Its an interesting exercise, trying to unpack something very complicated that you live in every day, so that its like water to a fish. The biggest challenge is, how do you break down and explain something that is basically a chaotic system? Well, here goes:
Operations.* Hospitals have essentially three or four different primary service lines from an operations perspective: the emergency department, surgery, medical, and (depending on the hospital) labor and delivery (L & D, in hospital parlance). L & D really is its own animal – the patients are mostly healthy. Surgery is divided into emergency and “elective”, which really means “scheduled”, not, as one would think, “optional”.
You can also divide up the different kinds of patients – inpatients (classically, patients admitted to the hospital for an overnight/24 hour stay), outpatients (patients who aren’t “bedded” because they are getting some kind of service, like radiology or infusion, that doesn’t require it), and observation patients (patients who are “bedded” but not necessarily overnight/24 hours). There has been a migration from inpatient to outpatient and observation, mostly due to advancing technology. More things can be done without overnight stays, especially surgery (knee and hip replacements, for example).
Patients can go from one category or service line to another. An inpatient may have been admitted as an observation patient, for example. Many emergency department patients (who start as outpatients) are admitted as observation or inpatients (roughly around 20% of ED patients get admitted). Someone who comes in for a medical condition may require surgery, or someone who comes in for surgery may develop a medical condition. Someone who is an inpatient may be discharged with outpatient followup treatment like rehab or infusion. Etc., ad infinitum.
Every hospital function is interconnected. While a patient is in a bed, the nursing, janitorial, food services, case management, and medical staff will be in and out of the room daily, and visits from the lab, respiratory therapy, wound therapy, and rehab are all a possibility. The patient may also need things they can’t get in their room, which brings in transportation and whatever they need – radiology, the cath lab, surgery, dialysis, and so forth. Or, they may need to be transferred to a different unit – we have about four or five different kinds of units for inpatients. Think of trying to organize the trades during a home renovation, only it happens every single day. This all changes on a constant basis, with knock-on effects galore, hence, a “chaotic” system in just about every sense.
To try to deal with this, we have committees (oh, do we have committees) on the theory that you need somebody at the table from every function that might be impacted by whatever you are doing. You also need policies (oh, do we have policies) to try to capture institutional knowledge and standards and spread them throughout the organization. Partly to amuse myself, I have succeeded in creating a policy on policies, standard work on standard work, and a committee on committees. Believe it or not, a bureaucracy like a hospital needs this kind of meta-governance.
Hospital capacity is very rarely determined by the number of beds the hospital has (although in recent years, for the first time in living memory, hospitals actually capped out at the number of physical beds they had). Licensed capacity is notional, as most hospitals are licensed for more beds than they actually own. The real limit on capacity is staffing, particularly nurse staffing. Around one third of our workforce is nurses, maybe a little less.
*No, not those kinds of operations.
Business. Hospitals cannot turn patients away, at least, not if they come in through the ED, due to the federal Emergency Medical Treatment and Active Labor Act (EMTALA). We also can’t discharge patients until they are safe to discharge (this includes having a place to go – skilled nursing facility, home, whatever is needed) and a plan for post-discharge care. Medicare patients can appeal their discharge, which means we have to keep them for a few more days. So we are stuck with our “customers” on the front end and the back end. We can’t turn them away, and we can’t fire them.
Hospitals get paid a flat fee for inpatients based on their discharge diagnosis (more jargon – the “DRG” or diagnosis related group), meaning, the final diagnosis of their primary health problem. It doesn’t matter how long they stay, what we do for them, none of that – it’s a fixed amount. We get paid for outpatients based on what we do for them – unlike inpatients, its usually a very defined and discrete service.
The rates we get paid are either dictated by the government (Medicare and Medicaid pay for roughly half, maybe more, of hospital patients, although it varies a lot by hospital) or are locked in for two or three years at a time by commercial insurance contracts. What this means is that as demand goes up, we can’t charge more.
Hospitals are expensive to run. Not only do we have a large capital plant (big building, expensive equipment) and expensive supplies, we also have a large labor force. There’s a whole lot of hospital work that is unavoidably hands-on. The nurse complement for a 30 bed “med-surg” unit will likely be around 18 FTE nurses (at one nurse per 5 patients, 2+ shifts per 24 hour day, plus a nurse manager and a charge nurse). For an ICU, the typical ratio is one nurse per 2 patients, and for some patients, the ratio is 1:1. There are also patient care techs, which different hospitals use (or don’t) at different levels. Throw in a hospitalist physician or so, various specialty nurses (wound care, respiratory, etc.) and it adds up.
And that’s just the patient care staff. There are also swarms of back office chair warmers (tips top hat), janitorial staff, biomedical equipment maintenance, facilities, landscaping, food service, laundry, instrument sterilization, on and on. We even have our own locksmith. The ratio of patient care staff to “other” is probably around 60/40.
