Would you take your parent to a teaching hospital for major surgery?


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So yeah - sitting here with my mom at University of Iowa and they just told me they accidentally severed her accessory nerve during surgery to remove and biopsy lymph nodes. Now she can't lift her arm well so we have a new f''ing problem we have do deal with. I thought I'd post here and see what med students think - would you send your mom to a teaching hospital where it's not 100% certain who's doing the surgery?
 

SurfingDoctor

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I've taken my children only to teaching hospitals... but then again, I make sure trainees who interact with my children have proper oversight.

However, if you think that private hospitals just have well-trained physicians doing everything and that outcomes are fantastic because there are no trainees... well that just isn't the case.
 

Raryn

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It's a known possible complication of the surgery that could happen no matter who is doing it. I'd feel perfectly comfortable with that being a trainee, since I think a complication like that might even be less likely with an extra set of eyes in the operative field.

That said, the one thing I'd request (and I think that would be reasonable for anyone to request) is for the surgeon to only be running one case at a time while my family member was in there. It always made me nervous when one attending would be running 2-3 separate, complex surgeries with different trainees in each room operating on their own except for the ill-defined "vital portions of the case".
 

exacto

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You said serious surgery, in that case no...I 'd go to a specialist with lots of prior experience.

Anything that is not life threatening, I would go to a teaching hospital.
 

Merely

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Do studies show that no residents or trainees in the case results in better outcomes? If thats the case then no trainees for me. It probably makes sense since one experienced surgeon is going to be better than a trainee who doesnt know wtf hes doing.
 

KnuxNole

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Yes I would, residents and fellows need to learn, and they are supervised by attendings. What you described is rare, which although it is an unfortunate situation, can also happen at non-teaching hospitals as well.
 
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catie_jane

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Do studies show that no residents or trainees in the case results in better outcomes? If thats the case then no trainees for me. It probably makes sense since one experienced surgeon is going to be better than a trainee who doesnt know wtf hes doing.
Studies actually have shown that teaching hospitals have better outcomes than private
 

The Wobblie

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While mostly subjective, if you were to rank the top 10 hospital systems in the US, I'm guessing the vast majority of them (if not all of them) are teaching hospitals.
 
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sloop

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Regardless of whether the outcomes are worse or not, I think people generally have a responsibility to not go out of their way to avoid being seen by medical students and residents. I know this seems odd to most people, but if you're seeing a doctor, you're benefiting from an educational structure whereby the doctor helping you learned his craft by seeing patients as a trainee. To benefit in this way but deliberately avoid helping trainees learn seems unjust.
 

TheThirdLevel

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At most teaching hospitals, a patient may be seen by a a med student, a junior +/- senior resident, plus a fellow or attending (especially on a surgery service). On top of that, the surgery will have the attending + resident (or fellow).
At most non-teaching hospitals that I've been to, the physician will breeze in, ask the questions they always do (that have proved relevant in their history of practice). A lot of those surgeries are either unassisted or they have the scrub tech assisting.

Personally, I would rather have the setup where multiple physicians are seeing the patient (less chance that something slips through the cracks), and even if the resident is doing the majority of the operation there is more than one eye on the surgical field at all times. I've also noticed that academic centers often have much better supporting staff (although this may vary place to place). If there was data on teaching hospitals having a significantly higher rate of complications, it would be all over the news and people would be in an uproar about not being treated by anyone less than an attending physician. Mistakes can happen anywhere.
 

Amygdarya

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Regardless of whether the outcomes are worse or not, I think people generally have a responsibility to not go out of their way to avoid being seen by medical students and residents. I know this seems odd to most people, but if you're seeing a doctor, you're benefiting from an educational structure whereby the doctor helping you learned his craft by seeing patients as a trainee. To benefit in this way but deliberately avoid helping trainees learn seems unjust.
Yep. For the past couple of years I've been going to a student dental clinic - to be entirely honest, I started going there because it was more affordable but I was pleasantly surprised by the quality of work and supervision (shout out to our fellow dental students). And yes, I also feel like it's only fair to let someone do their training on me.

