I have been a pediatrician in the ED, a hospital executive, and a consultant on organizational development. And every time I have to interact with the health care system as a patient or family member, I am embarrassed by the clinical, administrative, and organizational weaknesses of my own profession. Something is very wrong, and it’s not about money.

At 10 PM one night during a recent out-of-town stay, my 3-year-old slipped off the bed and cracked his head open on the corner of a nightstand. The laceration was a little less than a centimeter but showed subcutaneous tissue. So, at the suggestion of my son’s pediatrician, off we went to the ED of a prominent children’s hospital.

We arrived at about 10:30 PM and were immediately triaged. The actual wait began at about 11 PM, although I am sure their statistics say that we were seen within minutes after arrival.

The waiting room contained about 10 to 12 families. Because most looked less than urgent, and because a wave of 4 to 5 families was called in after half an hour, I decided not to declare myself as a pediatrician and gave the organization a chance to do its best.

Although the triage nurse was pleasant enough, the staff overall was aloof and spent more time interacting with among themselves than with the patients. My son played with my phone, and the time passed easily for him; not so for my wife and me.

Finally at about 12:30 AM, a nurse fetched us from the waiting room and showed us into an exam room. In what we think was an attempt to enhance patient satisfaction, she pointed out the TV controls and the nurse call bell, all the time sounding like she was reading from a script. She re-examined my son, questioned us again, and left with a mention of returning to put some topical anesthetic on the wound.

She had not returned by 30 minutes later, and I pushed the red call bell. After 10 minutes, I picked up the phone, spoke to an operator, and asked that someone come to our room. Another 10 minutes, and the nurse arrived.

Now, at 1:30 AM, I revealed my professional status and made it clear that we were not pleased. I didn’t demand immediate care; instead, I asked for a plan of care with the estimated time that each step would take. She looked bewildered by my request and left.

Minutes later a resident arrived, bumbling a little, and explained they were busy with a wound next door. After some fumbling around, she irrigated the wound with demonstrable inexperience; having once been a neophyte myself, I let it go.

But that was the thing that flipped the switch for my son. It was now close to 2 AM, and he just couldn’t hold it together anymore. The attending came in to close the wound with glue; the closure was less than perfect. We discussed removing the adhesive and repeating the closure; the discussion was couched in “if you want to, I will” language, which I have used myself.

I hid my fury at the whole thing—as a pediatrician I was embarrassed at the relative ineptitude of my fellow professionals; as a manager and former hospital executive, I was incredulous at the lack of discipline in their systems; and as a parent, I was a little overwhelmed. So I chose to spare my son another round of intervention and accepted both the level of care provided and the fact that my son may have a slightly bigger scar than if we gotten care 3 hours earlier.

Perhaps if my son had been sicker—DKA, blast crisis, head trauma—we would have gotten better attention. Notice I did not say better care. The problem here is the focus—or lack of focus—on the human side of the experience. It is beyond belief that our trip to the ED required a 4-hour wait for a 15-minute intervention, but more important is the lack of personal attention or connection associated with our experience. And that is a matter of choice, not cost.