Remember that part about being stuck with our customers? And the part about getting a flat fee for inpatients? That sets up a disconnect between the two different kinds of volumes in a hospital. There is the “average daily census” – how many patients in beds – and the number of admissions – how many patients in the door.
The average daily census drives cost. As long as a patient is in the hospital, the hospital has to staff that bed, order tests, etc., all of which feeds the cost side of the equation. Admissions are, really, the same as those discharges that we get paid for – the more admissions, the more you get paid. The average daily census and admissions marry up with the “length of stay” metric. Long length of stay means more expense and, when the hospital is running at capacity, less revenue because it has to decline admissions. A full hospital has to turn away what are called “direct admissions”, meaning (mostly) admissions that are transfers from other hospitals. Everybody else just calls the damn ambulance and they show up at the ED.
The sweet spot for most hospitals is around a 4 day average length of stay, and an average daily census of around 85%. Much above that 85%, and you start paying overtime and various other premium pay deals to staff the beds, and you can go underwater on patients at the margin.
With these kind of business dynamics, its no wonder most hospitals eke out low single digit margins. Currently, there are very few hospitals that aren’t losing money, a lot of money, because they are at capacity with a high length of stay. Nobody can explain it, but hospitals all over the country have sicker patients, and a lot more of them, than we did pre-pandemic. High average daily census plus high length of stay means upside down profit and loss statements. Especially in this labor market – our labor costs have gone up 40% (not a typo) over the last year, due mostly to various kinds of premium pay for nurses.
Medical Staff. You can’t overstate how essential doctors are to hospitals. Nothing (much) can be done for a patient without a doctor’s order, including admitting the patient. There has been some erosion of this monopoly in recent years, with nurse practitioners and other “advanced practice providers” getting privileges (including admitting privileges) in hospitals. As far as I know, the hospital industry is unique in that it is completely dependent on independent actors (not even independent contractors) doing business, for their own account, in the facility.
And it gets worse.
A hospital’s medical staff is the doctors (and more recently, the nurse practitioners and other advanced practice providers) who are allowed to practice in the hospital. The medical staff is “self-governing”; the closest analogy is probably the faculty at a university. They elect their own leadership (the medical executive committee), adopt their own bylaws, determine who is allowed to join the medical staff (“credentialing”), what they are allowed to do in the hospital (“privileges”), and who is kicked out (“peer review”). The hospital board is theoretically the final word on all this, but it would be a very foolish hospital board indeed that stuck its, err, nose, into medical staff governance. Even the CEO treads lightly around the medical staff; it is well known that nothing gets a CEO fired faster than getting on the wrong side of the medical staff.
To be fair, its pretty hard for somebody who isn’t a doctor to have an informed opinion on what a doctor should be allowed to do and when they should be kicked off the medical staff for screwing up. To get an informed decision on who is allowed in, what they are allowed to do, and whether they should be allowed to stay, you pretty much have to rely on other doctors, which is, really, the basis for the self-governing medical staff.
Fortunately, this doesn’t create opportunities for shenanigans, backstabbing, self-dealing or petty politicking at all. I can only imagine what it would be like if doctors had big egos and there was a lot of money at stake.
But wait! It gets even worse than that.
Remember that bit about how stuff is migrating from inpatient to outpatient? That also means its migrating out of the hospital to doctor’s offices, ambulatory surgery centers, and the like. This also means that hospitals are no longer essential to many doctor’s practices, and increasingly doctors aren’t bothering to join hospital medical staffs. Or, if they do, they don’t want do things that the hospital needs (like take emergency call). There is a brewing crisis over this newish mismatch between the specialists not needing hospitals, and the hospitals still really needing the specialists.
So, hospitals are heavily bureaucratized, can’t control who their customers are, can’t increase prices when demand is high, have large fixed costs, are beholden to the nursing staff for how many patients they can have, have low margins, and are completely dependent on independent actors who don’t pay a penny to use the hospital, make a ton of money by using the hospital, and control who else can use the hospital. And I haven’t even gotten to the legal and regulatory burdens. So how do hospitals work? Beats me. As near as I can tell, it’s a miracle they work at all.
Nice article. I am in insurance, so I see the other side of it.
Me too. Although I’ve both paid for medical care, medical malpractice, and healthcare facilities on fire.
Plus work comp on nursing staff…
Nobody can explain it, but hospitals all over the country have sicker patients, and a lot more of them, than we did pre-pandemic.
I’m trying to figure out if this is serious or sarcasm. Or if I should embrace the power of and.
So, hospitals are heavily bureaucratized, can’t control who their customers are, can’t increase prices when demand is high, have large fixed costs, are beholden to the nursing staff for how many patients they can have, have low margins, and are completely dependent on independent actors who don’t pay a penny to use the hospital, make a ton of money by using the hospital, and control who else can use the hospital.
What could possibly go wrong?
Thanks RC! This was interesting.
Does your hospital have a lab? I’ve seen some hospitals that lose a ton of money on the lab out of a sort of pride or claiming it’s for educational purposes.
