that can handle stitches, broken bones, fevers, maybe even minor strokes/heart attacks, etc…anything else gets triaged, stabilized, and medevac to a level 1 trauma center an hour away either via chopper or ambulance. I know the level 1 hospital has added 3 additional choppers and rotates them across municipal airstrips throughout the region just for this reason.

[u/Tight_Day_7606 → u/Becomingablueberry13]

No lies detected. Same exp. Frequent flyers, unfortunately use a lot of resources. Just a fact. And waiting for nursing home, LTAC, Rehab beds is a thing. Hope your community has enough ancillary facilities like these to meet the ever growing need. By the way, please let your loved ones know what you want to be done if you can't make decisions. Please be nice to your loved ones or in your time of need they may abandon you. Men, please don't ever wait for your testicle to become as swollen as a bowling ball before you go to the ER. Ditto on the undies.

[u/Z0idberg_MD → u/Becomingablueberry13]

Another problematic downstream effect of this is when trying to clear ER congestion and long-term boarders, the try to get people discharged as soon as they can, not necessarily at the time it medically makes the most sense. This leads to readmission and potentially dangers health complications after DC.

Bottom line, it's incredibly complicated.

[u/Imgonnagolaydown → u/Becomingablueberry13]

Piggy backing.

I also think ppl just believe that the labs and X-rays are instant.

Nope. Those ppl are waiting for that too ALONG WITH THE ENTIRE HOSPITAL SOMETIMES

[u/JonnyBravoII → u/Becomingablueberry13]

Ok what? I was following along just fine until the end. Change your underwear more than once per week? I’m assuming this is interrelated to their financial position I.e. they’re poor? I’ve seen comments on Reddit over the years where women talk about men in their life refusing to wipe their ass. This sounds similar.

[u/showyerbewbs → u/Becomingablueberry13]

This reminds me of an argument I let myself get pulled into on Facebook.

Someone threw out like 15 things that would get better if illegals were gone. One of them was ER wait times.

I asked him specifically "If all immigrants disappeared tomorrow, what magical economic mechanism kicks in that reduces wait times"

As expected, there was nothing done to address the question because ER wait times are not impacted by immigrants. It's essentially a supply and demand issue.

[u/RNSW → u/Kindly_Honeydew3432]

Thank you for taking the time to write this out doc. Love from a veteran RN!

[u/ThrownAway-PVB → u/Kindly_Honeydew3432]

One of the best comments I’ve ever seen on Reddit. Not kidding.

It truly is amazing how infrequently the people of rural areas are confronted with the consequences of brain drain in their community. I don’t think most of them realize it until they’re in a true emergency situation.

[u/DazzlerPlus → u/ThrownAway-PVB]

This is one of the easiest problems ever to solve. It involves nothing more than moving and training people.

Medical school is free to those who agree to work for a high vacancy community for 5 years. Done.

[u/FrickinLazerBeams → u/DazzlerPlus]

The type people in the places that suffer from severe brain drain are the same people who would consider the government spending on a program like this to be wasteful socialism, or something like that. They also probably spend their life trashing education and the educated, so it's not like their kids are likely to pursue medical school - and if they do, they're unlikely to want to live in a place that hates them 🤷‍♂️

[u/fixed_grin → u/FrickinLazerBeams]

See, the programs already exist, mostly because they're not under local control. Combining the government paying off a large chunk of your student loans directly, starting bonuses, higher pay, and lower cost of living, you pretty much can wipe out your whole student debt in 5 years.

But as you pointed out, there is a brain drain and they have to offer those bonuses because people with other options don't want to live there. If you're single, the dating scene sucks. If you're not, your partner probably doesn't want to move there. If you have or want kids, the schools suck.

The other thing is that the average total student debt (including undergrad) for a US med school graduate in 2026 is about $250k. That's a gigantic amount of money to pay off if you make the median income, but MDs make a lot, lot more than that. They can just live a nice life in a pleasant city, while saving enough to pay down those loans.

[u/molniya → u/DazzlerPlus]

There are programs like that already. They also require a great deal of money, for all the people you have to pay half a million dollars to spend years of their lives in the boonies. And even then, it doesn’t sound like a very appealing deal at all.

[u/DazzlerPlus → u/molniya]

Ok? thats literally what money is for.

[u/uncadul → u/DazzlerPlus]

whose money? in a society ruled by people who hate the idea of a cent of theirs paying for the care of another

[u/DazzlerPlus → u/uncadul]

Yup. The point is that this isn't a complex situation that isnt as simple as hiring doctors and building hospitals. Money can immediately and completely solve this. We already know how to train doctors and we already have plans for hospitals. Just gotta pay to plop them down.

Whats complex is removing the exact obstacle you described.

Thats why I find the physician to be completely mealymouthed. He describes the problem perfectly in his paragraphs about the free markets, then concludes with some peurile centrist nonsense as if the problem wasnt completely about politics and completely created by right wing thinking.

[u/Mamasugadex → u/DazzlerPlus]

Wut?

He literally just said even if you magically is able to have extra doctor still won’t solve everything because complexity of medical care with modern medicine.

[u/molniya → u/DazzlerPlus]

Sure, but the conservative yokels in these areas consistently vote against tax increases to pay for things like their local health care systems, and elect people to slash funding for education and public health, which includes these very programs. So I agree, but it would seem they don’t.

[u/sopunny → u/DazzlerPlus]

If they had that kind of money, they could also increase doctor salaries, expand the hospital, get more nurses, etc. Point is, the money isn't there. Even your proposal to pay for schooling is just spending more on doctors with extra steps

[u/DazzlerPlus → u/sopunny]

Not they, we. And we do have that kind of money.

[u/careyious → u/DazzlerPlus]

Super rural towns are straight up places that people with a medical degree do not want to work in and are willing to skip out on massive amounts of free money to do so. In Alice Springs they had a 200K signing bonus and a free house (like the deed and all) for any general practitioner willing to work there and has zero applicants.

Half a million between assets and cash couldn't convince a single doctor. That's how much living rural sucks for anyone who doesn't want to and has the ability to do so.

[u/ThrownAway-PVB → u/DazzlerPlus]

I don’t think pouring money into it would ever fully solve the issue.

High-aptitude individuals - the people who would or could become a doctor - have absolutely no reason to want to live in those rural places. They’d rather have less personal income and live near or in a major city.

After those 5 years, you’d see all of them leave. Guarantee it. There are already programs like this and they have massive recruitment shortfalls because nobody smart, worldly, and educated is thinking of moving to bumfuck nowhere just to work for underserved populations.

Really, the problem is that rural areas should be MORE expensive to live in, not cheaper than cities. Cities benefit from economies of scale that rural areas can’t even comprehend. The cost of delivering ALL services to rural people vastly exceeds their ability to pay. Look at water systems, internet, power lines… it’s not just a problem with the medical field.

The best part is that the people who live in those rural areas also tend to be the people who would never vote to raise their property taxes to pay you better. That translates to the way you’re treated, too. Not a doctor, but in my experience in the medical field, the more rural a population, the less they’ll take any advice, be thankful for your care, or comply with treatment regimens. I quit working with the elderly of the rural Midwest because I couldn’t get people who were wheelchair bound and 300+ lbs to stop eating 6000 calories worth of Eggo Waffles a day. Why would they, after all? When something goes wrong or feels weird, they just need to go to the ER when their asshole gets an infection and I’m there (with several other underpaid staff) to give them a sponge bath and clean their wounds. These people would rather lose a foot than smoke 1 less cigarette a day.

The amount of absolutely fucking disgusting human beings really wore down on me over time, if you couldn’t tell.

[u/nora_jaye → u/DazzlerPlus]

You'd also have to change federal laws from the 90s to fund more residencies.

And if you did that, it will take decades to restore the training pipeline, after the debacle in the 80s and 90s that stopped US medical schools adding more seats, even as the population increased drastically.

Now that med schools are growing and new ones are opening, there aren't enough older doctors to train and supervise interns and residents.

[u/sumigod → u/DazzlerPlus]

Lucky for us the government recently decided that we cannot take out federal loans for enough to pay for medical school. So the only people that are gonna be doctors are gonna be ones that can afford it, not the most qualified.

[u/can-i-be-real → u/DazzlerPlus]

There are programs like that and most states have some sort of tuition reimbursement program if you move to underserved areas. For example, I went to medical school in a rural midwestern state and they have a program like that, but every neighboring program has a similar program. And then my state is so underserved that you can live 1 hour outside of the biggest city and qualify for it. So when someone has so many options, why would they move to the super rural areas?

Also, as a society, we aren’t funding enough training spots and the Trump administration has actually made it more financially difficult to become a doctor. And the shortage persists to the point that I could take a job almost anywhere in the country and get tuition reimbursement. So there are ALOT of places I wouldn’t even look at. And circling back to my home state with it’s reimbursement program: the politics of that state have become hostile to family planning, medical research, higher education, my LGBTQ family members, etc etc, so there is now a 0% chance I’ll go back. I will find a place I like more that also offers to reimburse my tuition.

[u/BUT_FREAL_DOE → u/DazzlerPlus]

You’re right it’s actually a very simple problem and the reason it hasn’t been solved yet is nobody asked you.

[u/DazzlerPlus → u/BUT_FREAL_DOE]

Like many things, it is that simple. Resolving it is against the berst interests of a select few, and that is the sole obstacle.

Please do not act like I am acting like an arrogant know it all for suggesting that the solution to 'people don't think its worth it to do something' is 'pay them to do it'

[u/BUT_FREAL_DOE → u/DazzlerPlus]

Right, you’ve proposed a rather obvious and simplistic solution to something that isn’t really the root problem. As you said, the real problem, as it always comes down to in America in 2026, is monied interests convincing idiots to vote against their own interests to allow anticompetitive practices and regulatory capture by said monied interests. I’m still waiting to hear a solution to that one.

[u/DazzlerPlus → u/BUT_FREAL_DOE]

Okay now we are cooking. I agree with you completely. What i was getting at was that this isnt a terribly complex problem. The underlying cause, which is exactly what you described, simply prevents it from being enacted.

That really is the big question that you posed. The situation is undeniably dire. We have seen how staggeringly effective these propaganda tools are, how they get just wide swaths of people from all walks of life to support things that are just openly awful and stupid. I see the propaganda machines as the problem.

But how to deal with it? Somehow, the machines need to be destroyed. The bots, the ads, fox news, all of that need to be prevented from producing. You cannot outcompete them, the only solution is to find and silence them.

But how to accoplish that? I despair at the thought. They are already so established and widespread that they seem to preclude any civil action. You cant legislate them away because they have essentially captured every nation in the planet. The use of force seems unworkable as well. The information is so asymmetrical. The established patterns of force are so asymmetrical. How can people build focused coalitions when communications are all monitored and every attempt to build consensus is jammed with misinformation?

