I heard today from a physician whose hospital is on the verge of collapse, and an ICU nurse at a different hospital who is likely struggling with COVID, but being instructed not to get tested so as not to miss work. Two fairly typical stories from the edge of the healthcare abyss, but entirely predictable and a long time in the making. “Hospitals are understaffed” is now common knowledge, not a news story. The question is why. There’s no way to answer that question in the absence of information about staffing and budget decisions, themselves connected to facts about medical billing and collecting. This article is a case in point.
Yes, hospitals are understaffed. But that’s a matter of economics, and economics is a matter of math. What’s the math here? How much money do hospitals have at their disposal to make new hires? What does their accounts receivable look like, generally? How much would it cost to hire more, and at what wages? Obvious questions in search of answers. To fail to report on the spreadsheet-level details of these things, almost two years into the pandemic, is to keep the public in a state of perpetual ignorance–or else in a state of slogan-driven outrage. But from reading the mainstream press, I sometimes wonder whether that’s what journalists want. Math, as Jack Black famously put it, is a wonderful thing. Why do we read so little of it when and where it counts?
Six months ago, before I lost my car to a flash flood in Hurricane Ida (yes, I was in the car when it happened), I was engaged in a concerted attempt to find a part-time hospital job to supplement my income. I was turned down wherever I applied, even in this labor-scarce environment, even with hospital experience, even at a hospital that had promised me a job and had scheduled me for work. Staffing, I was told, was perfectly “adequate.” I knew it wasn’t. Front line staff insisted to me that it wasn’t. But managers know better, I guess: better to skimp a bit on hiring than do better than “adequate.”
I sort of gave up on my job search after I lost my car–much harder to get anywhere now–but it’s not as though these understaffed hospitals are calling me back to ask me to work. On the contrary, HR regularly ignores my calls.
It’s hard to feel sorry for these hospitals once you come to see from the inside how they’re run. Of course, the way they’re run is so inscrutable and opaque that it practically invites ascriptions of bad motivations even if you haven’t seen them from the inside. In this, as in so many things, the pandemic has exposed the weaknesses and defects of a hubristic society addicted to self-congratulation, but incapable of getting the basics right. What we need is a journalism that shows us the mechanics, and counts the costs.
Neither the Left nor the Right are really focused on the right things here. The Right equates better working conditions with “socialism.” The Left equates fiscal realism with the reign of Ebenezer Scrooge. Reality seems to fall between the cracks of their fixations without ever satisfying them, and without ever going away. But winter is here with its grim, countable realities–realities we should have learned to handle back on Sesame Street, but, alas, didn’t.
Policy of Truth 
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Yes, this is perhaps more expressive of a quantitative form of OCD than I had intended. And while I applaud the Count’s mathematical enthusiasm, I think we will probably get only limited insight into staffing shortages in health care if we count to four and leave matters there. That said, I sort of feel as though this song captures the average day of work in hospital revenue cycle management. Add a few references to Excel, Patient Financial Services, and denial management, and he’s basically nailed it. By the end of the day, I look and sound a lot like the Count.
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I’m embarrassed to leave the comparison in that crudely qualitative form, but I don’t have a good quantitative metric for capturing my similarity to the Count. There’s only so much counting I can do at 4:30 in the morning. Can’t wait to get up in 90 minutes, ride the train in to Metropark, and spend another eight hour day working myself up into a frenzy of counting.
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“I think we will probably get only limited insight into staffing shortages in health care if we count to four and leave matters there.”
Well, you’ve heard of the “crow epistemology”? This is something similar, the “bat epistemology.”
Yes, bats can only count up to four. That’s why Batman always has to rely on the Bat-computer.
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“But wait,” you ask, “didn’t Batman design the Bat-computer?”
Yes he did. Four circuits at a time.
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I came here to read about Carol, a college classmate whom I sadly never met but with whom I shared several mutual friends. I noticed this post and wanted to provide another perspective. I know nothing about hospital staffing, but I do know about outpatient medical staffing, at least second-hand. A close relative is the chief of an outpatient internal medicine practice in the Boston suburbs. It routinely takes the practice many months to receive any applications for job postings for physicians, PAs, and nurse practitioners. There is also a dearth of nurses and medical assistants applying for jobs, though not as bad as for clinicians. I don’t doubt that economics plays a significant role in hospital staffing shortages, but at least in the outpatient realm, the major driver is not economic decisions by practice administrators but a serious dearth of qualified people applying for jobs. This was already a problem before covid, but has become much worse in the last two years.
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The same economics that keeps people from applying also discourages others from pursuing the qualifications.
sean s.
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@ Sean
That may be part of the equation, as well.
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@Dmitry Gorenburg
Thanks for writing, and thanks also for reading my post about Carol.
You may well be right about staffing in non-hospital contexts, at least for large practices. My own experiences are relatively limited and idiosyncratic: I’ve worked in small surgical practices, and worked for environmental services in hospital settings. I taught philosophy to nursing students for about thirteen years, and now work in hospital revenue cycle management. My company has a few non-hospital clients, but I don’t know enough about the staffing side of their operations to know how the numbers play out. In short, I know some parts of the health care system, but other parts not at all.
It certainly is true that the pipeline from matriculation to credential is a long one for virtually all medical practitioners, which may well affect the supply of job applicants. The nursing school at my former university was proud of the fact that it had an 80% rejection rate–and justifiably so, I suppose. Lots of students wanted to become nurses…until they encountered Anatomy & Physiology.
I think my observations hold good for nursing and for ancillary staff in hospitals (EVS, technicians, sterile processing, etc.) Nurses famously complain about staffing ratios, and I think they’re often right to do so. This may be my narrow guild mentality speaking, but I also think that understaffing (and undertraining) of environmental services is a much bigger problem than is generally acknowledged. Hospital-acquired infections are a serious clinical (not merely aesthetic) liability in virtually every hospital in the country (regardless of the “grades” such hospitals earn from various accreditation bodies for their ostensible successes). Environmental services and sterile processing are the last lines of defense against hospital-acquired infections. But there’s an enormous reluctance to pay them properly, to hire them in adequate numbers, and to invest in proper training and equipment for them. The topic has yet to find its Upton Sinclair, but it desperately needs one. Those failures are almost entirely about the need to save money.
As a general point, however, I think journalists need to step up their game when it comes to integrating political and financial issues. You can’t really understand how an institution works–be it a hospital or a university–unless you understand the relationship between budgets and spending. But there’s enormous reluctance to discuss any of that in specifically numerical detail. I understand that some of the relevant information may be proprietary, but my point is that there is little understanding of the fact that absent that information, it’s hard to figure out what’s going on in a given hospital or hospital system, much less in “the health care system” as a whole. So health care remains something of a mystery to most people, the subject of slogans, but little genuine understanding. I say that as someone seeking the relevant sort of understanding, not as someone who claims to have it.
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