As I understand it, most hospitals are non-profit, so they do have that fund-raising angle although that’s probably a bad model for operational expenses even if it helps on the capital expenditures.
You really have to laugh at the notion of the U.S. having a healthcare system. It’s closer to the wag’s definition of a helicopter – a collection of parts moving in the same general direction.
Or state funded. No profit, but walking through the doctors’ parking lot is an easy way to see a variety of exotic cars.
I can’t wait to hear about Certificates of Need!
No state needs 23 hospitals?
Thanks – it’s interesting looking behind the curtain.
I thought my local hospital did a decent job of hiding the chaos during an 11-day vacation there a couple years ago. The experience could have been more unpleasant, I guess.
I had no idea! I always thought there was a daily charge for the stay in the bed.
Wish you stayed longer?
Fuck no.
This is so variable, even within the same hospital.
I’ve had incredibly smooth and “pleasant” experiences, and terrible ones.
Looking back, it seems the factor in our case has been what team or department interacting with:
Pediatric oncology team? Top-notch, with guidance every step of the way. Adult non-emergency surgery? Feels like the DMV, except they also all disappear at the same time.
Also, surgery centers are different experiences from actual hospitals. Surgery centers seem more casual and less chaotic.
Aye. We have a local-ish center that only does imaging. It’s efficient, quiet, easy.
When I had my ulcers worked on, the first attempt was in a surgery center, but they got in there and realized it was too complex for the facility (and the surgeon). So the second attempt was in a hospital with a different surgeon.
Surgery centers seem to be quiet. Hospitals…aren’t.
“Hospitals get paid a flat fee for inpatients based on their discharge diagnosis (more jargon – the “DRG” or diagnosis related group), meaning, the final diagnosis of their primary health problem. It doesn’t matter how long they stay, what we do for them, none of that – it’s a fixed amount. ”
How does this square with bills that charge per day? And single rooms costing more than double rooms?
thanks for the article
Very nice article. It’s interesting to get an insider’s view of health care.
Is this why, when I’m doing medical reports, the patients end up with a laundry list of diagnoses that had nothing to do with what happened while they were in the hospital?
Maybe it’s CYA to protect against a malpractice complaint.
Thanks, RC, really interesting.
Like many here, I’ve spent more time than I’d like in hospitals, for one reason or another, and have always been impressed how complex they are.
Your article also helped to answer the wonderment I’ve had for a long time when I’ve walked through empty wings of a hospital and was confused why they didn’t just accept more patients, as they have all these empty rooms and beds.
I sounds like an emergent system with no central control. And my guess is that if it was truly strained (and COVID didn’t strain anything) it would collapse.
I’ve read that one problem is that physicians’ associations like AMA try to keep the number of doctors in America low so that the salaries remain high.
Is that true? And if it is, maybe the fact that Boomers are getting seriously old means the medical associations need to lighten up a little and let more docs in.
We are taught from an early age that the doctor is always right, but experience has taught me otherwise. I trust the guys who say “we need to screw this plate into your leg to stick the bone back together” but not so much the “Don’t eat cholesterol or you’ll get high cholesterol” guys.
I’ve certainly had to save myself and others from “medical mistakes” so I think the docs can come on down from their pedestals anytime. I’d like to see good docs get paid more than hacks.
My husband’s long-time doc back in Minnesota was a practical, matter-of-fact guy, but when husband was diagnosed with diabetes, his advice was medication, follow the food pyramid, etc
Husband went keto under my guidance instead and not only lost weight but got his A1C down to 4.5. His doc couldn’t believe it.
Question everything.
Seems to me that for things like trauma and life-threatening emergency situations, our modern medical system is often great.
For chronic conditions and diseases, and general health and well-being, not so much.
And, given the (non)reaction of the general medical establishment to the politicized “care” for COVID over the past 2.5 years, my trust has lowered much more. Question everything indeed.
Exactly right.
My former doc was a vegetarian, supplement-loving, soft-spoken quack of a doctor. But he honored my request to be taken off Metformin, when my low-carb diet got me an A1C under 6.0. He was amazed that it could be done. He had never seen it in any of his other patients. Unfortunately, he retired rather abruptly.
The new kid docktor is a pill pusher…
/in the market for a new doctor
Most of them suck. The GlibFit articles have more useful information than 90% of GPs.
Not sure what the answer is, except to remind people that you are on your own. Plenty of good information out there, but you aren’t gonna get it from your doc.
*takes a deep bow*
I am amazed at how ignorant (supposedly intelligent) doctors can be.
Why?
They get less nutrition training than some Globo-gym personal trainer does.
I’ve read that one problem is that physicians’ associations like AMA try to keep the number of doctors in America low so that the salaries remain high.
I remember Groovus insisting this is not true. Though there is medical licensing, but I think he also said medical licensing is not controlled by the AMA.
Sounds like a very challenging business. I can’t even imagine all the competing forces.
Thanks, RC!
