A story in Monday's Washington Post incorrectly said that patients at D.C. General Hospital may have to wait weeks before seeing a dermatologist from another hospital. D.C. General does have a full-time dermatologist, who runs a dermatology clinic and is consulted on hospitalized patients. He said he sees any patient who needs a dermatologist within 24 hours of being asked to examine the patient.
It was shortly before 10 on an otherwise routine evening last Dec. 27, and a young doctor on duty at D.C. General Hospital was about to make a decision that was unprecedented in his career and that would haunt him for months.
Frank Flook, a Capitol Hill resident, had been shot in the head by an intruder at his home, and the ambulance had rushed him to D.C. General.
The doctor who examined him knew at once that if there was any hope of saving Flook, someone must open his skull to remove blood that might be pressing in his brain.
But D.C. General has no neurosurgeon. Since 1976, when the hospital's last one quit and the training program in neurosurgery closed, it has relied on private doctors who volunteer to be on call for emergencies. Unlike private hospitals where such specialists could lose their staff privileges, D.C. General has no recourse if the doctors are unavailable.
That night, the neurosurgeon who was supposed to be on call wasn't home, and no one knew where to reach him.
So with the help of another surgeon in training, the desperate doctor cut a hole through Flook's skull, an operation he had never done before. And since the emergency room had no tray with the tools he needed, he did the best he could, twisting a drill with his hand.
Flook died, and the surgeon -- who asked that his name not be used -- said he learned from autopsy results that his last-ditch effort had been in vain, that Flook had already suffered fatal brain damage. Nonetheless, several months later, the memory of that awful night is still vivid.
One tragic night does not a hospital's record make. In fact, most patients interviewed at D.C. General say they are satisfied with the care they receive. And doctors and nurses who have been there since the 1970s say it has improved dramatically since it lost its accreditation and a court battle over its deficiencies in the middle of that decade.
But gaps in services, staff shortages and an often-suffocating bureaucracy still cause delays in treating patients, and in many cases result in a level of care that is less than desirable.
If a patient needs to see a specialist -- a dermatologist, perhaps, or a plastic surgeon -- he may have to wait weeks before that doctor shows up from another hospital. If he needs a CAT scan -- a specialized X-ray of the head -- he may have to wait even more days or weeks before he is taken to a hospital that has that equipment.
Because the hospital is short of nurses, and they have so many elderly patients to take care of, a patient may wait a long time to have his temperature taken or a bandage changed -- or he may be forced to do it himself. t
He may get his care from a foreign doctor, across a language barrier. And the doctors-in-training who take care of him are likely to be supervised less closely than they would be at other teaching hospitals in the District, according to residents who have worked elsewhere.
There are shortages of basic items. A resident said that on his first day at the hospital, he went to get a beeper so he could be paged for emergencies, only to find the engineering department did not have enough of the devices for all the residents working that night.
During a recent operation, he said, the operating room lacked the proper chest and stomach tubes for the patient.
Despite a large number of patients with alcohol and drug addictions, there is no full-time alcohol and drug counselor, and no detoxification program.
Telephones are only now being installed for the first time in patients' rooms, and there are still no closets. When a patient is admitted, his clothes are locked up on the main floor -- and if he is discharged after hours, he often has to stay an extra day because his clothes are not available. h
A resident once had to call a high-level administrator in order to get his patient's clothes so he could leave.
Most patients interviewed in D.C. General's wards had few complaints about the care. Many said they had gone to the hospital all their lives, had received free treatments, and felt the service had been good. But most also said they asked no questions and made few demands. Only one or two knew their doctor's name.
Linwood McCowan, a former mover who has been disabled by a heart condition for 10 years, had been in the hospital for 23 days as of one recent visit. He spent five days in the coronary-care unit, then was transferred to a regular room. But the next day, after taking a cardiogram, doctors abruptly ordered McCowan wheeled back to the coronary-care unit. No one told him why. He said he still did not know whether he had had a heart attack.
Later, doctors tried to explain McCowan's illness to him, but he still wasn't sure what had happened.
Virginia Free, a silver-haired woman who works as a domestic in Maryland, stroked the sheet, trying to recall her doctor's name, "Doctor, doctor. . . . Doctor Darn. I think. There's very few questions I ask him."
Patients like McCowan and Free may not understand all the reason for their treatment, but they still cooperate because they want to get better. But for some patients at D.C. General, Delays in treatment and gaps in communication can impair care. Out of frustration and fear, these patients refuse needed tests or sign out against medical advice.
Dr. Thomas Cardella, who teaches residents in Georgetown University's medical program at D.C. General, told of one patient dangerously ill with meningitis, who refused to have a spinal tap because a resident did not explain the procedure well.
A reporter heard another patient, a man with a serious bone infection requiring weeks of intravenous antibiotics, mutter, "I'll leave if I can't find somebody I can talk to," after a foreign resident repeatedly misunderstood or ignored his questions. By the end of the week, the man had left the hospital.
