Would you go to a "teaching hospital" for your parent?

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

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username456789 said:
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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I'm sure they all appreciated your humble expertise.
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SurfingDoctor said:
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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Great thanks! Really useful post and saved the article as reference
 
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Psai said:
Nursing magnet is bull****. All of those awards are bull****. More educated, maybe. Better educated and better trained? Probably not. Does it matter? No.
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My wife, kids, and I only go to teaching hospitals. My parents go to a teaching hospital. We try and get my in-laws to go to one, but they won't drive there.

I have never had a patient refuse resident care. I have had some ask me about it, in which case I explain that most surgeries are better done by two people and I reassure them that I will be there (I run one room at a time).
 
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For something major like CABG I would make sure that the surgeon you think is going to perform the surgery actually does it. Before I was in med school, when my dad needed bypass surgery we went to a very famous heart clinic where we thought this famous surgeon would be doing the procedure. He did not inform us that residents would be involved. Ended up that the residents did the procedure with the surgeon supervising. My dad did not have a great outcome. If we could do it all over, we would have chosen a cardiovascular surgeon in private practice, without resident involvement.
 
Donald Juan said:
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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but but but on grey's anatomy
 
Light Yagami said:
For something major like CABG I would make sure that the surgeon you think is going to perform the surgery actually does it. Before I was in med school, when my dad needed bypass surgery we went to a very famous heart clinic where we thought this famous surgeon would be doing the procedure. He did not inform us that residents would be involved. Ended up that the residents did the procedure with the surgeon supervising. My dad did not have a great outcome. If we could do it all over, we would have chosen a cardiovascular surgeon in private practice, without resident involvement.
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Complications happen. The outcome could have been the same regardless of who did the procedure.
 
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Mad Jack said:
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.
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What a disappointing statement coming from someone in the field....with that you are doing a disservice to medicine and your loved one. Glad that the majority of patients don't share your line of small thinking or else medicine would be doomed
 
Dr.Smexy said:
What a disappointing statement coming from someone in the field....with that you are doing a disservice to medicine and your loved one. Glad that the majority of patients don't share your line of small thinking or else medicine would be doomed
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If you'd seen some of the amateur mistakes I've seen, you wouldn't be too thrilled at the prospect either.
 
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Mad Jack said:
If you'd seen some of the amateur mistakes I've seen, you wouldn't be too thrilled at the prospect either.
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Every mistake will likely create lasting memories of how not to repeat it and these residents will be the doctors that continue taking care of you and your loved one in the future. Small thinking along that line only care about the present and not the future...I want to see how happy you will be when you're a resident and your 5th patient in a row refuse to let you participate in their care. I'm sure you'll be over the moon since you won't be making any mistake and learning for that matter
 
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Mad Jack said:
If you'd seen some of the amateur mistakes I've seen, you wouldn't be too thrilled at the prospect either.
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Man it will suck for you when you find out that you're one of those people making those amateur mistakes
 
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Mad Jack said:
If you'd seen some of the amateur mistakes I've seen, you wouldn't be too thrilled at the prospect either.
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Yes, amateur mistakes are made by residents. In the setting of a system where those mistakes are being supervised by senior residents, fellows, and attendings that are used to dealing with and correcting those mistakes. When you disrupt the typical workflow of a system, you create problems because you've bypassed your usual quality control measures. When amateur mistakes are made by attendings, and trust me, I've seen plenty of them, they often go uncaught.

As a minor example, my chief popped into the case that my intern was doing just to check on him, and to be helpful he put in the orders while the intern was operating. Only he made a mistake and forgot to reorder the patient's antibiotics. Bummer, but mistakes like this of ommission or comission are quite common and to be expected. If my intern had done this, I probably would have caught it because i will often look over his orders, and the chief checks in as well, however in this situation it went uncaught for far too long.

With regards to surgery, there are relatively few surgical procedures that I perform that can be done with 2 hands. I tell that to the patient, and tell them that the other 2 hands in that case can be a scrub tech (who rarely is involved in assisting at an academic center, unlike at a private hospital), PA, or MD with additional surgical training.
 