Hi Tundra,
We avoided most of the serious wind, lost a few trees but my neighbor rescued them for saw logs (he has his own band saw mill) and firewood. My best friend a mile north was devastated, over a 100 big pine down, one brushed his house, one on the garage. Carport disappeared but he has just sold 2 collectibles a few days earlier.
North to town looked like Ukraine but mostly trees down. We lost power for 7 hours.
Roofer should be here this week to repair the snow damage and replace the chimney blocks on the north garage.
Yeah, my buddy’s place on Ruth took a pretty good hit. His dad and brother both live on the same lake and they got messed up as well. Lots of chain saw work ahead.
Glad your damage was minimal!
Drove through Deer River, MN with my girlfriend this last weekend. It is amazing how specific and discrete the violence was. The furniture store and the attached post office got hit hard, but the nearby VFW was perfectly intact.
Oh, my goodness, 4(20)! I hadn’t heard about that! Yikes! ?
Why has Mother Nature taken a sudden dislike to Memorial Day lately? ?
A good friend of mine is a general physician at one of the local hospital systems. He always has some choice words about how medical care is delivered – and he’s a left-winger! He’s also a Covidiot, so…
My big gripe was my hospital’s standard refusal (hospital policy) to replace my knees because I was overweight. I was caught in a catch 22: I couldn’t lose weight because I couldn’t walk and I couldn’t get new knees until I lost weight. Luckily I found a doc willing to take me on. And I’m happy to say I’m down 40 pounds (mostly because I walk 4-6 days a week now).
Now I can haz concierge medical care? Aforementioned friend says it will never happen here because the hospitals won’t allow rogue doctors admitting privileges.
Great job on the weight loss PON!
Seconded.
RE: Concierge care: I can see hospitals not wanting competition. Also, check laws. In NH, there is a law that effectively outlaws concierge service. If I remember correctly, it says you can’t have a cash-only medical provider, which is what most concierge services are. You have to take insurance and/or Medicare/Medicaid. There are one or two concierge services in NH. Legislators I know say the law in question doesn’t actually prohibit these things, but the medical board acts as if it does. The legislature had a bill making it clear that such services are allowed. I think it passed but I don’t know if the governor signed it.
Gleaned from today’s lunch with ER doctor:
1. Masks – virus’ s pass through the mesh, even N-95 masks. He wears N-95 in surgery to trap bacteria and keep patient squirting fluids from doc’s nose and mouth.
A mask will trap the virus contained in your sneeze or cough. But so will your elbow joint so don’t sneeze or cough into the air. Therefore masks are better than nothing but minimally so. The best advice for not spreading was the social distance aspect and not shaking hands and staying home if you feel ill. These practices are behind the much lower incidences of common colds and flus during the pandemic.
2. COVID-19 was developed in the Wuhan laboratory. Not enough evidence to say if it was deliberately released. Probably some lab dude wasn’t careful, caught it, and took it out into the general population.
3. It’s beginning to look like the booster shots led to more severe reactions, and COVID cases, than the original vaxes. He took three jabs and got a 2 day malaise from the booster.
It is impossible to know the unknown – that is, how worse (or better) would the pandemic have been without the shots. If it turns out the vaccines are harmful in the long run, then Trump will be blamed for rushing them into use.
4. Biden is in early stage of dementia, but not as “out of it” as conservatives would like to pretend. Still, anyone at his stage should not be president of the United States.
5. Strange that Biden has not yet – almost a year and a half into his term – done the whole “physical exam at Walter Reed” that previous presidents have done. Had Trump waited this long, the media would be screaming that the WH was covering up a serious physical and/or mental condition.
Sadly, “out of it” does get much worse than Biden’s present state – I’ve seen it in action.
But yes, he should not be president for that if not many other reasons.
This. My father, PhD in Genetics, professor for 30+ years, gunsmith, stained glass fabricator, etc. was brought to the level of a 1 year old by Alzheimer’s. Incredibly sad, and very, very dangerous.
My father had Alzheimer’s to the point he couldn’t live at home anymore so he’d been in a memory care place, then a VA memory care place for 4-5 years.
He was still mostly having a reasonably good time swapping stories with other vets but was going downhill fast and starting to get delusional and anxious, even paranoid.
He died in June 2020 of cardiovascular disease “with Covid”. No idea if Covid contributed to his death, but if so, it was one small mercy that came out of the pandemic.
RIP, Dad.
Patients can go from one category or service line to another….Every hospital function is interconnected….institutional knowledge and standards
I’m a total quality guy, which means my favorite amusement is watching people abuse statistics, look through the wrong end of their binoculars, and generally mis-model human behavior. A hospital is not an assembly line, but simple quality disciplines such as work standards, Pareto analysis, and root cause analysis have driven spectacular improvements in levels of care. In my world a product/component/service is not a success until it is designed and delivered in the correct configuration and quantity to the right place at the right time: medicine has stepped up in the past three decades to see that holistic practice can be much more than a buzzword. I’m stunned at how bad some things were in my early adulthood and how much better those same things are just a few decades later. My favorite notion in medicine is “continuity of care.”
