Wednesday, October 17, 2007


A while ago I wrote about choosing a surgeon. Related is the decision to have care (surgery, of course, would be the subject here) in a community hospital, as opposed to the famous medical center. A commenter on a recent post referred to the BHD, the "big hospital downtown." I'll call it the BFH and let you figure out what I mean.

Like everyone else during training, when I was at a BFH learning to be a surgeon, I basked in the belief that I was at the only place a person could go to get good care. I thought derisively of the silly referring docs; so did my confreres. I even wondered how I'd be able to care for my patients when I didn't have a retinue of people following me around happily (or not) doing whatever I asked, as I did when Chief Resident. It took a minute or two in practice to disabuse myself of the mythology.

Think about it: if those BFH's are so wonderful -- and in many ways they really are -- ought it not be the case that the people they train to go out into the world are also pretty damn good? Is it only within the great walls that folks have mystical powers? Powers that poof when passing the portals on the path to private practice?

Wisdom may be generated in the BFHs but the whole idea is for it to flow outward. Most treatments for most diseases have been pretty well worked out, and the information is readily available. And as it evolves, the news spreads. If it were really the case that the only people who know what they're doing reside within a BFH, wouldn't that mean that they'd failed in their central mission? That they'd created incompetents and loosed them upon the populace?

The fact is that when I began my practice, I felt I'd been very well trained; nor was it self-delusion (trust me, I'm a doctor). And, by golly, I found it was easier to get things done, to provide personal and expeditious care when all the BF accouterments were stripped away. With academic largess come layers, complexities, and, yes, arrogance. The most stunning thing in the comment I referenced above was the demand by the BFH that care be transferred up front, sight unseen. While I doubt such a thing is universal, it's revelatory.

It's decidedly NOT my position that people should avoid the BFH. Were that to happen, the system would grind to a halt in half a generation. And clearly, for very specialized care -- transplants, for example -- such places are the only places to be. It's just that for most care, given a little time to check out the local folk, I believe strongly -- based on years of observation and participation -- that excellent care is available in most community hospitals; people should feel good about that. (So as not to upset anyone, I'll stop short of saying that for the commonplace, care is better in the community hospitals; but that's what I believe. Given the right players.)

[In re-reading my earlier post, linked via the fifth word of this one, I realize I've said much the same, in different words, previously. This means two things to me: 1) it's tempting to re-write a lot of what I've written in this blog, and 2) I'm starting to bang against the bottom of my brain. It bodes ill, futuristorically.]


Anonymous said...

sorry to disagree but the data shows that trauma patients belong in a bfh level 1 center and have worse outcomes in the "community hospital"

arrogance is a 2 way street..I've seen just as many arrogant physicians with smaller kingdoms in the community hospitals

23 year healthcare veteran

Sid Schwab said...

You'll note, anon, that I said "commonplace." I don't consider trauma -- especially major trauma -- commonplace. Readers of this blog will have seen my comments on that elsewhere; I said here, and I've said aloud in medical staff meeting, that if I were shot or run over at the entrance to our local ER I'd want to get transported to the Level 1 center down the road. No question.

37 year healthcare veteran

Rob said...

Aricept 10mg PO qD.

Helps a lot.

I am with you on this as well. There are specialties in which BFH is better (for pediatrics especially), but for routine care, the system actually makes the care worse at most teaching hospitals. The patients feel disenfranchised and are thrilled when we start caring for them as a person.

10 years bringing my dog to the Vet.

DDx:dx said...

One reason I was so happy with UW was that it, at least, SAID it valued and respected the family doc/ primary care doc...And that respect fostered my faith in doing multiple referrals to BFH UW over the years. I always felt a connection in the treatment and the records came back with the patient...I felt I got excellent phone advice and consults from 300 miles.
My hesitation is that I now sense an abandonment of Family Medicine. I think if you got the BFH muckymucks in a room they'd all nod sadly that, yes, Family Medicine is dying. So Sorry.
So, maybe off point, but the BFH has a place in the heirarchy of medicine and it should be to educate, and to lead, by clinical research and policy advocacy.
I feel it has failed in the latter from the primary care perspective.

Anonymous said...

Ummm, I have nothing of value to add to this discussion except - I got my copy of Cutting Remarks in the mail yesterday and I can't put it down. Love it!!

46 year going to the doctor vet

Greg P said...

This seems to be going off in the direction the various ads from medical centers suggest they should: "Go to Shazam Medical Center, where the best care happens."

The reality is, you are not helped or made better by the walls, the computer systems, the fancy hardware and software of the latest technology or even the administration or the hospital's board. You are made better by the people that work there, and the better health care workers, doctors, nurses, techs, other professionals are not better because they say they're better.

shadowfax said...

I saw a lot of substandard care given in the Best Freaking Hospital in the World when I was a resident. (Hint: It's in Baltimore and has a dome) Much of the substandard care was delivered by overtired and incompletely-trained residents given responsibility beyond their skills (myself included -- no sanctimony here). Great way to learn, not great care in many cases.