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Dr.Smexy said:
Every mistake will likely create lasting memories of how not to repeat it and these residents will be the doctors that continue taking care of you and your loved one in the future. Small thinking along that line only care about the present and not the future...I want to see how happy you will be when you're a resident and your 5th patient in a row refuse to let you participate in their care. I'm sure you'll be over the moon since you won't be making any mistake and learning for that matter
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Knowing they won't make the same mistake again is little solace when your loved one has lost life or limb.
Psai said:
Man it will suck for you when you find out that you're one of those people making those amateur mistakes
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I wouldn't trust me to take care of my family. I'm well aware of my personal limitations and am in no way better than any other physician in training- I'm astoundingly average. But for my family's surgery? I don't want an average trainee, I want an exceptional attending.

Pre and post-op care and whatnot, I'm chill with residents being fully involved. Hell, even for medical care 95% of the time. But surgery is different unless it is something minor or incredibly routine like an appendix or a gallbladder.
 
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Mad Jack said:
Knowing they won't make the same mistake again is little solace when your loved one has lost life or limb.

I wouldn't trust me to take care of my family. I'm well aware of my personal limitations and am in no way better than any other physician in training- I'm astoundingly average. But for my family's surgery? I don't want an average trainee, I want an exceptional attending.

Pre and post-op care and whatnot, I'm chill with residents being fully involved. Hell, even for medical care 95% of the time. But surgery is different unless it is something minor or incredibly routine like an appendix or a gallbladder.
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How do you think exceptional attendings get that way? The days of residents running roughshod all on their own are, appropriately, going away. There is substantial regulatory pressure for increased intraoperative oversight of trainees.

I think the point people are making is that the best care is an exceptional attending working with a resident / fellow.
 
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ProfMD said:
How do you think exceptional attendings get that way? The days of residents running roughshod all on their own are, appropriately, going away. There is substantial regulatory pressure for increased intraoperative oversight of trainees.

I think the point people are making is that the best care is an exceptional attending working with a resident / fellow.
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^ This. It also applies to medical care too. If you want your family member who is critically ill to receive the best care and attention possible, you need trainees with in house attending support who can troubleshoot any issue the moment it arises day or night. These are the benefits of teaching hospitals and the care they provide.

http://www.ncbi.nlm.nih.gov/pubmed/22564956
http://www.ncbi.nlm.nih.gov/pubmed/12413375

However, these staffing models also cost a lot of money for the institutions. This balance of care and cost are something that many academic centers are struggling with, especially since many academic centers are supported by Medicare or Medicaid, which reimburse poorly for services provided, yet the payments are linked to outcomes. So to get the best payments, you need top quality care, which cost money whose payer offers poor reimbursement. Kind of a vicious cycle. But there is also a lot of bloated care, so there is fat to trim. Deciding what to trim that won't impact patient care is the tough part.

https://www.medicare.gov/hospitalcompare/linking-quality-to-payment.html
http://health.usnews.com/health-new...fs-is-obamacare-to-blame-for-hospital-layoffs
 
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I think there's a middle ground - if you make a stink that you're worried about trainee involvement, and that you want the attending very involved, in my limited experience, that message tends to get passed around to all the staff and anytime said stink was made I think we all sit up a little straighter. Basically, you can go to a training hospital and reap all its advantages while still putting everyone on notice that yours is the family to be very careful with. Attendings tend to be sensitive to potentially litigious patients. That's definitely where supervision gets stepped up.
 
sliceofbread136 said:
Maybe find a safe space or w/e it's called? We'll get through this together!
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I was more or less joking but maybe you are that ******ed. Acknowledging that it's uneccsary or rude to make fun of someone's injury to their loved one isn't being politically correct. I'm not triggered. In fact I'm wildly bored waiting to start my next rotation. I didn't say what you did was illegal or even should be able to be punished by some overbearing administration. But that doesn't mean we can't call you out for being a dick. So no I don't need a safe space. Feel free to act however you want. But don't throw around accusations if you don't like the response you get.
 