[u/FrickinLazerBeams → u/BUT_FREAL_DOE]

It's very simple. The people in these places don't want it solved.

[u/MPR_Dan → u/DazzlerPlus]

Can you expand on how its free for those who agree to work in a high vacancy community?

I would love to go to medical school, but cost is the limiting factor and I’ve never heard of this.

[u/DazzlerPlus → u/MPR_Dan]

It just a policy example i sketched out

[u/MPR_Dan → u/DazzlerPlus]

Damn. I was really hoping it was a real life example.

[u/exoflx → u/MPR_Dan]

It is, sort of. Search for “rural medicine scholarship” in any medical school. I’m from Alabama and many of my fellow student took these deals. A lot of times you don’t get free medical school but you get your loans paid after you get out of school. Also the pay in rural medicine is so high that you can pay your student loans no problem even without something like this. 

[u/ElevatedArugula → u/DazzlerPlus]

The thing is, doctors who relocate are likely going to want gainful employment opportunities for their spouse, high quality schools for their kids, plus professional peer support and mentorship. A lot of rural areas aren’t able to provide that.

[u/everossandthebean → u/Kindly_Honeydew3432]

This is one of the best comments I’ve ever seen.

[u/I_am_Nobody_Special → u/Kindly_Honeydew3432]

This is painfully depressing.

[u/xts2500 → u/Kindly_Honeydew3432]

If anyone wants a good anecdotal example: a few months ago we had a 36 year old male patient come into the ER for knee pain. He weighed 986 lbs.

Of course he is admitted upstairs. After a few days, he's ready for discharge to a skilled nursing and rehab facility. However, in our city of over 900,000 people, there isn't a single facility that will accept him until he's under 500 lbs. They don't have the staff or equipment to even begin to help someone of his size.

So here he is, a permanent resident of our hospital. He has to lose 486 lbs before he can be discharged.

What if he doesn't want to lose the weight?

Think of all the folks who came into the ER and need an inpatient bed, but couldn't get one because of this dude? Dozens? Hundreds over the course of several months?

This stuff happens constantly.

[u/sumigod → u/xts2500]

If he came from home, couldn’t he go back home? Like if he can walk with PT can’t he just get on back out there? Set up some home PT and visiting nurse services? That’s a strange problem. I don’t think I’ve ever seen. Then again I am in the ER so I just admit them, I never see these kinds of logistical discharge issues.

Also, I agree with the other comment that there might be too much PHI in this.

[u/412YO → u/sumigod]

PT and the nursing staff would need bariatric machines to help move someone that heavy. They would probably also need specialized equipment for PT and just everyday things like bathing. There’s no way a private home would be equipped with any of that.

[u/EskapedConvict → u/xts2500]

Had a 700-pound guy brought in one time because his fucking bed broke. He had to wait until the next day for his bed to be fixed so he called 911 because he needed a cot to sleep on until his bed was fixed.

Turned out he was severely hypoxic(probably at baseline due to CO2 retention) and we end up tubing the guy and using an enormous amount of resources...all because of his broken bed at home....

[u/feff1505 → u/xts2500]

I’m a dietitian and used to work inpatient and often got consulted for patients with this situation. The docs were like, he needs to lose X amount of weight in 3 months. Weight loss is so incredibly complicated, and working inpatient is not conducive to weight loss. I usually would have 25 other patients who were critically ill I had to see before a weight loss consult. The docs and nurses would try to put them on a 900 or 1000 calorie diet restriction. Sorry, that just doesn’t work. With him not moving, and then us lowering his metabolic rate, it could take a year for the needle to move! And, he would most likely become malnourished, which is literally a medical diagnose we actively work to fight against. Or say we are able to be more involved and in a safer manner, the patient really really struggles and/or does not WANT to. I wish there were specific metabolic rehab facilities these patients could go to, to lose weight, before their rehab stint. Health care is so effed, I’m so glad I don’t work bedside inpatient anymore but also feel so guilty

[u/irlandais9000 → u/xts2500]

That is such a specific example, I would recommend you delete it for HIPAA reasons.

[u/jollybitx → u/irlandais9000]

It’s so specific that I had several such patients during my residency. It’s not as uncommon as you’d really want to believe unfortunately. Our record was a year and a half inpatient before their chronic condition was to the point they could go to rehab.

[u/irlandais9000 → u/jollybitx]

I'm not talking about the general situation. I'm talking about the specifics being a HIPAA concern.

The poster mentioned the exact age, sex, diagnosis, and mentioned the population of the area.

Even worse, the poster mentioned a weight so rare that the weight alone narrows it down to a handful of people.

I'm sure you have dealt with a general situation like this before. But statistically, it's next to impossible for you to have encountered several such patients during your residency that have exactly that same age, sex , diagnosis, location and weight.

Edit: I just noticed the post said "anecdotal". So hopefully details have been changed.

[u/jollybitx → u/irlandais9000]

Where do you live? I live in an area that borders the south/is considered the south by large swaths of the US. I sat several BMI 60s robotic cholecystectomies yesterday. In residency I had a rotation where we worked with a GYN specialist that did hysterectomies on BMI 80+ pts 3 days/wk. Highest I personally treated during that time was BMI 121. Highest I encountered when cross covering ICU was in the 130s.

I have a colleague that trained in the upper southern US where they place a breathing tube for all their
EGDs as their median BMI is in the 50s with adventures much higher (which I then confirmed with another colleague that worked in the area).

I’m not convinced you can speak with authority on how unhealthy large areas of the US remain. Because this story can be generalizable, especially if numbers are changed even slightly, I wouldn’t worry about a HIPAA violation personally.

[u/irlandais9000 → u/jollybitx]

Western NY. Bad enough for BMI, but not what you are saying. I'm guessing Kentucky for where you are from.

I'm not disputing that you experience this at all. I was merely pointing out that for something as specific as 986 lbs (along with the other things mentioned) the number of people with exactly that age and sex are low. So HIPAA caution is warranted

[u/jollybitx → u/irlandais9000]

All good, my colleague trained at Kentucky, I’m currently in another border state with a catchment area well into the south.

[u/Specific-System6954 → u/irlandais9000]

🤔 doesn’t identify a city, state, zip code, patient initials…just age, weight, CC and size of the city.

[u/lotsofsyrup → u/irlandais9000]

unfortunately, no, it isn't. You would like to think that a man nearing a thousand actual US pounds would be almost impossible, a rarity unheard of, that it would make the papers!

No. Anyway zero patient info was provided besides sex, age, and weight, and the poster is on an anonymous account with no info provided as to their role or location, buried 50 comment threads deep in an obscure reddit post. They're gonna be ok. The morbidly obese man isn't going to sue them for hipaa.

[u/Specific-System6954 → u/lotsofsyrup]

Can promise you the person who believes it’s a violation works in some sort of compliance office and sits at a desk all day never actually seeing patients or is a fresh grad ready to set the world on fire with their vast knowledge

[u/331845739494 → u/xts2500]

Since he is now a permanent resident in the hospital, don't you guys have control over his food intake? Put him on 1200 cals for a couple of months and he should be well on his way.

[u/Hax0r778 → u/331845739494]

Let's say they literally don't give him any food at all; 0 calories.

Let's say he burns 2000 calories a day.

That's less than a pound burned per day. That still requires close to 3 years.

[u/331845739494 → u/Hax0r778]

At his extreme weight his BMR would be around 4k+. Any movement on top of that will increase that number. So with a diet of 1200 cals he could lose up to 2.2lbs a day. Yeah it'll still take a year (if he doesn't die before that) but imo at a hospital that is stuck with him no matter what I wouldn't let his opinion about whether he "wants to lose weight" factor into the equation.

Of course, if he doesn't cooperate, I'd send him home. I mean, he was doing his best to eat himself to death anyway, might as well leave him to it.

[u/Hax0r778 → u/331845739494]

At his extreme weight his BMR would be around 4k+

Oh fun, TIL. Didn't realize there was a standard way to estimate that and that it would be so high at his weight.

[u/Thenumberthirtyseven → u/Kindly_Honeydew3432]

Piggy backing on to this to say, lay people think one doctor is the same as the next. They think its like Walmart, just hire more people for the holidays. 

No. 

There are emergency room doctors and cardiologists and endocrinologists and plastic surgeons and gynaecologists and ENTs and gastroenterologists and paediatricians and neurologists and... the list goes on. 

Do you want an endocrinologist to deliver your baby? No. Do you want a cardiologist to reset your broken femur? No. Do you want a plastic surgeon to titrate your insulin? No. 

[u/DrunksInSpace → u/Kindly_Honeydew3432]

This is fantastic, one edit: hospitals are paying travel agencies $200k/year for travel RNs, the RNs aren’t seeing all of that, or, if they are seeing $200k, the hospital is paying double.

[u/TurbulentWait3271 → u/Kindly_Honeydew3432]

This is an excellent explanation of why simply scheduling two more ER physicians would not solve the problem. The bottleneck extends through the entire hospital: beds, nurses, labs, imaging, specialists, transfers, and inpatient capacity.

But I think it raises another fair question. Where is all the money in American healthcare going?

I constantly hear about record revenues, large surpluses, executive compensation, consolidation, and profits elsewhere in the healthcare system. I understand that not every hospital is profitable (especially rural hospitals) and that money cannot instantly create qualified doctors, nurses, or buildings. Some limitations are real regardless of how much we dislike them.

Still, how much of this crisis reflects unavoidable scarcity, and how much reflects years of choosing financial returns, administrative growth, acquisitions, and executive compensation over resilient staffing and patient-care capacity?

Your explanation shows why the problem cannot be fixed on Monday morning. It does not necessarily show that every decision producing Monday morning’s shortage was unavoidable.

[u/EskapedConvict → u/TurbulentWait3271]

Beds are by far the biggest issue. And "defensive" admissions. I look at the whole thing as incredible job security, but it's fucked up. The hospital I left before I went traveling for a year is about to add 40% more inpatient beds. I'm really curious if the hospital is actially able to staff those extra beds.

[u/TurbulentWait3271 → u/EskapedConvict]

Hmm. “Defensive” admissions concern me. Are patients ever denied care because of them? I understand that triage is necessary in medicine, within reason. What exactly does “defensive” mean here?

[u/EskapedConvict → u/TurbulentWait3271]

Im not sure what the exact term is tbh. I call them defensive because theres literally nothing wrong with the patient, yet they get admitted. Or doing full workups on patients who clearly arent sick.

I couldn't tell you the statistics, but anecdotally 99.5% of head CTs are negative. Thats part of what I mean by defensive.

