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Tuesday, August 30, 2016

Jeopardy

ˈjepərdē/

noun

danger of loss, harm, or failure.

Two weeks ago, I did something that I have never done in my entire medical career. Had I come close to it before? Yes. And is it something I probably should have done a few times in the past? Definitely.

So, what was it that happened, you ask? Well, I'll tell you. Um, yeah, I'll tell you even though, after 20 full years of not doing this, it's pretty hard to actually confess. I, I, sigh. Okay. I, I, I, whew.

I. Called. In. Sick. *squeezes eyes closed and turns head so you won't look at me*

Yup.

It was the week of our interns' orientation in the hospital. Those first few days had gone just fine and at the end of the hustle-bustle of a particularly crazy afternoon, I popped by a casual eatery to grab a late lunch. And that part was fine, too.

Yep.

It wasn't until about an hour and a half later that I began feeling this cramping sensation in my midsection. My tumbly became rumbly and before I knew it, I was in and out of the restroom doing what the Grady elders (and my daddy) refer to as “running off.” Somehow I managed to get a long enough window to get over to get the kids from their camps but admit that I sprinted from my car to the front door.

Thank goodness I did.

And you know? The running off part I could mostly deal with. I mean, I was hydrating and such and told myself that if there wasn't anything in my gut, the “running off” would eventually “run out.” But then came the nausea. And then came the vomiting.

Uggh.

And so. I pretty much spent the next several hours trying to decide which end of my body to aim at the commode. I tried all those home remedies like ginger ale and the non-home remedies, too, like antiemetics and antidiarrheals. But mostly, this was something that was just going to have to run its course. Literally.

I didn't catch a wink of sleep until about 4:30 that next morning. My alarm went off at 6 a.m. and I just sort of stared at it for a few beats before silencing it. Finally, I sat up on the end of the bed and prepared to treat the day like any other Thursday. I grabbed a t-shirt and a pair of sweats, pulled on some socks and shoes and prepared to walk Willow. And that was fine, too.

Well, I take that back. It actually would have been fine if I wasn't lightheaded from my certain dehydration and on the verge of vomiting the remains of the Canada Dry ginger ale and the electrolyte drink that I'd carefully sipped all night. After only two steps toward the door, I felt my belly churning again. But still, I grabbed the leash (and my tummy at the same time) and took Willow for what I am sure was the least gratifying dog walk ever.

You know? I didn't even think to wake Harry and ask him to take the dog out instead. Even though I knew he would have, I didn't. Then, when I came back inside, I stood staring at the medicine cabinet and trying to decide which concoction would allow me the best chance at not barfing all over a patient. Or passing out on them.

Yeah.

But somewhere in the middle of all of that, I spoke out loud even though no one but me was awake. “I really, really feel like shit.” Which, I am sure, is exactly what I said. Followed by a dry heave.

And right then and there, I had an ah hah moment. I recalled all of the times I've told countless residents that self-care is essential. Even though, particularly when it has come to personal illness, I've never given my health priority over going to work.

Nope.

It dawned on me that if I were advising any of my students or residents, I would tell them to immediately contact a supervisor in order to afford that supervisor as much time as possible to cover the clinical duties. And then I'd tell them to drink, drink, drink fluids like crazy and get in bed under the covers and get some legit rest. And/or seek medical attention if it is even more serious.

But for myself? Chile please.

So with my dog at my feet wagging his tail and me hunched over the kitchen sink on one elbow out of fear of projectile vomit, I made up my mind to do the unthinkable. Yes. I decided to call in sick.

Um, because I was. Sick, that is.

Now. I tried as hard as I could to recall a time ever in my career that I'd done that but came up with nothing. And I think I came up with nothing because that adequately represents how many times I've decided to stay in my household infirmary versus crappily do my job while ill. And how many times I acknowledged that I was too unwell to work.

I blame jeopardy. Confused? Okay. Let me explain.