A third man, a 60-year-old inmate from Lorton prison, was admitted to D.C. General's jail ward after a surgicial resident diagnosed a probable cancer at the root of his tongue. He had preliminary tests, but then spent days waiting for throat specialists to do more definitive tests that would determine whether he needed surgery.
In the meantime, according to Dr. Eid Mustafa, Howard University's chief surgical resident at the hospital, other prisoners in the ward started talking the man out of surgery. "He told the nurses. "These guys are going to experiment on me,'" Mustafa said.
At last, the man insisted on being sent back to Lorton without surgery. "We couldn't keep him any more," Mustafa said sadly.
As at other hospitals affiliated with medical schools, patients at D.C. General receive much of their day-to-day care from residents -- medical school graduates who still must complete at least three more years of training before they go into practice. Georgetown and Howard medical schools both maintain training programs at the hospital in medicine and surgery, as well as other specialties.
But residents and staff doctors at the hospital say that doctors-in-training are given far more responsibility for patients at D.C. General than at other hospitals in the Washington area. No patient at D.C. General has a private doctor while there -- so, more than at other hospitals, the patients' welfare depends on the training and the zeal of inexperienced residents.
Dr. Etienne Massac, a surgical resident in Howard's program at D.C. General, said he has performed three pancreas operations there -- complicated surgery that at other hospitals is usually given to more experienced surgeons. Massac said he is in only his third of five years of surgical training.
Although actual operations are supervised by staff surgeons, residents in both the Howard and Georgetown programs make many important decisions about treatment on their own.
"You're scared as hell that you're going to hurt somebody," said a resident in Georgetown's surgical program at the hospital.
Dr. Louis Diamond, acting head of the Georgetown medical program, said the amount of responsibility given residents would be unheard of at a private hospital, where private doctors admit their own patients.
"That's the way it has evolved [here] over generations," he said. "What you're dealing with is a long-standing concept that it's legitimate to deliver hospital care in a city hospital in a different way."
Dr. Stanford Roman, the medical director, also is concerned about lack of supervision of residents. He blamed not only tradition but also the hospital's civil service system, which he said encouraged a clock-punching attitude among staff doctors.
Doctors at D.C. General are federal civil servants, paid for 40 hours of work a week. They are not compensated according to how many patients they treat, nor are they paid overtime. Those who work late or come in at night to supervise residents do so on their own time.
Roman said the most a doctor can earn at D.C. General is about $50,000 a year -- far below what a private specialist, particularly a surgeon, usually makes. This makes it hard for D.C. General to recruit full-time specialists -- such as a neurosurgeon, as the Frank Flook case demonstrated -- and encourages doctors to open legal but time-consuming private practices on the outside.
Outside private practices, Roman said, are common among D.C. General's surgeons, obstetricians and radiologists. The effect on patient care is difficult to assess. Cecil O'Neal, director of management services, said he sees staff doctors leave the hospital for hours during weekdays when they are supposed to be on duty. Roman said he is less concerned with logging their hours than with making sure they are supervising residents. And hesaid that although some staff doctors are dedicated others shrik responsibility for their D.C. General patients.
D.C. General accepts no patients referred by private doctors. This policy was set in the days when the hospital was maintained exclusively for the care of patients without health insurance, and it has never been changed. Staff doctors, therefore, must admit their private patients to other hospitals in the area, and this creates potential conflicts between their duty to D.C. General patients and their duty to private patients.
The residents who carry the medical burdens at D.C. General vary greatly in their training, skill and efficiency. The differences among them were highlighted by an in-hospital study last year of how patients fared under the care of various groups of trainees.
The study revealed what Roman called disturbing variations in how long a patient with a medical or surgical problem remained in the hospital. And the variations depended largely on which group of residents cared for the patient.
A patient with a medical problem (say, pneumonia) treated by Georgetown medical residents averaged five more days in the hospital than a patient with a similar problem treated by Howard medical residents.
On the other hand, a surgical patient (for example, one with appendicitis) stayed 3 1/2 days longer when treated by Howard surgical residents than by Georgetown residents.
Roman said the variation partly reflected differences in the quality of residents in the training programs, and partly different attitudes of the staff doctors supervising the residents. Howard surgical patients, Roman believes, may remain in the hospital longer because the chief of the service, Dr. Lewis Kurtz, prefers to admit them several days before surgery to perform needed tests.
The study was most damning to the Georgetown medical program at D.C. General, whose patients averaged the longest stay in the hospital -- 17.5 days. That program is run separately from the one at Georgetown University Hospital, and the residents in the D.C. General-based program spend almost no time during their three-year training at any other hospital. Because of D.C. General's troubles in recent years, the program has had difficulty attracting any applicants from American medical schools, so it is filled almost exclusively by foreign residents.
