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.

Inspirational Medicine

Last Friday NPR’s “Day to Day” radio program broadcast a segment about low morale and disaffection among primary care doctors.

A lot of doctors said they would prefer to be in another profession. Furthermore, only about five percent of the doctors-in-training are choosing primary care because of the significant medical school debt they have to repay and because they are discouraged by the daily example of unhappy older doctors.

One of the physicians interviewed on the program told how she stopped participating in health insurance plans a few years back. Another doctor who left practice complained about insurance companies that “put profits over patients.”

A third physician lamented the loss of patient contact, as well as the decline in intellectual satisfaction. The physicians said that medical practices are succumbing to the time pressure of seeing many patients with little opportunity for attention to individual situations.

I've written before about the coming shortage in primary care physicians.

Training these physicians is a source of satisfaction and pride. Each quarter a new group of family practice residents rotates through the internal medicine service at Community General Hospital. These second-year residents are from the training program St. Joseph’s Hospital Health Center, and they provide a real service to patients as they learn from Community’s attending physicians.

Last week one of the residents was honored as a local hero by the American Red Cross. One morning in August Dr. Michael Loeb (photo) came across a bad accident at the New York State Fairgrounds on his way home after night duty at Community General Hospital. The exhausted resident did not hesitate to stop his car and help the injured family.

Dr. Loeb described the situation for a local television station:

"…[T]he day of the crash was the day after one of the most brutal calls I’d ever had,” he said. “It had just been a crazy night…My first reaction was ‘I need to get over there [to the accident site],’…and my second was ‘This isn’t going to be pretty.’”

Dr. Loeb got out of his car and crossed the lanes of traffic to provide assistance. The following morning, I saw Dr. Loeb in the emergency department when one of the attending physicians told me what he had done. I thanked him and said his example was inspirational.

Dr. Loeb reminds us why people choose medical careers, despite the demands, distortions, and pressures of the medical marketplace. People choose medicine because they care about patients, and they want the knowledge and training to be of help.