What now?
After completing my interviews, I felt stuck. I had an abundance of information (nearly four hours' worth of recorded interview material) and many different directions in which I could steer the remainder of my project.
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Once I gathered my thoughts, I had a lot of lingering questions that seemed to follow a couple of themes.
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Hospital organizational structure:
Does it really make sense that the hierarchy of a hospital and that of a corporate office have so much in common? What are some ways the hierarchy within a hospital can change that might improve patient care? What would it take to flatten the hospital hierarchy?
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Supply and Demand of Doctors:
I noticed that the biggest reason my interviewees cited for there being a lack of communication between doctors and other hospital workers like nurses was that doctors are pressed for time. Naturally, this leads to the question: why don't we have more doctors? What are the barriers to becoming a doctor?
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Below you can see what I found in my attempt to investigate these questions and what others are saying about these same topics.
Flatten the Hierarchy
You may recall that during my interview with Laran, I was able to draw a clear parallel between the organizational structure of her workplace and my future workplace, IBM. But by the end of our conversation, I began to wonder if it made sense that her hospital unit was run in the same way a corporate office.
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Thus, I began to search for if anyone had studied how this organizational structure impacts patient care and if this hierarchical structure was a global standard. Almost immediately, I stumbled upon a paper titled To what extent does hierarchical leadership affect health care outcomes? Perfect, exactly what I was looking for!
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In this paper, Dr. Nilesh Fernandopulle, a gastroenterologist, argues for the flattening of hierarchies in healthcare settings. Fernandopulle claims, hierarchical leadership in health care "can have unintended negative consequences in a pressurized environment." Furthermore, he says, "...flat hierarchies are gaining popularity, as they afford the flexibility and equality that is vital in a caring environment, where no one should be afraid to raise concerns and voice their opinions."
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Fernandopulle follows a similar journey as I did in my investigation pointing out that hierarchical leadership in health care is "not uncommon in large-scale organizations, including in the corporate world" and noting that "in a field that is concerned with the health and wellbeing of its 'customers,' the patients, it can seem ironic that such decisions are taken by figures that are often away from the frontline."
"We Need more Doctors"
Another way to think about flattening out the hospital hierarchy is to work towards evening out the numbers of who is currently at the bottom of the hierarchy and who is at the top. Right now, there are a lot more nurses and nurse aides in the U.S. than there are doctors. The answer to this sounds straightforward, we need more doctors. Though the shortage of doctors (and more recently nurses) is something I've heard about my whole life, I realized I didn't know much about why this was the case.
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Some quick research led me to the following factors about why people say there is a shortage of physicians in the U.S.:
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It takes a long time to become a doctor.
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Becoming a fully-licensed physician requires between 10-14 years of education/residency
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There are large financial barriers to becoming a doctor.
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Most medical students graduate with an average of $200,000-$215,000 of educational debt
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For context, the average medical school debt in the U.S. in 1978 was $13,500 ($60,580 when adjusted for inflation)
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"If debt continues to outpace the cost of attendance at the present rate, the average medical student debt will exceed $300,000 by 2024"
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Residency funding has been restricted by the government.​
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In an article I read in The Atlantic, there was a snippet of an interview the journalist, Derek Thompson, completed with Robert Orr, a policy analyst who studies healthcare policy at the Niskanen Center. This is what Orr had to say about solving the shortage of doctors in the U.S., "The first thing I would do is to expand the residency system so that more doctors can become residents after med school...The medical schools say they can't easily expand, because there aren't enough residency spots for their graduates to fill. But there aren't enough residency slots because Washington has purposefully limited federal residency financing."​
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There was no good explanation for why the government had limited funding for residency programs in The Atlantic article. But, further research revealed to me that this funding is often targeted when there is a focus on decreasing the federal budget deficit. For the full story, check out this amazing journal article: here. ​
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My Thoughts
Going into this project, I knew there were be no easy answers or simple conclusions to any of the questions I have. Really, the goal of this project was for me to learn more about the healthcare system. This site was a space to record some of my findings, as well as to share some of the sentiments I have heard over and over from the healthcare providers in my life. ​
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Though there are no easy answers and my understanding of healthcare is still relatively limited, here's what I think at the conclusion of my investigation. Fun thought experiment: If I were tasked with modifying the healthcare system, had unlimited money and resources, and unanimous support from the federal and state governments here's what I would try first:
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Experiment with the organizational structure in hospitals
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What would happen if the hierarchy was flattened and there was more communication between doctors and nurses?​
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Make it easier to become a doctor
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Instead of making people go through four years of undergraduate school and four years of medical school, what would happen if we had a combined 6-year program?​
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Increase government funding in medical schools and residency programs. This will also make it possible for more medical schools to be built.
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Increase support for PAs and NPs
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In response to the doctor shortage, there has already been an increase in Physician Assistants and Nurse practitioners to fill in the gap. Increased support and awareness of these career options can continue to help ease the burden of the doctor shortage.
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I have one more confession to make. I would not call this project entirely complete. Part of that is due to the fact that at the tail end of this semester, I myself had a close encounter with the hospital. An ultimate frisbee injury (which turned out to be a torn ACL and meniscus) landed me in the ER for 7 hours one night. In between being bounced around a couple of different referrals and my impending graduation, I did not have as much time or mental space to continue working on the conclusion of my project as I had initially anticipated.
Therefore, this project (as is any piece of writing) is still a work in progress. I have no doubt that I will keep learning about ways in which the organizational structure can be changed, and ways to improve the healthcare system. And, finally, I know the stories I have yet to hear from the healthcare providers in my life will inspire even more future avenues of research.