Does going into hospital make you sick?
Unpublished research suggests that a stay in hospital weakens us so much that, far from restoring us to health, we are more likely to get sick again after discharge. A professor at Yale says enough is enough - it's time to completely rethink patient care.
When a hospital discharges someone, both patient and doctor are usually united in a hope that they will not see one another again soon.
But for some time it's been known that about a fifth of patients who leave US hospitals are back within a month. In England the number is lower - about 7% - but readmissions still cost the NHS £2.4bn in the 2012-2013 financial year.
In both countries, and many others, re-admission rates are taken as a measure of the quality of care a hospital provides. However when Dr Harlan Krumholz at the Center for Outcomes Research and Evaluation at Yale School of Medicine asked doctors about re-admissions, he got a rather curious response.
"They would say, 'How can you blame me when they come back with pneumonia after they were in for heart failure? We took care of the heart failure, it's not our fault that they came back with pneumonia!'" Krumholz recalls. "Or they would say, 'Why are you blaming us when they fall over - it's not our fault.'"
Krumholz learned that only about a third of patient readmissions were related to the original cause of hospitalisation. Patients' reasons for returning to hospital were diverse and linked to their immune systems, balance, cognitive functioning, strength, metabolism and respiratory systems. It was as though they were mentally and physically below par, off-kilter, out of whack.
Could it be, Krumholz wondered, that the very experience of going to hospital had made patients more vulnerable to disease and accidents?
In a series of opinion pieces in top medical journals, he has developed the concept of "post-hospital syndrome" (PHS), which he defines as "an acquired, transient period of generalised risk".
"My premise is it's the cumulative effect of a lot of insults to the body, of all the stress coming from all different directions," he says.
"What do we do to them? We sleep-deprive them, we malnourish them, we stress them, we disturb their circadian [sleep] rhythms, we put them at bed rest and de-condition them, we confuse them with lots of different people and new routines - we don't give them any control."
A recent, yet-to-be-published study lends support to Krumholz's theory.
Dr Paul Kuo, chairman of surgery at Loyola University Medical Center in Illinois, supervised research in which records from about 58,000 patients who had gone in for a hernia operation in California were carefully analysed. The research team identified a sub-group of 1,332 patients who had been in hospital in the 90 days leading up to the operation.
They found that in the 30 days following the hernia operation, this subgroup was roughly twice as likely to visit the emergency department, and five times as likely to have to be admitted to the hospital as an in-patient. It seemed their previous stay in hospital had "de-tuned" them, making them more vulnerable to complications arising from the hernia operation, even though it is a very straightforward, same-day procedure.
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Listen to Dr Paul Kuo talking to Health Check on the BBC World Service.
One clear implication of the research is that hospital doctors should resist the urge to fix a patient's health problems in quick succession, but leave time between operations for recuperation.
"These findings are hypothesis-generating," says Kuo. Clinical trials are required, he suggests, to understand what is causing PHS and to confirm any link with readmission rates.
But Harlan Krumholz thinks hospitals need to fix the problem rather than study it. Improving the patient's experience of hospital is as urgent in his view as tackling a hospital infection.
In an article co-authored with Dr Allan Detsky at the University of Toronto, he lists dozens of ways in which hospitals could reduce stress. Why are hospitals so impersonal? Why can't wards look more cheerful, like they do in children's hospitals? Why do patients have their blood taken so frequently nowadays? And why is hospital food so unappetising?
Instead of thinking of the hospital as a place of healing, Krumholz says his profession sees it as a battlefield. Medical staff come to work to "fight" disease and injury, and everyday niceties fall by the wayside.
For example, it's not unheard of for patients to miss four meals in six, if they fast for an evening operation, which then gets postponed to the following evening. It's not very good for the patient, but it gets chalked up as collateral damage in the bigger fight.
But Krumholz says it's also true that hospital systems have developed to serve the people who work there, not the clients. He gives the example - which will be familiar to many - of doctors telling patients on their morning rounds that they will stop by that afternoon to examine them, give test results or have a proper conversation.
But because this promise of an appointment is not attached to a specified time, the patient - and sometimes, his or her family - is left waiting all afternoon, afraid to leave the bedside in case the doctor is missed.