OT: I despise the concept of “healthcare system.” There’s no system, no one owes you anything, and no amount of semantics will make the system exist; it’s MSNBC bullshit to pretend that there is a system, as if the government can fix everything if the right people get enough of my money to do so. That ain’t how it is, and we need to cut off such prose. You can purchase services wherever you wish, but, unless you’re enrolled in the VA, you’re just a customer surfing through various markets of services. No one is going to do anything about it if you stop seeing doctors, fail to take your medicine, or opt out of rehab. Like anything else in life, if you want to see how your healthcare is going to be managed, consult a mirror.
It is scary that “evidence based medicine” is a relatively new thing.
Stop? I haven’t seen a doctor since either Reagan or GHWB was president. Not sure of the exact timing. I suppose I’ll have to at some point — but boy, the last couple of years doesn’t make me think there’s a real need until something comes up.
Now do Surgery Center of Oklahoma.
Admittedly, they are scheduled surgeries only. But at least they list their prices.
OT
AAHHHHH…. God Damn!!
Cormac McCarthy had a new book that was supposed to drop this month. I pre-ordered it, but of course it has been delayed until Oct. Seriously, I have been waiting for this for a decade. And now they tease me with this shit? God Damn!!
And in looking, it has been sixteen years. Damn, time flies.
Also, looking at the binding, it is in a style I am not a fan of. Which is a shame, as I would love to see these in full cloth with japanned endpapers, on linen.
Cormac McCarthy
weirdest University of Tennessee alumnus ever?
Irish Catholic grows up to write in Southern gothic and then move to west TX and North NM….finding his way
I don’t think he graduated. Went into the AF instead
we can’t let that get in the way of the core observation: odd unit
Anyway, I’m the last guy to say anything about whether someone graduated: I’m a member in good standing of the UT Alumni Association but never got a goat skin from them. I noticed Austin calls theirs TX-ex. I asked a guy once if he went to Miss St: I slept in their dorms, he reported; I slept in Knoxville’s classrooms but somehow most of my professional ability still osmosed during those slumbers. I’m also the last guy to take Latin instruction from, but the root of alumni gives “pupil.” I’ll stipulate standard usage has been “graduate” if we can all agree that such connotation comes to us from Ivy League frat daddies and weigh it accordingly.
Eh, I went to a top ten engineering school… for something completely different. I was a local. But I hated formal education so much that I dropped out as soon as I started working in a used bookstore. I have no idea what they call the former students there, nor do I care.
My stay last year was expensive but treatment was limited to therapy and rest.
I know when I last had an extended stay in the hospital (pulmonary embolism after a 13 hour flight back from China, 75% blockage), it was VERY beneficial to have an advocate (ex-wife) there in the hospital for me. I was strung out on Hydrocodone, and belligerent at all the inconveniences of being stuck in a hospital bed, and perhaps NOT MAKING THE BEST DECISIONS under their influence.
This is super important, and one of the things that’s gotten messed up by COVID policies. My grandfather recently went through two years of medical hell (thank God he’s doing so much better now). His first hospital stay in 2019, we had someone with him 24/7. His last hospitalization in 2021, only my grandmother was allowed to visit and only during limited hours, so the rest of the time, he was by himself having to make decisions about his treatment even though he was on painkillers.
That is fucking awful. Is that even legal?
Probably not but still justified by The Science ™
If the condition is life-threatening and the patient can’t give informed consent you can treat without it. I just wished they’d let my grandmother be there so she could help him with the decisions, and that they’d let the rest of my family be there so we could take care of my grandmother. COVID was the least of anyone’s concern at that point.
Gee, the Rangers lost another away game. I am shocked.
Acktchually, I didn’t even bother watching. Predictable result is predictable.
Hopefully that means you watched Babylon 5. Also acceptable, videos on how to snipe Street racers from a high floor.
Dammit.
Can’t believe it took me this long.
https://youtu.be/HyHXQ9VRYSw
The Hospital Song – 10 cc
https://www.youtube.com/watch?v=K4NYG6DZHIg
Cold War Kids – Hospital Beds
https://www.youtube.com/watch?v=jyhkQzPLjcA
David Gray – Hospital Food
https://www.youtube.com/watch?v=GqlagDc6iCE
Thorazine Shuffle – Gov’t Mule
https://www.youtube.com/watch?v=TlfoIphZPJY
They’re already calling the election for Newsom. This state is so screwed. I know it was before, but in a year where he fucked over the entire state, these clowns are still voting for him?
It looks like 4X as many votes, too. Damn.
For run-off in Nov, I should clarify. I think – though I’m not 100% – that there’s no auto-win with enough votes. It’s just top two go to Nov.
So hopefully, Dahle holds on to be 2nd so there might actually be some competition rather than the usual of choice between one terrible Democrat and one communist.
