Hospitals Should Only Be Places of Last Resort

A friend of mine called saying he had acute urinary tract infection. He had fever and burning while passing urine. His urine examination showed pus cells and he had raised white blood cell counts. An ultrasound of his kidneys, ureters and urinary bladder did not show a stone or any other abnormality. He needed intravenous antibiotics. In the King’s Circle/Matunga area, in Mumbai, there are facilities for homecare where physicians attend to the sick at home and provide care with nurses and ward-boys. He was keen on getting treated at home.

Unfortunately, a family physician they knew got them admitted to a local hospital, telling him that if he didn’t do so, things could go really badly wrong. Once that fear of “things can go wrong” was put into him, he had no choice but to agree. His family and he regretted this decision from the moment he was admitted, since the only reason for admission was the administration of intravenous antibiotics, which could easily have been done at home in his own comfortable environment.

It took two days for my friend to finally get back home, after taking discharge against medical advice, and being warned multiple times that the doctors would not be responsible if anything went wrong. Seriously?

The practice of medicine is fundamentally that of healing and if that is not possible, reducing suffering. Why does that have to be done in a hospital?

Hospitals are a modern phenomenon, paralleling the rise of modern medicine. They began as places where castaways and vagrants and those who could not be managed at home were brought to and left to die, often forgotten by their friends and family. Over a period of time, they became places where doctors congregated, medical students were taught and where people came to be rid of their diseases.

In the last 50-75 years, for a variety of reasons, a large swathe of the population has come to believe that when they are sick, the only place to go to is a hospital.  Hospitals also serve the reductionist approach of modern medicine where one size fits all…“sick means hospital”. As healthcare and hospitals have become more and more profit making ventures, the mantra “sick means hospital” has become even more loud, further buoyed by the fact that insurance and Government reimbursement in most instances needs hospital admission.

Hospitals are important. There are many surgeries and procedures that are just not feasible outside a hospital setting, where doctors from different specialities are all available within the premises to manage complicated situations.

Here is a short list.

1. Acute injury that is so serious that you need to be in a hospital for surgery or stabilization.
2. Acute stroke - brain attack.
3. Acute heart attack.
4. Acute abdominal conditions such as appendicitis, perforation of the intestines, etc.
5. For major surgeries that cannot be done in daycare.
6. Other acute conditions that just cannot be managed at home.
7. Complicated pregnancies

The other reasons for hospital admission are social and economic.

1. Insurance. If insurance only pays if spend time in a hospital, then you don’t have a choice.
2. Lack of support at home. If you don’t have anyone to open the door to let your homecare people in, for example, then perhaps it is best to be in a hospital.
3. Money. If you don’t have the means and resources, then a hospital perhaps is the best option.

But apart from these issues, there is no other reason to get admitted to a hospital, especially since hospitals come with their own set of problems.

1. Cost. Hospitals are just far more expensive than any form of equivalent homecare.
2. Infections. You can pick up all kinds of infections in hospitals that can then be far more difficult to treat than community acquired infections. Low and middle income countries like India have far higher rates of hospital acquired infections than the Western countries, even in the so-called “best” hospitals [1].
3. Lack of privacy and comfort and depersonalization. Nurses and wardboys and doctors come at their own time, disturbing your sleep and rest. You are part of a larger ecosystem, where you have to fit in and behave in a very specific manner so that everyone else can function efficiently. Everything happens at times that are convenient to the staff, not yours.
4. Noise. People and machines are constantly creating a din, making it difficult to rest and sleep, both of which are needed to heal.
5. Mistakes and iatrogenic problems. There are so many things going on that it is not difficult for mistakes to occur. Apart from hospital acquired infections, injection of wrong drugs, inappropriate treatment, overlapping medications that interact adversely, different doctors not communicating with each other…all lead to problems that can be worse than the original reason for getting admitted.

Unfortunately, there are no studies in India comparing homecare to hospital care. There are however quite a few from the Western countries that show that not only is homecare cheaper, it is often better and even in many acute settings, equally good [2,3].

In short, homecare works and in a country like India, where the legal and manpower complexities of medical management are far less than in the Western countries, and the supporting social structure far more accepting, treatment at home should be the first option…always.

The pendulum is also thankfully, slowly but surely, swinging back to personalized medicine, which was how medicine was practiced for centuries, which includes personalized care in a home environment…though it will take a few more years to change doctor and patient mindsets to start saying…"sick means care at home". A home environment is always better than a hospital environment.

A hospital should be a last resort, a place to go to only when there is no other option.

What does this mean for you and I? Always question the need to go to a hospital. If the situation can be managed at home, it should be. Ask your doctor if that is possible or not and keep asking until you have a definite answer…not just things like…"you never know what can go wrong…". Start making a list of doctors in your neighborhood who can provide homecare along with a list of nurses and ward-boys who can provide round-the-clock service.

The bottomline is…unless you have absolutely no choice, opt for homecare and avoid hospitals at all costs.

Footnotes

1. Mathur P et al. Lancet Glob Health. 2022 Sep;10(9):e1317-e1325.

2. Levine DM et al. Ann Intern Med. 2020 Jan 21;172(2):77-85.

3. Levine DM et al. JAMA Netw Open. 2022 Aug 1;5(8):e2229067