Should I be here?

Every hospital has things it does well. Most of the time the hospital does patient care well. There are, however, many hospitals that don’t provide adequate care. They don’t for a variety of reasons. Some of these reasons may directly affect your health others affect it indirectly.

Physician Privileges
As indicated in prior posts, no medical school prepares a physician for the actual practice of medicine. Medical school prepares a physician to study to care for patients. Then, after completion of a prescribed course of study a physician is eligible to take a certifying exam in a specialty.

Each hospital maintains a set of requirements that a physician must meet in order to have privileges to practice at that hospital. Sometimes the criteria are rigorous and strict sometimes they’re relaxed. Sometimes the bar is set so low that they’re virtually nonexistent. Essentially every certifying board in the US states emphatically that passing the exam indicates only that the physician has met a minimum level of training and skill. Yet many hospitals allow physicians who cannot achieve even the minimum level of skill to have privileges. You should re-read that again- hospitals allow physicians to practice who cannot meet minimum training and skill levels. You read that right. That’s what is means to have a physician who is not board certified. (There are a few legitimate reasons not to be board certified. But usually it means more than the physician just doesn’t pass the exam.)

Common examples are trainees who are allowed to “moonlight” in emergency rooms (ER). The hospital wants to have an emergency room so that local physicians can send patients. Yet local physicians are unwilling to staff the ER, or even pay to have qualified physicians cover shifts in the ER. Additionally, hospitals use the ER as a “gateway” to admission. This is good for business since every admission represents profit (the hospital would close if it could not provide inpatient services without financial loss). Thus when you are most vulnerable and have the least choice in your physician you are most likely to have an unqualified physician who may actually kill you.

Another common example is using inadequately skilled physicians from other specialties. Perhaps the most common is tertiary-care hospitals that use family practice physicians as the primary ER physician. While a family physician may do great care in the office I certainly don’t want one taking care of me during my heart attack or after a car wreck or gunshot wound.

Finally, hospitals may simply allow physicians to have privileges that are counter to community values. Would you want a recovering drug addict or alcoholic as your doctor? How about a child abuser? Many state boards of medicine maintain an on-line database of physician discipline. These databases can be checked. Even states without a database will respond to a written request for information (sometimes a small fee applies). Wouldn’t you like to know if your doctor had sex with an underage patient? Wouldn’t you like to know if your doctor kept inadequate records? How about a requirement that he not drink (ever) or that he only see patients with a chaperone?

I’ve seen all of these requirements. You will too if you look.

It’s your health. Take charge and take care.

Who are these people- residents?

Medical school doesn’t really prepare students for anything except more school. Modern medicine has become sufficiently complex that essentially no one is able to graduate and begin to care for patients without additional training. The additional training is so important that very few states will even license a physician without it.

Residents are graduates of medical schools who are pursuing this additional training. The Accreditation Council for Graduate Medical Education (ACGME) is the body responsible for defining specialties and the required training for a physician to be called a specialist. Most residency training positions are filled in an arcane process known as “the match.” The match is run by the National Resident Matching Program (NRMP), an organization simultaneously reviled and lauded.

While still in medical school most students decide on their career in one of a large number of training programs and specialties. Subsequently the student typicall applies and interviews with the selected programs. After the residents and programs have all made their super-secret choices then the choices are fed into a giant computer. Magically, one day in March of each year the results are disclosed. On that day depression is mixed with elation as the students find where they’ll spend the next 3-7 years of their lives and more important what they’lll be doing. This is more than just residency and location selection. In a very real sense this is career selection. On the fateful day would-be orthopedic surgeons find out that they will in fact be pathologists, dermatologists find they will be internists, surgeons find they will be psychiatrists unless they are able to change programs at a later date. OK, so I’m exagerrating a bit. The match will only match what students and programs have offered as possibilities.