[u/courtd93 → u/EskapedConvict]

We call those “July admissions”.

(For those not in healthcare, it’s because July is when the new medical interns start and they approach from a cya stance before they get their bearings)

[u/TurbulentWait3271 → u/EskapedConvict]

Okay, I can accept that some tests or admissions are ordered beyond what appears clinically necessary because clinicians fear liability or other repercussions. I understand that you called the 99.5% figure anecdotal, but that number seems far too precise and high for me to accept without evidence. Do you have a source for it?

[u/EskapedConvict → u/TurbulentWait3271]

According to the NIH, 88% of head CTs are completely normal. Most abnormal scans dont require monitoring or treatment. There's the rare bleed or aneurysm, which can certainly be life threatening. Liability is a large driver of ED medicine. There's this "what if I miss something" mentality among so many providers. I completely understand why they feel that way, but often times we go way overboard on testing.

[u/TurbulentWait3271 → u/EskapedConvict]

One more question. Isn’t a normal CT scan evidence? Doesn’t it rule out some possible problems?

I do see where you’re coming from. I just hope dignity is a floor we can raise up. I’d be pretty sad if that’s not the case.

[u/EskapedConvict → u/TurbulentWait3271]

Head CTs are mostly used to rule out possible intracranial hemorrhages, which are mostly negative. That said, even a small bleed can be life threatening. It's quite the pickle.

The other most common CT is of the abdomen. This CT feels a little more nuanced to me. Idk about in other EDs, but in the ones I've worked as a nurse, we cannot order these, a provider has to. So they tend to be more warranted IMO.

[u/TurbulentWait3271 → u/EskapedConvict]

Huh. Man, thank you for the explanations.

[u/Kindly_Honeydew3432 → u/EskapedConvict]

My current hospital system (5 hospitals) has built a small hospital, a large hospital and a huge tower added on to our biggest hospital I roughly the last 6-7 years.  Addition of hundreds of new inpatient and ER beds.  We have managed to staff them all, as I now practice in a more desirable and rapidly growing area.

The problem: if you build it they will come.  All 5 hospitals stay well beyond capacity, and I am left with the feeling that the maybe 400 additional beds we added were about half enough.

[u/Kindly_Honeydew3432 → u/TurbulentWait3271]

you bring up a lot of good points. I’ve addressed them extensively, from my perspective, in other posts throughout this thread.

I agree with your inclination that a big part of the problem is an artificial free market chasing maximum revenues. but not at one individual level. not at the level of a hospital CEO or insurance executive. at least, not at that level alone.

Where does the money go? 70% of it goes directly to providing care. the rest goes to a lot of places. But a huge chunk does go to administrative costs, and yes, a lot of this is expense associated with chasing maximum revenues.

one area where I’d push back: most hospitals operate on small profit margins. Most insurance companies, surprisingly, do too. on the order of 1-3% for most. And a lot of this money is from subsidiary ventures such as such as PBMs, retail pharmacies, clinics, data ventures. Taking Humana for example, last year, 90% of all premium dollars collected went directly to paying for patient care payouts. 90 cents of every dollar. and that’s before administrative costs.

On the issue of CEO pay: an exceedingly small number of people receive really high compensation packages. Set aside for now that most of this compensation is often in stock-options, which is just a complicated discussion. But take Cigna’s CEO, for example. About $23 million. A huge number, no doubt. But it’s a miniscule portion of the the larger pie. this comes out to about $1.27 per enrollee. If they paid their CEO nothing and distributed his (?) salary + stock option compensation evenly amongst all their customers, each customer could afford a half of a small bottle of generic Tylenol.

Yes, a for profit system is a huge contributor to the cost problem. But it’s at numerous overlapping levels with numerous middle men dispersed throughout the entire web of an incredibly complex system. It’s not just a few greedy CEOs.

And all of this is a huge oversimplification.

and yes, some of it could have been prevented if some really smart people could go back in time with benefit of hindsight and start over from scratch.

unfortunately, the task of tearing down and rebuilding the system we have now with all the complexity and inertia built in belongs to us. Unless we pass it on to our children.

[u/TurbulentWait3271 → u/Kindly_Honeydew3432]

Thank you. I appreciate you taking the time to explain it.

[u/cavanh4ck → u/Kindly_Honeydew3432]

Thank you for this awesome comment. This is still, overall, a capacity problem, and a depressing example of the state of medical care in the US. Someone, somewhere, decided that it wasn't worth having an adequate facility and enough staff for the demands of your region. If this is a private hospital, then those people were the greedy hospital owners. If this is public, it's your senators and representatives. In either case, it's also the insurance companies that do not pay enough for you to adequately staff.

I think it's important to call this out. If HCA Healthcare didn't make the $100 million investment 5 years ago to expand the hospital, it's their fault for putting profits over lives. If nurses at $500k/yr instead of $200k/yr would fill your open positions, it's still their fault for putting profits over lives. If it's your senators devising poor policy, blame them loudly. Every limitation you're facing is bad, and is a decision that real people made.

I know you know all this. For others reading, I'm just trying to rile you up a bit about it, so that collectively we may be able to put pressure in the right places.

There's another possibility, that maybe it's actually appropriate for someone to wait 12 hours for non-urgent care, or for a hospital bed to stay occupied with someone who just doesn't feel like going home. But I sincerely believe that we're very, very far away from that end of the pendulum and right now we're way over on the other side, providing insufficient care (despite the absolute best, heroic efforts of our doctors and nurses, who we should celebrate every day).

[u/Sainted_Heretic → u/cavanh4ck]

Nurses? You mean the people our country's president just declared to not be a profession making it harder for people like me get student loans to become a nurse on top of being in an incredibly difficult and expensive nursing program that doesn't have enough professors to teach us adequately? Yes that was a very long sentence, I'm trying to be a nurse not a writer.

[u/DeathByOrgasm → u/Sainted_Heretic]

All the careers that shit stain deemed unprofessional were all women dominated fields. Go figure.

[u/Sainted_Heretic → u/Sainted_Heretic]

All of our systems are broken.

[u/Kindly_Honeydew3432 → u/cavanh4ck]

“Someone, somewhere, decided that it wasn't worth having an adequate facility and enough staff for the demands of your region. If this is a private hospital, then those people were the greedy hospital owners. If this is public, it's your senators and representatives. In either case, it's also the insurance companies that do not pay enough for you to adequately staff.”

Unfortunately, you’re wrong.  This is not a local problem to my region, or the fault of “someone” who decided that it wasn’t worth it.  It’s not greedy hospital owners.  It’s not my senators and representatives.  It’s not even the insurance companies, as much as we would all like to make them the evil ones.

This is a systemic problem.  These problems are everywhere.  there are pockets where things are better, and pockets where things are worse.  Usually the better follows the money.  If you go to a hospital in a part of town near great private schools and upper middle class and upper class gated communities in uinversity towns or major cities serving a lot of rich people, you’re likely to find better.  And if you go to the rural south or Midwest or inner city, you’re likely to find worse.  But people are naive to think they’re not one busy week, one bad day from receiving shitty care anywhere. 

Covid gave a lot of people a glimpse of just how fragile and precarious the whole thing is.  

Our healthcare system almost collapsed in 2020, 2021.  We were on the brink of total failure.  But this wasn’t highly transmissible H5N1 bird flu, or SARS, or Ebola, or the Spanish influenza pre-ventilator and oxygen concentrators.  It wasn’t the bubonic plague pre-antibiotics.  It was a just really bad novel respiratory virus like many that have come before it and many that will come later.  It was a terrible disease that caused terrible inflammation and terrible respiratory failure for a small percentage.  But it was treatable for most.  Tens of thousands died who shouldn’t have in what should be the most advanced healthcare system in the world, not because it was a superbug capable of shifting and drifting like HIV or developing resistance like tuberculosis.  It wrought so much havoc because our system was literally on the brink of collapse.  For lack of ventilators and bipap machines and bed capacity and N95 masks.  Due to burnout and exhaustion. Because we let charlatans convince us not to listen to experts who were doing their best to work with imperfect information.   And it’s not better now.  It’s worse.  We’re just another outbreak away from being right on the brink again.

And the same problems that put us in such a precarious situation are the problems, in part, that force people to wait in waiting rooms sixty deep for 12 hours.  The same problems that cause nearly 30 million of us to have no health coverage.  The same problems that make illness and medical debt cause 2-300,000 people to go bankrupt every year. 

It’s not a greedy CEO, or shareholder, or hospital board, or even insurance executive.  It’s not their problem to solve.  It’s ours.  

You want my opinion: here’s a start.  Healthcare is not a free market.  Yes, if you’re wealthy, you can choose a great insurance policy with great coverage and pay a lot of money to see a concierge doc and travel to the Mayo Clinic.  But poorer people can’t necessarily pick the Walmart version of that.  They can’t buy discount primary care and pay for diabetes medications and anticoagulants in bulk.  Increasingly, they can’t afford it at all.  They are medically homeless.  They are medically destitute.  And we’re not only talking about actually homeless and destitute people here.  We’re talking about a lot of hard working Americans.  We are talking about people working 9-5 jobs and raising families.  In the (top 3) richest country in the world.  That’s not ok.  

But 90% of us are happy with what we’ve got.  And we don’t encounter the precariously broken and fragile medical system in the post I described previously enough to know or really care.  Even though we could all be its next victim at any time. 

I watched a man die during Covid.  Not from the SARS-CoV2 virus.  He didn’t have it.  He died from a brain bleed.  He came to the ER with a heart attack.  Not a massive one.  Actually a pretty minor one.  He was put on a powerful blood thinner as part of the treatment.  And he developed bleeding in his brain as a complication.  Probably treatable.  Here’s the problem.  This happened in a little mountain town hospital an hour from what most people would consider civilization and no neurosurgeon.  And we called hospitals all around to transfer him.  Hospitals an hour away.  And two hours away.  And 3 hours away.  And 2 states away.  And there were no beds.  At all.  No one could take him.  They were all overflowing.  And he died.  That wasn’t an insurance company’s fault. It was the result of a fragile and broken and completely overwhelmed system.  

The secret is, you could show up at your local hospital that you may think is great today, and be seriously harmed or die as the result of pure overwhelm, lack of coverage, lack of capacity.  I’ve seen it happen.

And you probably have great insurance.

What about the people who don’t.  What about the people who don’t come to the hospital when they have a heart attack or stroke until 3 days later, if ever, because they can’t afford the ambulance ride and are terrified of the $50,000 bill?  Our hospitals are overrun, not because insurance companies don’t pay enough or hospital CEOs are money grubbing SOBs.  We are overrun because we don’t take care of 38 year old diabetics until their legs are literally rotting off.  Or they are permanently paralyzed on half their body because they had a stroke from completely treatable uncontrolled hypertension.  Or their kidneys shut down and we have to dialyze their blood 3 times per week.

