Tuesday, December 30, 2008

In praise of community hospitals

Sunday's article ("Are the elite academic hospitals always a patient's best choice?") quoted Dr. Donald Berwick, President and CEO of the Institute for Healthcare Improvement, in the Boston Globe. Dr. Berwick's perspective is interesting but not necessarily surprising.

Some thirty years ago, Dr. Robert Westlake, Sr., who was then the Vice President - Medical Services (predecessor of today's Chief Medical Officer) at Community General Hospital, used to say that academic medical centers were better than community hospitals "if you happen to be an interesting case."

Dr. Westlake (shown in a photo from 1979) passed away in 2003. During his career, he was a proponent of primary care by internists (he was one) and family practitioners. He called primary care doctors "the captains of the ship," and he argued that the primary care physician knows the patient best (clinically, as well as within a family and social system context) and is best equipped to refer and supervise ("to captain") medical and surgical subspecialists who become involved episodically in a patient's care.

He also maintained that a routine case ("uninteresting" to academics) could languish in an academic hospital where it was more likely to receive cursory or disinterested attention from a resident staff (doctors-in-training).

We've seen many changes in health care since Dr. Westlake's day. The technology and medical expertise has improved in both academic and community settings. Services and technology that were esoteric ten or twenty years ago are now routine at community hospitals. And expertise that was once limited to the hospital setting has moved to outpatient settings.

There is, of course, a touch of ego and turf-protection in broad pronouncements about academic and community hospitals. Is an academic medical center always preferable to a community hospital? Is a "brand name" residency program always preferable to residency at a state university hospital?

My own informed self-interest tends to agree with Dr. Berwick -- and with Dr. Westlake. The community hospital serves an important role.

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