"It serves us so well to say, 'Well I'll be there when I'll be there'," says Krumholz. "And it's kind of an abuse of power, quite honestly."
Eventually, most doctors and nurses find out what it's like to be in-patients too. That time came much earlier than anyone would have hoped for Dr Kate Granger, who was diagnosed with a rare form of cancer as a 29-year-old trainee in Yorkshire, England. She was told she would probably die in about 12 to 18 months.
"Sometimes I had amazing care, and sometimes I felt very lonely in hospital," she says. "And I felt quite faceless at times, like I was this girl-with-a-rare-cancer, and I didn't really have any other meaning to my life."
She found herself at the receiving end of ward rounds in which large groups of staff and students gathered around her bed - "and how vulnerable that feels when you're not looking your best, you're in your pyjamas and you've got all these people standing over you," she says.
But the real "eye-opener" came one day when she arrived at hospital through Accident and Emergency, with post-operative sepsis. A couple of days after she had been admitted, a porter introduced himself to her, and she realised that of the dozens of doctors and nurses she had seen, very few had shown her the same courtesy.
"It just felt really wrong," she says, "who are these people doing things to your body?"
She wrote a tweet about the experience with the hashtag #hellomynameis and very soon a big campaign had started to get NHS staff to introduce themselves. It went on to be endorsed by just about every senior figure in British medicine.
"It's a stepping-stone to compassion, really, in the sense that if you introduce yourself, you see a human being in front of you," she says. "You make a connection with them, and then you start a relationship. If you don't introduce yourself you're hiding behind the anonymity of healthcare."
In defiance of her prognosis, Granger is still campaigning four years after she found she had cancer, and has just started her first post as consultant, or senior doctor. Even though she works in hospitals every day she confesses that she can't stay there as a patient for longer than about three days because, as she puts it, "I start to go a bit crazy."
One of the main reasons is that she simply doesn't get enough sleep in hospital. She says she is woken through the night to have observations performed and fluids changed, and then not allowed to sleep during the day. As a doctor, she says she doesn't really understand why a patient who is sleeping soundly and breathing normally would ever really need to be woken.
"Anyone who's in healthcare, when they themselves get sick, is usually rather shocked at what it's like to be on the other side," says Harlan Krumholz, who has often cited disruption to sleep patterns as a cause of concern in hospitals.
At his own hospital, Yale-New Haven, all non-essential observations are now banned at the hospital between 23:00 and 06:00. And during the day, staff perform hourly rounds to check patients are comfortable, help them to the toilet or just say "hello".
The hospital's other innovations include "patient excellence awards" for staff and a bulk procurement of folding chairs, to encourage doctors and nurses to sit at the bedside.
Overseeing these changes is Dr Michael Bennick, the hospital's Associate Chief of Medicine.
He says that PHS is a particular problem for the elderly. "When older patients are discharged from the hospital, almost 30% may never fully get back to their prior functional status and recover their ability to wash, dress or feed themselves, even six months after leaving the hospital."
The Oxfordshire-based doctor and writer Druin Burch says the concept of PHS may go some way to persuade National Health Service bosses of the need to improve the patient's experience of hospital, but real change will only come once they are convinced that Harlan Krumholz's ideas improve clinical outcomes and save money in the long run.
"The NHS - we try and run it efficiently, which is another way of saying we try and run it on the cheap," he says.
"A lot of the things that Harlan talks about would be expensive, so you don't just need to know they work but you need to know they work enough to be worth the money."
But there are other things on Krumholz's long list of suggestions, he says, that cost very little, and that any hospital should be acting on now.
"The trolleys that get wheeled past patients at 3am - they shouldn't clatter so that they wake everyone up," he says.
"The bins when a nurse throws away a pair of gloves shouldn't crash so they wake everyone up.
"Those sorts of simple things we should be getting right and I think most people would feel we're not doing those things well enough."
And who knows, they could result in hospitals not only curing us of one illness, but also leaving us in better shape to resist the next one.
Listen to Dr Paul Kuo talking to Health Check on the BBC World Service
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