Resident physicians are so called because the used to “reside” in the hospital. After all medicine is a calling. The last twenty years have seen enormous changes in work conditions and hours for residents. The ACGME prohibits residents from routinely working more than 80 hours per week. Regulations further limit the number of consecutive hours a resident may work. Despite stiff penalties some prgrams continue to ignore the 80 hour work limit. Always ask the resident when he/she last slept. If the answer is more than 12 hours ago consider sending him/her away. After all if you’d been up for 20 hours and had been working for 70 hours in the last 6 days would you use a power saw or other dangerous equipment? Why would you let someone you don’t even know risk your life or health? These people are so fatigued that they can’t even drive why would they think they can make life or death decisions? Some residents are so horribly misguided, foolish, or egotistical as to believe that fatigue and sleep deprivation can “condition them.” They are wrong.

A resident’s scope of care is defined by the training program and institution. Generally each must work under the direction of a fully-trained attending physician. Under most circumstances the resdent’s entire scope of practice is further lmited by the attending physician’s supervisions and scope of practice. In essence the resident acts as an agent of the attending and all authority is delegated by the attending.

Unfortunately many attending physicians are frankly irresponsible, stupid, uncaring, or some combination of all three. In such circumstances you may find yourself having an operation at 3:00 am from a resident who has already worked 70 hours in a week and has been awake continuously since 7:00 am the prior morning. Can that happen you ask? Yes. It can. In fact depending on the hospital the resident may do so without the supervision, presence, or even the knowledge of a responsible, fully-trained surgeon. In fact some attendings are sufficiently self-serving that they will cloak their laziness in “educational concerns.” That is simply bovine excrement. Yet, it happens everyday, somewhere. Don’t let it happen to you. There is no need to be a victim of your own health care.

So why would you go to a hospital that has residents? The care is frequently better. The hospitals tend to be tertiary-care centers with large numbers of specialists who can rapidly diagnose and treat you. The residents, paradoxically, spend more time with patients than attendings (back to that caring and responsibility thing again).
The value of resident care is, however, completely dependent on hospital rules and the competence and diligence of the attending physician.

So what should you do? Ask what residents can do. Ask everyone who enters your room to identify him/herself. If a resident oprders medications, tests, or therapy ask if the attending knows and approves. Make sure that your attending physician visits everyday. If you are to have surgery ask your surgeon who will do the actual surgery. Ask what the resident’s role will be in the operating room. Do not sign the surgical consent until you see your surgeon preoperatively. Make your surgeon commit. Document your agreement in the chart and consent as to duties of the attending, resident, and medical students. Do not let them put you to sleep until/unless you see your surgeon in the operating room with you.

Similarly, if a resident is preparing to perform a minor procedure on you or a family member be equally aggressive. Assure yourself that your attending is aware or physically present, as you desire. You have the right to determine who performs what procedures.

I recall several years ago my son cut his finger while working on a ranch. The cut was not huge but needed a couple of stitches. He went to the emergency room of a university-afiliated, tertiary-care hospital. A resident closed the wound and did a nice job. A few weeks later I got a big fat bill from the hospital and a big bill from an emergency-room attending physician. Interestingly, my son had mentioned already that he only saw the resident. I called and asked for the documentation of the attending physician’s participation in the care. The hospital was unable to produce any such documentation. When I asked if they were aware that sending a bill for services not rendered was a federal offense they put me on hold. A few minutes later another person came on the line and informed me that I could ignore both of the bills and thanked me for my patience. The point is that some attendings are irresponsible, uncaring, and occassionally, frankly criminal. Residents may actually do fine work. But they are only trainees. If you let them work unsupervised you may not get the best care. In some cases you actually get inferior care that jeopardizes your health.

Residents may improve your care but it’s still best to think of them as “advanced medical students.”

It’s your health. Take care of it.

What Medical School: Alternatives?

In the US there are several types of “medical schools.” Let’s look forst at some that are generally considered “alternative medicine.” There are schools of chinese medicine and acupuncture. These schools teach various forms of traditional medicine. Graduates, if permitted to practice in your state, will typically have some form of licensure from a state medical board. These students rarely have contact with hospitalized patients and there is little formal post-graduate training in the US.