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I dunno, perhaps my experience is atypical but the attendings in medical school didn't seem to be especially involved in most procedures. Sure they were scrubbed in, but appeared to be more supervising with a touch of assisting. The senior residents were the ones doing the majority of the procedure. Contrast this with community surgeons who do every step every time. Seems like for the more routine procedures, the community guy doing his 8th lap chole that week (500th overall) might have better outcomes than the 5th year resident doing his 30th total (2nd that week). Now obviously if you need something less common, I'd rather the university that does 20 a year versus the community guy whose done 2 since residency (TIPS procedure being the thing that comes to mind most readily).

My approach (and what I tell my patients) is for routine things, stick with your local community hospital. For complicated or rare issues, go to the University.
 
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I guess this highly depends on a lot of factors, but i still think that I would a lot and what it needs to for my parents.
 
VA Hopeful Dr said:
I dunno, perhaps my experience is atypical but the attendings in medical school didn't seem to be especially involved in most procedures. Sure they were scrubbed in, but appeared to be more supervising with a touch of assisting. The senior residents were the ones doing the majority of the procedure. Contrast this with community surgeons who do every step every time. Seems like for the more routine procedures, the community guy doing his 8th lap chole that week (500th overall) might have better outcomes than the 5th year resident doing his 30th total (2nd that week). Now obviously if you need something less common, I'd rather the university that does 20 a year versus the community guy whose done 2 since residency (TIPS procedure being the thing that comes to mind most readily).

My approach (and what I tell my patients) is for routine things, stick with your local community hospital. For complicated or rare issues, go to the University.
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I have no idea when you finished medical school, but at least where I work, there is increasing pressure for the attending to be more involved. Being scrubbed in and directly supervising a resident is acceptable. The attending knows the resident, knows his/her skill level, and can jump in immediately if something seems to not be going right. The more dangerous situation, which is happening less and less nowadays, is when the resident is operating and the attending is not in the room.

I suppose we are all affected by our experiences. As an academic surgeon, my partners and I have had many situations, both in training and in practice, where we are called upon to address complications caused by a community surgeon doing a "routine procedure." As in academia, there are good and bad surgeons in the community. I am sure as a primary care physician, you have a good idea who in the community is good and who isn't and can guide your patients appropriately.
 
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ProfMD said:
I have no idea when you finished medical school, but at least where I work, there is increasing pressure for the attending to be more involved. Being scrubbed in and directly supervising a resident is acceptable. The attending knows the resident, knows his/her skill level, and can jump in immediately if something seems to not be going right. The more dangerous situation, which is happening less and less nowadays, is when the resident is operating and the attending is not in the room.

I suppose we are all affected by our experiences. As an academic surgeon, my partners and I have had many situations, both in training and in practice, where we are called upon to address complications caused by a community surgeon doing a "routine procedure." As in academia, there are good and bad surgeons in the community. I am sure as a primary care physician, you have a good idea who in the community is good and who isn't and can guide your patients appropriately.
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2010, though admittedly the surgery program at my school is notoriously bad. The only thing I ever saw residents do unsupervised were central lines, and then only by PGY-3 surgery residents or above (which seems quite reasonable).

Y'all getting the complications is no surprise. Lap chole has a known risk of bile duct damage (low, but not zero). If that happens, most community surgeons don't have the experience to repair the damage so those patients get shipped out. I see this as similar to ureter damage that every OB will cause at least once in their career - calling in the urologist to fix it isn't a sign that they are a bad surgeon, merely that they know someone else can do the job better. The thing you have to remember is that for every complication from a routine procedure you're seeing, there are likely orders of magnitude more patients that don't need your expertise.
 
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VA Hopeful Dr said:
2010, though admittedly the surgery program at my school is notoriously bad. The only thing I ever saw residents do unsupervised were central lines, and then only by PGY-3 surgery residents or above (which seems quite reasonable).