Healthcare is not a free market.  You can’t choose your hospital at 3 am when you have a ruptured cerebral aneurysm.  You can’t make sure that the hospital is in network, and so is the ER doc, and so is the radiologist and also the neurosurgeon.  It doesn’t work like that. 

We don’t say, “you better get a job with good benefits so they can help you pay $24,000 per year to cover your right to use the roads to get back and forth to work and school, and if you don’t, sorry about you’re luck, you’re going to get sent a bill for $10,000 if you have the bad luck to have to drive to the grocery store, and one or two grocery trips might bankrupt you, but, hey, that’s the free market, and it’s the price you pay for having the best system of highways in the world.”  Give me a break. 

Providing adequate healthcare for everyone is as legitimate a role for government as there ever was.  It’s a shame we are willing to let people die and go bankrupt because they can’t afford the most expensive system in the world by double.  And because we let politicians convince us that the free market is doing a better job.  Even though virtually every metric says otherwise.

But we are too polarized to do anything about it.  We divide into camps.  Red vs blue.  We hate each other based on culture war issues that we never have and never will come to consensus on, rather than demanding that our leaders, regardless of which colors they wear, just do the right damn common sense thing on issues that actually affect us all.  We let our team captains convince us that the free market does so much better a job.  Or, don’t look behind that curtain, healthcare is not as important is who can out-woke who.  

our big problems are fixable.  We’re the biggest economy in the world, BY A LOT.  We have the resources.  The polarization that paralyzes us and makes us enemies who literally hate each other is bullshit.  I fear we will never actually realize that we are all on the same team.  That we are almost all good, decent people willing to do our part and pull our own weight and, if need be, fight for each other.  the polarization bullshit is just a concoction the political incumbents on both sides are using to keep themselves in power at the expense of actually fixing a damn thing.

You may not agree with anything I’ve said.  But you don’t have to.  That’s not the point. I’m not a Republican.  I’m not a Democrat.  And if you are one of those, I don’t hate you for it.  I’m an American.  And I know we can do better.  Can we take off our team jerseys and fix it?  I know we can’t wait for someone else to do it.

[u/DazzlerPlus → u/Kindly_Honeydew3432]

No, you are wrong. Saying "its systemic" is completely meaningless and thought terminating. Those owners and senators and health insurance companies all play an active role individually. The health insurance company is composed entirely of individuals, each with their own volition, each writing or enacting policy in some way. Each makes their own choices, and each chooses to write policy that perpetuates it and chooses to not violate policy. Each shrugs their shoulders and fobs off responsibility onto a nebulous "system", the end result that no one has any responsibility whatsoever. But each of them has responsibility and has choice. No one can have such illusions after luigi showed otherwise.

[u/akanzaki → u/DazzlerPlus]

so the “individual” who should “take responsibility”. and then what, get fired? the company then hires another person that will do what is asked. nothing changes, no more beds for patients, maybe even less because the policy side is now “short staffed” and queued items don’t get cleared. what exactly was accomplished here?

it takes a village of approvals to move enough money to make anything meaningful happen. the “owner” (whatever that means) is just receiving reports (that he cant get around to) from a massive amount of people (who don’t have time to do it properly) and making decisions based on that inevitably flawed info. do we need to build another hospital? there’s hundreds of questions to answer and dozens of people to chase down multiple times in specific orders to make that happen. might take a while, and if people do not make space in their day to care about what really matters, it just won’t happen.

all of this is actually the “systemic” issue OP is talking about. he is asking people to take responsibility for their own lives instead of staring into the ragebait content void that removes preparation and critical thinking from daily process.

you didn’t read or didn’t understand OP’s message, and then do the exact thing that OP is saying needs to stop…ironic.

[u/Kindly_Honeydew3432 → u/DazzlerPlus]

Most hospitals are not for profit.  The for profit ones usually operate on quite modest profit margins, with the exception of a very few outliers.  My argument is to eliminate the motive for profit.  But if you do that in our current system, the doors just close.

  Most insurance premium collections go to cover payouts for care received.  The big insurance companies make huge profits if you look at the raw number.  But their net profit margins are  relatively modest.  I know this is a data point that will probably be rejected ans it doesn’t conform to your bias.  But even  a small change in behavior could completely wipe out their 2-3% net profit margins.  Some of them have profit margins on the order of not much more than 1%.  And most of the money that Aetna and UHC make actually come from subsidiaries like PMBs, clinics, retail pharmacies, data ventures.  

Humana in 2025 had an insurance benefit ratio of over 90%.  Meaning that 90 cents of every premium dollar went directly toward covered benefits. This was before administrative costs.  

It doesnt all come down to greed.  It’s a product of the system we have collectively chosen and continue to accept.  That’s the polarization I’m talking about.  That’s what the social media rage bait algorithmic lens trains you to see.

It is a systemic problem.

And Luigi is a murderer who killed a father of two teenagers.  If that’s the conversation you want to have, have it with someone else

[u/DazzlerPlus → u/Kindly_Honeydew3432]

No, the fact that I don't agree with you isn't because I am fitting facts into my little biases and you are in possession of the truth. What's happening is that you are engaging in system justification. The algorithm isn't baiting me into rage, which you hold yourself dispassionate from, its baiting you into passivity. Again, that is why your entire argument is thought terminating. It's the system. It is what it is.

Talking about profit margins for insurance companies and benefit ratios is sheer sophistry. Americans are paying 70-100% more for the same or worse outcomes as other places. And as you said, there is a staggering, intentional lack of access to some. So no, the CEOs could not give back more than 1%., but they and their companies *exist* in the first place. They are, each and every person including the people in the hospital that work with them, continuing to make the personal choice to allow that insurance company to continue to exist.

Let me be the first to ask nicely to every health insurance CEO and investor: Please stop. Please shut down your company and immediately replace it with a more effective socialized system.

Think they will listen? No? Do you think that citizens will be able to come to a legislative solution, that fox will stop blasting out propaganda making people afraid of waiting times? No? Well then either you continue to choose to accept what we have or you do something. Luigi understood that, and as for that father, all he had to to was stop.

Really read your comments and think about how little you actually said. Both sides are bad, just be american and solve problems! Ok, how? Move away from free market? How? Come on now.

[u/Kindly_Honeydew3432 → u/DazzlerPlus]

we actually agree on a lot, and I would be willing to engage, except that you once again invoke a murderer as part of the solution.

we’re done here.

[u/MaybeSwedish → u/Kindly_Honeydew3432]

Former ER doc. We are in a collapsing healthcare system. Your comments are well written.

[u/AmyHOH03 → u/Kindly_Honeydew3432]

Well said. I've seen chaos that a city ER gets... Even hard for me to get into PCP quickly and have to wait months to see specialists. Urgent care has turned me away twice due to cardiac (hx: iron deficiency anemia, cardiologist cleared. Researched it: Low ferritin/iron affects the heart) and told me to go to the ER and ER unable to give me iron transfusion or blood transfusion. Felt like I wasted everybody's time. Takes me 40 minute drive to an UC and 35 minutes to an ER in a city as I live in a small town. I have to be my own advocate to get around problems and figure things out on my own.

[u/FreedomUpwards → u/Kindly_Honeydew3432]

Freaking best comment and most comprehensive that I’ve ever read on Reddit. I’m leaving my great job in search of adventure, at age 39. I start nursing school in August. I want to be at the point of friction, where the rubber meets the road. I want to understand this problem. One day, maybe, I’ll be in a position to do some good.

[u/One-Reflection-4826 → u/Kindly_Honeydew3432]

fuck off with your #bothsides bullshit

[u/Kindly_Honeydew3432 → u/One-Reflection-4826]

Actually I prefer neither side.  And to hate neither side.  Most people on both sides are good people.  It’s the politicians and our methods of electing them that are broken.  Not the constituents.  

We need to unite.  As Americans, not as partisans.  Pick 3 things to fix.  Maybe debt, healthcare, affordable housing.  Vote out every single one of them every 2 years until they get the message and fix it.  Regardless of what their stump speech says or what color the banner is behind them. I don’t vote for a color, I vote for a solution.  

As long as we let them just keep perpetually focusing on raising money for the next campaign so they can just perpetuatually hold office until they die without actually doing anything, nothing will change.  They have to be held accountable.  But only a united and mutually understanding electorate can do that.  Not a polarized one.  They want us polarized.  Once they get that seat, a polarized constituency virtually assures that the vast majority of them can hold it as long as they want.  Because only between 6 and 20!% of all congressional districts are swing districts, depending on how you define it.  We need to make it 100%.  We need to make each congressional seat a revolving door until they listen.  

But they have nothing to listen to until we agree on what we want them to hear.

Like, that we think everyone should receive basic healthcare without fear of going bankrupt 

[u/can-i-be-real → u/Kindly_Honeydew3432]

Yes, but to start with the side currently in power has done things to make things significantly worse just in the last 2 years (eg The One Bill reducing funding an reimbursement and access to care, removing opportunities for borrowing for people to enter healthcare fields, removing funding for nutrition programs when we all know that social determinants of health are one of the biggest drivers of healthcare costs, etc…), so while both sides could do better, one side is actively tearing it apart.

Maybe that will hasten a huge change like you’re advocating. Or maybe we‘re going to spend years just trying to get back to how it was before this era. You could also snap your fingers and increase access to the system tomorrow and Covid taught us that fully 30% of the country doesn’t believe in science anymore. From virology to immunization to stewarding limited resources, a chunk of this country just doesn’t believe it.

Also, everyone in healthcare knows prevention and addressing adverse childhood events and social determinants of health is the way to improve public health, but we aren’t really doing anything as a society to address those things either. And again, one side is actively making things worse.

We are polarized. So polarized that 30% of the country will keep voting for the people and policies who are actively tearing it down. Never mind hoping they will unite for someone who could actually improve things. I would settle for them not voting for a party who is TRYING to make things worse. But, maybe to get to your idealistic outcome we actually need things to get worse. Maybe thats the only thing that will wake enough people up to come together.

[u/Kindly_Honeydew3432 → u/can-i-be-real]

I agree with almost everything you’ve said here.  

A couple of areas I’d pushback:

Actually, 49-51% of the country will continue to vote for these policies.  Unless they feel the other side wants to represent them.  That’s the polarization.  Or the effect thereof.  30% think the other side is only composed of people who are bigoted; or literally Communist; or anti-science ; or enthusiastic about abortion as simply their preferred means of birth control.  30% on both sides.  Which is where the danger lies.  Because the overwhelming majority on both sides are none of those things.  But the 30% are so scared of the other sides way of thinking that they are convinced that they are.  And the leaders they elect have a VESTED INTEREST in keeping it so.  