Unrelated to that, I would actually *prefer* going to teaching hospitals for serious medical or surgical conditions (assuming appropriate supervision - yeah, one case at a time for attending surgeons please) because these tend to be the hospitals where highest level tertiary care is concentrated and, as the above poster mentioned, you'll be seen - and your case will be discussed - by multiple people.
 

themockjock

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Anything that is not life threatening, I would go to a teaching hospital.
Lolwut? If it's life threatening, the only place I would ever go is a teaching hospital.

This isn't to say that there aren't good docs out in the community. There are some truly excellent ones. But really, when you're talking the sickest of the sick, the only place that truly has the resources to properly care for these people are major academic tertiary centers.

Let's play a game of choose your own adventure: Young (30ish) woman with a SBO from previous gyn surgery. Gets peritonitic fast. Goes to OR. Refuses NGT adamantly. Aspirates on induction in a giant way (liters of feculent vomitus). Desats. Desats. Peri-arrest.

Choice 1: Community hospital #1
Patient continues to desat, ICU vent brought into OR, gets put on APRV. Still desats. Bronched in OR, still desats. Arrests on table goodbye.

Choice 2: Community hospital #2
Patient continues to desat, oscillator brought into OR, still desats, bronched, desats, gets put on helicopter to local ivory tower but by the time she gets there pupils are fixed and dilated so goodbye after neurology does their thing. Neurology's thing is offering condolences.

Choice 3: Ivory tower academic hospital
Patient continues to desat, CT anesthesia brought in, ICU vent brought in. Patient continues to desat. CT surgery of course is in house and are called and bring an Avalon cannula in and hook her up to VV ECMO. A few tense days go by. Lungs get better, ECMO weaned and she walks out of the hospital 3 weeks later.
 

Snoopy2006

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It's a fair question. I would. In my experience the level of thought at academic centers is just a higher level. Attendings are forced to stay current and on top of recent advances to keep up with residents/students who are always learning, there's more academic discussion and back-and-forth, and I believe the overall care is improved as a result. More specialists and subspecialists are available should a need arise. In many cases, the technology and equipment needed is better (though certainly not always).
 

neusu

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Lolwut? If it's life threatening, the only place I would ever go is a teaching hospital.

This isn't to say that there aren't good docs out in the community. There are some truly excellent ones. But really, when you're talking the sickest of the sick, the only place that truly has the resources to properly care for these people are major academic tertiary centers.

Let's play a game of choose your own adventure: Young (30ish) woman with a SBO from previous gyn surgery. Gets peritonitic fast. Goes to OR. Refuses NGT adamantly. Aspirates on induction in a giant way (liters of feculent vomitus). Desats. Desats. Peri-arrest.

Choice 1: Community hospital #1
Patient continues to desat, ICU vent brought into OR, gets put on APRV. Still desats. Bronched in OR, still desats. Arrests on table goodbye.

Choice 2: Community hospital #2
Patient continues to desat, oscillator brought into OR, still desats, bronched, desats, gets put on helicopter to local ivory tower but by the time she gets there pupils are fixed and dilated so goodbye after neurology does their thing. Neurology's thing is offering condolences.

Choice 3: Ivory tower academic hospital
Patient continues to desat, CT anesthesia brought in, ICU vent brought in. Patient continues to desat. CT surgery of course is in house and are called and bring an Avalon cannula in and hook her up to VV ECMO. A few tense days go by. Lungs get better, ECMO weaned and she walks out of the hospital 3 weeks later.
What? No. Your answers make no sense whatsoever.
 
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Wordead

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I'd take them to a teaching hospital, but say that no residents are to participate in their surgery. It is something you are allowed to request.
Our attendings' standard answer to that is "I can't take care of you without my residents".

If someone refuses to have residents in their surgery they should also request they not be involved in their postop care. Which would be fair.
 

Mad Jack

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Our attendings' standard answer to that is "I can't take care of you without my residents".

If someone refuses to have residents in their surgery they should also request they not be involved in their postop care. Which would be fair.
Eh, I was at a pretty big and well respected major medical center back in the day, we obliged such requests as a matter of both respect and policy.
 

Amygdarya

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Our attendings' standard answer to that is "I can't take care of you without my residents".

If someone refuses to have residents in their surgery they should also request they not be involved in their postop care. Which would be fair.
Yeah, and who's gonna assist the attending during the procedure if no residents are allowed? A scrub tech who's not experienced in assisting because guess what - it's the residents (or even medical students ) who do that all the time. You want to have another attending to assist? What makes your case so special? And who's paying for that?

