Chapter 3: The Moral Climate of Health Care

 Section 4. The Role of PATIENT

Every social institution assigns roles within them to the principle groups. In education there are educators and those receiving education. The providers are called teachers and the recipients are called students.

There is a problem when people come to regard the human beings occupying the social role within an institution as little more than what is represented by that role. Students do not cease being men and women , brothers and sisters, mothers and fathers, friends, coworkers and a lot more when they enter a building to receive educational instruction. Neither do human beings cease being human beings when they enter a doctor's office, a hospital or a medical laboratory.

Some, perhaps too many ( way too many), health care providers appear to focus only and specifically on the social role of "patient" when they look at and interact with the recipient of health care.

Economy and efficiency appear to support a viewing of the human being as a unit for treatment and billing.

For the hospital the recipient of health care is a billing unit and for the physicians and nurses and most others the recipient is called a "patient".

As a "patient" the human being is now removed from being seen and treated as human with all the civility and respect that a human deserves and should expect.

Once labeled as a "patient" the person is lost and the billing unit or treatment entity is now to be processed within the health care institution.

This common labeling and dismissing of the uniqueness and humanness of the individual leads to a number of problems for the individual. Some of them are coming to be realized by the health care institution but not because there is the desire to become more humane and to offer service and care to human beings and not just billing unit or patients but because the labeling reinforces a callousness that leads to mistakes and that leads to malpractice suits and adverse judgments and that costs money. Take one example. In one hospital facing an ever increasing deductible amount in its malpractice insurance coverage a hospital review committee determined that some errors could be avoided by talking greater care to properly identify who was to receive what treatment. An order was issued that no one was to render any service based on an instruction unless the person receiving care was referred to be name, by the full name. Hence there were to be no more orders to :

1. draw blood from B- meaning the person in cubicle or bed B

2. give 15cc of cumidin to the patient in 233-meaning the person in room 233

At first the staff responded that the order would be too difficult to follow. However, it was observed. The recipients of care are often made to wear some identification device upon their body. This is there to insure they are properly identified. Those rendering care should make an effort to insure that they recognize by full name the person who is to be given any service.

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CASE:

In a NYC hospital, a very fine hospital, a brain surgeon performed an operation on the wrong person. The recipient of the wrong operation was a woman from India. the whole incident might have been given little attention were it not for the fact that the woman was the mother of one of India 's leading celebrities, a movie star. Now the media was given the story. The incident was examined. It turned out that a nurse thought that the name on the woman's wrist was not the same name as one the documents being read by the surgeon. the surgeon pressed ion with the preparation and performed the surgery. He dismissed that alarm of the nurse by stating that " Those Indian names are all alike"

The woman received the wrong operation and on the wrong side of her brain. Her daughter removed her from that hospital and had surgery performed at another NYC hospital.

Now the key issue here was that the surgeon was only there to perform the surgery and had no knowledge of whom he was to operate upon nor did he seem to care. An operation was scheduled on a patient in operating room C at 9:30am and he went in a did that procedure.

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CASE:

See the movie , THE DOCTOR( with William Hurt), for another example of a failure to even note the name of the person. " patient in room 525" is not good enough particularly when there is more than one person to a room. This movie illustrates a number of very good points for Biomedical Ethics. A number of procedures were carried out on a doctor who himself was callous, indifferent, insulting and violate of patient's rights. He had a radical change in view once he received the treatment and attitude that he once perpetrated upon others.

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When a person is labeled as a "patient" they are expected to act in certain ways. There are expected behaviors. They are assigned places to sit or stand and "clothes" to wear and times and materials to eat. "patient" are to follow the orders they receive. They are cast into the role of recipient and so they are not expected to give orders or to take the initiative in any respect. While nurses who are "patient" advocates are supposed to be supportive of the "patient" asking questions about diagnosis and prognosis of their physicians, physicians are less tolerant of the questioning and the exploring of alternative treatments by those whom they treat and whose lives are involved.

A good number of the procedures and rules that "patients" are expected to observe and follow are for the benefit of the health care providers and the efficiency and economy of the operation. The wearing of a garment that is drab and difficult to secure and exposing is for the efficiency of the examiners when they get around to the actual examination. Woman are subjected to additional indignities and discomfort in their examinations by physicians using equipment designed by male physicians for their convenience. Women are regularly made to lie on their backs and place their legs up and feet into holding device so that the physician can sit and examine them. The examination table could have been a raised chair and the physician could sit lower or lie down and examine the woman while she was sitting legs apart but that is not the way it is done.

