Your loved one is having a chest pain.  You call 911 — the paramedics arrive quickly.  They tell you they are heading to the closest hospital, just a few minutes away, which provides care for heart attacks.

Should you tell them to bypass it — take your spouse to The Ivory Tower Hospital, aka the university hospital, located 30 minutes further away?

All entries in this series will be able to be found here.

The World’s Best Medicine?

If there’s one thing that is supposed to set Ivory Towers apart from everyone else, it’s the quality of the medical care.  After all, the Ivory Tower has more world-renowned doctors, more resources, and always provides cutting edge care.

It may not always be as efficient, some people think it’s less personal, and it can be more expensive, but it’s always the best care out there.  Right?

This is the fourth post in our Ivory Tower series.  We’ve discussed reasons to avoid working there, the money, and the politics.

Today we dive into whether the quality of medical care is better.

The Family Trade

I am related to many physicians (hi Dad!  Hi Big Bro!  Hi Little Bro!).  By virtue of my profession and family, I have many physician friends (and extended relatives) working in a variety of settings.

My exposure to medicine goes back to childhood.  Not just having a father in medicine, but pulling weeds in the parking lot of my dad’s practice, stuffing envelopes with bills with my mom, and sitting in random hospital doctor lounges drinking hot chocolate while my dad did inpatient rounds on weekends.

My entire medical career has been within the Tower system, but I’ve learned bits about solo private practice, and outpatient and inpatient employed practice in a non-university setting.

As part of my job I routinely interact with physicians at other hospitals.  Physicians in other EDs or clinics often call for advice or to send us patients.

Unfortunately I believe it is those brief interactions — assuming care of a patient that has been treated elsewhere — that often lead to the poor dynamic between doctors in different practice settings.  A lot of judgment can be passed without ever meeting someone.

I do not think the calls themselves give me great insight into practicing medicine in other settings — it’s easy to question the inappropriate test (some of them really are inappropriate), it’s difficult to understand the sequence of events that led to the testing.

Is Medicine Better In The Ivory Tower?

Let’s answer this directly — sometimes.  Hope that clears it up.

You can, and quite frequently do, receive excellent medical care in non-Tower settings.  This includes care for routine and complex medical and surgical problems.

When can you get better care at the Ivory Tower?  The more rare the condition, the disease, or the event, or the more rare the specialist  that treats that issue, the more likely you will receive optimal care at The Ivory Tower.

Get shot in the chest?  The local ER doc in the community hospital — an unsung hero in my opinion — can probably secure your airway and put in a chest tube — which will save your life — but full trauma teams and operating rooms that give you the highest chance of survival don’t exist in many hospitals.

Have a really really sick kid?  Pediatric anesthesiologists, pediatric surgeons, and high-level pediatric ICUs, and ECMO teams for kids are not super common outside of the Tower.

Have a rare genetic condition or rare form of cancer?  The specialists who know all the details and nuances of that disease, and the ones conducting research that may treat or cure that disease, are most likely at the Ivory Tower.

There are many places that are not part of the Tower System that can provide aspects of these care at a high level.  Sometimes, perhaps often times, better than the Tower.

There are heart attack and stroke centers that are not part of the Tower.  Oncologists who practice in small towns can provide the ideal treatment plans, and they may also get to know you better than the Tower doctors.

There are great doctors (and nurses, PAs, RTs, etc) in many settings.  Working in the Tower doesn’t magically bestow better skills on us.  If we do provide different or better care, it’s often because we may have spent more time training in a certain area (i.e. the sub-sub specialist), or because we simply see more of that particular problem.

What often distinguishes the Tower is the expectation we should be able to handle more varieties and more volume of them.  The Tower hospitals and clinics, often by virtue of location, treat patients that are more sick (and with less resources, i.e. no insurance), which often provides a breadth and depth of experience that isn’t seen everywhere.

