New Yorker Article

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The article is too long for anyone to care about it. But, from the first page, the jist is clear. Yes, medicine will become a chain (and already is) even more down the road. It will become standardized and perhaps even to the point at which there may be a "menu" of services to order from...some more expensive than others. The standard suture may be covered, but want to order the super dooper stitch that reduces scarring by 60%? That order may cost you.

Regardless....with so many people to service, and the population growing, not to mention with the burden of all the illegal foreigners here, and those requiring health services who don't pay taxes; it may be inevitable.
 
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chorosz said:
The article is too long for anyone to care about it. But, from the first page, the jist is clear. Yes, medicine will become a chain (and already is) even more down the road. It will become standardized and perhaps even to the point at which there may be a "menu" of services to order from...some more expensive than others. The standard suture may be covered, but want to order the super dooper stitch that reduces scarring by 60%? That order may cost you.

Regardless....with so many people to service, and the population growing, not to mention with the burden of all the illegal foreigners here, and those requiring health services who don't pay taxes; it may be inevitable.
Click to expand...

Maybe you should try reading the rest of the article...it actually went in a different direction entirely.

Personally, I'm excited by the prospect of increased standardization and an increased emphasis on total care. As it stands now, healthcare is set up as a marketable service, but without any transparency on quality, cost, or outcome. This makes it difficult for patients to make an informed choice of provider, which in turn means that there's no real reward for improving quality or decreasing costs. If this system increases consistency of certain hospitals or doctors, it gets us one step closer to a more functional healthcare setup (I'm not saying our current one isn't functional, but this sounds like it has the potential to improve it!)
 
Turning the healthcare system into a corporate chain franchise is a bad, bad idea. In fact, we know it's a bad idea because dentistry already tried it with horrific results (chains regularly prescribed unnecessary procedures, inferior procedures that happened to cost more, pressure-sold patients overpriced caps and dentures (that were also often unnecessary), did shoddy work, and placed a heavy emphasis on seeing as many patients as possible over providing quality care).

It's all but certain that the same thing would happen in medicine if we tried it. The precedent is that every time you have a market where you have a very specialized service that the layman knows virtually nothing about, many businesses will attempt to rip people off with unnecessary, exorbitant costs and subpar work. For example, auto mechanics and computer repairmen are both notorious for this, as are the dentists I mentioned previously. Considering that medicine is pretty much the ultimate in the consumer/provider knowledge gap, there's no reason to think that this sort of thing wouldn't happen in a chain clinic or hospital either. Sure, physicians may be sworn to an oath, but that hasn't stopped physicians from volunteering to be executioners at prisons so why it would stop them from ripping off patients if their employer tells them to?

edit: Also, I'll admit right now I only skimmed over the first page (not going to read 10 pages). If the article later went in a different direction then nevermind all of this.
 
Fascinating piece.

Something that should be noted: moving towards big medicine successfully diffuses the accountability (not just responsibility) the doctor has. Implications? Many.
 
OCDOCDOCD said:
Turning the healthcare system into a corporate chain franchise is a bad, bad idea. In fact, we know it's a bad idea because dentistry already tried it with horrific results (chains regularly prescribed unnecessary procedures, inferior procedures that happened to cost more, pressure-sold patients overpriced caps and dentures (that were also often unnecessary), did shoddy work, and placed a heavy emphasis on seeing as many patients as possible over providing quality care).

It's all but certain that the same thing would happen in medicine if we tried it. The precedent is that every time you have a market where you have a very specialized service that the layman knows virtually nothing about, many businesses will attempt to rip people off with unnecessary, exorbitant costs and subpar work. For example, auto mechanics and computer repairmen are both notorious for this, as are the dentists I mentioned previously.
Click to expand...

All of this is true, however it can be solved one thing: "customer" satisfaction. Especially in the age of Yelp, Angie's List, etc., word of mouth is a very, very powerful thing. If you're a practice that rips people off and attempts to bill for unnecessary procedures, you will develop a poor reputation and "customers" will stop seeing you if they can avoid it. If, on the other hand, your patients are satisfied with your service, are comfortable around you, and get the sense that you truly care about them (rather than strictly the bottom line), you will develop a good reputation and patients will flock to you.