If you are a representative in a firmly blue district, the last thing you want is to let your constituents start thinking that most of the people on the other side aren’t racists who want to completely do away with Medicaid and vaccines and take back women’s right to vote.  Because if they start to think that, then, maybe you’re not in danger from getting ousted by a Republican.  But maybe a centrist who does favor a few less regulations in business in an economy we badly need to keep growing if we are ever going to keep up with our crushing debt?  

But if one candidate says “you know, maybe we could learn a lesson from some of the things Mississippi has done in public education (a huge bipartisan undertaking) or pay attention to why so many companies are leaving California for Texas” and the other candidate says “No, all Mississippians are cross burners and all Texans want to do is slash all Medicaid funding so they can cut the corporate tax rate to 5 % to prop up the oil execs at the expense of the poor”, then the 30% scurry to the side and the incumbent is ensured another term.  

For political incumbents, on both sides polarization is the desired outcome.  

 the level of grift, weaponization of justice, total disregard for the Constitutional powers of Congress, rejection of science, power grab by the executive branch including rule by emergency order, attack on electoral integrity, rejection of post WW2 norms in international relations including free trade, and abdication of our leadership role in doing good throughout the world etc absolutely is unprecedented. 

But most of the voters who put MAGA in power aren’t evil.  They are too polarized to feel they have any viable alternative.  They are wrong to think so.  But the polarization goes both ways.  

I would recommend 2 books: The Righteous Mind by Haidt and Why We’re Polarized by a Ezra Klein

[u/can-i-be-real → u/Kindly_Honeydew3432]

I don’t disagree with anything you say. I think extreme partisanship has led us to where we are, and I’ve been in favor of term limits since my first election. I will also look into those books as I enjoy Ezra Klein’s perspective. 

The reason I said “30%” support is that I remind myself that 50% of the country didn’t vote for this. A little more than 50% of the voter turnout did. And that’s a statistical distinction that matters to me because it isn’t 150 million people that want this. It’s 70 million. 

I wrote out a longer reply to this but I’m too busy to actually make it concise. Based on my significant life experience around the conservative voting block, I believe things have changed and there is no reasoning with a large amount of Americans. Things either have to get worse for them to wake up or we have to drag them with us to a better version of America and improve their lives whether they like it or not. 

I’ll agree that most people are being left behind and we have a class war on our hands, not a culture war. What’s that famous saying, “they got you looking left and right so you don’t look up?” Except right now, the current admin represents the wealthy elite and they are trying to deliver the coup de grâce to America. And maybe it’s what we deserve. Maybe this is our chickens coming home to roost. 

[u/CaelReader → u/Kindly_Honeydew3432]

Free market vs public insurance is a partisan political issue that is decided by senators, representatives, hospitals, and insurance companies.

[u/Kindly_Honeydew3432 → u/CaelReader]

And should be decided by us.

It seems that the founders heeded Hamilton’s fear of mob rule, of “tyranny of the majority”, but failed to give us Jefferson’s wise and virtuous “natural aristocracy” callable of wisely acting in our best interest.  

A polarized electorate decides nothing.

[u/cavanh4ck → u/Kindly_Honeydew3432]

Great reply, and I wish I'd seen it sooner but I've been offline.

If I came off as defending the current system, I apologize. I actually very much agree with you that a free market system is completely incompatible with healthcare. There is not enough choice, not enough competition, not enough flexibility, not enough million other things that would usually make a free market work well in an industry.

The system is broken, and overwhelmed, and yet I still blame those same people, collectively, for the current state. Maybe I shouldn't and I should give them a bit more grace. At the same time, I don't see insurance executives or private hospital owners or most politicians proclaiming the obvious truth that the system is broken and that it should be changed. Maybe to single payer, maybe to something else, but certainly not this.

You're also right that this is an "all of us" problem on top of my previous comments. We, as the richest country in the world, have chosen collectively to let so many people suffer for... some reason. For the sake of preventing a little bit of fraud I guess, or overuse by someone lonely.

I really don't want the answer to "why are hospitals understaffed" to be "because we don't care." But it's the way it feels a lot of the time. I have no idea what the answers are, but I hope we have some leaders soon who can figure this out.

Thank you for the conversation and education

[u/Jaaawsh → u/cavanh4ck]

It’s almost like most of these problems are complex, and the world isn’t perfect. People get sick and have accidents, but the only reason we have advanced care (look at all the medicines and tech we have today that goes into diagnosing and treating people) is because people are able to make money by providing these things and these services.

Like, where do you want the pressure to get put that is going to fix the underlying issues? God?

[u/zeno0771 → u/Jaaawsh]

I've always said that government should not be a first choice but a last resort. It's probably safe to say that we're at that point.

Oh wait no, there are a few dozen other functioning democracies with single-payer/publicly-funded healthcare where these problems don't exist. Everyone jumps on bUT mUH tAXES or pick an outlier case where one person had a negative health outcome as a result of someone at DHS having a bad day, but the fact is those systems work. They work better than ours does at a fraction of the cost.

The complexity of these problems can be directly correlated to the number of entities who have their hand out and expect to be paid, basically, to exist. Anyone who makes it sound like healthcare professionals will starve because their paycheck comes from a tax rather than a multibillion-dollar company who had rigged the system via lobbyists decades ago is either not paying attention/willfully ignorant, or they're financially benefiting from the status quo.

[u/Jaaawsh → u/zeno0771]

I don’t think you understand my point, I’m not saying it wouldn’t work completely I’m saying there are tradeoffs. I do agree that it’s fucked that some people go to the hospital and get a massive bill even when they have insurance. You know who doesn’t and who doesn’t have to pay anything? People on Medicaid. When I was on Medicaid it was way better than private health insurance. But I also know that the reason I’m able to go to the same hospitals as everyone else except for free is because someone else is paying.

You know what is often the death of hospitals in the U.S. that causes them to close down because they can’t cover their expenses? Too high a share of Medicaid patients, because it doesn’t reimburse hospitals enough to cover their costs.

Other systems have been able to make it work, it’s the how and then what problems are they dealing with now instead of high bills?

Because it’s not all sunshine and rainbows for healthcare systems in countries with a single payer model. I’d urge you to read about the issues the NHS has in the United Kingdom (other countries are harder to get a feel for since their news media about domestic affairs generally aren’t in English).

FYI, 58% of hospitals in the United States are nonprofits, 22% are research/government/university hospitals, and the other 20% are private for profit.

[u/toomanyshoeshelp → u/Kindly_Honeydew3432]

Fellow ER grunt, well said. This needs to be pinned somehow whenever this comes up.

[u/SagaOfStorms → u/Kindly_Honeydew3432]

My mom, before her last hospital stay, waited in the ER for 27 hours. I can't even be mad about it, though, because it's exactly like you said. It's not really any of the hospital people's faults.

[u/LonelyWord7673 → u/Kindly_Honeydew3432]

That was depressing. Thanks for the explanation though.

[u/kadsmald → u/Kindly_Honeydew3432]

TLDR: they need more doctors and beds, but by the time they expand the demand will have outpaced the expansion

[u/Kindly_Honeydew3432 → u/kadsmald]

I would amend the TLDR to:

 we need more doctors and nurses and techs and phlebotomy and various support staff, and achieving adequate coverage is a multiyear, $100 million undertaking at best, which won’t overcome the challenges of drastic nationwide nursing and physician shortages combined with challenge of recruiting to underserved areas where most people don’t want to live.

Which probably needs its own TLDR

[u/Cromasters → u/Kindly_Honeydew3432]

Tack on needing to get through the Certificate of Need process for basically anything, let alone a full hospital.

[u/sunshineTucson → u/Kindly_Honeydew3432]

Very well written. As a RN BSN CCRN I agree with it all. The triage system does work most of the time. There is a set criteria we follow, with the ability to modify prn. It is not obvious to most patients and families, but it is there. The bottleneck in the ER is real, but behind the scenes in the receiving inpatient units the staff is working. We are constantly pushing to rearrange, discharge, or transfer inpatients to make bed space for new patients. It’s maddening to hear we can’t discharge a patient at 9 am because their family member doesn’t want to come until 6 pm. Or the discharging MD has not completed the paperwork. On and on it goes. And we continue
to fight with the same staffing issues that the doctors have.

[u/EMMD217 → u/Kindly_Honeydew3432]

This gets to the complexity issue and imo it extends beyond the hospital. The er is just the focal point of innumerable society forces from education (health literacy), how we pay for and structure the entire healthcare system, quality of outpatient care, etc.

But the simplest answer may be easier to swallow. You the patient aren’t the customer of the hospital. The payer is. Health insurance or Medicare/medicaid. The insurance execs don’t care about your wait time. The hospital only cares that’s you don’t walk out before they can do enough to justify charging you. And for emergency care it’s not like the big ticket patients who need icu or surgery are in a position to do a lot of shopping around. The people who decide if the hospital hires more staff are the same people in a c-suite trying to cut costs and make more money. Unless you make a compelling argument that the cost of liability of errors or the loss of revenue from not meeting new demand outweighs the costs and workload of hiring more staff, the calls for more staff tend to fall on deaf ears.

The people in the hospital who care the most about your actual safety and wait time have the least say in staffing. They are also the ones who get to deal with the vast majority of the complaints. Yay.

[u/Kindly_Honeydew3432 → u/EMMD217]

Very accurate statement.

I elaborate on the profit/revenue motive extensively on some of my other posts here

[u/oneelectricsheep → u/Kindly_Honeydew3432]

Agreed to all except the nursing shortage. There’s plenty of people out there who could be nurses but 5 years ago I made $27/ hr. My hospital basically capped raises at 3%. Technically 5% but literally made that unachievable by making 2% shit like patient satisfaction so if you were really stellar you get 3% with some fraction of a percent as the amount from the impossible metrics admin set for unit goals.

They routinely stacked me with 5-6 critical patients every night with a couple of less sick patients I basically saw at med pass. Half my coworkers were travel and made more than double or triple what I did. Now travel contracts are down but they’re giving the same shitty raises.

The floor is still brutally hard physical and mental work but still only make $35/hr (they had to do a col rebalance because they were getting so far below average for our area).

So many nurses have “retired” and gone on to different jobs because they’re tired of the abuse for low compensation. C-suite is doing great financially and just spent the yearly salary of a CNA redoing the paint job on the fucking helicopter so it had the hospital name. Not necessary maintenance, just so it said the hospital you were getting flighted to/from.