Y'all getting the complications is no surprise. Lap chole has a known risk of bile duct damage (low, but not zero). If that happens, most community surgeons don't have the experience to repair the damage so those patients get shipped out. I see this as similar to ureter damage that every OB will cause at least once in their career - calling in the urologist to fix it isn't a sign that they are a bad surgeon, merely that they know someone else can do the job better. The thing you have to remember is that for every complication from a routine procedure you're seeing, there are likely orders of magnitude more patients that don't need your expertise.
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True. Those complications I understand. The ones I am thinking of right now, however, are directly related to poor patient selection, poor surgical technique, or refusing to care for a routine complication (like wound infection). Again, this is not every community surgeon, but there are bad ones, and patients need help guiding them to surgeons who are not going to cause harm.

I am not trying to argue that academic centers are better for everything. I would argue that they are better for complex stuff and at least equivalent for routine stuff. In my opinion, the presence of residents in the operating room is not a sign of poor care delivery as long as the resident is doing procedures that are appropriate for their level and with proper supervision.
 
jw3600 said:
I was more or less joking but maybe you are that ******ed. Acknowledging that it's uneccsary or rude to make fun of someone's injury to their loved one isn't being politically correct. I'm not triggered. In fact I'm wildly bored waiting to start my next rotation. I didn't say what you did was illegal or even should be able to be punished by some overbearing administration. But that doesn't mean we can't call you out for being a dick. So no I don't need a safe space. Feel free to act however you want. But don't throw around accusations if you don't like the response you get.
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Lol wow for someone not triggered you seem to be awfully mad
 
sliceofbread136 said:
Lol wow for someone not triggered you seem to be awfully mad
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Stop trying to ascertain my mood or my tone from written text. This isn't redditor or 4chan; your immature online defense mechanisms make you look even more foolish.
 
jw3600 said:
Stop trying to ascertain my mood or my tone from written text. This isn't redditor or 4chan; your immature online defense mechanisms make you look even more foolish.
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I think you should calm down and try to keep the discussion civil like I am. No need to get so emotional my friend
 
I would take my parents to both - and I did it several times.
My mother undergone an open TAH+BSO with sacrocolpopexy because of giant leiomyoma in a teaching hospital several years ago. It was a very busy and crowded central ob-gyn hospital. A last year resident who was a honest and kind guy performed the surgery. I even did not know the attending in charge. We had an uncomplicated surgery and my mum did well since then. She underwent several nasal polip excisions in a major university hospital and we admitted to private operation by one of the well-known professors of there. Her polips recurred several times. Then she underwent an another excision in the university hospital where I was in its medical school. Her last surgery was successfull and never recurred her polips again. Now she is on follow-up for DM, HT, obesity and gonarthrosis in my current hospital (a town hospital with one attending in every branch).

For the results of surgery I want to make it clear that complications happen. Low complication rates not always result of good surgery, sometimes it reflects good patient selection or it would be a spoof of a good advertisement company. Long degree lists may not guarantee the result of surgery. And one can ensure himself about a yesterday-started resident can never take a case and kill him on the table. If someone is allowed to perform the whole case or participate in or prepare the case for attending, because of his/her competence in it. We live in medico-legal age. No attending wants to get sued because of some resident's mistake. I think the resident or fellow intervention holds no effect on the results of surgery.

In every kind of health care, the major expectation of the patients and relatives should be the honesty and attention. The best results may be obtained by a good communication under the common work plan of the health facility. I think most errors are results of break down of the usual diagnose and treatment pathway. And the best results of surgery can never be perfect. It is surgery. Complications are part of it. Both in private, academic, teaching or non-teaching.
 
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Hell, I've worked in both types of hospitals and I would choose the teaching hospital every single time. It's true that you might risk a resident making a mistake, but the **** that I've seen in these private institutions is mind-boggling. This is coming from the perspective of a pharmacist, where at least I had an opportunity to intervene with a med issue. Who the hell knows what may go on in the OR.
 