At nearly every residency training program, there is this back up schedule that is designed precisely for moments such as these. And you know? Nearly every residency training program calls it by the same name: JEOPARDY.

Yup.

So when one is sick, they call the chief resident or schedulers or whomever, and that individual refers to the “jeopardy schedule” and notifies some unlucky soul who, up until that moment, was basking in an awesomely easy assignment. Only to be thrust into the firing line of some essential patient care situation such as the intensive care unit, hospital service, or something else even more hellacious. And yeah, it's exactly as sucky as it sounds when you get called.

Yup.

Similar to, say, jury duty, everyone knows that the jeopardy schedule is everybody's necessary civic duty. That is, in the resident community. But, just like jury duty, it isn't one of those things anybody is particularly pumped up about getting notified about. But physician jeopardy is more complicated than that.

Totally.

When I was a resident, we had this longstanding culture of bravado when it came to toughing it out through illness on the job. And I can't say that it was because our program leadership wasn't supportive of our personal needs. It was just this thing that sort of happened, you know? Most of the time they had no idea.

Nope.

Well, I take that back. They were supportive when a person actually endorsed being ill as a reason to call off. But because they came up in the same system, I can't ever remember anyone insisting that someone leave back then. Go lie down for a few moments? Sure. But full on leave and cause another resident to be called in? Never.

Oh, and before I go further, I will say that there is always this teeny, tiny subset of individuals that call jeopardy 200% more than anyone else in their entire program. Most notable was this girl who had taken 2 Benadryl on accident and called in because she was afraid she'd be drowsy. (Me countering her with the half life of Benadryl, which she'd consumed 4 hours before, didn't seem to make a difference.)

Anyways. The vast majority of my resident colleagues worked when ill. Furthermore, there was this esprit de corps between us that caused us to rally around the sick guy and fill in the gaps. (Forget the fact that everyone was getting exposed to whatever illness the person had.)

Uhhh, yeah.

A few times stand out in particular. One was my junior year when I was taking call in the cardiac care unit (CCU.) I came down with fever, chills and a terrible headache. My neck was tight and I had some nausea and diarrhea, too. It was the summer and I had just come off of the pediatric inpatient service where kids with aseptic meningitis from enteroviruses was rampant. I even had a tell-tale viral exanthem (rash) to go with my constellation of symptoms. And you know? I was 99.9% sure that viral meningitis was exactly what was going on with me.

Maybe even surer than that.

I called one of my classmates (who was also on call) and asked him to come examine me in the nurses station which he did. “Dude. You probably got viral meninge. You gonna go to the ER and let a second month intern do a spinal tap on you?” He bit into the room temperature honey bun he was eating and laughed at his own joke.

“No way, dude. Did you see my rash?” I asked while pulling up my sleeve.

“Cool,” he replied. “So what are you gonna do?”

“I think if I take some Motrin, I can make it through the night.”

“Yeah, probably so.”

And I am not kidding you. This is what happened. I took the call, fever, stiff neck and all.

Super stupid. Especially since it could have been something far more serious.

That same friend called me the following year (when we were both on call again) to check him out in a call room. He'd developed some shaking chills and a nasty, rattly cough rather suddenly. When I got there, he was breathing super-fast. “Dude! Holy shit. You look like you're about to code.”

“I feel like I'm about to code.”

I listened to his lungs. “Yikes. You've got signs of consolidation. This looks like a bad pneumonia. And that history, man! You might have pneumococcus, I think.”

“Hmmm. Cool. Think I can tough it out?”

“You're breathing pretty fast, bud. Let's go to the PICU nurses station and pop a pulse oximiter on you to see if you're hypoxic.” Which is exactly what we did.

Guess what his oxygen saturation was? 82% (96-100% is normal.) Craziness.

Let me tell you. This guy? He looked sick-sick. It was NOT a soft call. At all. That said, I am convinced that were it not for the whole needing oxygen thing, he would have slugged it out through that call with his pneumonia.