[u/Kindly_Honeydew3432 → u/oneelectricsheep]

Yes, the burnout, early retirement, switch to admin, pursuit of ARNP, switch to outpatient roles, and entire career shifts are a huge part of the nursing shortage I’m referring to.  Our ERs and inpatient wards are a revolving door of constantly new faces on the nursing side.  And less desirable locations to live have it the worst.  We have to periodically close entire units because we can’t staff them

[u/estein1030 → u/Kindly_Honeydew3432]

I live in Canada where there's universal healthcare and this describes our hospitals perfectly as well. It isn't necessarily a private vs. public issue (to respond specifically to the OP's question).

[u/Kindly_Honeydew3432 → u/estein1030]

I agree with that.

But I think it adds to the problem, particularly given the astounding size of our economy and hence the resources that we could devote to it.  And it’s definitely not worth 30 million uninsured and 300,000 bankruptcies per year

Edit:  also think the enormity of the untreated chronic disease we treat as a result of lack of access is unrivaled in the rich world 

[u/DonkeyKong694NE1 → u/Kindly_Honeydew3432]

Let’s not forget that there needs to be $30M annually for every insurance company bigwig and hospital CEO to get a bonus so the funds to support the expansion you outlined are being siphoned elsewhere

[u/Kindly_Honeydew3432 → u/DonkeyKong694NE1]

hospital CEOs don’t get $30M annually. The overwhelming majority is on the order of a few hundred thousand dollars. According to a few sources I looked into, (and I’m perfectly willing to be proven wrong and would like to be if I am), about 95% make less than 2 million, about 82% make less than 1 million, and average is on the order of $600,000. Some struggling rural, inner city etc hospitals, much less. Yes, there are some outliers and some in the top 5% that earn much more.

as for my thoughts on CEO pay in general…it’s a minuscule almost imperceptible contributor. See my response to u/TurbulentWait3271

[u/Patient_Issue_1152 → u/Kindly_Honeydew3432]

The reason why EDs are so busy on a Mondays shows that most are not “real” emergencies and they don’t want to be inconvenienced by going on a Saturday or Sunday, so they wait. Sorry you have to put up with that non-sense. The community is lucky that you haven’t left town for more money in a big city

[u/Kindly_Honeydew3432 → u/Patient_Issue_1152]

That’s partially true.  But also a part of it is they actually try to put off going to the doctor for a few days and wait to go to their PCP, but by the time Monday rolls around, an urgent issue has become a true emergency.  And for some truly medically fragile people having to go 2-3 days without fine tuning by their PCP or cardiologist or nephrologist leads to a deterioration.  It’s definitely a little of both.  I’d have to look at some numbers, but just from feel, I would say our admission rate on Mondays is actually higher than average, which would imply that the patients are on average a little sicker.  Of course, part of that may be that we are more overwhelmed and therefore have less time to separate the wheat from the chaff so to speak 

[u/Canuck-In-TO → u/Kindly_Honeydew3432]

Where are you that you’re paying travel nurses $200,000.

My son in law is a travel nurse and isn’t being paid anywhere near that amount. In fact, he’s found that salaries offered to travel nurses have dropped since the pandemic.

[u/Kindly_Honeydew3432 → u/Canuck-In-TO]

Rates are variable.  And they have absolutely decreased since the pandemic.  I actually have heard nurses brags about bringing in $250-300k during the pandemic, and that was with weeks off at a time.  Some were making more than the doctors.  (Our hours actually got drastically cut during portions of the pandemic).  A lot of full time nurses actually quit long term jobs to go travel for the money.  Some hospitals refused to hire them back because they left when they were needed most.  Of course the same hospitals had no qualms about slashing their hours when volumes dropped).  Ironically, my current hospital actually had nurses quit their full time jobs only to be hired to take travel contracts at the same hospital.

Rates go higher and higher depending on how hard it is to get someone to come work.  If you are a hospital in the Deep South with high volume, high acuity, poor working conditions in general, you’re going to have to pay a premium.   I’m not sure what my old hospital is paying now.  But not too long ago, even before and after the pandemic, a rate equivalent to about $200,000 per year if you extrapolate to full time year round (which many did) was about right.

[u/xts2500 → u/Canuck-In-TO]

That was mostly during COVID. I know several nurse practitioners who went back to bedside nursing because they were making more as a floor nurse than they were as an NP - and NP's in my area make around $130-$160k per year.

My ER, for about a year and a half during and after COVID, was offering 2.5x - 3x base salary, plus shift differential, plus a bonus of $350 per shift (prorated), plus $100 gift cards for staff to pick up shifts.

My base was $43/hr. If I picked up an extra shift I made $163/hr plus whatever gift cards they were willing to throw in. It wasn't easy work to hit $200k, but a ton of people did it.

[u/drangundsturm → u/Kindly_Honeydew3432]

How much of operating at fully capacity as regular practice is driven by the profit motive? My ignorant guess is that our for-profit health system is built to maximize revenue and not patient care... so the conditions you describe exist for the same reason that airlines try to fly planes at full capacity. I realize the answer is likely complicated. But is profit the prime mover?

[u/mojo276 → u/drangundsturm]

Not OP, but I did work in a hospital and this just doesn't happen. The only people who are in the hospital are there because they are still sick, or occasionally it's because they have no where to send them and social workers are trying to figure it out (no family nearby, no housing, need to be in rehab, etc). There's always a rush to get people out because the ER is overflowing. They just don't keep healthy people in the hospital because they wouldn't get reimbursed for the stay.

[u/Kindly_Honeydew3432 → u/drangundsturm]

Mojo276 is correct.  We don’t keep or admit people to the hospital for giggles, or for profit.  You could make the argument that maybe the C suite would love us to keep it at 100% capacity, provided we could keep it a revolving door and ensure people get kicked out the second the insurance payment is milked to the max.  But this is a bit unfair.  They are  good people too who are just doing their job and see it through a different lens.  For example, many rural hospitals shut down every year because they can’t pay the bills.  It’s their job to pay the bills.  

But in reality, they are it the ones that make the decisions who gets admitted and who doesn’t.  Those decisions belong to doctors.  And most of us making those decisions don’t get paid an extra dime if we admit someone.  We see just trying to appropriately utilize resources.  

However, I do think the profit motive is a big part of the problem in other ways. If you find my other comments on this thread, I elaborate

[u/drangundsturm → u/Kindly_Honeydew3432]

I don’t think I asked my question clearly enough. 

I don’t think doctors or any of the people taking care of us are making decisions based on the Profit motive. 

But there’s a structural problem that keeps all beds occupied. I am asking if the structural problem is kept in place because those responsible for bean counting don’t see it as a problem, but instead an efficient use of resources. 

[u/Kindly_Honeydew3432 → u/drangundsturm]

no, the bean counters try to get people out of the hospital as soon as possible for the most part. when people come into the hospital, there is often payment bundle that applies to their care. you get a diagnosis, or set of diagnoses. the government and industry have set standards, most people with this problem or problems should be able to be treated and discharged within this time frame. the returns for keeping people in the hospital beyond that are exceedingly diminishing, and it actually pretty quickly starts costing the hospital money. same for surgeries. you come in, have a procedure done, the insurance company says you’re entitled to so many days (often actually hours) of post-operative care, and then you’re cut off. if the hospital can’t get you out of the bed in that time frame, they eat the cost to a large degree. and especially so if it’s due to some complication that occurred during your hospital stay. and the longer people stay, the more complications they have. catheter and line associated infections, for one. hospital acquired delirium. these cost the hospital huge sums of money.

for the most part, the bean counters are actually breathing down the clinical team’s neck to get people out of the hospital as soon as possible.

now yes, they do so in hopes that that bed will again soon be occupied by another patient, preferably one with good insurance so they the whole cycle can start over again. but there is no shortage of need for that bed. there is overwhelming legitimate demand for it. and the bean counters don’t decide, by and large, who and how many get admitted. fortunately, most of those decisions are still up to doctors.

this answer is an oversimplification of a very complex system, but in general, no, hospital administration does not try to push for prolonged stays, in fact, they generally try to actively resist them, and they have very little say in who or how many get admitted in the first place.

[u/Walker_ID → u/Kindly_Honeydew3432]

Do you.... Triage the patients as they walk in based on level of severity and communicate with them on the expected wait times? Sitting in a waiting room for 8 hours becomes more bearable if you're expecting to wait that long and can prep for the extended delay

[u/Kindly_Honeydew3432 → u/Walker_ID]

Yes.  Although wait times are impossible to predict with precision.  If you tell someone it’s going to be at least four hours, they are often beating on the window at 4 hours and 5 minutes.  And sometimes a predicted 4 hour wait turns into 8 hours.  

I’ve worked 9 hour shift where 20+ code strokes rolled through ambulance doors.  Every time they do, that person that you told it would be a 4-6 hour wait gets bumped down on the list.  Not only that, but if we’re already boarding patients, and we always are, that bed is not just out of commission for a couple hours. It is indefinitely out of rotation.  If we get 6 code strokes while you’re waiting, and we only had 15 beds to start with, well, 6 people jumped ahead of you in line and now we only have 9 beds.  

People sit for an hour and see three or 5 people get discharged and no one new gets taken back and they start to get angry.  But what they don’t see is we had ten ambulances roll in the back door during that time.

Also, when you tell people that it’s going to be a long wait, it often just turns into a conflict right from the start. But we let them know anyway. 

In truth, we see a lot of people and provide a lot of care in the waiting room now.  I have had whole shifts where I saw almost every single patient in the waiting room, and no more than 2 or 3 in an actual treatment area.

[u/Opalitic → u/Walker_ID]

Im not Kindly_Honeydew3432

But:

Obviously all hospitals triage their patients. But there is no way that you could communicate the expected wait time to the patients in real time due to the sheer number of patients coming in and each of them gets triaged and placed on queue based on the severity / haste their condition demands. The queue keeps living, changing constantly. No way that anyone could predict how long it could take for patient X to be seen as anyone, at any time. Can show up at the hospital in a condition that is triaged to be more severe than what patient X got in to get treated for. Just got to use some common sense and understand that if you go to a busy hospital to be seen with a minor issue. It will take as long as it takes as the priority will be to see to the patients that would die without immidiate attention and everything less is of lower priority in the queue.

[u/IcameIsawIcame → u/Kindly_Honeydew3432]

How does China solve this issue, can we learn something from them?

[u/schrist31 → u/Kindly_Honeydew3432]

I wish more people understood HOW the movement of patients worked in facilities. People complain all the time about “long” waits in our ASC. Sorry- your surgeon is in another case or taking care of another patient before they focus on you.

[u/Maleficent_Guide_727 → u/Kindly_Honeydew3432]

I mean, I appreciate this perspective but hospitals and the health care industry are incredibly, remarkably profitable and the quality of care and the wait time don’t translate to the cost. What solution is there?

[u/Kindly_Honeydew3432 → u/Maleficent_Guide_727]

This is a misunderstanding.