I was hoping for Shellenbarger myself but I will take anyone not Pol Pot over Newsom.
Looks like a pretty steady 4th place, not bad, but yeah I wish it was higher. I feel like his ballot blurb that said “homeless advocate” was a bad choice, though – if you don’t already know who he is, it sounds like he’s a fruitcake.
My only dog in this fight is having grown up in the state, and a deep family history there, so I am not too familiar with the ins and outs anymore. But, when they went to the redistricting council, that is when the state officially went in the handbasket. Newsome is a fools fool, but Trump broke too many on that side of the line, and any idea of an R (who split themselves pretty hard in the runoff) is going to be a poison pill at best. And as long as they can keep feeling that all is ok, they will keep going blue. It’s like an alcoholic who hasn’t hit rock bottom yet.
It is a damn shame.
I feel the same way OTA but I’m unsurprised. The failed recall drove home how much of this state was fine with shutting everything down (and probably have daddy issues). This state is screwed. I don’t believe it will get any better any time soon. I know I will retire elsewhere.
At least Boudin’s out, looks like. They finally struck bottom in SF. And unless it’s changed recently, the new DA can fire everyone they want, since that office has no civil service protection (unlike LA). Now if RecallGascon can get its shit together and take him out, too.
Boudin shitcanned?
Oh yeah.
Yeah, I just took a gander at the preliminary results, and while utterly unsurprising after the recall going down in flames, it is depressing that there are that many idiots here to vote for that greaseball after the shit he pulled during the Panic. I knew that Boudin would be shitcanned, even for here he was way too lefty and people are fed up. Hopefully Gascon will also get a recall election.
It’s good to know SF has some limits.
Post recall, I don’t think anyone in the rest of the field really pushed. I know when it came time to look at the ballot, I knew I hadn’t heard anything from any of them. The focus seemed to be on the House races around here (due to redistricting moving our Pelosi-lackey away).
And yes, bloody depressing.
Great article RC. I have a theory about, “Nobody can explain it, but hospitals all over the country have sicker patients, and a lot more of them, than we did pre-pandemic.” For nearly two years people couldn’t get regular care due to the unknown virus of unknown origin (h/t Critical Drinker). In that time, avoidable conditions manifested and treatable conditions got worse. Now So, hospitals are seeing sicker patients than was previously normal.
I live in Canadia so my references are shallow. Yes, you are usually not paying a dime for your care but the meal is so bad and the portions, so small. What we have up here is triage, writ large. I’ll be visiting my “family doctor” on Thursday for my allotted 10 minutes and he will either order more tests or slough it off to a specialist. This practice is so paranoid that you need to slide an envelope under the door to make an appointment. Even when you get there they make you wait outside until his assistant lets you in. Ten minutes does not make for good medicine. He hints at things and I have to go home and google the terms. “Brain lesions? That doesn’t sound good…” Reads up on it a bit. “Gah!” Same doctor dropped Judi’s boy from his practice a year ago. This is a man that is fucked up and disabled. He needs nothing more than the doctor’s signature to get into some kind of supportive housing or residential treatment program. It’s all fucked up and getting worse by the day.
You’re making the NHS sound good by comparison.
It is really bad. I could tell tales about how they mix patients from the pre-op and post-op ward with the ones that should probably be behind locked doors. Our local is a teaching hospital. Imagine the worst of the frat-bros and sorority sisters basically running the place. Last time I was in there they treated me like “Piggy” from Lord of the Flies. All night long there was a dorm party happening. I’ll die by my own hand in the back shed before I ever go back to that sort of treatment.
Frat bro doctors and sorority girl nurses sounds like the start of a good 80s porn script.
I never thought this would happen to me…
Bow chicka bow bow
It ain’t sexy when it is happening to you.
Todd: High five!
What we’ve got here is failure to Firsticate
Some men, you just can’t reach
So, you get what we had here, last week
Which is the way he wants it
Well, he gets it
And I don’t like it any more than you men
Those “death panels”? Yeah, they are actually happening up here but more granular. No one is sitting in be-robed judgement. Nope. It’s just the rank and file that decide who lives and who dies. I’ll hang on for a time but my step-son will be dead within 6 months if he doesn’t get some of that sweet, sweet socialized medical care.
It always comes down to the bureaucrats. I’m so sorry, Festus.
My shame. Again.
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Something just occurred to me. The mothership seems to keep score differently than we do.
Imagine a 2-3-4-9 – we give it a decent 18 but they give it the worst winning score (9 turns). I wonder if our Quordlekeeper(s) have reckoned that score in their sacred texts.
Yup, the home site only considers the last solve meaningful.
Glibscore rewards luck, flashes of insight and taking risks.
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TMI. I only got the one word because my mom let me read Penthouse…. Thanks, Mom.
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Surprise Zoom last night, surprise cartoon tonight! I’m just full of surprises lately!
There was a Zoom last night?
I was off too.