What you worry about isn't limited to corporations/integrated medical providers. A douchebag physician is going to be a douchebag physician no matter what practice environment he's in. There is nothing intrinsic about large-scale medical practices that causes them to be terrible. As an example, see Mayo. If you think academic institutions or other practice setups are immune to this, you're sorely, sorely mistaken.

I recommend that you set aside the 10 minutes it takes to read the article. It's about, you know, your future career and all.
 
Decathlete said:
Fascinating piece.

Something that should be noted: moving towards big medicine successfully diffuses the accountability (not just responsibility) the doctor has. Implications? Many.
Click to expand...

I'm not sure I see how it diffuses the accountability. The way it's discussed in the article, it seems to apply primarily to scheduled, nonemergent procedures. The doctors still diagnose the patient, perform the operations, etc...the difference is in supplies, transparency, and communication with postop staff, as well as an increased reliance on evidence-based medical practice (rather than just doing it the way your predecessor did it because that's what you were taught).

The only instance I see where the accountability is diffused is the tele-ICU. That could have serious implications, but it seems more likely to increase documentation and decrease instances where lawsuits could crop up than to turn it into a pointing game. The patient is still the doctor's responsibility; the tele-ICU is a resource, but not a substitute for proper care, in the same way an ICU nurse is not a substitute for the doctor, but can bring things to the doctor's attention to help them do their job better.

If, however, the tele-ICU is given authority to write orders, then any results of those orders prior to them being assessed and confirmed by the on-site attending, who has higher authority, would be the responsibility of the remote doctor.
 
I guess I should have added that what I was referring to isn't completely covered by this piece. I agree the the tele-ICU wouldn't necessarily decrease accountability.

But there has to be something in the back of a doctors mind thinking something along the lines of "Hey, somebody's now looking over my shoulder. I have somebody to correct my mistakes." Maybe not, I mean, I'm not a doctor, but I feel like this is the natural human reaction. Psychologically, there has to be some sort of difference.

Also, I had an interesting conversation about big health care and its implications with a doctor I was shadowing. He basically viewed standardizing medicine as something that will allow doctors to diffuse responsibility. He thought something along the lines of this: he would work 40 hour weeks and then just be done (no overtime pay: no incentives). His practices would be standardized so that he would be less accountable for personal judgment calls. All of his colleagues seemed to be in agreement, and then they went on to joke about how Canada must have the most laid back and least stressed doctors in the world.

While much of this is outside of the scope of the piece (and I doubt the exact examples my doctor cited would actually come to fruition), I still think it's very interesting to think about.
 
Deca, I think we're discussing two completely different kinds of standardization. The one you're referencing seems much more like the ones Choroz or OCDOCDOCD were assuming the article was about, which seems detrimental and in many ways the opposite of the one discussed in the piece.
 
Big medicine may play a role but it will because of meek new grad doctors who want to shirk their responsibility to set up practices and groups and hand those responsibilities to private equity firms that only care about one thing: the bottom line.

Then, medicine will devolve into something like chiropractic care where the only thing that matters is consumer demand and consumer satisfaction. Why? because those that are calling the shots are not doctors. They'll be business men - not inherently bad - but they increase profits with a heavy emphases on marketing and scaling.

Physicians will be just another cog in the corporate machine. No thanks.

EDIT: And honestly... Cheese Cake Factory? That's a standard to aspire to in an analogous sector? lol. I avoid chain restaurants for a reason.

*****Double Edit****** The author, Atul Gawande, is all about standardization and checklists. I remember him from TED. He has some pretty radical views on how medicine should change from an autonomous field, specific to each patients needs, into a cog like "pit-crew" model where patients are treated like robot model A vs robot model B. Basically, a bunch of providers who execute checklists and flow charts. Pretty sad if you ask me - dumb medicine down so trained monkeys can do it - then blame it on the flow chart if things go wrong.
 
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I think they're all related. I admit the 40 hour work week may seem like a stretch, but what about some of the other practices this article articulated? Specifically, the standardized practices of the orthopedic surgeon. Again, at least to me, it seems like this practice reduces the amount of liability an individual surgeon would have on any particular case. I could be wrong.

More importantly, I have to imagine that this article can't possibly cover the only instances of standardizing health care. It's only articulating some of the first steps that have already been taken. It's really difficult to say what could change in the coming years!

I should add that I just ate at the Cheesecake Factory last night, funny enough.. I really disliked my dish. :/ This better not be any sort of eerie foreshadowing of my (hopefully) future career!
 