Not to mentioned there are plenty of situations where residents are actually more proficient at some smaller procedures than attendings because they've been doing a lot of those recently, and attendings may not have done those in years. "I want only the best! I want an attending, not a resident to do this!" - "Ahem, our senior residents are actually the best people for this job."

And in general I don't think it's fair to take advantage of the good that teaching hospitals have to offer without also accepting the "bad" of having residents involved in your care.
 

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I would definitely go to a teaching hospital and allow residents and med students to participate in care. The only exception that I'd have personally, and my female family members have had, is that no med student is delivering a baby. They can watch if they want. :p
 
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Temeraire

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At our hospital, if you ask to not have residents participate in your care, then you get punted to the nonteaching service made up of private practice folks, and let me tell you, you don't want to be on the nonteaching service. Each attending has to cover more patients on their own than a senior resident, and no one checks their work. And it shows.
 

Donald Juan

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I'd take them to a teaching hospital, but say that no residents are to participate in their surgery. It is something you are allowed to request.
You are allowed to request whatever you want. It doesn't mean someone has to honor it or entertain it. It's also a silly request. Mayo Rochester isn't known for both great training and a place people from all over the world fly to for surgery because the attendings kick residents out of the OR.
 
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njtrimed

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My personal feeling is that in general, you want to be at a university hospital for any serious medical or surgical intervention. You'll get the most attention and the most access to the latest and greatest treatment options. However, I wouldn't leave. Regardless of your level of training, you can tell when something sounds wrong. Here's one of several examples from my own experience: a few years ago, my sister was admitted to a major NYC teaching hospital and they planned to keep her over the weekend. When I pressed the nurse to ask the attending in charge of her case why that was, there wasn't a good reason and they discharged her instead. Staying in the hospital three more nights would not have only been exorbitantly expensive, but would have put her at risk for infection in her compromised (but stable) state, besides the fact that she had young kids at home and it was an unnecessary stress on her family.

Our family had a different experience at a local private hospital recently; there was better continuity of care from the nurses and hospitalists, and really no red tape. Had the case been more complicated, we would have asked for a transfer to a better equipped university hospital, but our role in advocating for the right care may have also been more complicated.

TL;DR: know when you need more elaborate care, but stick with the smaller, private hospital when it's not a tough case. Always have someone there who is capable of asking the right questions. And (as per usual) nurses are your best friends in helping you figure it out when you're not entirely sure.
 

njtrimed

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You are allowed to request whatever you want. It doesn't mean someone has to honor it or entertain it. It's also a silly request. Mayo Rochester isn't known for both great training and a place people from all over the world fly to for surgery because the attendings kick residents out of the OR.
Oh, and if you're at a teaching hospital, you're foolish to request that residents are not involved in surgery. I have plenty of anecdotes about attendings performing surgery when they're usually on the teaching side of the OR table. Leave that dynamic alone; they have it figured out and it works. Don't mess with success, seriously.
 

cabergoline2

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I d prefer going to a teaching hospital compared to a standalone private one ,no matter how rich I am. the level of oversight in a teaching hospital is much higher than a private hospital..today I was rounding in a large midwestern teaching hospital....the patient was seen by med students , foreign trainees (externs) , pgy1 through pgy3 , chief resident , a junior attending , a very senior attending (prof level) , a pharmacy resident , a pharmacy professor , subspecialty fellows through attendings etc....patient was prescribed a particular antibiotic by an attending to which he had a reaction 10 years ago...corrected by pharmacist...senior attending of a subspecialty wanted to make a modification to the treatment plan..corrected by pgy3....in the end the care the patient received was excellent...in a private set up the layers of redundancy would be nowhere close...so if a senior attending makes a bad decision , no one corrects it...
 
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Krukenberg

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I think it's unreasonable to request that no resident be involved in care, but totally reasonable to ask that the attending perform the key steps of the operation.

Attending surgeons make that decision of whether they'll let the resident/fellow do key steps every day so why not ask that they just do the key steps themselves?

I don't care if the attending does the sternotomy, but I definitely want them doing the anastomoses.