Homeopathic medicine involves the use of dilute solutions of chemicals to treat various ailments. Like chinese medicine these graduates have little formal post-graduate education in clinical settings.

http://www.naturopathic.org/ involves the use multimodal therapy to assist the body in natural healing. Several schools exist with varying degrees of hospital involvement.

Chiropractic medicine is well known to most Americans. Licensure for chiropractors is available in every US jurisdiction. Chiropractice education, like most other alternative therapies, generally has little formal post-graduate education.

Other smaller schools based on less common treatment modalities and philosophies exist. These are almost too numerous to count. To varying degrees, under various circumstances these are viable treatment options. None have the scientific rigor of traditional allopathic (MD) or osteopathic (DO) medicine.

Without addressing the merits of alternative therapy there are several questions to address before looking to these modalities. The questions relate to the therapy itself and then to the individual practitioner.

Patients must look to the scientific validity of the medical care. Search hard for real research that confirms the efficacy of the treatment proposed. This is not limited to alternative providers- patients should also verify the validity of mainstream treatment. Some therapy may have value for an individual patient even if there is no clear scientific evidence of overall value. Even placebo makes some people feel better. Second, or multiple opinions, is an excellent way to obtain the necessary information. If your provider is offended that you want additional information or opinions- you need a new provider.

It’s a bad idea to rely on testimonials from family friends or worse- television ads. Testimonials are worthless. Why would you care if someone else got better- unless the treatment has clear scientific validity. Remember- even placebo makes some people feel better. Before you let a provider use your time and take your money, make sure the therapy will work.

After determining that a particular treatment modality if right for you you must find a qualified provider. This is not as easy as it may seem. Ideally you should have someone with formal education. The provider should be subject to licensure and discipline in your state.

Be aggressive and pursue all of your questions. Assure yourself that the therapy is safe, legal, and that the provider is qualified.

It’s your health. Take care of it.

Who Are These People: medical students?

Some of you have already experienced medical students. They’re the bright young faces that typically accompany the horde of physicians that visit you when you’re in the hospital. One of them is frequently the person who sees you initially on admission to a hospital. They may take your history and do your initial physical examination.

But who are they?
Most every medical school in the US requires that students have a college degree. A few medical schools have combined undergraduate/medical programs in which exceptionally well-qualified high school graduates are admitted directly into a six-year medical school curriculum. But basically every medical student in the US has some kind of college degree. Some have more than one. A few have other professional degrees- lawyers or veterinarians for example.

Some medical students are actually “off-shore students.” These students are enrolled in a medical school outside the US. One of the best known (and better schools) is Ross University in Dominica. However some of these medical schools are little more than diploma factories for students unable to gain admission to US schools. The quality of the medical education can be measured by its acceptance by state medical boards. In a later edition we’ll address international medical graduates and their integration into American medicine. For now it’s enough to realize that, particularly in smaller hospitals, the medical students are often Americans from foreign schools. These are generally very bright students who go to medical school in another country for a variety of reasons. The hospitals and instructors are chosen carefully to provide a acceptable clinical experience comparable to, but arguably different from, a US school. Just because your doctor went to medical school outside the US does not mean (s)he’s not good.

Medical students are NOT doctors.

Medical students function only with the delegated authority of the supervising physician. They may not make diagnoses or authorize treatment. At virtually all hospitals where medical students are found their presence is indicated in your admission paperwork. Most every hospital and medical school requires medical students to introduce themselves as students as well as wearing an identification badge clearly indicating their status. If you have doubts about who the person is in your room ask them. The opportunity to talk to you or examine you is a privilege that only you can grant to students. You have the right to refuse.

The future of your health depends on our ability as educators to train medical students. You should let them participate to the extent that you are comfortable. But you should make clear to your physician any limits that you wish on the participation of medical students. These discussions should be direct, blunt, and followed up with written confirmation. If your physician won’t honor your wishes then you need a new physician.

It’s your health. Be active.