When an automobile or truck is taken to a shop for an oil change, the laborers (mechanics) do not say " pick it up and flip it over for us" they raise the car and work below it . So too could the gynecological examination have been done differently were it the decision of and for the sake of the women and not the physicians.

NOT NECESSARY!

Many, perhaps most, of the rules and procedures are not necessary for the health and well being of the persons receiving care. They exist for the economy, efficiency and protection of the health care providers. Take for example a simple policy: a woman has a baby in the hospital.

When it come time for her to leave, no matter what her condition is, she will be told to sit in a wheeled chair and is taken to the exit door of the hospital. She may then rise and walk on or get into a vehicle. The wheeled chair is to protect the hospital from a lawsuit should the woman fall on the premises of the hospital. Preventing her from falling is in her interest as well as the hospital but so are many other things that the hospital does not do. The chair is there and its use is required for the hospital's benefit not the woman's!

If there is any doubt about the necessity of these rules and procedures simply consider what would be the case if a Bill Gates or Donald Trump were to enter the hospital for care. Would he be called the "pt in 233"? Would people enter his room without permission? Would he be subject to the many humiliations the average person must endure when entering into such an institution in need of help?

If such people as are as rich as Gates and Trump receive a different type of care why would we all not be entitled to that care as human beings. If money makes the difference, should it? Is the difference between being treated with the respect a human beings deserves and being treated as a billing unit money?

Case: "Was that the bed or the window?” by Alison Prunty (NCC, 2009)

The following is a true story that occurred on Long Island, NY  in a local hospital. 

 In Hospitals all across the US people are not identified by name, but by room number. “Mrs. Smith” becomes “the lady in 21.” or “the window patient.” This is dangerous for a number of reasons. Read below and see for yourself.

 

            “Laura” was a nurse on the neuromedicine unit at a local hospital. She had been working there for 2 years and enjoyed her job. She became quite fond of a 60 year old man with MS (multiple sclerosis) named “Joe Jamison.” MS is a debilitating disease that causes loss of muscle tone and control. Joe was a “frequent flyer” on her unit, coming in for IV medication during exacerbations of his MS. He had no family or friends and liked to talk with the nurse’s and staff during his sometimes lengthy hospital stays. This particular time he was in room 409B. Laura greeted him as she came on shift and saw that he had a new roommate. She received report from the previous nurse and learned that the new patient was “Edwin Jones”, a 58 year old male with cancer. He had a craniotomy (neurosurgery) 3 days ago to remove a malignant tumor in his brain and was awaiting a transfer to the 8th floor where he would begin receiving chemotherapy. Chemotherapy is only administered in certain areas of the hospital by trained staff. No one on Laura’s unit was certified; henceforth Edwin’s transfer was definite. During her shift a resident she had not seen before stopped by her med cart and tapped her on the shoulder. “Are you the nurse for 409B?” “Yes, that’s Mr. Jamison” replied Laura. “How do you find his strength on the left side?” asked the resident. “Mr. Jamison?” questioned Laura. She thought this was an odd question because Mr. Jamison had MS and was obviously weak on his left side. “Yeah,” replied the resident. “Well, he is very weak in all four extremities, although he is able to feed himself using his left hand and arm.” “How about the drain? How much has it put out today?” asked the resident.  “The drain? Mr. Jamison doesn’t have a drain. He’s here for MS exacerbation. Do you mean Mr. Jones in 409A?” “Yeah, the craniotomy guy.” stated the resident.  “Mr. Jones’s drain has put out 20cc since 7am.” stated Laura. “Alright, I’ll be up here later on to write some new orders for him,” the Resident stated. “Okay,” replied Laura. As it became time for Laura to leave, she checked the charts once more for new orders. Nothing new noted for anyone she was caring for. She gave report to the night nurse and left for the day. She was off the next day. Upon her return at 7am on the second day she noticed that Joe’s bed was empty. She asked the night nurse, “What happened to Joe?” “Oh…it was terrible. Last night around 11:30pm he just coded out of nowhere. We got a heart beat though and he went to the MICU.” stated the night nurse. “Does anyone know if he made it through the rest of the night?” asked Laura. “I’m not sure.” stated the night nurse. On her break, Laura went down to the MICU and inquired about Joe. She was told by the MICU nurse that Joe had coded again around 1:30am and this time he did not make it. Laura felt sad. She liked Joe and wondered what could have happened. He seemed fine when she left 2 days ago. The MICU nurse told her that upon reviewing his chart it was discovered that in addition to his IV steroid regimen for MS, he had received a dose of IV chemo yesterday in the afternoon. Apparently the resident who Laura had spoken to about Mr. Jones in 409A, had written an order the following day, for Mr. Jones’s (409A) IV chemo meds in Mr. Jamison’s (409B) chart. The order was picked up by a nurse who was new to the unit and sent to the pharmacy. The med should have never made it up to the 4th floor, as chemo was not administered there, but it did. The nurse administered the medication and several hours later Mr. Jamison went into multi system organ failure. Although Laura never saw the new nurse who administered the med, she did see the resident again. She never heard anything else about Mr. Jamison. When she asked the nurse manager on the unit about what was going to happen as a result of this tragedy, the nurse manager replied “Probaly nothing else. He had no family, no one even showed up to claim the body. The investigation is being handled internally by QA.”

