Intensivist Armand Girbes and his colleagues conducted a special study with test subjects six years ago, namely into the size of the shoe with which you could reach the resuscitation room the fastest in the hospital. The largest size in the test was 47, the shoe size of Usain Bolt, world record holder in the 100 meter sprint. The research, which was published in an international journal, showed that size 38 shoes get you there fastest.
“Yet a shoemaker will rightly prefer to rely on his own skills and give you the shoe that best suits your feet, not size 38,” says Girbes (Groningen, 1959), that Friday says goodbye as professor of intensive care medicine at the VU. The shoe trial is a kind of parody of the randomized clinical trial. “It is very much on a pedestal in medical science, but does not always provide useful information,” says Girbes. “Our research showed that data that we do not measure is more important than the data that we do measure for the chances of survival in serious lung diseases and sepsis [bloedvergiftiging].”
Girbes, who led the intensive care unit (IC) at the VUmc for a long time, often makes critical comments about healthcare and medical science – in columns, books and interviews. During the corona pandemic, he at one point advocated no longer automatically prioritizing Covid patients over, for example, heart and cancer patients. “That led to arguments with people who disagreed with me,” he says. “But my prediction that we would have excess mortality among non-Covid patients in later years has unfortunately come true.”
In his latest book, Sick care (2025), Girbes breaks down the staff about the regulated market forces, which were introduced in healthcare in 2006. Since then, health insurers increasingly determine which care is provided, how, where and by whom. With a forest of rules, quality marks, standards and procedures for the product ‘care’, which is divided into more than 4,000 closely described procedures (DBCs). “Doctors and nurses therefore increasingly feel that they cannot provide patients with what they consider to be the best care,” Girbes notes. “And rightly so.”
Good care is aimed at the entire patient plus their network
Because in Girbes’ experience, good care is ‘holistic’, i.e. aimed at the entire patient plus their network. “That is why, for example, I have appointed family counselors in my ICU,” says Girbes. “They help family members deal with emotions, but also with practical matters such as where you can get money from the wall.” Good care also means that doctors and nurses can look at a patient from the full breadth and have sufficient professional autonomy to determine for themselves what is needed.
In practice, according to Girbes, doctors must adhere to many very detailed protocols. For example, at the start of an operation, those involved go through the surgical procedure together as standard. “Useful,” says Girbes: “But if the surgeon walks away in between to answer a question, for example, the procedure has to be started all over again. The reasoning is that the surgeon could walk into the wrong operating room.” The care protocols are derived from those for aviation: “There it is often the case that pilot and co-pilot work together for the first time, but in healthcare we know each other.”
The desire for protocols can derail much worse. For example, a hospital was penalized because a nurse was wearing a watch. “The inspectorate regarded this as negative zero toleranceas a serious violation of hygiene protocol,” says Girbes, “while there is no evidence that a watch increases the risk of spreading germs.” A very experienced nurse diagnosed an ICU patient with bedsores, but was not allowed to order a special mattress. Only a specialized nurse is allowed to do this, who was unfortunately absent. Girbes: “That caused a delay of 24 hours.”
The broad approach desired by Girbes is further narrowed by far-reaching specialization in hospitals, which, for example, are allowed to treat certain types of cancer and not certain heart diseases. Academic hospitals must mainly focus on very complex, often rare conditions and leave the ‘ordinary’ conditions to non-academic hospitals. The idea behind the specialization is that quality increases if, for example, a surgeon often performs a certain type of operation.
“Of course you get better at it if you do an operation not twice a year, but twenty times,” says Girbes, who himself worked in a surgical department for a long time. “But I very much doubt that fifty times is better than twenty times, especially if a surgeon performs many other operations in addition to those twenty specific operations.” At the same time, according to him, there are many disadvantages to what he scornfully calls “half hospitals”.
Communication with doctors in another hospital is less good than in your own hospital
Many patients have multiple conditions, Girbes explains. “For example, I treat a heart patient who also has diabetes, which is often the case. The patient then has to go to another hospital for that diabetes, because we only provide complex care.” Annoying for the patient, says Girbes, but also bad: “Some of the information is always lost during the transfer. Communication with doctors in another hospital is less good than in your own hospital.”
With the specialization, expert colleagues also disappear from the hospital. “I have learned a lot from other medical specialists,” says Girbes. “Then I asked a cardiologist to take a look and he would say, for example: maybe you should think about this some more. The threshold for asking advice from a doctor in another hospital is higher. This makes me less good at my profession and therefore the patient is worse off.”
The remaining doctors are increasingly becoming super specialists, such as an orthopedic surgeon who no longer dares to perform hip surgery because she only does shoulders. Scientific research is declining in the academic hospital, Girbes thinks, because it is still mainly done on “diseases that are not common”. This type of hospital is also no longer suitable for trainee doctors to gain practical experience, because the patients there are not representative: “As a result, young doctors are less exposed to colleagues who regularly ask: is this really the case?”
Specialization can be very useful, Girbes emphasizes, for highly specialized procedures and rare diseases such as “stem cell therapy or operations for pancreatic cancer.” And there are also very useful protocols, such as the rule that you should not store very different substances in identical bottles. “And of course there have to be checks and balances but not in the form of checklists.” How? “Through an approach culture, what I call: Looking Into Each Other’s Kitchen. Have a doctor shadow another hospital for a while and note what can be improved. This will help the patient.”