/kicks rocks
Lol. I binged the Boys season 3 episodes 1-3 on Monday night. Holy cow, they turned up the gratuitous gross sex and violence up to 11. It’s one thing If the gore/gross-out/violence furthers the plot, but this season seems like the writers held a contest of who can write the grossest scene.
I kinda want to see what’s next, but I think it’s jumped the dolphin.
They shorted my pay. It’s just one fucking thing after another. I give up. I’m done like dinner.
Enough to fight for, or is it an exit tax?
It’s about $1500.
Sorry Festus.
Someone stole my parting gift from the staff and now they are fucking me over for vacation pay. I’ve always played by the rules. What a fool believes.
A gold
watchplunger?Should have been a gold butt-plug.
Stopping caring now. I’m a broken Man. Fuck it, bring it on.
Ive been there and what makes a man is how you go through it. With snark and general fuck the world attitude has worked for me in the past.
Are you fucking serious? Someone stole your parting gift?
Thieves should be shot.
I’m goin to listen to Orson Welles adaptation of The Murder of Roger Ackroyd (Agatha Christie) now. 1939, 1 hour long.
https://orsonwelles.indiana.edu/items/show/2002
I have stopped actually reading books. I drink way more than I ought to but it does not settle me the way that the old side-to-side did. I have read literally multi-thousands of books.
Told my boss she has 1 more year out of me until I leave. She was surprised but threw her support behind whatever connections I may need in finding where I will land.
Did you say “Sproing”?
Don Martin gives a salute!
+1 shtoink
+ 2 floppy feet! Bawing!
from his Wiki page:
“Martin’s dedication to onomatopoeia was such that he owned a vanity license plate which read “SHTOINK,” patterned after the style of his famed sound effects.”
Sign me up!
Disconnect from work and let the horses of Iceland reply to your emails while you are on vacation.
None of these things would be an issue if hospitals were government run as they should be. Health care would be cheaper and of better quality.
See Festus above.
Morning, Glibs.
Mornin!
how goes it in your neck of the woods?
I hired a dude yesterday. It’s damn near impossible to add employees these days.
What’s up in NY?
Evil, unconstitutional things.
So, the usual.
Good morning, U, Sean, Tulip, and….there’s DEG and Lack! I don’t see anybody else from within the last couple of hours.
Boss is WFH today, but that’s no guarantee he won’t be bothering me.
I’m in the office, and apparently they’ve gotten so sick of the turnstyles downstairs breaking that they’re replacing them.
You work in a stadium? Don’t lie – you’re really a gladiator, aren’t you?
Afraid not. They’re just gates that allow employees to card in while making visitors go to the security desk to sign in. A lot of state offices have them.
Do you have to go through metal detectors too? Once I had to go downtown either for jury duty or for some business related to my notary, so it was probably the county building, and I thought I’d cleared all the metal from my bag. Set off the detector with my little can of lock de-icer.
Thankfully not. Even when I had access to a building with a metal detector, the employee access gate bypasses it. Yes, there was a time when I could card into the capital building. (There is a tunnel connecting it to the building where my datacenter was at the time, so the route from my cube to the datacenter took me through the capital)
Open or concealed, as long as you are packing. We’re family friendly.
https://philadelphia.cbslocal.com/2022/06/07/delaware-marijuana-veto-bid-fails/
Everyone must get stoned.
https://fox5sandiego.com/news/grand-jury-returns-indictment-against-11-charged-in-pb-demonstration-attacks/
Meh. Let me know when they get convicted.
So, I hit East coast and West coast news.
Here’s what fly over country headlines I got:
https://fox4kc.com/news/dog-the-bounty-hunter-visits-missouri-prison-to-help-inspire-those-behind-bars/
So far, my morning commute route looks to be clear of wrecks, and it’s not supposed to rain until…time to drive home. That’s all the local news I can handle first thing in the morning.
Random: https://m.youtube.com/watch?v=wYNzMrYpuAk
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Weird ones today. And shouldn’t be spoilers — but in honor of yesterday’s Highlander refs, I did have to start with Candy.
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Mornin’ all!
Off to the gym.
Good morning quordleheads and regular glibs.
I like opening a home, but God is it a lot of work. Of course we just discovered some mold, so we may have a while different level of fun soon.
I’m going to assume it’s one of those awful living kinds and not molds for pouring ceramics or injecting plastic,
Ruh roh! Hope it’s nothing Kilz can’t handle.
Dunno yet. Woke up one morning to spots all over one ceiling, spreading it down with a mold killer made it disappear, but no idea how widespread it is or where it came from.
The source of the moisture feeding that mold is going to cause worse problems in the future if you don’t find it.
Good luck with that mold. We just had remediation done in our (unventilated) upstairs bathroom. Fortunately for us we caught it early, hope yours works out as well.
‘Nobody can explain it, but hospitals all over the country have sicker patients, and a lot more of them, than we did pre-pandemic.’
It’s a mystery.