 

Now it is well known that people are more inclined to do violence to humans when they depersonalize the victim. Taking away a person's individual identity and imposing a label, stereotyping, is a way to prepare to harm people beyond the dehumanizing labeling. This is the case with racial epithets as well.

The label "patient" is no different. People so labeled are harmed in a number of ways.

  • They suffer indignities.
  • Their privacy is invaded
  • They are denied important information for decision making
  • They are coerced into decisions
  • They are physically harmed by wrong medications, wrong amounts of medications, wrong treatments.

In hospitals "patient" are denied a wide range of choice in diet. The staff may enter the room without knocking or permission. Staff may take blood samples without explaining or getting formal permission.

Physicians and others may hold back information presuming "patients" could not understand what the physician knows so why burden them.

"Patients" may be denied being informed about treatment options that the physician does not personally favor or that the insurance coverage does not allow.  "Patients" are not permitted to wear their own comfortable clothing nor to select from a variety of comfortable dignity-preserving pieces of apparel supplied by the hospital, clinic or treatment facility.

"Patients" are subject to timetables for procedures for the efficiency of the hospital. "Patients" have their records reviewed by people who have no need to know about their condition nor was permission received for the dissemination of their information to so wide a group as often have access to it.

"Patients" are wrongfully medicated and this causes over 30,000 deaths in the USA each year. There are over 15,000 deaths in New York State each year as a result of malpractice.   Some of these errors are the result of improper identification of the person to receive the medication or procedure and some of those cases could have been avoided were the person to have been continually referred to by their names and not "patient in OR 3"  or some similar institutional abbreviation or shorthand such as "pt".

Were malpractice listed as a cause of death and not the original condition that lead to the malpractice, then medical malpractice would be one of the top ten causes of death in the USA. A good part of that malpractice is the result of misidentification of the person to be treated. Another part is due to not knowing the person other than as a "patient". 

It is now an advisable practice for people who are to have surgery to take a dark marker and write on their own body parts what is to be done and on the area involved. This is often done by surgeons on themselves! Some physicians are now doing it on their "patients".  The federal government requires hospitals to utilize this procedure as a method to reduce mistakes and make them less liable for malpractice suits and to keep their eligibility for Medicare and Medicaid.

This could have been avoided if the health care providers would just learn to know who the person is who is to be given care and what care is to be given. If a health care provider (surgeon knows Mrs. Johnson and that her left leg is gangrenous and is to be removed, then it is not likely that the surgeon would remove the wrong leg of Mrs. Johnson the next morning in the OR. Problems do arise when a surgeon is simply told to perform the surgery on the patient in OR C at 9"30am.

In this course I shall refrain from using the label "patient" as often as possible.

The role of "patient" as understood by health care providers is a factor exacerbating situations that have moral problems as one of their key characteristics. It is a word denoting a social role in an institution: health care. It has many possible detrimental effects for humans. There are similar words in health care and in other social institutions that do the same thing: dehumanize.  In health care things have both gotten so bad and this has been realized that attempts are underway to combat the dehumanization and what goes with that.

The creation of a "Patients Bill of Rights" is both a sign of the problem and repetition of the problem.

"Patients" have NO RIGHTS because the are merely social role players. ANY and ALL rights that human beings have they have as human beings. So the "Patients Bill of Rights" is simply a reminder that the "patients" are people and do not stop being people-humans- when they enter health care.

We know that terms like bitch, nigger, kike, whore, whitey, spic, honkey, towel-head,  etc.. are words that dehumanize and make it easier to do violence to others because they remove part of the humanity from them. The words that reduce whole human beings to their social roles do the same. In health care the term "patient" has contributed to many of the harms done to people in the role of the recipient of care.