Anon is in some degrees right -- if I had cholangiocarcinoma, I'd go to the local BFH. But I'd let Sid take out my gallbladder if that's all I needed.

BTW, much of the trauma care at the BFH down the road is trapped in the 1970s thanks to a certain neurologist-turned-trauma-doc. Maybe when he leaves it might improve, but it's all rotating tourniquets and leechcraft now. The surgeons there are great, no doubt. But I have confidence that our modern-trained ER docs fresh from residency will do a better job with your GSW than the R2s at the BFH.

Sid Schwab said...

shadowfax: interesting. I don't doubt that you're right. Unless things have changed, though, I'd rather be at BFH if it came to the need to get to the OR in a hell of a hurry, with a full team available, along with blood and instruments... It's not the ER care, but what comes after, within the first few minutes. Or so I'd say...

And yeah, if I saw a cholangioCA, I'd send it along, too.

Buckeye Surgeon said...

Anon- Your comment is absurd. Trauma is a different animal altogether. Level I trauma patients will end up in a level one trauma center, no questions asked. Protocols are in place nationally to ensure this.

Other cases to send downtown:
1. Cholangiocarcicnoma
2. Major liver resections
3. Transplant patients and all their complications
4. Low rectal tumors/ileoanal pouch cases
5. Consider necrotizing pancreatitis cases; the resource expenditure will exhaust you and the community hospital
6. Family or patient request
7. Complicated enterocutaneous fistulas (for the reasons stated in #5)

1 year healthcare veteran.

Misha said...

I am weighing in from the midwest. Our CEOs tell us that patient expectations are VERY high here. I think that is interesting because I have always generalized midwesterners as more down to earth/easy-going and easterners/westerners to be more demanding. I am a frequent customer of health care and especially in peds I find the individual care when I travel to my BFH (UIOWA) to be wonderful. I spend much time at the hospital meeting others from around the state AND around the world. They RAVE about the care and especially the staff at all levels. It is interesting that you can go to a large institution and get what you believe to be individual attention and stellar customer service. I think the difference between the BFH and the smaller, community hosptials I visit is in what the professionals expect from one another. The BFH staff seems to have a goal of being excellent and they hold one another to that goal. I don't see that in my smaller, community health care observations. They seem to be very comfortable with mediocrity. I sense some frustration on the part of my specialist & team when I talk about my frustrations of getting good care once I return home! Just my observations.

borborygmi said...

The rush to transfer the critically ill to the BFH has a distinct downside - especially in trauma. It's called delay in source control. More than I care to count have I heard about patients sent out of my small hospital by the ED because they were "too sick to stay" or "too much for us to handle here", or because the ED docs were more enamored with following the triage protocol than treating the patient appropriately. The next thing I hear about how they didn't make it to the BFH in the copter, or got there nearly dead because nobody thought to get the bleeding stopped or the shit out of the belly before transfer.

Source control is the great equalizer where the commuity surgeon can save a life that the BFH guys can't simply because of the time factor involved.

If I were shot I'd want the closest decent general surgeon who understands source control to have at me first (if there are any left, what with everyone nowadays going into bariatrics or breast surgery or some other hyperspecialized field), then I'd want to be transferred to the BFH with the hot and cold running ICUs, interventional radiologists, and sleep-deprived residents with MRSA smeared all over their scrubs.

walt dandy said...

Another thought provoking post. I'm getting more and more interested in reading your book. Here are some of my observations. In our training program we spend equal amounts of time at the BFH and a community hospital. The decisions made by the private guys seem driven by matters of practicality and pragmatism and things are done very efficiently. The philosophy can be summarized as "put the tumor in a bucket, and ask questions later." At the BFH there are extensive (and often endless) discussions about how the patient is to be positioned, how much steroid is the right amount, what genetic profiles should and should not be performed on the tumor, etc. etc. etc. Sometimes I find myself annoyed at the waffling and sometimes seemingly pointless discussions about minutae when it seems we should just get to work and get it done. Not to imply that one should go charging into an operation with reckless abondon, but there is clearly a point when it is time to stop talking and start working. On the other hand, I agree about the trauma. For the purposes of illustration, lets say someone shows up with a giant subdural hematoma at 2am. Here is how it goes at the community hospital: 1. Call the house supervisor and tell him/her we need to take a patient to the OR emergently. 2. Wait for the scrub and circulating nurse to come from home 3. Once they arrive, field 20 questions about what instruments will be needed. 4. Make an incision 1 hour after you saw the patient (on a good night). At the BFH: 1. See patient in trauma bay 2. Turn to OR charge nurse (who came down to see if OR will be needed) and tell him/her that we need to go right now. 3. Anesthesia (who also came down to see) switches the patient from trauma bay monitors to transport monitors 4. Get in the elevator and roll into the OR where the scrub personnel already have the instruments open and ready 5. Make an incision 10-15 minutes after deciding to go to the OR.

P.S. If anyone is interested in medical/surgical history google the real Walter Dandy, who was a pioneer at the BFH in Baltimore with the dome.