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njtrimed

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I think it's unreasonable to request that no resident be involved in care, but totally reasonable to ask that the attending perform the key steps of the operation.

Attending surgeons make that decision of whether they'll let the resident/fellow do key steps every day so why not ask that they just do the key steps themselves?

I don't care if the attending does the sternotomy, but I definitely want them doing the anastomoses.


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Just curious: if you knew that the attending has essentially only stood on the other side of the table for the past decade, teaching the residents deemed most gifted to actually perform the procedure, would you make a different request? Or would you let the attending decide whether s/he is more capable than anyone else to do so?
 

Mad Jack

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You are allowed to request whatever you want. It doesn't mean someone has to honor it or entertain it. It's also a silly request. Mayo Rochester isn't known for both great training and a place people from all over the world fly to for surgery because the attendings kick residents out of the OR.
The vast majority of hospitals will allow you to refuse resident care intraoperatively. It's actually a recommended practice to protect the integrity of the physician-patient relationship, as consent is a cornerstone of care and refusing to provide or delaying care in the name of teaching is at odds with the goals of medicine. This isn't just a matter of opinion, this is a part of the core AMA Ethical Principles:

Ethical Principles

• Non-maleficence: the health and well-being of the patient should

never be harmed in the interest of training physicians

• Beneficence: intervening to benefit the well-being of the patient

AMA Opinion on Resident Physicians’ Involvement in Patient Care

• Appropriate supervision with graduated responsibility appropriate to

level

• Clearly identify residents as part of team supervised by the attending

• Patient should be able to refuse care from resident and transfer care if

desired


Some care is considered unreasonable for an institution to provide without residents, but surgery rarely falls under this, as residents are considered to be "assisting" the surgeon and the surgeon must be present for most operations anyway (and can often perform them faster than the resident by a good margin). Asking that an attending physician personally perform your operation is your right as a patient, and is completely in-line with the ethics of the medical profession.
 

Mad Jack

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http://www.aaos.org/downloadasset.aspx?id=31362

This ethics paper by the AAOS actually explores this very question, for the record. There are two sides of things, but if a surgeon refuses to operate because he can't do it without a resident, it could pose an ethical dilemma if the patient were to later file a complaint with the state medical board claiming the surgeon could have performed the surgery without a resident and their treatment was delayed or a negative outcome occurred because of the physician's failure to do so. It's kind of a dicey situation.
 
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Mad Jack

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Dat reading comprehension yo
Transfer of care is not required- it is only necessary if the attending physician is unable or unwilling to perform an operation without a resident involved. In the case of emergent care, attending refusal to perform the case when no transfer is reasonably available or when delay could have substantial negative outcomes would likely result in discipline by the state medical board. In regard to elective procedures, we had hospital policies about it that ethically placed beneficence ahead of attending autonomy- all patients had a full right to refuse intraoperative care by residents. This right wasn't exactly flaunted, but if a patient didn't want residents participating, they got their wish. On the medicine end of things, they could also be removed from the teaching hospitalist service once they were in the floors if requested (as we had both teaching and non-teaching teams on the floors, but such requests were impractical in surgery or stepdown/ICU).
 
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WildcatS11

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Earlier this week we placed a young lady who was a drowning victim on ECMO in the ED. Good luck getting this to happen at your average community hospital, especially in the ED within an hour or two of arrival.
 

Mad Jack

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Our hospital has no surgical non-teaching services so such a request could and would not be accommodated. Having trainees as a part of the care is a part of the blanket admission forms that patients sign when they come into the hospital.

Emergent care presents a whole host of different issues including EMTALA regulations.

For an elective operation, it is certainly within reason for a surgeon to refuse and transfer their care.

However, this is all really stupid and mostly an intellectual masturbation: I have yet to encounter a situation in 7 years where, after a reasonable discussion with the attending and resident and patient, a mutually agreeable conclusion wasn't reached. The overwhelming majority of patients are very comfortable with residents being involved in their care. Most misunderstandings come from concerns over TV stereotypes and media junk.
I can count on one hand the number of times it came up. It was never a big deal though- every single one was a cancer patient and the hospital treated surgical oncology patients like kings, and we had no shortage of full time surgical PAs to assist. Missing a teaching opportunity was viewed as a small price to pay compared to developing a reputation as a destination cancer treatment center.
 