NickNaylor said:
All of this is true, however it can be solved one thing: "customer" satisfaction. Especially in the age of Yelp, Angie's List, etc., word of mouth is a very, very powerful thing. If you're a practice that rips people off and attempts to bill for unnecessary procedures, you will develop a poor reputation and "customers" will stop seeing you if they can avoid it. If, on the other hand, your patients are satisfied with your service, are comfortable around you, and get the sense that you truly care about them (rather than strictly the bottom line), you will develop a good reputation and patients will flock to you.

What you worry about isn't limited to corporations/integrated medical providers. A douchebag physician is going to be a douchebag physician no matter what practice environment he's in. There is nothing intrinsic about large-scale medical practices that causes them to be terrible. As an example, see Mayo. If you think academic institutions or other practice setups are immune to this, you're sorely, sorely mistaken.

I recommend that you set aside the 10 minutes it takes to read the article. It's about, you know, your future career and all.
Click to expand...

The difference is that the current system at least tries more often than not to be altruistic. With chains though it becomes all about profit no matter the cost. It's not about scale, it's about the business model.

The whole idea that businesses will have no choice but to be honest due to market forces is naive. The real world is full of examples where that high school economics rule has been broken. It's extremely common with monopolies, but can also occur whenever the consumer is too uninformed to realize they're being taken for a ride. Both are very possible with medicine. Monopolies are guaranteed to occur in rural and under-served areas, and I think it's safe to say that most people know jack **** about medicine. Also keep in mind that people rely on brandname appeal more than anything else. It doesn't matter if your business is one of the worst out there and has pissed off legions of consumers, if you've got the brandname appeal and an inflated marketing budget you can ride out the bad PR for decades or longer. Just look at for profit colleges like Phoenix or DeVry.
 
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pseudosquam said:
Big medicine may play a role but it will because of meek new grad doctors who want to shirk their responsibility to set up practices and groups and hand those responsibilities to private equity firms that only care about one thing: the bottom line.

Then, medicine will devolve into something like chiropractic care where the only thing that matters is consumer demand and consumer satisfaction. Why? because those that are calling the shots are not doctors. They'll be business men - not inherently bad - but they increase profits with a heavy emphases on marketing and scaling.

Physicians will be just another cog in the corporate machine. No thanks.

EDIT: And honestly... Cheese Cake Factory? That's a standard to aspire to in an analogous sector? lol. I avoid chain restaurants for a reason.
Click to expand...

The article never proposed having non-doctors set protocol. It proposed having doctors communicate and work together on setting protocol based on evidence and outcome statistics.

Hospitals are already trying to make money; they try to improve tons of statistics such as how many ER walk-ins leave without care, how many beds are full, etc...and some of those are less useful than others. What's wrong with trying to focus on offering the best possible care with the most efficient utilization of time and resources? People hear the words 'big medicine' and immediately jump to the (unfounded) conclusion that this implies assembly-line surgeries, poor decision making, etc...

Having knee replacement doctors work with a single company doesn't hurt patients, yet can greatly cut costs. Making deals with corporations to treat their employees for lower costs actually helps patients, and also helps the hospital.

Personally, I think it's sad that the motivation to shorten patient recovery time, remove extraneous, unhelpful steps, and improve results has to come from an economic standpoint. Shouldn't doctors be practicing evidence-based care already? Shouldn't standardization happen naturally as doctors gravitate towards the practices most supported by statistics and literature data? Why is this a 'big medicine' thing and not just an 'adequate patient care' thing? Even for practices with equivalent results, why would you choose to use different protocols in the same hospital when handoffs and postoperative care could be improved by using one practice (remember, it's no better or worse than the others) so that the nurses and other doctors can more readily recognize what they should look for and how they should handle patients of this type?

If we cut out the label 'big medicine' and who is responsible for these shifts, we could have a lot more productive debate about standardization and avoid the gut-instinct, "I hate corporations" talk.
 
Mehc. Because when I go see a doctor I don't want a "doctor-in-a-box" or to be treated as if I'm a protocol. I want to be treated as an individual with a specialized care plan based on literature and studies as you suggested. But also the physicians education and understanding of the practice of medicine.

Practicing medicine will (should) never be the same as operating as a line-cook at a chain eating establishment.