Yup.

Would you believe that he got admitted to the hospital that very night? And you know? We were so entrenched in that culture that I can remember like yesterday cracking jokes in his room about him spreading TB to the interns and telling him that I was totally going to present him in morning report the next day.

Which he found funny, too. That is, when he wasn't nearly about to code.

Uh, yeah.

I blame this word “jeopardy.” The actual definition means “danger of loss, harm or failure.” I can't think of anyone who has ever wanted to be the one responsible for putting someone in that situation--that is, one involving jeopardy. Especially another overtired resident who finally, finally, finally is on a lighter work assignment.

But see, that word just underscores the culture. It sounds heinous, punitive even. And to tap into it literally puts another person in peril, if you follow the definition. And I think that's a part of the problem, frankly.

The one time I called jeopardy as a resident was when my father had a massive heart attack requiring emergency surgery. And you know what? I actually took call all night before taking a flight out, now that I think about it. We also have a jeopardy schedule (also called “jeopardy”) in my current faculty position and you know what? The one time I called jeopardy with this group then was on November 15, 2012--the night my sister Deanna passed away.

Yup.

So yeah. I am reflecting on all of this and realizing that doctors who neglect themselves really aren't the best physicians at all. Coming to work while truly ill puts patients in danger, can make things worse and it probably increases the chance of an error happening.

Now. Do I think folks should be calling off for sniffles or allergies? No. Do I think taking two benadryl should allow a rain delay at best but not a full on call off? Damn right. But do I believe that a vomiting, diarrhea-ing, teeth-chattering person should have another able physician working in their place? Definitely.

If you ask me (though no one did) the first step is changing the name. Instead of calling it “JEOPARDY” it might be better to refer to it as “FAMLY EMERGENCY/ILLNESS PATIENT CARE BACK UP.” This way, those who need it will understand when it is to be called. And those who get called will feel okay with being called in.

We could even call it “FEIBU” (pronouced FAY-BOO?) for short. As a reminder that this is for FAMILY EMERGENCIES and ILLNESS when back up is needed. And that FAMILY EMERGENCIES and ILLNESS happen and aren't a sign of weakness at all.

Mmmm hmmmm.

Oh, and the times that folks get pulled in because of human scheduling glitches NOT due to the needs of a colleague dealing with a FAMILY EMERGENCY or ILLNESS? Well. Keep right on calling those times ”jeopardy.”

Ha.

So yeah. I acknowledged that I was ill and called off the other day. My colleague Stacie S. was great and made sure I didn't have to feel guilty. And my other colleague Alanna S. was super kind about picking up my slack in the resident clinic that morning. And you know? I think if my patients knew of my decision, they would have appreciated my choice to call off, too.

And so. I drank fluids and rested in my bed all day. That photo is proof that I was exactly where I was supposed to be, too. I went through a whole lot of hand sanitizer and considered going to get a bolus of IV fluids at one point. But the next morning, I felt a thousand percent better which taught me a mighty lesson.

And you know the best part? Not a single patient was harmed or put in jeopardy, thanks to my decision to first put the oxygen on myself.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Thursday, August 25, 2016

The evolution of hospitals

Once upon a time, a hospital was a place you went if you were sick. Doctors would (ideally) figure out what was wrong, offer treatment, and you would convalesce.

The longer you stayed in a hospital, the more the hospital could charge you (your insurance, really, if you had it).

This all changed in 1983, with the advent of the DRG system (it stands for Diagnosis-Related Group). Almost overnight, the incentives for hospitals changed. With DRG payment, the hospital would get 1 bundled payment for the whole hospitalization based on the patient's diagnosis. Average length of stay for hospitalized patients went from 30 days (imagine: a month(!) in a hospital). Hospital executives saw the need to minimize length of stay. Depending on the payment for each diagnosis, there would be an inflection point when a patient staying beyond a certain number of days would result in financial loss.

