Physicians were distressed to learn of the psychiatric patient who died while waiting to be seen in a Brooklyn hospital. How can such tragedies be prevented?

Several weeks ago, JAMA published a commentary, "Physicians Behaving Badly," detailing some of the inhumane ways in which doctors (and, I might add, hospital staff and office personnel) treat patients (JAMA 2008;300:21-2).

The recent incident, ending in the death of a patient at Kings County Hospital Center in New York, ranks as an egregious example of patient treatment. New outlets across the country ran numerous stories and pictures of a woman who had waited for almost 24 hours in the hospital's psychiatric emergency department for help. Eventually, the patient fell out of her chair and reportedly stayed on the floor for almost one hour before hospital personnel made efforts to revive her.

Staff members reportedly came into the waiting area on several occasions, looked at her, and walked out. The patient died face down on the floor. She was 49.

Now that she's dead, six staff members have been fired or suspended, the family is suing for $25 million, and everybody in New York City is investigating the incident. One thing we do know is that the staff entered information in the record that was contradicted by the surveillance video that captured the woman during her ordeal.

What can we make of this? We all know that many patients, every day, are treated rudely and thoughtlessly. This lack of respect happens at the hands of doctors and staff who either give the wrong medicines or provide the wrong treatment.

Medical errors are well documented, and thousands of patients die annually because of them. We have instituted quality assurance and a variety of other bureaucratic efforts to stop these events. Kings County Hospital officials vow to implement several reforms to its psychiatric emergency program, such as 15-minute checks and "expanded crisis prevention training for staff, including managing of agitated patients." Too often, however, such reforms are to no avail. Falsification of records or enormous hospital-wide efforts starting 2 weeks before the inspection are common activities. In some hospitals, every record is read and adjusted to demonstrate the "excellent" care that people are getting in the particular institution.

But every doctor knows that these errors are human. These nasty, inexorable events involve ordinary human beings such as the staff members who saw the woman lying on the floor and did nothing. Why does it happen every day in almost every hospital in America?

In response to the incident, Dr. Nada Stotland, president of the American Psychiatric Association, released a statement saying, "Incidents like this reflect a complete breakdown of the mental health system." She went on to say that the time to intervene is "long before a person finds herself in the position of needing emergency help from a hospital that is ill-equipped to care for her."

I agree with Dr. Stotland, but it seems to me that problems that this case illuminated go beyond the mental health system. People don't seem to care or are too occupied with paperwork, or need a cup of coffee, or it's lunchtime so patients are neglected or they feel as though they are neglected. They push the nurse button endlessly with no response, and the staff in the nurse's station see who's ringing and decide, "Oh, she's such a pain," or "She's always complaining," and the result is neglect.

The assumption by the staff that they know what to do and will do it in their own time is the first thing that needs to be corrected. And if the patient wants to see or talk to his doctor, the staff protects the doctor by lying to the patient about when he'll arrive.

One disturbing case involves a Denver woman, Esso Leete. Several years ago, Ms. Leete had gone to the same hospital several times with symptoms of schizophrenia, became very depressed, and returned to the hospital for an examination and medication. She was sitting quietly despondent on a gurney in the ER, when suddenly four large techs held her down and strapped her to the gurney. "They thought I was going to get violent," Ms. Leete said later (Hosp. Community Psychiatry 1987;38:486-91).

Making assumptions about patients before the history and physical examination are done is just wrong. But such assumptions contribute to the nasty way in which patients are treated. The human factor is very important, and policies come from the top down. Often, these policies are made without any clinical input or thought of how they might affect the patient.

When I was a first-year resident in the inpatient service, the head nurse, who essentially ran the hospital, decided that all the beds should be made--all with similar bed covers--and that patients would not be allowed to lie down or nap during the day. We all know that psychiatric patients get tired and want to rest, but such action was forbidden.

When I wrote an order that my patient should be allowed to lie down after lunch every day, I got into a lot of trouble, and the order was countermanded by the head nurse. Here is an example of antipatient policy that can truly do harm. Yet everyone allowed the head nurse to get away with this for more than a decade.

The woman's death at Kings County Hospital could have been prevented had there been a sense of urgency on someone's part. People don't come to the hospital ED for fun or rest and relaxation. (According to the hospital, the woman who died that day had been brought by emergency personnel the day before suffering from agitation and psychosis). Excuses for poor staff behavior are too numerous to count. Excuses don't get to the heart of the problem.

Dr. William Osler and other great physicians have written endlessly on humanity and medicine--how to treat the patients in a humane way, not to laugh at them, not to ignore them, and not to make assumptions.

Days in the hospital are dull and seem endless. Patients find themselves waiting--for a visitor, for the next meal, for a doctor. Worst of all is waiting for pain relief. How to get doctors and staff to understand that the patient is suffering and needs help is the question. The fear of addicting the patient with too much pain medication is often heartless. It sometimes takes a long time for doctors to learn their duties to the patient, or to learn what the doctor-patient relationship is supposed to be about.

When my first wife was in the hospital with a serious cancer, I approached the neurosurgical resident in the nursing station and asked him to see her because she was having abdominal pain, which I attributed to an impaction. He said to me in a supercilious way, "First we'll get a flat plate of the abdomen." I said I didn't think she needed an x-ray. He had no idea I was a doctor; it was not a hospital in which I had ever worked.

After I told him I didn't think she needed it, he responded, raising his arms and pointing to the ceiling and shouting: "First! We'll get a flat plate of the abdomen!" This all occurred with no interest or concern about my wife being in pain.

I recall that incident frequently when I am confronted with doctors who don't understand their role. What is more important than the patient's interests, concerns, or pain? We in psychiatry are often preoccupied with our patients' human elements--their thoughts, feelings, desires, or needs--so we are frequently disturbed when we hear about poor medical care that they received. It is painful for me to hear how my patients or their family members cannot get decent care. It is often just as easy to do the right thing as it is to do more of the egregious things that patients experience.

Medicine has learned to tolerate staff who deliver poor care. We turn away or refuse to look at what is happening. Later in the day, we might laugh over it with a colleague, not to do anything about it but just to get some emotional relief for ourselves. The new techniques we invent to try to deal with our inefficiencies and inadequacies do not solve the problem.

For example, having talked about electronic medical records for several decades with the sense that it would make the entire medical care system more humane because "everyone" would have more time to do patient care, now we find that the opposite has occurred. The electronic record is now often the total preoccupation of staff. Such preoccupation can, unfortunately, lead to greater neglect of duties related to patient care.

Instead of ignoring the patient, the staff at Kings County Hospital could have bent down, examined her, called for help, lifted her up, and done the things that were necessary to save her life. Who knows? She could have been dead by that time, and nothing would have helped her. We'll never know, and we are left with a dead woman lying neglected on the floor of a hospital ED. We and the entire community are horrified.

This kind of incident escalates the talk about the philosophy of medicine and the need for all doctors and medical staff to be humane, caring, and kind. Many patients respond to a smile, a soft touch, or a kind word and think the doctor is marvelous without having any idea about his or her clinical skill or knowledge.

Patients need to feel confident in their doctors. They need to trust their doctors' judgment and be willing to follow their instructions, prescriptions, and orders. The whole interaction is tenuous, and it is regularly damaged by incidents such as this one.