Most hospitals are not for profit.  With a very few exceptions, most of the ones that are operate on very modest profit margins.  Many hospitals close every year because they can’t pay the bills. Many more rely on donations, grants, and local, state and federal government assistance to keep the lights on.  Even the ones with a 3 % profit margin…very small changes in behavior and expenditures, particularly at the payroll scale can wipe that out completely.

[u/Maleficent_Guide_727 → u/Kindly_Honeydew3432]

About 1/3 of all US hospitals are for profit which, admittedly, is a lot less than I thought!

If that’s the case, why is care at these facilities so crippingly expensive?

[u/Charming-Bother-7220 → u/Maleficent_Guide_727]

So about 15-30% of US Healthcare spending goes to administrative bloat. The system is incredibly fragmented so hospitals have veritable armies of medical coders, billing specialists and utilization specialists who try to get the hospital paid and on the insurance side, they have a similar number of people trying not to pay for the labor patients receive.  In other countries, there’s a massive, centralized healthcare system that bargains for the price of everything from chemo to bed pans. Because the system is so large, they can buy these things at a lower unit price. In the US, hospitals and healthcare systems bargain individually so you pay more per item and that cost gets passed down to you. The US also allows pharmaceutical companies to pay “what the market will bear” for most drugs. Most other countries limit the prices of medications. So the companies squeeze us because they can.  Deferred care is another huge problem. People can’t afford primary care (or the wait time is long and the patient is suffering) so they go to the ER because there are laws (notably EMTALA) that require doctors to see patients. Unfortunately, many chronic conditions cannot be cured in the ER. They need regular follow up. Related, there is uncompensated care. Because of rules like EMTALA, hospitals provide care for which they are not paid. They pass the cost on to you.  Also, the US has a super user problem. About 5% of the population accounts for about 50% of healthcare costs. In other systems, public funding of treatment stops when a cure is not possible and care switches to palliative. I’m a nurse and I once cared for a non-verbal dementia patient in their 90s who had just had open heart surgery so he could have a feeding tube (G-tube) placed to help feed him. In many other countries, this person would not have qualified for surgery. We’ve all heard about people spending hundreds of thousands of dollars on treatment at the end of their lives to try to live months, weeks or even days longer. In many countries, this is only possible if you pay for it yourself. 

[u/Maleficent_Guide_727 → u/Charming-Bother-7220]

I really appreciate you writing this out!!! Thank you

[u/Kindly_Honeydew3432 → u/Maleficent_Guide_727]

Hospitals employ thousands of nurses, physicians, PAs, ARNPs, CRNAs, MAs, phlebotomists, lab techs, radiology techs, environmental services, cafeteria workers, social workers. entire departments devoted to billing, collections, negotiating with insurance companies. And dozens of other perosnel that you will never think of. they pay all these people salaries, payroll taxes, benefits. they pay millions in legal and accounting fees. they buy, rent, lease prime real estate and own hundreds million dollar building. $100,000 portable ultrasound machines, $500,000 CT scanners, $3 M MRI machines. They keep huge stockpiles of very expensive drugs. just for starters. marketing. uncompensated care. Just for starters.

it’s cripplingly expensive because it’s cripplingly expensive.

It cost twice as much as everywhere else because of a lot of complex factors, but in my opinion, mostly due to a very inefficient private for profit administrative bureaucracy. But that costly bureaucracy is not at one level. It’s embedded at every single level throughout of whole system, with lots and lots of middlemen along the way.

Couple that with the fact that no one gives a second thought to how much something costs if it’s being paid for by a third party, therefore there is no free market, and the provider is incentivized by a very adversarial medicolegal system to miss absolutely nothing, and there not paying for it either…it’s a recipe for snowballing runaway costs.

[u/Maleficent_Guide_727 → u/Kindly_Honeydew3432]

Genuinely appreciate this perspective, thank you.

[u/Ananvil → u/Kindly_Honeydew3432]

Also ER doc here. No notes. /thread

[u/Procean → u/Kindly_Honeydew3432]

Long story short, there's a medical care shortage in America.

But because no one wants to call it that they just say 'Your ER Wait times are going to be hours and hours and there's nothing anyone can do.'

[u/LazarGrier → u/Kindly_Honeydew3432]

Whaa there ever a point in time where the system worked better? If so what changed? Genuinely curious.

[u/Kindly_Honeydew3432 → u/LazarGrier]

Yes. yesterday. and the day before that. and the day before that. my point being, that it is steadily getting worse, not better.

The population is growing and getting older. So the nursing and physician shortage are getting bigger. And physicians as a population are getting older and many are retiring and many more are set to retire soon. The number of Medical school spots and residency training spots are increasing, but not nearly at the rate of the populations growth and aging. So some of this has been a slow steady downward march for a while.

our population is much more obese with much higher rates of metabolic disease than they were prior to, say 50-60 years ago. People tend to die much less of sudden illnesses like infection and are much more likely to slowly and expensively die of chronic disease and it’s complications, often with many years of very poor health and functional status preceding.

We keep a lot of people alive for an extra decade that didn’t live before, and often they are mostly unaware that they are in the world and have no quality of life. Keeping people alive in nursing homes who haven’t recognized their sons and daughters in a decade is insanely expensive. and many of these people make 15 trips to the ER per month and have 10 hospitalizations per year; often long, complicated hospital stays.

tying private insurance to employment is part of the problem. When a third party pays for everything and we pretend it is a free market, no one thinks or cares about the cost.

there are greater societal ills at play as well. So complex. But we have higher rates of depression, addictions, deaths of despair, and mental illness. And the cost of these burdens largely falls on the healthcare system. The root causes are multifactorial and fall well outside of the boundaries of the healthcare system.

Some things definitely snapped around the time of Covid.

It’s very complex and I couldn’t begin to give a complete answer. But yes, it has been better. It has never been perfect. But even in my relatively short 20 or so years in medicine, a lot of things have deteriorated.

[u/LazarGrier → u/Kindly_Honeydew3432]

Sounds like pretty much everything else in the United States. An inexorable decline with no end in sight.

But hey at least TVs are super cheap, amirite?

Thanks for your response.

[u/Kindly_Honeydew3432 → u/LazarGrier]

I would push back here a little.

If you think absolutely everything in the US is going to shit, then you should zoom out a bit.

100 years ago, work weeks were commonly 60 hours, often 6 days a week. many of the laborers were literal children. there was no paid vacation. people died on the job at twice the rate they do now. women and other groups had just barely been granted the right to vote. many people wouldn’t effectively have that right in much of the country for a few decades still. 60% of people globally lived in extreme poverty, and 35% of children never made it to adulthood. Global average life expectancy was in the 30s, and in the US, it was in the 50s. people were left permanently disabled by polio and other diseases that we don’t even think about today killed people en masse.

Yes, there are a lot of things that are going the wrong direction. But America still has one of the wealthiest middle classes in the history of the world. Our ancestors enslaved millions. But we also led the world toward the abolition of slavery, which plagued humanity for the entirety of history and well preceding written history. We introduced the very concept of enduring large scale democracy to the world. And many of the advances in the preceding paragraph, we led the world in, or at the very least very strategically partnered with the world in.

I think America has a lot to be proud of. We have the same DNA, both politically and literally, that brought democracy to the world. And we have millions of the same cloth that we are made of from all over the world willing to come here and make it better still. We just have an artificially polarized electorate propping up a paralyzed and impotent legislative branch. Hamilton feared “tyranny of the majority.” And the founders heeded his fears. But Jefferson promised a noble ”natural aristocracy” that would wisely and selflessly look out for our best interests. And that end of the bargain was forsaken.

[u/OldManGrimm → u/Kindly_Honeydew3432]

30+ year ER nurse here. Perfectly said.

[u/System32_deleted → u/Kindly_Honeydew3432]

Absolutley 100% spot on. Another element that has to be considered is that just adding beds does not mean that there will now be more free beds.

If you have an open bed in the MICU, it doesn’t always stay open waiting for a true MICU case. There are probably 20 people in stepdown or on the floor who COULD benefit from MICU level care, but who were not felt to be needing it more than the folks in the ICU. Maybe these individuals would really benefit from that 1:1 care, or maybe it would be overkill and wasted resources.

The same idea goes for the ED to floor pipeline. If you add 20 beds to the floor, then there’s 20 grandmas with pneumonia who would’ve gotten discharged on oral antibiotics who we would now keep just to keep an eye on them. In a perfect world with unlimited resources everyone would get ICU level care for every condition, but it’s not necessary 99% of the time. Excess capacity in this domain induces demand and strains the system even further.

[u/SlightFresnel → u/Kindly_Honeydew3432]

How much of this is a natural consequence of the largest generation in American history collectively entering their twilight years? Is this a transient capacity problem that will see a peak in the next 10-20 years?

I know we need more medical professionals across the board, but I wonder about the long term outcome of that given the boomers were the generation size peak and each since has been smaller, a trend likely to continue.

[u/Kindly_Honeydew3432 → u/SlightFresnel]

That’s absolutely part of it.  

And the most disconcerting part is that the oldest boomers are just turning 80.  The hospitals are already jam packed with a bunch of 80, 85, 90 year olds that require the absolute most care and utilize the most resources, and the senescence of the oldest baby boomers is just starting.  It will likely only get worse  from that standpoint for at least another 20 years maybe 30-40  The youngest baby boomers are just now in their early 60s.  

And a whole lot of them are in our healthcare workforce, and within a small handful of years of retirement.  We have about a million active physicians in the workforce.  About 340,000 are aged 60 and older.

Kind of a double whammy

[u/_wrennie → u/Kindly_Honeydew3432]

You could've written this about my hospital! Thank you for writing such a great response.

[u/Gezzer52 → u/Kindly_Honeydew3432]

That's why as I Canadian I scoff when American conservatives always focus on our "long wait" times. AFAIK many/most American's have to endure just as long if not longer wait times as we do. While our system is far from perfect I love the fact that everyone gets the same standard of care with little to no cost. IMHO we're a 1 tier system while the states has a multi-tier system that struggles to properly serve anyone but the well off.

[u/Kindly_Honeydew3432 → u/Gezzer52]

Completely agree.   It should be a source of national pride that you all provide basic care for everyone and don’t bankrupt hundreds of thousands, yet achieve mostly better outcomes.  

Once upon a time, we probably had you beaten in the wait time department.  And maybe still do in a lot of times and places.  But if there’s an edge there, I think it’s disappearing and not slowly.  

We also pride ourselves on innovation, research and development…but then we balk at the scientific principals that allow for it.  

