Is it torture?
Rarely do I come across an article in a leading medical journal discussing a subject so seemingly unrelated to the practice of medicine as one dealing with “official torture techniques”. The article that caught my attention included a review of a few of the highlights of several CIA torture practices, referring to the official 1983 document whimsically entitled Human Resource Exploitation Training Manual. This describes the techniques that lay the foundation for what constitutes and how to perform “enhanced interrogation” – or torture. A training manual like no other. I don’t know if it has been peer-reviewed, or if there has been an updated version created since then, nor did I see any references that were cited, but the authors’ message is clear.
Why was the Annals of Internal Medicine publishing an article about torture? Frighteningly, the authors found far too many parallels between these CIA recommended best torture practices and how patients are often treated in the hospital. They note that the purpose of torture is to degrade autonomy and willpower, humiliate individuals, violate privacy and make individuals’ lives unpredictable. When the purpose is torture, the issue is to remove someone’s sense of control and create psychological regression.
Unfortunately, even when the purpose is providing good medical care, the same loss of control and psychological regression occurs when we use our various versions of these interrogation techniques.
The authors cite numerous examples of how hospital practices can inadvertently mimic these enhanced interrogation techniques designed to break the individual’s spirit. From the ill-fitting and ill-covering gowns people are forced to wear, to the repeated and usually redundant questions asked by multiple professionals. From the frequent interruptions and phenomenal sleep disruption, to using the bathroom with a staff member present without privacy. From the lack of ability to control the temperature in our rooms, to the unfamiliar or absent views of the external world. From the lack of ability to tell day from night, to the multiple ways we perform electronic monitoring we do a lot that looks pretty sinister when you compare it with the CIA recommendations. We take these practices for granted because they are “required” or “efficient”, but really we probably do these things because it is what we have learned and what everyone else does, and it is what we know. Do we ever really stop and look at what we do to our patients vis-à-vis some of these practices, and what effect it can have on our patients physically and psychologically?
Ultimately, the authors are not trying to make a clever observation as much as they are trying to identify a real problem and come up with a better direction for us to take. It seems very clear that such practices affect our patients powerfully, and we do not fully recognize the effects. So first we need to be aware.
Second they suggest that we empathize with the patient’s loss of control and appreciate that some of the behavioral or attitudinal issues that we see in our hospitalized patients are related to these practices.
Ultimately they recommend being more mindful about wearing clothing, nocturnal interruptions, encouraging ambulation, and being more communicative with our patients about processes, procedures, and the disruptions patient are experiencing.
I would add two things to their list. First, there is no place like home. We think that patients “need” to be here when in fact many of them would probably be better at home. Custom and habit oftentimes have replaced mindful consideration of what is best for our patients. There is also the financial aspect of each day in the hospital running several thousands of dollars per day suggesting that the only people should be here are the people who truly cannot be treated or cared for in any other more appropriate setting. Using that standard a lot of people could go home much faster than they do right now.
The second item I would add is being thoughtful about using “nonchemical restraints”. The most obvious offender is the tremendous overuse of telemetry monitoring in patients who simply do not need it. Telemetry has many unintended consequences well beyond the stated purpose of evaluating heart rates and heart rhythms. For starters, monitoring makes patients unable or unwilling to ambulate, putting them at risk for falls and lengthening their hospital stay. It also makes us and our patients more likely to “accept as normal” wearing their open hospital gowns rather than their street clothes. Maybe that should not be so normal anymore. Telemetry also serves the purpose of having somebody view themselves as sick and disabled, with many unfavorable consequences to such a mindset. There are certainly a number of people who truly need telemetry, but our telemetry utilization includes many individuals for whom it is truly a harm, and should no longer be thought of mistakenly as a value-added benefit. It simply is not for these people. It can cause harm
So – be mindful, find ways to avoid inadvertently torturing your patients and recognizing when our daily practices may look sinister and burdensome to our patients in ways we don’t always appreciate. I would expect that we can improve our patient satisfaction scores, and shorten our length of stay by looking at these and other new ways to do things better.
If you are looking for the article in question it is titled “How Hospital Stays Resemble Enhanced Interrogation” and was published at annals.org on July 21, 2020.
