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Trust in teaching hospitals

My mother, who worked in nursing for 40 years, used to say, "If I ever get sick, make sure you get me to a teaching hospital right away." She wanted an academic medical center, with residents and medical students all over the place, and she knew what she was talking about.

So I always assumed that everybody knew this: that you actually want a bunch of trainees in the environment, questioning doctors' assumptions and asking patients the same questions over and over.

My experience, however, shows that many otherwise intelligent people think they should stay far away from anybody in training. I figure this perspective is based on TV shows and urban myths.

But let's look at the data. A 2003 study by the Association of American Medical Colleges summarized the results of 23 studies between 1989 and 2004 comparing various measures of quality in teaching versus nonteaching hospitals.

So-called "process measures" of quality, like the percentage of patients with heart attacks who receive aspirin on admission, were better in teaching hospitals in all but one of the studies. In the remaining study the numbers were similar.

Death rates, adjusted for severity of illness, were lower in teaching hospitals in nine studies, higher in teaching hospitals in one, and the same in five.

Let's also try a thought experiment. You've probably heard of Massachusetts General Hospital, which some people believe is the best hospital in the world. Royal families go there. Teaching conferences from the hospital are published in the New England Journal of Medicine, arguably the most influential medical journal in the world. Probably all of us would be comfortable with being admitted to that hospital, should the need arise.

Now imagine that hospital without any teaching. No fellows, no residents, no medical students, no grand rounds, no teaching conferences. It obviously would no longer be one of the best hospitals in the world.

You might say, how about being admitted to a teaching hospital but staying away from the residents and the students? They're young and inexperienced, and they sometimes make mistakes, and sometimes they even look stupid. Surely they can't be good for me?

Well, maybe. But I don't mind students and residents taking care of me, and apart from altruism there are good reasons.

The more people you have thinking about your case, the more eyes on the chart and hands poking at your belly, the less likely it is that something will be missed.

This is why you get asked the same set of questions by the nurse, the student, the resident and the attending: it's a life or death issue. We all talk to each other and compare notes. We try to maximize the accuracy of information. And people change their stories over time: they remember things, and refine their impressions of past events. They even stop or start lying.

This is related to why you get slightly different or even contradictory stories from the various providers who take care of you: it's not that we're stupid, it's just that we each have a different opinion of what's going on and we're arguing with each other, behind the scenes, in the chart and in person. Just like in the legal system, where adversarial arguments ideally reach a higher level of justice, we bash our opinions together in a field of uncertainty to get to a more fundamental truth. Pardon the mixed metaphors.

It might be comfortable to have only a nice, smiling Marcus Welby stop by your hospital bed once a day to give you a reassuring comment about how well you're doing. But that's not what makes the highest quality care.

Dr. Mike Merrill is an internist and author practicing in Buffalo. His column appears once a month on this page. E-mail your comments to him at driconoclast@yahoo.com

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