The thing about doctors is really interesting. I never understood WHY hospitals don’t hire doctors. Assuming I’m reading that correctly they are basically unaffiliated with the hospital except as having admitting privileges. Also, of that particular cartel had so much control and power how is it that they allow anyone else to admit patients?
Anecdotally, I have seen midwives all lose privileges due to a single bad practice. Why can midwives and other medical professionals who are not doctors practice without an internship type system?
I can’t get licensed as an engineer without x years of experience under a licenced engineer, seems these professions should have a similar restriction. The midwife in question politeness her own practice right out of school (privileged background….) And killed a bunch of kids by not knowing wtf she was doing.
Thanks for the article RC. my wife works in a hospital on occasion so I’ll be sharing this with her. I assume there will be a follow up?
Mornin’, reprobates!
Good morning, ‘patzie! Any wildlife making their presence known around your home this fine day?
Morning all,
Haven’t seen the news yet, other than what Sean brings. Probably don’t want to, seems like it’s never good. I don’t have much contact with real people so that’s another reason not to watch TV. Though I could watch Fox with the sound off just to enjoy the ladies.
Good morning, 4(20)! From your comments last evening, it sounds as if you’d get all the news you’d need from the weather report.
Mornin’, GT, and thanks for the tune. Love singing that as I walk through the park.
In that case, please accept another good walking song, as you should be doing so with these.
Why is it that the closer to my day of departure, the angrier the ex (who cheated on me, dumped me, kicked me out, and is keeping my kids) becomes? Bitch, you did this. This was all your idea. Everything you wanted to happen is happening. Just let me go in peace.
Anyway… bleh! Today’s words were hard.
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Also, waffle can suck it as well.
#waffle138 1/5
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? streak: 1
wafflegame.net
Is it almost upon us?? Or rather, I suppose, you??
(Is she angry because she’s losing her “free child care”?)
Probably. Also, all the “free” housekeeping, lawn maintenance, IT support, etc.
Yep, 2.5 weeks away from my new life toiling for WebDom, Spud, and OMWC. I can’t wait. I’m so excited that I just can’t hide it.
Does that mean I’ll get to meet you in person at the end of July? ? (Assuming all are still welcome on the 30th? I do hope someone will post the details. I want so much to be there!)
You’ll be in good stead, I0b0t. As one of the youngsters you’ll have to put up with their jokes and puns, ’til you get some seniority.
Day of departure is followed by day of arrival. Going to a better place. Will you be able to be with the kids from time to time?
Yep, and perhaps when I’m back on my feet, the custody battle will ensue. A boy can dream, can’t he?
Dream on.
https://m.youtube.com/watch?v=89dGC8de0CA
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Festus, my heart is breaking for you. I’m ever so close to the nothing to lose portion of my life. Does your boss need a visit from the spirit of Marvin Heemeyer?
When my ex died I did a little dance. It took a long time but the wait was worth it. That was 25 years ago and I still dance, in my wildest dreams.
Sometimes doing nothing is the best solution.
Advice is worth what you pay for it, however.
Fourscore, advice from you is worth it weight in gold. Thanks.
Not bad, but probably not good enough. Nobody beats the Whiz.
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Ham sammich
Interesting times may be coming to Bergen County.
https://www.nj.com/bergen/2022/06/nj-live-primary-election-results-2022-bergen-county.html
Caligula for county executive? Party time!
Wait, you also have a Jim Tedesco in state office?
Seems pretty explainable to me.
1) Deferred care during the lockdowns led to incoming patients with worse conditions
2) Significant weight gain during the pandemic and lack of exercise
3) Experimental “vaccines” with significant side effects including, but not limited to, compromised immune systems and vascular inflammation.
I thought about going into medicine while in engineering school. Frankly, I think I dodged a bullet.
Sorry to miss the conversation – I’m on my annual fishing trip. To answer a few questions:
Surgery centers are not hospitals. Completely different business.
The only people who might see a bill with daily inpatient rates are people with no insurance whatsoever.
We want every little thing wrong with a patient documented for both clinical and billing reasons – we get extra pay for “with complications”.
Many hospitals employ hospital-based docs – ED, hospitalists, intensive study, etc. Many hospitals belong to systems that employ other docs – its a long-term trend. On ly academic medical centers can get by with a fully employed medical staff, with very few exceptions. My hospital employs relatively few specialists.
COVID did indeed strain hospitals, during the peak of the worst wave – there were times when there were literally no beds, elective surgery was cancelled, etc.
We don’t think delayed medical care is still a factor in the high rate of hospitalization any more.
Y’all have fun. I’m off to drink coffee with Pater Dean and the staff.
suh’ fam
whats goody
Oh hey- I just got laid!
Come again?
Paid, he just got paid.
Tall cans on Tres
At my age? Not for another week!
/heyoooohhh
TMI
The perfect gift to give a coronary to the arachnophobe in your life:
Spider Sleeping Plush Monster Home Decor Extra Large Plush Pillow Faux Fur Plush Doll White Witch Bedroom Decor Tarantula Art Doll