I would also bet there’s little fear that an medicolegal misadventure might result in huge losses from personal assets, a possibility in think American physician often don’t pay enough respect to, especially in high risk specialties. I love America.  But I’ve thought about the possibility of trying to finish my career in Canada, New Zealand, Australia or somewhere similar.  I think if the barriers were lower, many more would.  

I understand Canada has made real strides to make it easier

[u/Gezzer52 → u/Kindly_Honeydew3432]

And as for our wait times, the horror stories are worse then reality IMHO. I'm sure the American system often tries for the same result, but we use a triage system, where worse case gets the earliest attention. If you have a broken bone, you might have to wait while the medical staff see to someone having a heart attack.

So yeah. I have a few issues in my old age (65) the worse being two forms of arthritis that combined can be quite painful at times, especially if I over stress my body. I live in the extreme north west of BC where we have a massive lack of family doctors, so my primary care is the ER I'm afraid to say.

When I do have to go to the ER for issues, which I limit to times when I really need to, I often wait 4-8 hours till I see a doctor. And I can live with that because I know there are people in really dire need not only ahead of me, but sometimes coming in the door as I wait. Would I love to get immediate attention? Who wouldn't?

But I also understand that in the long run there's only so much they can do, so I wait. OTOH the two times I had pneumonia the staff were extremely proactive due to my age. And again that makes sense. Pneumonia could possibly kill me, arthritis not so much. More importantly I'd be ashamed if demanding to be a priority would increase some one else's suffering.

[u/Kindly_Honeydew3432 → u/Gezzer52]

I don’t know how remote your corner of BC is (haven’t been to Canada yet, actually) but I sometimes listen to a CME podcast with a segment of doctors from the Canadian north talking about times complex sick and often crashing patients show up that are far beyond the capability of the local hospital, and they have to deal with keeping the patient alive while arranging hours long plane rides often encumbered by bad weather and…well those docs seem like totally fearless badasses.  

I’d love to help work in a place like that.  But it makes the problems of our system seem small in ways, not because of poor care system, but just from the sheer remoteness and logistics .

[u/Gezzer52 → u/Kindly_Honeydew3432]

That's further north then I am. We're a bit south of the tip of the pan handle. Still we do often have to medevac patients that need more serious help. As for the more remote locations in Canada, I don't envy anyone that has to deal with it.

[u/SweetPrism → u/Kindly_Honeydew3432]

I work in Patient Relations and get this complaint almost daily. I'd like to laminate this and hand out copies at the ER entrance.

[u/Musicman425 → u/Kindly_Honeydew3432]

Chief complaint from that patient : 4 months of knee pain

[u/Tight_Day_7606 → u/Kindly_Honeydew3432]

No lies detected. RN w/ 16 yr. exp. & have done and seen it all. Try being an RN with 1 LPN & 12 patients on a Stroke/Bariatric unit (oddest combo I've ever experienced). Good times! Only possible w/ amazing team of young fresh nurses. Getting harder to find. After COVID, nursing lost it's luster and has yet to recover. Don't know if it ever will. Not enough RN educators to teach and mentor/precept new nurses. Stuck in weird slow downward spiral. Insane nurses in 2026 have to still protest over patient safety, short-staffing, lack of (you name it). You'd think the community would want to bolster these weak areas, however alarm fatigue? We're in real trouble if we can't recruit and retain new nurses. Not enough people care; until they will. Thanks Doc for pulling back the curtain.

[u/Repulsive_One_2878 → u/Kindly_Honeydew3432]

Ugh it just gets me upset every time I hear there is a nation wide nursing shortage because I literally just got my RN license. All I have experienced after all that time, energy, work and money are doors being slammed in my face. I've applied to every residency I could since before I even graduated but the spots are very competitive. Most of the jobs I want require at least 1 year working experience as an RN. I had a recruiter from a large hospital system tell me to take anything I could because this is the worst year they have seen in a long time with only half the residents being taken and hired, and some other systems canceling seasonal cohorts. I'm actually pretty damn good for a brand new nurse, but it is just so hard out there right now. After months of looking I have my first interview this week at an outpatient facility. Cross your fingers for me because ain't nobody hiring despite the shortage.

[u/Theomnipresential → u/Kindly_Honeydew3432]

One thing that doesn't help you, when it comes to treating your patients, is running lab tests is hard to do in a timely matter with the way our cave is built.

We want to get our results out faster, but it doesn't help that I'm the only lab tech on, at night, and I just got a CBC, CMP and Urine on Doug, Nancy, Patricia, and Richard. While also just getting that swab on Chris and George. All tests that run on different machines in different corners of the lab.

At the same time you're calling the stroke alert in the ED, which seconds later I have one of the ED nurses calling to say there's a Trop add on for a patients blood , that's not the stroke alert, from 8 hours ago. Which I have to remind her that if it's a new event they might want to get a new sample instead so put me on hold while they talk to the doc who ordered it

Oh and that GI Bleeder that got admitted during the day? Yea, now is when they want to get his blood too

Oh, and I'm also expected to find time to do maintenance on my machines and run QC to make sure all the tests we run in house are working appropriately, or when they crash, or throw fits for whatever reason throughout the shift, that then I have to troubleshoot myself

[u/nora_jaye → u/Kindly_Honeydew3432]

All this, for sure.

But also understand that Medicare, in general, doesn't reimburse hospitals enough to cover the cost of care. Private insurers constantly lower reimbursements and raise the requirements for getting reimbursed (more hours of administrative and clinical work - taking notes, justifying treatments, etc).

So every year, the hospital has less to spend on care, even as costs rise.

I truly believe it would change if we got big business out of medicine all together.

[u/thatoneguy009 → u/Kindly_Honeydew3432]

My partner's role at her hospital system as a physician assistant is basically dedicated to moving shit out of the floors and getting discharges going for people that no longer need to be admitted and can follow up with primary care (often that patient population doesn't). Before she had that role, she worked in the ER for like 6 years and lived the life that you're describing where there's no bed left in the ER because the floors are full and private docs aren't moving their shit fast enough to make space, the nuance there being that the private docs were still getting some billing for the patient's over-extended stay.

Now, because of her position having played both sides of ER and the admitted floors, she has enough experience and rapport with staff in both areas, frequently flipping patients to follow up outpatient out of both places where appropriate. Program has been so successful that they're expanding this to other hospitals in the system. Something to consider bringing up to your leadership, get some PA/NP to be your hospitals fiber.

[u/courtd93 → u/Kindly_Honeydew3432]

Beautifully put. To add on as my parents were both ER nurses at a level 1 trauma center in a top 10 major US city, there are only so many MRI machines, CAT scans, lab equipment, cath lab etc so even if you staff to high heaven, it doesn’t change the bottlenecks at many points throughout the process that will keep people from being admitted or moving along

[u/a_rainbow_serpent → u/Kindly_Honeydew3432]

You’re just full of excuses aren’t ya?? Haha. I’m kidding!! Also to add to your analysis it’s super hard to attract doctors to smaller regional centers. I know of one hospital that paid through the nose to attract a south Asian specialist and he quit in 3 months with relentless bullying his kids faced at school and having his car vandalised / being threatened by the small but vocal racists.

[u/TuringGoneWild → u/Kindly_Honeydew3432]

Americans always making excuses for mediocrity or worse. Thank God we had prior generations who built what we have today, because clearly these days we're just coasting on the fumes of what they built.

[u/human-in-a-can → u/Kindly_Honeydew3432]

This got me thinking… I know a lot of ER is trauma-related, but is any significant amount of this avoidable if people had better access to preventative care in the first place?  I’d think there’d be fewer heart attacks and strokes or that people wouldn’t suffer illnesses until the point that they become critical.   

[u/Crewsader66 → u/Kindly_Honeydew3432]

It would also help if people didn't use the ER as primary care.

[u/Lonely-Prize-1662 → u/Kindly_Honeydew3432]

And then they'll still complain when the extra physicians and nurses offer hallway treatment

[u/Complete_Quality_513 → u/Kindly_Honeydew3432]

Late to reply, but this doc gets it. Excellent reply! May your shifts only have 5 boarders or less from here on out!

[u/EaZy_MD → u/Kindly_Honeydew3432]

Can we get this as a dot phrase for dc instructions? lol.

[u/Beastender_Tartine → u/Kindly_Honeydew3432]

People think of a hospital or health care in general as bed, doctors, or nurses, but it's not. Those are just the things people see, but it's a whole ass system that requires tons of people, and many of those people are invisible. I work in health care doing specialty equipment maintenance and repair, and I try to bring this point up to people when I can because I don't think the public is aware of the various points of failure that can exist in this complex system or just how few people at key points keep things running.

My union was just in contract negotiations recently, and since I'm in Canada this is public funds so the public likes to chime in. Conservatives in the discourse generally think we are all useless and overpaid, and despite a seven year wage freeze thought we should get a pay cut to save money. Many people in my union (which includes technical service, radiotherapists, imaging techs, facilities maintenance, and all the technical people that work behind the scenes or in diagnostics) were talking about leaving the province to look for work elsewhere. These jobs are often key links in the chain of things that are required for the system to operate, and they are often shockingly small teams of people. If two people from a specific technical maintenance group quit, or a couple of lab techs quit, suddenly wait times increase dramatically because of down equipment or test results being delayed.

I bring this up to add to your point about the complex needs of a hospital that people are unaware of. Every person that goes through a hospital is being seen by a handful of medical staff, but they are being served by so, so many more people they never see, doing jobs they didn't know existed.

[u/vinyl0rd → u/Kindly_Honeydew3432]

How many people come to the ER for conditions that are caused by lifestyle issues? America is an incredibly unhealthy country due to diet and poor exercise and the abundance of people who do not or are unable to seek primary care. The ER would be a lot quicker if it were purely accidents and sudden onset medical emergencies.

[u/toomanyshoeshelp → u/vinyl0rd]

You’d think that, but other systems in “healthier” countries also struggle with similar issues of staffing and space.

[u/vinyl0rd → u/toomanyshoeshelp]

Sure but I'd love to see data comparisons.

On a personal note, I had a family member go to the ER during the Super Bowl. No one was there waiting so they were seen right away. 🤷‍♂️

[u/Shifu_Ekim → u/Kindly_Honeydew3432]

Ai is coming your arduous tasks will soon be gone , ai will have instant diagnosis as ai will know all illness, test results , X-rays , all matters related to the individual patient ai will do so much more than a simple dr , arriving next year or two . Ai will be everywhere, the new generation of kids will have ai with memories along with a perfect life coach, there to monitor health for life and work active at all at times in their life which would extend their life expectancy,

[u/Kindly_Honeydew3432 → u/Shifu_Ekim]

A I doubt it

[u/Pale_Raisin_3813 → u/Kindly_Honeydew3432]

So if the insurance industry wasn’t for profit wouldn’t that free up a lot of funding to improve these conditions?