Some are excellent. But Cardella, one of the residents' teachers, said that gaps in the training and language proficiency of others had hurt patient care and demoralized faculty members.
Dr. M. K. Jalota, a second-year Georgetown resident from India who worked at a private hospital before coming to D.C. General, said the residents would do better if they had more support from staff doctors, nurses and technicians. He said they quickly become frustrated by caring for many elderly, sick patients without much teaching, and by being asked to do "scut" -- paperwork and blood-drawing -- that in other hospitals would be taken care of by technicians.
"It's caring we are lacking a lot," Jalota said. "This place depresses me.
If I were sick, I wouldn't like to be admitted to this place."
When patients at D.C. General complain about lack of caring, they focus most often on the nursing staff. D.C. General is still short of nurses, although it has had some success in recruiting: since 1975, the number of patients per registered nurse has fallen 75 percent.
But this statistic does not reflect the day-to-day situation on all wards and on all shifts. Residents said that at night on some wards there are sometimes two nurses for 30 patients. And the strain of caring for many elderly, immobile patients, as well as "burnout" from too many years at the hospital, contribute to low morale and a high absentee rate among nurses at D.C. General.
"You got nurses in here, they say, 'We've just got to do a job and that's it," said Brenda Ivy, who was interviewed three days after having her third child at D.C. General. "They're not going to put any of their friendship or personality into it."
Other patients said they had encountered both good and bad nurses.
Rachel Smith, a supervisory nurse who has worked at D.C. General on and off for 14 years, said that D.C. General's nurses are providing better care than those at other local hospitals.
"Nurses here work very, very hard," she said.
Other employes disagreed.
"I think the staff here is for the most part horrible," said one employe in the obstetrics department. "It pays pretty well, and the benefits are pretty good. People stay for years. They get bored, they don't care, they don't follow through with things. It's an ill-pervasive attitude."
A number of doctors and residents echoed that assessment, saying that factors such as inadequate supervision by head nurses, too much job security and the lack of a team atmophere were resulting in mediocre care.
"Patients are harder here . . . But the problem isn't shotage of linens," Cardella said. "They're just not in there doing all the time."
Nonetheless, improvements are being noted. Nurses who have worked at the hospital for years said that working conditions are better, nurses no longer are required to empty trash cans or count pills, and can therefore spend more time with patients.
Olivette Gill, director of nursing, said the hospital is trying to recruit new blood and increase educational opportunities for nurses on the job. But she said that recruitment efforts have been hurt by the citywide nursing shortage and the presence of so many elderly, bedridden patients at D.C. General.
Gill blamed the high absentee rate -- as high as 9 percent on some floors -- partly on back injuries the nurses suffered from lifting elderly patients from their beds. The hospital's civil service system allows up to 45 days' compensation for each such injury.
Both Roman and Gill said the civil service system hampers attempts to improve D.C. Gneral because it is overprotective of employes. Roman described three occasions when employes assaulted patients or coworkers; so far, one has been disciplined, and with only a temporary suspension.
He said it took weeks of documentation by a special committee to amass enough evidence to fire an emergency room doctor who flagrantly neglected patients.
"If you are . . . providing a highly risky service, you cannot afford to keep anybody on for six or eight months while you go through the firing process," Roman said.
At every level of the hospital, things move slowly, with little sense of urgency, hampered by bureaucracy and tight funds.
Doctors said vital equipment -- such as machines that measure oxygen in the blood of patients on respirators, or monitor babies before they are born -- breaks down frequently because it is poorly maintained by the biomedical engineering department. Equipment may also be unrepaired for weeks, eventually require thousands of dollars in repairs, and in the end, the hospital often is forced to buy new equipment anyway.
But purchases of new equipment are often delayed for lack of funds. Dr. Robert F. Donahoe, former chief of the pulmonary service, said he resigned last year mainly because he could not persuade administrators to buy equipment he thought essential to good patient care.
Donahoe's successor, Dr. Michael Boyars, said he had had the same problem. He was forced to rent two respirators out of an emergency fund to get through the winter of 1978-79, spending as much as it would have cost to buy one. (The hospital has since bought four new respirators.)
Administrators are gradually solving a number of the hospital's most obvious problems -- such as hiring more nurses, improving the training of intensive-care unit staff, adding more fire exits, overhauling the medical records department.
But some doctors in the emergency room and in the wards contend that the administrators are insensitive to the more subtle troubles the doctors face because the administrators are insulated from the daily work of caring for patients.
"What they have in mind is keeping us out of the bad press, keeping us accredited," said Boyars. "Why don't they just work at running a good hospital?"
Johnson, the executive director, and Roman, the medical director, as well as others at D.C. General, say they ae doing the best they can with what they've got.
"Sometimes I'm exhausted at the end of the day and I say, 'I'm never going back there,'" said Rachel Smith. "But by 7 the next morning, I'm right back here ready to roll again."