The guy they interviewed that was managing the Cheesecake factor was obviously confusing his mothers stay at the hospital for that of an all inclusive hotel or assisted living facility. Those sentiments really should not be entertained unless the cost can be passed off onto the patients as they cost considerably. Physicians are professionals - not "workers". You honestly think CEO's, engineers, bankers, law, work as "line" personal? They have autonomy and use their expertise to solve novel problems.

If you want to follow a protocol and have decisions made for you become a mid-level or RN. Atul has an agenda and the comparison between food-mill-line-cooks and physicians is a logical fallacy.

An interesting point that I would like to make is that a lot of the movement towards "big medicine" has been caused or expedited by federal regulations & bureaucracy like EMR, malpractice, medicare & cain changes to reimbursement. Interesting that these changes has favored private equity & big corporations.

This is not a coincidence. Big medicine as Atol describes is crony capitalism proper. Nothing like a new mandate to expedite it and shift power from individual physicians to the board room.
 
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The point that the article was making is that care is often not fully based on literature. For example, the use of a continuous-motion device after surgery is common, yet not really supported. Similarly, the more expensive protheses were costing patients even though there was little evidence to support the additional expenses.

I'm not saying that we should have a 'doctor-in-a-box', where everyone who comes in with knee pain gets the same recommendation, treatment, etc. I'm just saying that if a specific procedure is indicated by the doctor and chosen by the patient, it should be done in the most efficient possible manner, which benefits patient and hospital and doctor. You will get a specialized care plan: the best knee replacement protocol that physicians (with their education and understanding) have been able to implement, based on research and studies.

The issues brought up with the mother's stay at the hospital highlighted issues that cost everyone...the patient spent more money, the hospital had a bed full for longer than needed, and the doctors failure to communicate effectively wasted the time of the neurologist and likely others before it was worked out.

They aren't taking away doctor autonomy or decision-making ability; they leave the details up to them. However, they are forcing them to reconsider poorly-thought out postoperative plans and instead implementing THE MOST EFFECTIVE one. If your doctor was truly bothering to personalize your care plan and base it off of sound literature, you'd probably end up with the same one, or one with an equivalent result. As long as it works just as well for you, why would you object just because all the other knee replacement patients get the same treatment?

It seems to me like the current system is more like 'doctor-in-a-box', with each doctor simply performing the same procedure the same way every time without updating their methods or communicating with postop. The patient has no idea whether the doctor is using the best techniques or protocols, because it's difficult to shop around for surgery; most places don't even bother discussing the price with you. As long as you have insurance, they assume you can work it out on your own.
 
NickNaylor said:
What you worry about isn't limited to corporations/integrated medical providers. A douchebag physician is going to be a douchebag physician no matter what practice environment he's in. There is nothing intrinsic about large-scale medical practices that causes them to be terrible.
Click to expand...

Haha, well said.

Really interesting article though. As someone who often irrationally shies away from chain restaurants (and is about to start down the long road toward, fingers crossed, a career in health care), I thought his open-minded perspective on standardization and chains in health care was pretty thought-provoking. Most definitely worth the read -- come on people, the 10 pages are each really short, and there's even a button to put it all on one page.
 
I don't think that's true. I've meet many physicians that are very concerned with quality and read lit. and attend M&M conferences to develop best practices. I like the idea of physicians doing this rather than there corporate overlords forcing them to. There will always be lazy physicians. Perhaps taking the thinking out of medicine will create more...

Besides, it's very difficult to determine what is "best". I would argue that individual physicians who are devoted to their profession will stay on top of research faster than a large business will. Especially when you introduce profit motive.

mehc012 said:
It seems to me like the current system is more like 'doctor-in-a-box', with each doctor simply performing the same procedure the same way every time without updating their methods or communicating with postop. The patient has no idea whether the doctor is using the best techniques or protocols, because it's difficult to shop around for surgery; most places don't even bother discussing the price with you. As long as you have insurance, they assume you can work it out on your own.
Click to expand...
 
You keep assuming that businessmen will be in charge of doctors' protocols, when that was not indicated anywhere in the article. Doctors are still in charge of patient care. If you have a group of 10 surgeons using the same post-op procedure (they didn't change anyone's individual methods) and getting a group discount on prosthetics, you have the resources of 10 surgeons looking for improvements in technique. If they say 'hey, we should be doing this specific rehab technique' it can be discussed and benefit the patients of all 10. If they find a better prosthetic, it can be spread to all 10. If they happen to be one of those 'lazy' doctors who doesn't do the work, their patients will have improved care because they will benefit from the research of the group.
 