“Throughput” became the term of art. (Like widgets on an assembly line.)

Now the average time someone spends in a hospital is a little more than 4 days. (Of course, for mothers with normal births, this is even less, about 2 days. Many surgeries that used to necessitate several days in the hospital are now done on an outpatient basis. Length of stay in those situations: zero.)

A recent essay on this topic in the New York Times by Dr. Abigail Zuger brought back memories for me. I once had a teacher tell me, “No one should ever need to be in a hospital. Except for some cardiac conditions that require immediate care, the only people winding up in hospitals are frail elders, and those with social problems and no place to go: the mentally ill, the destitute, the homeless.” I remember feeling a bit shocked by this, but as I reflected on it, I realized he had a point. I should start with the assumption, he told me, “that almost no one really needs to be there and they're better off at home.”

The modern condition leads us to keep people in hospitals for as short a duration as possible. But something is clearly lost. As Dr. Zuger writes:”Hospitals were where you stayed when you were too sick to survive at home; now you go home anyway, cobbling together your own nursing services from friends, relatives, and drop-in professionals.”

Patients often go home feeling brutalized by all the blood draws, hospital food, and lack of sleep. Rare is the patient who says, “I feel better now. Can I go home?” Often we send them home before they feel ready.

It sounds a bit cruel, and like there's a perverse incentive at play. But keeping people in the hospital is also inherently risky. Hospitalization can cause infections, loss of muscle and coordination (especially in older folks), falls, and delirium. So getting people out as quickly as possible is in many ways the right thing to do.

The truth, however, probably lies somewhere in the middle.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

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Wednesday, August 24, 2016

Love of my life

For as long as he could remember, she was there. From those early days sitting criss-cross applesauce on the porch shelling peas with grandmama, right along with the unmistakable scent of red Georgia clay was the hint of her presence wafting by with every humid breeze.

“I can't remember a time without that being a part of my life,” he said. And when he said it, he looked down at his hands and sighed. “I just can't.”

There was a sadness about him. This heavy cloak of melancholy that pushed against the agenda I'd planned before entering the room. See, this was supposed to be a congratulatory conversation. Me applauding his triumphant separation from alcohol.

Yep.

But as soon as I came into that room and laid eyes on him, I could feel it. Yes, this was a good thing he'd done for his health. And definitely, abstaining from Jack Daniels for 16 full months after nearly a lifetime of being his best friend is no minor feat. So, yeah. I had all these lofty plans of shaking his hand hard and telling him how great it was. Reaching out with both hands and staring deep into his eyes to let him know that I meant it.

Because I did.

But. None of that felt right once I actually sat down. His shoulders were curled inward and his expression was lonely. Like some middle school kid chosen last in the kickball lineup, the kind you immediately want to hug and defend. Yes, Mr. Caldwell had crossed the 1- year hurdle with AA and had the improvements in his health to show for it. But still. He didn't seem happy.

Nope.

I guess I'd sized him up with this assumption of what he'd be like and where his mind should be, you know? Imagining some gum chewing chap with a bunch of AA key fobs proudly telling it on the mountain that he's just taking it 1 day at a time. I was expecting a testimony of how now even the smell of alcohol makes his stomach turn a little, especially now that he's broken free of that stronghold. But that isn't what I found.

At all.

“You seem sad,” I finally said. “What you've done for yourself is so amazing. And you're doing so great, too. But you seem … I don't know … sad.”

Mr. Caldwell just stared at me for few moments without speaking. Then, instead of saying something in response, he just sighed and shrugged. His lips moved and I think he said, “Yeah,” but it wasn't audible.

“Is everything okay at home? Did something happen?”

“No, ma’am. Everything fine with my people, Miss Manning. My kids so happy I don't drink no more.” When he said that, the corner of the left side of his mouth turned up a bit.

