Sunday, July 17, 2016

Do New Medical Interns in July Threaten Patients?

Would you have elective surgery in the nearby major teaching institution on July 4th?
Why not, you wonder?

Prowling around the hospital wards every July are the fresh faced interns wearing starched white coats, with stethoscopes draped across their shoulders, with pockets stuffed with reflex hammers, K-Y jelly, and various cheat sheets to rescue ailing patients.

These guys know nothing.  How do I know this?  I was one of them.  Luckily, I knew that I was clueless and never pretended that I could treat athlete’s foot or even a splinter.

Imagine you are in a hospital bed in early summer complaining of chest discomfort.  Your nurse summons the intern who speeds into your room peppering you with questions.  Before you finish your answer to a question, another question erupts.  This physician is barely out of his shrink wrap and is understandably anxious that he is witnessing an impending cardiac catastrophe.   With his spanking new stethoscope, he establishes that there is a beating heart nestled inside your chest.   Your heart rate is high, most likely as a result of anxiety from witnessing the intern’s state of near panic.  I’m sure you will calm down when he whips out his Tips for Chest Pain Cheat Sheet which he will use to treat you. 

If the intern tries to test your reflexes with this - run!

Teaching hospitals have an important teaching mission.  This is the venue where physicians learn their trade – on real patients.  New interns start in July and they know nothing.  Sure, there are multiple levels of supervision over them, but these many layers can cause gaps and vulnerabilities in patient care.  The supervising medical resident, himself with only a year or two of experience, has several interns he is responsible for.  He can’t be with every intern every minute.  Sure, the intern can always call for help, but what if he doesn’t know that he needs help?

Patients at teaching hospitals enjoy many advantages.  There is often state of the art equipment and a renowned faculty.  They claim that with so many physicians of different hierarchical levels seeing patients, that this built-in redundancy catches errors and oversights.  This may be true, but as I have expressed, it is also a cause for miscommunications, excessive medical diagnostic testing, errors, exploding costs and gaps and lapses in care.

Imagine you are admitted by your internist and a cardiologist and a gastroenterologist are both consulted, a very common scenario.  Each of these 3 physicians has his own team of fellows, residents and interns.   You could be seen by 10 physicians in a day.  Communication lapses are expected as it is not possible for all of these physicians to know what all colleagues on the case are thinking and planning.

Contrast this with the situation in a community hospital, such as the ones I practice in.  There are no interns, residents or fellows.  I perform my own history and physical examination and take ownership of the patient.  I communicate with the nurses and other physicians on the case personally.  While this system is not perfect, there is much greater accountability to the patient.  There is no one I delegate to.  There aren’t layers of doctors pushing their own agenda to the extent there is in a teaching hospital. 

Our mission in the community hospital setting is patient care, not physician training.  In my experience, having been in both types of institutions, I think community hospitals have an intrinsic quality advantage.  Teaching hospitals would argue this point.   I don’t think it can be argued, however, that there are conflicts of interest in teaching institutions as patients are exposed to excessive medical care in order to provide education and training to young physicians.  This is undeniable.

If a July 4th hospitalization is in your future, you can choose your local community hospital or the Medical Mecca downtown.  If you choose the latter, get ready for some fireworks.

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