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If there was actually something wrong with me, I would go (and have gone) to my school's affiliated teaching hospital. I would recommend the same for any member of my family. I also think it would be very hypocritical of me, a medical student, to disparage teaching hospitals.
 

CherryRedDracul

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At our hospital, if you ask to not have residents participate in your care, then you get punted to the nonteaching service made up of private practice folks, and let me tell you, you don't want to be on the nonteaching service. Each attending has to cover more patients on their own than a senior resident, and no one checks their work. And it shows.
Absolutely this. I've had patients transferred to me from non-teaching services and they become so thankful for not being under that care.

Also, after seeing hearing and seeing enough patients getting the weirdest treatments and management at non-teaching hospitals (a 6 week course of top-line antibiotics for bilateral cellulitis which was more obviously [to me] stasis dermatitis from chronic venous insufficiency), I would never step foot in a non-teaching hospital if I had the choice.
 

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I would not only always seek to receive care at academic centers, where the best doctors get to do the most and most unusual procedures but, I would absolutely NEVER ask to have residents not involved in my care. Not across the board. Maybe if one were awful and I found that out, sure. But just to ban all trainees from participating in care is not a good idea.

For one thing, surgery is a team sport. If you don't have a resident to help the attending, someone else is going to have to scrub in, or they are going to be working short handed. Some surgeries can be done more quickly and easily without the resident there. I've known attendings that would try to rush to get their appy's done before the resident could get there when they were in a hurry and not in the mood to teach. But anything more complex... somebody needs to hold that retractor and cut those sutures and man the suction and and and. If you refuse to let the surgeon have a resident to assist them, they may end up having to have a less skilled scrub tech or surgical nurse jump in to help. Not to say that OR staff aren't competent, but we aren't surgeons, not like the residents that we would be forced to try to fill in for because you chose to write "NO RESIDENTS" on your consent form.

Outside the OR, the residents are often the ones with the most recent information about new advances in their field, and their general medical knowledge is fresher and more up to date than that of their attendings. (I'm talking trends here. There are attendings who are up to date on everything that happens in every field, not just their own... or at least it seems that way from talking to them. And there are residents who don't know jack and can't write a discharge without someone holding their hand. Let's leave the outliers aside.)

Accidental cutting of the thoracic nerve is a thing that happens. Complications happen. But I'd say that they are more likely if you tie one of your surgeon's hands behind her back by refusing her the trainee assistant who she has been taking great care to instruct on precisely how to do the procedure you need.
 

cabergoline2

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I would not only always seek to receive care at academic centers, where the best doctors get to do the most and most unusual procedures but, I would absolutely NEVER ask to have residents not involved in my care. Not across the board. Maybe if one were awful and I found that out, sure. But just to ban all trainees from participating in care is not a good idea.

For one thing, surgery is a team sport. If you don't have a resident to help the attending, someone else is going to have to scrub in, or they are going to be working short handed. Some surgeries can be done more quickly and easily without the resident there. I've known attendings that would try to rush to get their appy's done before the resident could get there when they were in a hurry and not in the mood to teach. But anything more complex... somebody needs to hold that retractor and cut those sutures and man the suction and and and. If you refuse to let the surgeon have a resident to assist them, they may end up having to have a less skilled scrub tech or surgical nurse jump in to help. Not to say that OR staff aren't competent, but we aren't surgeons, not like the residents that we would be forced to try to fill in for because you chose to write "NO RESIDENTS" on your consent form.

Outside the OR, the residents are often the ones with the most recent information about new advances in their field, and their general medical knowledge is fresher and more up to date than that of their attendings. (I'm talking trends here. There are attendings who are up to date on everything that happens in every field, not just their own... or at least it seems that way from talking to them. And there are residents who don't know jack and can't write a discharge without someone holding their hand. Let's leave the outliers aside.)

Accidental cutting of the thoracic nerve is a thing that happens. Complications happen. But I'd say that they are more likely if you tie one of your surgeon's hands behind her back by refusing her the trainee assistant who she has been taking great care to instruct on precisely how to do the procedure you need.

In addition to what you said , having a resident do initial steps can actually help the attending in long and tiresome procedures like cabg of whipples...eg if a resident does a sternotomy in a cabg or laparotomy and kocherization in a whipple before the attending scrubs up , the attending will be fresh and less tired when it comes to doing the key anastomosis in cabg and doing key dissections during the whipple...
 