“That's great, Mr. Caldwell!” I did my best to ramp up the enthusiasm to counter his somber mood. It didn't work.

“I'm okay,” he finally said. Then, to make sure I knew he meant it, he repeated himself, this time a little more firmly. “I'm okay.”

I leaned into my palm with my chin and squinted my eyes a bit. “You know? You don't seem so okay, Mr. Caldwell.”

And something about that—my body language and that last statement—unlocked something. I could tell. His eyes focused on mine some more and I could tell he was trying to decide whether or not to tell me something.

“Tell me,” I pressed. “Tell me what is making you so sad.”

Mr. Caldwell took a big drag of air through his nostrils, closed his eyes and then shook his head slowly. Then he just froze for a beat with his eyes still closed before parting his lips respond. “I … I just … “ He sighed once more and went on. “I just miss it is all.”

“Miss what? You mean drinking, sir?”

“Yeah. Like, I keep waiting for that point where I lose the taste for it but it ain't never happened. So when I see it or smell it or see folks drinking, I guess it just make me feel sad.”

“Hmmm.”

“Like, you know how when you was little how your main memories are tied to how stuff smell or the sounds you hear? See, that's how it is with me and drinking. Like, I come from a long family of alcoholics. But not fall down drunk and cuss you out alcoholics. Happy, domino and card playing drinkers. Shit talking and laughing. Having fun. But drinking the whole time. Even with kids around.”

The image he'd painted was so vivid that I was at a loss for words. He kept going.

“My grandmama and my granddaddy drank a lot. I was raised around them and both my parents died from problems related to drinking. So I know that it's bad for my health which is what got me to quit, you know? That time they kept me in the hospital, I knew I had to quit so I did. But I guess as time go by I'm realizing that just about every memory I have involve either me drinking or being with somebody who was drinking. Going all the way back.”

“You know what, Mr. Caldwell? I never thought of it that way.” I said that because it was true. “For you, alcohol is like an old friend.”

“Naaah. It's even more than that. Alcohol for me? She family. As much a part of my family as anything. Even when I was a kid.”

“You started drinking as a child?”

“Naw, not at all. But my auntie’nem used to sit us on the porch and braid our hair down in cornrows. My mama didn't like cutting out hair so us boys always had braids. I'd be sitting right on the step between her legs. Every so often she'd fuss at me or my cousins saying, ‘You bet’ not knock over my damn drink!’” That made him laugh. But it was fleeting. “It's funny ‘cause whenever I smell some gin, I want to cry for missing my auntie so much. That mixed with Newport menthols. And then along with the smell of some collard greens cooking with ham hocks and the sound of somebody cranking a ice cream maker.”

And that? That made my eyes sting. Partly because I finally understood what he meant. But also because I knew there wasn't really anything I could do about it. I started to counter him with some canned commentary on the health benefits of no longer drinking but none of it felt right. Instead I just twisted my mouth and nodded. Because I got it.

I put my hand on his and squeezed it. “Thank you for giving me a new perspective, Mr. Caldwell. I get it.”

Finally, he let out an unexpected chuckle. “Sometimes seem like the ones you can't get enough of don't love you back, do they? I love her but she don't love me.”

“Yeah, she's funny like that.”

“But I miss her. Every single day. Even though I shouldn't, I do. And all the people I loved though the years that's associated with her. My whole world different. My whole life different.”

“In a good way?”

“I'm alive, which is good. I ain't getting DUI charges, which is good. But just imagine if whatever it is that connect you to all your favorite people, favorite memories and favorite things, you can't do no more. Or if you couldn't be around none of it no more. It's hard.”

“That sounds super hard.”

After that we just sat in silence. Him looking directly at me, face washed over with this complicated grief, and me squeezing down on his hand with mine. I kept wanting to say something or feeling like I should but nothing was feeling authentic enough. I stayed quiet.