Mehc. Doctors already do that.
 
OCDOCDOCD said:
The difference is that the current system at least tries more often than not to be altruistic. With chains though it becomes all about profit no matter the cost. It's not about scale, it's about the business model.

The whole idea that businesses will have no choice but to be honest due to market forces is naive. The real world is full of examples where that high school economics rule has been broken. It's extremely common with monopolies, but can also occur whenever the consumer is too uninformed to realize they're being taken for a ride. Both are very possible with medicine. Monopolies are guaranteed to occur in rural and under-served areas, and I think it's safe to say that most people know jack **** about medicine. Also keep in mind that people rely on brandname appeal more than anything else. It doesn't matter if your business is one of the worst out there and has pissed off legions of consumers, if you've got the brandname appeal and an inflated marketing budget you can ride out the bad PR for decades or longer. Just look at for profit colleges like Phoenix or DeVry.
Click to expand...

Do you somehow think hospitals and current medical practices aren't worried about the bottom lines because they're classified as "non-profits?" You're using outlandish examples. How about we look at the overwhelming majority of businesses that operate on a for-profit basis and don't screw people over?

(sent from my phone)
 
A very interesting article. Dr. Gawande can write some pretty good pieces. My thoughts, consolidating and standardizing care among different medical facilities does have its advantages, as Dr. Gawande pointed out. But I can see the issues that can rise with a few group of people (like Drs. Wright and Ernst) making decisions that will rain down on many. The structure of 'power' in decision-making will need an extensive re-evaluation and I'm not sure if that is something that will be implemented so easily in medicine.

A fine read, nonetheless.
 
pseudosquam said:
Mehc. Doctors already do that.
Click to expand...
So where's the harm in making sure they actually do it, streamlining the process, and making the patients more aware of it? Are you so confident that they all actually do it on their own, with no incentive?
 
The big questions are

1) How will this affect our salaries?

2) How will this affect our work hours?

3) How much power will the physician have in this new system?
 
ElCapone said:
The big questions are

1) How will this affect our salaries?

2) How will this affect our work hours?

3) How much power will the physician have in this new system?
Click to expand...

My predictions:

1) Depends on what your alternative is. Compared to academic positions, they'll probably be higher. For PCPs they'll also likely be higher compared to a private practice. For more lucrative specialties they'll likely fall.

2) My guess is decrease as there will be more physicians available to cover a particular time period. However it'll likely vary from group to group depending on how much work/call they expect their physicians to do.

3) Definitely fall on an individual level, though this perhaps might give physicians a collective voice via more organized labor.

(sent from my phone)
 
That took me a couple of Led Zeppelin songs to get through, but an interesting read.

When the tele-ICU was being described, Orwell and 1984 just came to mind with Big Brother Medicine, but it could work as long as it doesn't become authoritative; I wouldn't want CEO's piping in randomly while I'm replacing someone's knee.

But more standardized care is in order, and I wish physicians cooperated more with each other on this, rather than having the suits enforce it.
 
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ShenanigansMD said:
When the tele-ICU was being described, Orwell and 1984 just came to mind with Big Brother Medicine, but it could work as long as it doesn't become authoritative; I wouldn't want CEO's piping in randomly while I'm replacing someone's knee.
Click to expand...

Agreed; I think it would ONLY work if they kept it to medical professionals. Its purpose is really to have another layer of observation, like having more ICU nurses or interns or something. I can think of no reason for an administrator to use it at all!
 
ShenanigansMD said:
When the tele-ICU was being described, Orwell and 1984 just came to mind with Big Brother Medicine, but it could work as long as it doesn't become authoritative; I wouldn't want CEO's piping in randomly while I'm replacing someone's knee.
Click to expand...

Why on earth would a CEO decide to watch a knee replacement?
 
Not to mention the fact that the tele-ICU is in the patients' rooms, not everywhere. It's not like you should be doing anything in a patient's room that you wouldn't want people to see; on a personal level, the patient can see you, and on a professional level, all of your actions should be charted anyway. Honestly, it's the same as having another nurse around, and it chimes when they turn it on so that you know they're there. If anything, I can see this extra layer of observation helping, either by preventing you from screwing up, or by providing a backup witness in case of a lawsuit (while it isn't documented in the chart, I saw that Dr. X stopped by to check on the patient at least twice during the night...)
 