Some of the basic moral principles that are involved in Health Care are often ignored when the focus is on a "patient" and not the PERSON. Persons, human beings, people have rights. "Patients" have roles.

What do we use if not the word "patient"? Well any word or phrase such as "recipient of care" if used repeatedly and as a designation of a role and not a person would eventually have the same potentially negative consequences as using the word "patient". So what do we use?

Consider referring to people as "people" or person. You can say "sick person" or "injured person" or "person in need of assistance".

You might also consider using the name of the person: Mrs. Smith, Jane Erlinger, Bob Reilly, Umerto Ferrara, etc...

In the health care setting information about persons that is personal needs to be protected and so people should not be talking about people being cared for with those who do not need to know such things. However, there are those who do need to know about the people in need of care and so those who are to receive that care should be referred to by NAME so that there will be less chance of an error being made.

"Please administer the medication to Mrs. Smith" and not "Please administer the medication to the patient in 501 B."

Here is an article from the New York Times on this matter.

August 16, 2005

In the Hospital, a Degrading Shift From Person to Patient

Mary Duffy was lying in bed half-asleep on the morning after her breast cancer surgery in February when a group of white-coated strangers filed into her hospital room.

Without a word, one of them - a man - leaned over Ms. Duffy, pulled back her blanket, and stripped her nightgown from her shoulders.

Weak from the surgery, Ms. Duffy, 55, still managed to exclaim, "Well, good morning," a quiver of sarcasm in her voice.

But the doctor ignored her. He talked about carcinomas and circled her bed like a presenter at a lawnmower trade show, while his audience, a half-dozen medical students in their 20's, stared at Ms. Duffy's naked body with detached curiosity, she said.

After what seemed an eternity, the doctor abruptly turned to face her.

"Have you passed gas yet?" he asked.

"Those are his first words to me, in front of everyone," said Ms. Duffy, who runs a food service business near San Jose, Calif.

"I tell him, 'No, I don't do that until the third date,' " she said. "And he looks at me like he's offended, like I'm not holding up my end of the bargain."

Entering the medical system, whether a hospital, a nursing home or a clinic, is often degrading. At the hospital where Ms. Duffy was a patient and at many others the small courtesies that help lubricate and dignify civil society are neglected precisely when they are needed most, when people are feeling acutely cut off from others and betrayed by their own bodies.

Larger trends in medicine have made it increasingly difficult to deliver such social niceties, experts say. Many hospital budgets are tight, and nurses are spread thin: shortages are running at 15 percent to 20 percent in some areas of the country. Average hospital stays have also shortened in recent years, making it harder for patients to build any rapport with staff, or vice versa.

Some hospitals have worked to address patients' most serious grievances. But in interviews and surveys, people who have recently received medical care say that even when they benefit from the expertise of first-rate doctors, they often feel resentful, helpless and dehumanized in the process.

In a nationwide survey of more than 2,000 adults published last fall, 55 percent of those surveyed said they were dissatisfied with the quality of health care, up from 44 percent in 2000; and 40 percent said the quality of care had gotten worse in the last five years. The survey was conducted by Harvard University, the federal Agency for Healthcare Research and Quality and the Kaiser Family Foundation, an independent nonprofit health care research group.

"The point is that when they talk about quality of health care, patients mean something entirely different than experts do," said Dr. Drew Altman, president of the Kaiser Foundation. "They're not talking about numbers or outcomes but about their own human experience, which is a combination of cost, paperwork and what I'll call the hassle factor, the impersonal nature of the care."

Loss of Identity

It is practically a patient's birthright to complain about arrogant doctors, foul hospital food and the sadistic night nurse. These are real problems at some places, and since at least the early 1980's, medical schools and hospitals have worked to solve them, giving doctors classes in bedside manner and including patient representatives on staff, among other things.

Yet the deeper psychological transformation from citizen to patient that occurs in almost any medical setting can be more jarring, and anthropologists say it begins immediately at admission.

A clerk, often distracted, often sitting behind glass, hands out confusing forms that demand detailed personal information. The newly designated "patient" then strips to underwear and puts on a flimsy hospital gown, open at the back, a humiliating uniform that often bears the name of the institution.

The psychological dynamics of this identity change have evolved little since the 1950's, when the sociologist Erving Goffman detailed the depredations of life inside a mental institution in his classic book, "Asylums."