Finally, Mr. Caldwell sighed and gently pulled his hand back. “I appreciate your concern, Miss Manning. I do.” He began sliding his papers and medications back into his little knapsack and then pulled the drawstring closed. Patting the bag, he said for closure, “Yeah. So I guess I'm sad ‘cause it's the end of a love affair. But not just any love affair—like the love of my life.”

“Wow,” I whispered.

“Sound crazy, don't I?”

“No, sir. You sound honest.”

Yeah.

In the 20 years that I have been a physician, I have asked the same question of countless patients struggling with alcohol use disorders: “Did you grow up with any drinkers?” To date, I have never once heard a response that included anything other than the affirmative.

Nope.

This? Mr. Caldwell's story? It opened my eyes. He taught me a new layer of why it's so hard for people to let go of alcohol. And you know what else? Thanks to Mr. Caldwell, I will never look at alcohol abstention the same way again.

Ever.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Tuesday, August 23, 2016

How to make medicine safer

I have 2 very inquisitive sisters, and they've raised 4 inquisitive children. I give them full credit for this, although my parents must have had something to do with it, as in 7th-grade math I won an award for my “unique ability to question the trivial.”

Of course, trivial is in the eye of the beholder. Sometimes the trivial questions are the hardest, like: “What is 0?”

One of my sisters asked me a not-so-trivial question a few years ago:

“So, as a doctor, are you ever worried that you'll make mistakes?”

“No,” I answered, “I know I'm going to make mistakes.”

This is something other industries such as airlines have understood for decades. Medicine is only starting to learn what this means. Throughout our training, we are taught over and over to double- and triple-check our work. We devote hours and hours to memorizing drugs and their interactions. But we aren't taught how mistakes really happen, or even that they do. We are taught that mistakes are not inevitable, are a sign of personal failure and that only our own actions can prevent them.

This is very, very wrong.

Several years ago, a professor from Johns Hopkins, Dr. Peter Pronovost, realized that individuals make errors, and came up with an idea to improve systems so that the imperfections of individuals will matter less.

The Keystone project is simple and made immediate, measurable improvements in patient care. For example, the rate of infections of IV lines in ICUs dropped to essentially 0 soon after implementing Keystone.

And what was this enormously successful intervention?

A checklist. In brief, in non-emergent placement of IV lines, nurses are given the authority to make sure doctors follow a brief, simple checklist, and to stop the procedure if it isn't followed. The program also educates clinicians on the basics of preventing line infections and makes sure the need for an IV line is reassessed daily so that they will not be left in unnecessarily.

These relatively simple system changes have been made successfully in other hospital settings, but are not yet truly a part of medical culture.

In the U.S., medical care is fragmented. My patients often ask me why I don't have access to their electronic records. The answer is simple: Different doctors and hospitals use different systems, and these systems don't talk to each other. The technology exists, but our culture hasn't realized the importance of it.

If I were able to look up any patient of mine and see every test done, every medication prescribed, their care would be safer. But this simply isn't done, and the reason is cultural. In the U.S. we are afraid of anything that smells of “socialized medicine” and anything that might violate our medical privacy. These aren't trivial concerns, but they ignore the fact that as healthcare becomes better, it also becomes more dangerous. Detractors love to cite statistics about how many deaths in the U.S. are attributable to the healthcare system, but this distracts from the real problem. Modern medicine improves lives. And people in hospitals are very, very ill compared to the past.

Even when we get to the point where Keystone-like systems are the norm and sharing of medical information is automatic, people will be injured and die in hospitals because that's where we go when we're sick. People don't die at Wrigley Field because they don't go there for their cancer or heart disease.

“Have you washed your hands?” seems a trivial question, but it turns out to be life-saving. Individuals easily forget, but a system designed to ensure your compliance saves lives.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

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Monday, August 22, 2016

Do new medical interns in July threaten patients?

Would you have elective surgery in the nearby major teaching institution on July 4? 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.

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 2 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 4 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.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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