BYU2010 said:
http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande?currentPage=1

Kind of a long read, but very good.

Any thoughts?
Click to expand...

I'm buying the beet salad next time i go...

I'm a huge Atul Gawande fan and this is the first time i've read one of his New Yorker articles in full length. I definitely see hope in Big Medicine. From the examples he showed, it seemed as if all the systems that have accepted a standardized form of health care are really benefiting from it (better care, lower costs). However, since many doctors, nurses, and other health professions have their own of doing things (techniques for procedures, equipment used, etc.), it just seems almost impossible for Big Med to be a main stream form of care.
 
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NickNaylor said:
I recommend that you set aside the 10 minutes it takes to read the article. It's about, you know, your future career and all.
Click to expand...

Ha, took me a little bit more than ten minutes. But yes, definitely recommend that everyone reads it.
 
mehc012 said:
Agreed; I think it would ONLY work if they kept it to medical professionals. Its purpose is really to have another layer of observation, like having more ICU nurses or interns or something. I can think of no reason for an administrator to use it at all!
Click to expand...

mehc012 said:
Not to mention the fact that the tele-ICU is in the patients' rooms, not everywhere. It's not like you should be doing anything in a patient's room that you wouldn't want people to see; on a personal level, the patient can see you, and on a professional level, all of your actions should be charted anyway. Honestly, it's the same as having another nurse around, and it chimes when they turn it on so that you know they're there. If anything, I can see this extra layer of observation helping, either by preventing you from screwing up, or by providing a backup witness in case of a lawsuit (while it isn't documented in the chart, I saw that Dr. X stopped by to check on the patient at least twice during the night...)
Click to expand...

Agreed. I would see no help from an admin peeping in on patient's rooms. And if all the recordings of a patient's visit is saved to some file somewhere, it can basically be apart of the patient's chart.
 
Omppu27 said:
I'm buying the beet salad next time i go...

I'm a huge Atul Gawande fan and this is the first time i've read one of his New Yorker articles in full length. I definitely see hope in Big Medicine. From the examples he showed, it seemed as if all the systems that have accepted a standardized form of health care are really benefiting from it (better care, lower costs). However, since many doctors, nurses, and other health professions have their own of doing things (techniques for procedures, equipment used, etc.), it just seems almost impossible for Big Med to be a main stream form of care.
Click to expand...

What I see as an advantage of the type of Big Med discussed here is that it doesn't require anyone to change up the individual details (procedure technique, personal equipment), but rather sets a better standard of care and mandates more up-to-date, evidence-based practices. It doesn't dictate how the operation is to be done, or what the doctor uses to measure x, y, or z, but seems more concerned with the overall sequence of steps. In other words, they try to govern a patient care arc of 'diagnosis --> surgery --> immediate p.t. --> outpatient rehab' rather than 'do the surgery this way' or 'use these p.t. exercises.' While that may seem like a trivial difference, timing and communication can have a huge impact on hospital stay and recovery time, and can be adjusted without forcing anyone to change up their personal style.

The only equipment requirement was that the prostheses be below a certain price or shown to be more effective than their lower-cost counterparts, which seems fair when you consider that those costs are shouldered by the patient, who may not know that there were cheaper alternatives.
 
Omppu27 said:
Ha, took me a little bit more than ten minutes. But yes, definitely recommend that everyone reads it.
Click to expand...

Agreed, I feel like a SLOW reader compared to Nick.

But then again, I don't read novels or articles often so that could explain it :O
 
I think what many of you fail to realize is just how UNstandardized the vast majority of medicine is. Only very very recently have people even started to take outcome tracking seriously and started to look at controlling the quality of medical encounters and surgeries. Everyone has this idea that "medicine is an art" which translates into "the way I do things is the best and I won't even look to see if anyone else is doing it better". Seriously, you can't even get doctors to wash their hands before going into patient rooms without some corporate oversight. I seriously had an ICU resident say to me once, "I don't believe in the whole washing your hands thing. There's bacteria all over the place in the patient rooms, what's slapping your hands around with some soap and water gonna do?"
 
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