Commentary

A medical center is not a hospital

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I use to be a hospital guy. I was only a few days into my third-year medicine clerkship in medical school nearly three decades ago when I fell in love with the hospital and knew I was going to be an internist. The hospital wasn’t called a medical center back then. It was a fascinating and magical place, where internists were fired in the furnace of rounds, night call, and morning report. I loved the association with the great case, the flush of excitement that accompanied the difficult diagnosis, the hard-earned annual promotion through the hierarchy of trainees seeking the rarefied air of the attending physicians. We bonded as fellow house officers more tightly than with friends outside the hospital. We prowled the wards, intensive care units, emergency room, and laboratories and never slept. The hospital was the most exclusive of clubs, and our training granted us lifelong membership.

A humming beehive of academic activity, the hospital was also a web of powerful social relationships. Everybody knew everybody, from the hospital CEO to the night security officer. The nurses called you by your first name and worked with you for weeks at a time, fostering mutual respect and sometimes even affection. In those days, nurses actually nursed their patients, spoon-feeding them broth with their medications, washing them in bed and bathroom, holding their hands and heads. Patients came to the hospital to be diagnosed and treated until they recovered from whatever illness had felled them. They stayed long enough so that you knew them and their families as well as you knew your own.

I have been a general internist and clinician-educator for 23 years, working in two university hospitals and one community hospital. That’s more than seven generations of house staff with whom I’ve toiled and learned. Somewhere along the way, I became increasingly aware that teaching clinical medicine to students, interns, and residents was getting harder and harder. The patients were sicker and stayed only 3.2 days in the hospital. What we were teaching wasn’t how to diagnose and treat diseases, but how to manage only their most serious complications—the respiratory distress from pneumonia, the ketosis of uncontrolled diabetes, the septic shock from infections. The wards became intensive care units, and the critical care units the province of “intensivists” who were more adept than we were at taming all the machinery and technology. We struggled to keep up with the unending deluge of arcane demands from the accreditation organizations watchdogging our teaching efforts. We pretended that we somehow distinguished teaching rounds from working rounds, and documented the silliness in computer files. Medical education slowly slipped from being a calling to folks like me, finally succumbing to bureaucratic lunacy. The pace of teaching and caring for acutely ill patients became intolerable. Rounds went from the bedside to the classroom to the cell phone. The house staff were getting cheated out of the whole point of residency—the miracle of turning medical students into attending physicians in a little over a thousand days.

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