After a patient's admission, Dr. Goffman observed, a kind of psychological contamination occurs. In normal life, people can keep intimate things like ailments, thoughts and their bodies to themselves. In an institution like a hospital, "these territories of the self are violated," he wrote. "The boundary that the individual places between his being and the environment is invaded and the embodiments of the self profaned."

Sandra Ramundt, 52, felt this so deeply that she decided to break out of the hospital while recovering from brain surgery last year.

Ms. Ramundt's room was private - she paid extra for that, she said - but despite her expectations, staff members came and went without knocking and rarely closed the door, and the hallway noise was relentless.

Despite repeated requests, no one cleared away the scattering of French fries left by the previous occupant, she said, and sometimes, unwitting attendants would leave her bedside phone just out of reach.

On the night after surgery to remove a tumor, Ms. Ramundt said she lay in mute agony. The emergency call-button was attached to a retractable railing on her bed, which was in the down position, also out of reach. She fell to the floor reaching for the button and lay there for a long time, she said; a friend found her and helped her back into bed.

When, weeks later, Ms. Ramundt had the strength to move, she disconnected her I.V., dressed, stole off the hospital premises and bought herself lunch. She ate it at a neighboring park, before returning to the hospital.

The outside lunches became a routine.

"I did it because I could, and because, to be honest, I was concerned about losing my mind," said Ms. Ramundt, who lives in Los Angeles and is a nurse. "There's this overwhelming sense being a patient of having no boundaries, no privacy, no control over anything, and you feel so awful you can't do anything about it."

At least Ms. Ramundt had some idea how hospitals work, and she could eventually advocate for herself without feeling that she was being unreasonable. Others have found that even minimal objections win them a reputation for being difficult.

Michael Sieverts, a cooking instructor in Santa Monica, Calif., who had brain surgery in 2001, said that one of the most awkward moments during his care was when a nurse tried to insert an intravenous line in preparation for radiation treatment.

At the time, Mr. Sieverts had not yet decided he wanted radiation, he said, and he needed time to research the treatment. Yet in refusing to allow the insertion of the intravenous line, "it was clear that I was putting the nurse into a terrible predicament," he said in an e-mail message.

"She had been sent in to do a job, and she was going to come out of the room having failed," he added. "At that moment, I became a 'bad patient.' "

The Psychology of Illness

Even when doctors, nurses and nurses' aides take care to treat people more graciously, as they often do, the patient may have a vastly different perception of the service.

In the winter of 1998, Jeanne Kennedy, then the chief patient representative at the Stanford Hospital and Clinics, in Palo Alto, Calif., broke her knee cap rushing to a meeting. A member of her staff wheeled her to the employee health department, where a nurse practitioner she had worked with for years began arranging for her care. But the nurse spoke to the woman pushing the wheelchair and ignored Ms. Kennedy.

"It was crazy," she said. "Here I was in my own hospital, hurt but perfectly capable, and she's being very professional but she's talking over my head as if I were a child. And we worked together. She knew me!"

Ms. Kennedy, who retired from Stanford University hospitals in December after more than 25 years and now speaks to health care groups, said injury and illness make people more likely to perceive slights than when they are healthy. "Even if the nurse says, 'Sure, I'll go get that,' and does so promptly, it can sound rude to the patient in this vulnerable condition," she said.

This vulnerability, many patients say, makes noises seem louder, time seem to slow down and anything that is less than indulgent compassion feel like coldness.

People who have had chronic pain know this dynamic intimately. For a nurse responding to a request for pain medication, appearing five minutes later may seem a prompt response. For the patient, the same minutes may seem a purgatory, or even a kind of punishment, into which a desperate mind can project its worst fears.

"When you are in rip-roaring pain," Ms. Duffy said, "you're asking for drugs all the time, and you're thinking: O.K., am I an addict? Am I asking too much? Am I offending the nurses? Are they taking so long on purpose to get back at me?"

So it is that hostility grows between conscientious, reasonable nurses or doctors and conscientious, reasonable patients. And once the feeling is there, some patients begin to fear the very people who are caring for them, they say, and are very reluctant to call a patient representative or file a formal complaint.

The Importance of Names

After spending almost a year in an oncology ward being treated for leukemia, where she said she was spoiled by the nurses, Shawna Needham, 31, of Thomasville, N.C., had what she called a nightmare experience in a rehab unit.

"The nursing staff was inconsiderate and lazy; it would take them 15 to 30 minutes to answer, just to get help going to the bathroom," Ms. Needham said in an interview.

But she was afraid to complain to the hospital. "If I did that, that's the big time," she said, "and if they got into trouble and found out I complained, well, I didn't want anyone coming at night to slit my throat, put it that way."