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Yes for one simple reason - teaching hospitals tend to never be understaffed unlike most of the major hospitals.
 
Spectre of Ockham said:
Yes for one simple reason - teaching hospitals tend to never be understaffed unlike most of the major hospitals.
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I'll give you a partial point- teaching hospitals usually have significantly more doctors... but that's counting trainees. This is a major plus outside of 9-5 hours because there's certainly better physician staffing at that point than most (smaller) community hospitals, who might (at best) have a hospitalist, ED physician, +/- Ob/anesthesia available in house. Larger community hospitals *might* also have a surgeon or two around, but that's about it.

That said, during the daytime, the extra manpower from the physician standpoint probably doesn't make too much of a difference.

On the other hand, community hospitals frequently pay better for ancillary staff and are often better staffed with nurses, PTs, etc etc. This probably makes more of a difference to the day-to-day patient experience than any amount of residents around.
 
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Raryn said:
On the other hand, community hospitals frequently pay better for ancillary staff and are often better staffed with nurses, PTs, etc etc. This probably makes more of a difference to the day-to-day patient experience than any amount of residents around.
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This is absolutely true. Any sentinel event I've ever seen has been the result of lack of supervision and/or lack of eyes available for patient monitoring. Given the cost-cutting necessary in most teaching hospital to maintain operating margins, I have seen the latter be sacrificed with unfortunate consequences. It is not to say sentinel events don't happen at community hospitals, they do, but those sentinel events are usually more do to lack of experience/expertise and not nursing staff ratios, at least in my experience.
http://archive.ahrq.gov/research/findings/factsheets/services/nursestaffing/nursestaff.html
 
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Teaching hospitals are great for specialty training or getting yourself prepared to enter a subspecialty, but when it comes to primary care (gen surgery included) it does its trainees a disservice. You make your money as a physician doing the bread and butter cases of your specialty and large academic teaching hospitals are notoriously bad at getting residents enough of these experiences.

So if my family members needed a basic procedure I would stay clear of the teaching hospital - unless there happens to be a surgeon/physician I have worked with or was recommended to me by an anesthesiologist in the area (those guys are gold when it comes to finding a good surgeon).
 
IsWhat said:
You make your money as a physician doing the bread and butter cases of your specialty and large academic teaching hospitals are notoriously bad at getting residents enough of these experiences.
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Was wondering where you were getting your opinion from, but I see you're just a medical student.

I will as someone who trained at two separate academic teaching hospitals, say that is not the case at all. You will get the bread and butter cases until your eyes blur because that is what keeps the hospital running. The exception is you will also get all the zebras as well, unlike at a community hospital.
 
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IsWhat said:
Teaching hospitals are great for specialty training or getting yourself prepared to enter a subspecialty, but when it comes to primary care (gen surgery included) it does its trainees a disservice. You make your money as a physician doing the bread and butter cases of your specialty and large academic teaching hospitals are notoriously bad at getting residents enough of these experiences.

So if my family members needed a basic procedure I would stay clear of the teaching hospital - unless there happens to be a surgeon/physician I have worked with or was recommended to me by an anesthesiologist in the area (those guys are gold when it comes to finding a good surgeon).
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Gen surg is not primary care. There are more than enough appys, gallbladders, hernias, chf, pneumonia, etc. at large academic teaching hospitals. I'm not sure what you're talking about.
 
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IsWhat said:
Teaching hospitals are great for specialty training or getting yourself prepared to enter a subspecialty, but when it comes to primary care (gen surgery included) it does its trainees a disservice. You make your money as a physician doing the bread and butter cases of your specialty and large academic teaching hospitals are notoriously bad at getting residents enough of these experiences.

So if my family members needed a basic procedure I would stay clear of the teaching hospital - unless there happens to be a surgeon/physician I have worked with or was recommended to me by an anesthesiologist in the area (those guys are gold when it comes to finding a good surgeon).
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...No. Was at a large academic teaching hospital for med school, at another one for residency, and we do not lack bread and butter cases in the slightest.
 
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