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ortnakas

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I might avoid teaching hospitals on July 1... mostly joking but not completely. Even in July, teaching hospitals are often probably a safer bet than non-teaching ones. As an aside, I always find it funny when patients absolutely insist on having their surgery performed at one facility over another when it's by the same surgeon at either location.

I probably would avoid my own teaching hospital... but mostly because A) it would be super awkward to have my close friends suddenly be my official treatment team and B) I'd like to retain some modicum of privacy from my school/attendings/etc. Obviously, if I were to break my ankle or develop appendicitis while I'm working at the hospital, I'd swallow my pride and get treated there.
 

SurfingDoctor

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Beyond physicians and medical trainees, some of the best nursing and ancillary staff also work at academic hospitals. All the best children's hospitals also have a nursing magnet status. So usually speaking, the care all around is better trained and educated.
 
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Beyond physicians and medical trainees, some of the best nursing and ancillary staff also work at academic hospitals. All the best children's hospitals also have a nursing magnet status. So usually speaking, the care all around is better trained and educated.
Nursing magnet is bull****. All of those awards are bull****. More educated, maybe. Better educated and better trained? Probably not. Does it matter? No.
 

SurfingDoctor

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All of those awards are bull****.
Well, usually with awards, follow prestige and higher rankings. Those in turn, attract higher caliber staff. I will say I think that ranking #1 versus #20 really doesn't have any meaningful difference in care, but having awards and being ranked is a general measure of the level of hospital care, especially since many awards having outcome metrics associated with them (though, the metrics aren't perfect). Yes, the awards individually don't mean a lot, but they do signify something collectively. Usually people aren't going to a hospital or school because it has the least awards.
 
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Lawper

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My answer is teaching hospitals for serious and urgent cases and private hospitals for less serious cases. However, even after reading this discussion, I'm not really sure about the disadvantages pertaining to trainee care. I realize that for surgeries, an attending supervising one case at a time is reasonable to maintain proper supervision, but besides that, I really don't see what's wrong with being treated by residents/fellow + students assisting. It's a collaborative and focused environment that ensures optimal treatment outcomes.

Are the disadvantages to teaching hospitals really due to fears that residents aren't experienced enough/skilled enough to handle complex procedures? Because they are still supervised by their seniors and attendings... and continually refine their skills and update their medical knowledge. So I don't see the disadvantages here at all, but I'm probably wrong.
 

SurfingDoctor

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So I don't see the disadvantages here at all, but I'm probably wrong.
The biggest disadvantage of academic hospitals has to deal with the non-profit status (even though that status is required to support training through Medicare). Because non-profit hospitals function on a lower financial margin than for-profit hospitals, non-profit organizations generally have to make concessions. These concessions are usually not designed to impact care, but in order to improve margins, sometimes the negative consequences of the concessions are overlooked and may impact care. I'm sure this happens at for-profit hospitals too, but I have witnessed several times at academic hospitals where concessions or monetary deficits resulted in sentinel events (or near misses). This is usually related to inadequate staffing or services for the level of patients.

http://www.aha.org/research/reports/tw/twsept2009teaching.pdf (see Chart 7 and 8)

That being said, this disadvantage of monetary support so rarely impacts care that for the most part, it is irrelevant (well at least for now)
 
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Crayola227

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Meh who needs an accessory nerve anyway!
Considering OP's just described that their mom just had hers injured and is having disability as a result, this joke of yours was not at all funny and just in poor taste.
 

username456789

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Absolutely this. I've had patients transferred to me from non-teaching services and they become so thankful for not being under that care.

Also, after seeing hearing and seeing enough patients getting the weirdest treatments and management at non-teaching hospitals (a 6 week course of top-line antibiotics for bilateral cellulitis which was more obviously [to me] stasis dermatitis from chronic venous insufficiency), I would never step foot in a non-teaching hospital if I had the choice.
Bilateral lower extremity cellulitis does not exist. It was indeed stasis dermatitis. But believe me, the teaching services where I did residency were just as clueless as non-teaching services when it came to this. I have had to teach and reteach this to residents and attendings of all services.
 
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