Besides, she said, "I really had no idea who my nurses were; I knew none of their names."

Names matter enormously, patients say.

In Dr. Goffman's account of life in a mental institution in the 1950's, he describes the admission process as a stripping away of possessions, "perhaps the most significant of which is not physical at all, one's full name."

In modern medicine, patients more commonly become exasperated because they do not know the names of the doctors or other medical staff. At many clinics and hospitals, staff members come and go without introductions, patients say. Name tags are in lettering too small to read easily; the names embroidered in script on doctors' coats can get lost in folds.

In hundreds of focus groups conducted by Planetree, a nonprofit group based in Connecticut that helps hospitals become more responsive to patients needs, one of the most common complaints that patients had was that they could not tell who was on the care team or who was doing what, said Susan Frampton, president of Planetree.

"What we encourage hospital staff to do is introduce themselves, always, and patients should demand it," Dr. Frampton said.

James Edwards of Kinston, N.C., devised an especially effective technique. After being blinded and suffering severe injuries in a chemical plant explosion, Mr. Edwards spent about six months in a burn unit, where he got to know the medical staff by the sound of their voices.

Mr. Edwards was pleased with his care over all, but he became upset when hospital staff members entered his room without speaking to him.

After one doctor slipped into the room unannounced and tried to give him an injection, Mr. Edwards decided that he had had enough, said his father, James (Red) Edwards Sr., in an interview. His son posted a sign on the outside of his door. It read:

"ATTENTION:

1) Please announce yourself when you come into my room (let me know your name and why you are here).

2) Please let me know what you're going to do and how it will feel before you touch me for any reason.

Thanks - Jim and Red"

The hospital where he was treated, at the University of North Carolina in Chapel Hill, has included Mr. Edwards's sign in a training video for its staff.

Grim, drab, soulless, disorienting - these are the kinds of words patients often use to describe medical buildings, and the words evoke both the buildings' designs and their effect on guests, experts say.

Even the humble doctor's office, if laden with medical tomes and framed medical degrees, can make a patient feel like an intruder in an exclusive space; unwelcome or even unworthy, say environmental psychologists.

Larger facilities can pose more practical, mundane complications: many people have trouble navigating the parking garage, much less finding the front door or the admissions office. And once patients check in, they may get nothing more than a wave of a hand pointing them to an assigned room.

"And then off you go, into this dreary, unattractive maze" that is often entirely cut off from the natural comforts of the outside world, said Dr. Roger Ulrich, director of the Center for Health Systems and Design at Texas A&M University.

The Discomfort of Noise

Noise levels may be more integral to effective care than hospitals realize. Television sets blare, moans issue from the room next door, nurses gossip in the corridor.

In a recent study, Dr. Ulrich and researchers at the Karolinska Institute in Sweden monitored the health of 94 heart disease patients. About a third of the patients received care in a unit with commonly used plaster ceiling tiles, which bounced sound waves back into the room. The other two-thirds were treated in rooms with sound-absorbing ceiling tiles, which muted echoes and reduced overall noise noticeably.

After three months, the study found, the patients in the quieter rooms were less likely to be readmitted for further health problems than the others, and on questionnaires they rated the staff higher. They also had significantly lower pulse amplitude at night, a marker of better circulatory health.

"Not to mention that when it's quieter, you can actually hear and understand what staff members are saying to you," Dr. Ulrich said. "These are the kinds of environmental factors that do not show up in a hospital's brochure but we're finding are very important not only to outcomes - how fast people get better - but to their overall experience as patients."

Experts say that many hospitals have already incorporated design improvements, including clearer hallway signs, courtyards, fountains, even flat-screen television sets in some rooms. In May, Dr. Ulrich was in England to advise the government on patient-friendly design for some $40 billion in new hospital projects, he said.

But if the social and psychological culture of patient care is to improve, experts say, it is likely to depend on patients and families knowing their rights and acting on them.

Ms. Duffy now works as a hospital volunteer, giving other breast cancer patients advice on how to avoid situations like her post-operative humiliation: Stop being a good girl, she says; you've got a mouth; you should use it. Have someone with you at all meetings with doctors, if possible. And take notes.

"Otherwise," she said, "you cease being a person and become 'the carcinoma in Room B-2,' like I was."

What to do if you are to develop a relationship with a provider of health care?  Here is something to consider.

READ: Well-Chosen Words in the Doctor’s Office

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© Copyright Philip A. Pecorino 2002. All Rights reserved.

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