But even within the Towers there is a great deal of variation.  It’s possible that patients with heart attacks seen in the Tower may have better outcomes during academic medical conferences when the most senior or experienced doctors are away.  Sometimes those wizened doctors in the Tower may not be the ones you want to see.

There are Harvard trained doctors practicing everywhere — those that left the Tower didn’t suddenly become clowns, and those that stayed are not always the Dr.  House (which may be a good thing).

The Tower’s Tentacles

The majority of medicare care in this country is not delivered in Tower hospitals by academic doctors such as myself.  We may be the primary place for training and research, but the majority of medical care happens elsewhere, though the lines are starting to blur.

Many medical schools are strengthening their affiliations with large healthcare organizations and beginning to have influence over hospitals and clinics across wide areas. The influence of these medical schools can then permeate through a large healthcare system.

This is happening at my own institution, particularly in pediatrics.  Most sick kids are concentrated at children’s hospital — thankfully, there just aren’t enough sick kids for every hospital to see a ton of them.

That means that practitioners in some settings may infrequently treat very ill children, and may be less comfortable with them, and also spend less time trying to learn the latest evidence for kid-type problems.  If sick kids are only 5% of your practice, it’s reasonable that most of your time is spent learning about adult problems, when a heart attack or stroke victim walks in the door every day.

That is just one way university affiliated physicians can influence care without ever seeing a patient.  They/we are trying to help ensure our colleagues in other settings have easier access to the latest evidence though updated clinical care pathways and guidelines, and also provide more resources so they can have a higher comfort level providing that care themselves

Sometimes just telling a doctor over the phone they can trust their judgment is enough to enable them to provide excellent care.

Colonoscopy in Aisle 6

It is often impossible for the average healthcare consumer to compare hospitals and doctors. It’s sometimes close to impossible for experienced medical professionals to do so as well.

As a result, medical care is in places beginning to be treated like a commodity.  Walk-in clinics and urgent cares are popping up everywhere, willy-nilly, with little oversight of the quality of care.  CVS, Walgreens, and even Wal-Mart are in on the act.

Patients want and deserve high-quality care, but when you aren’t in a position to be able to judge “quality,” convenience is a great substitute.

Sometimes this means seeing someone really quickly, doing a bunch of tests, and giving them a medication they may or may not need.  The patient walks aways satisfied because “something was done.”

I want to have faith in the system as a whole, but overtesting and overprescriving are common problems in the US healthcare system.

A chain of urgent cares has sprung up in my town, now with over 20 locations.  Almost all have CT scanners inside the urgent care, which are usually located next to strip malls.

If you build it you will use it.  Suddenly our ER is receiving pediatric patients transferred from these urgent cares where young children are receiving CT scans.  Results are sometimes useful, often not, but when they don’t know what to do, they send the child to us.

Never mind that the CT likely could have been avoided, and should have been avoided, in order to spare the child the radiation (and the cost).  These places are not competing on quality of care.  They are competing on speed and perceived access to care.  If you can do a lot to someone in a little bit of time, it sometimes feel like a win-win, even if the only person that wins is the guy that runs the company.

Contrast the local urgent cares with another large healthcare system in our town that has many pediatric specialists but is not affiliated with any university.  This system is a national leader in telemedicine, with a goal of improving access to care while reducing costs for their patients.

They are aggressively trying to higher more pediatric specialists to provide top-level care within their largest hospital, and trying to then help them provide care to patients in rural/remote areas.  They are not conducting “research,” but they are advancing care in novel ways.

End-game

What does this mean for you, the consumer?  You do not necessarily need to come to the Tower Hospital and Clinic for every problem.  You do need to ask questions and make sure you understand the care you are receiving,

Google and WebMD are not substitutes, no matter where you receive care.  It’s great to read up on a problem to help you understand a bit of background.  An educated healthcare consumer is an empowered one, but just realize that no matter where you go for care, most of the time we’re doing the best we can.

And especially remember that if you have a long-wait to see me.