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618 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 NUMBER 9 SEPTEMBER 2008

COMMENTARY

THOMAS FRANKLIN LANSDALE III, MDInternist in private practice; Assistant Professorof Medicine (part-time), Johns Hopkins University Schoolof Medicine, Baltimore, MD

A medical center is not a hospitalEditors note: We are interested in your thoughtson this article. See the Editor-in-Chiefs com-ments on page 616.

I . I was onlya few days into my third-year medicine

clerkship in medical school nearly three de-cades ago when I fell in love with the hospitaland knew I was going to be an internist. Thehospital wasnt called a medical center backthen. It was a fascinating and magical place,where internists were fired in the furnace ofrounds, night call, and morning report. I lovedthe association with the great case, the flushof excitement that accompanied the difficultdiagnosis, the hard-earned annual promotionthrough the hierarchy of trainees seeking therarefied air of the attending physicians. Webonded as fellow house officers more tightlythan with friends outside the hospital. Weprowled the wards, intensive care units, emer-gency room, and laboratories and never slept.The hospital was the most exclusive of clubs,and our training granted us lifelong member-ship. A humming beehive of academic activ-ity, the hospital was also a web of powerfulsocial relationships. Everybody knew every-body, from the hospital CEO to the night se-

curity officer. The nurses called you by yourfirst name and worked with you for weeks at atime, fostering mutual respect and sometimeseven affection. In those days, nurses actuallynursed their patients, spoon-feeding thembroth with their medications, washing themin bed and bathroom, holding their hands andheads. Patients came to the hospital to be di-agnosed and treated until they recovered fromwhatever illness had felled them. They stayedlong enough so that you knew them and theirfamilies as well as you knew your own.

I have been a general internist and clini-

cian-educator for 23 years, working in twouniversity hospitals and one community hos-pital. Thats more than seven generations ofhouse staff with whom Ive toiled and learned.Somewhere along the way, I became increas-ingly aware that teaching clinical medicine

to students, interns, and residents was gettingharder and harder. The patients were sickerand stayed only 3.2 days in the hospital. Whatwe were teaching wasnt how to diagnose andtreat diseases, but how to manage only theirmost serious complicationsthe respiratorydistress from pneumonia, the ketosis of un-controlled diabetes, the septic shock frominfections. The wards became intensive careunits, and the critical care units the provinceof intensivists who were more adept thanwe were at taming all the machinery andtechnology. We struggled to keep up withthe unending deluge of arcane demands fromthe accreditation organizations watchdoggingour teaching efforts. We pretended that wesomehow distinguished teaching rounds fromworking rounds, and documented the sillinessin computer files. Medical education slowlyslipped from being a calling to folks like me,finally succumbing to bureaucratic lunacy.The pace of teaching and caring for acutelyill patients became intolerable. Rounds went

from the bedside to the classroom to the cellphone. The house staff were getting cheatedout of the whole point of residencythemiracle of turning medical students into at-tending physicians in a little over a thousanddays. Worse, though, was the ebbing of the life-blood of the hospital. Now the medical center,riddled with centers of excellence instead ofdepartments, answered only to administratorswho cared nothing about medical education,except for the Medicare dollars they would

lose if they cut the training programs. They

I loved the

association

with the

great case,

the flush of

excitement that

accompanied

the difficult

diagnosis

8/14/2019 A Medical Center is Not a Hospital Editorial CCJM 2008

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622 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 NUMBER 9 SEPTEMBER 2008

COMMENTARY

spent enormous amounts of money marketingthe centers of excellence, and they cut every-thing else to manipulate the bottom line. The biggest casualty, of course, was the

nursing staff. Underpaid, depleted of leader-ship and morale, they simply disappeared.They were replaced by agency nurses whoworked their shifts and didnt know the doc-tors or the patients. The complex bedsidecare of increasingly sick, old, and vulnerablepatients was delegated to people with highschool equivalency degrees. Nurses now caredfor their patients by managing their own sup-port staff, and spent much of their time enter-ing useless information in the computer. Thedoctor-nurse collaboration I grew up with as a

trainee and young attending didnt exist any-more, and patients suffered as a result. In 2000, the Institute of Medicine informedthe public and the medical community thatbeing a patient in an American hospital wasdangerous.1We were told that at least 44,000and perhaps as many as 98,000 patients die an-nually in US hospitals as the result of prevent-able medical mishaps, more deaths than areattributable yearly to motor vehicle accidents,breast cancer, or AIDS.1 Although there hasbeen an emerging body of literature pertain-ing to this epidemic, not much has changed, atleast not in my hospital. We remain absurdlycomplacent about rising iatrogenic infectionrates, knowing all too well that we are allow-ing immunocompromised patients to die un-necessarily in our intensive care units. Thereare alcohol-based hand-washing gels every-where, but no police or policy with teeth init to enforce handwashing. We lurch towardphysician computer order entry, clinging tothe false belief that software programs will pre-

vent adverse drug reactions and delivery of the

wrong dangerous drug to the wrong patient.We understaff our pharmacies so that theycant get the medications to the patients ontime or alert us to our own prescribing errors.

We burn out our nurses despite years of loyalservice. And worst of all, we capitulate to thefor-profit insurance industry that informs usthey wont pay for day 4 of Mr. Jones hospi-talization because he has failed to meet somearbitrary criteria in their manual. I stepped down as chairman of my depart-ment 3 years ago because I couldnt stand itany longer. I couldnt stand the managementretreats in which we obsessed about customerservice while the waiting time in the emer-gency department ballooned to 12 hours be-

cause there were no beds. There were plentyof beds, but no nurses to staff them. I was mar-ginalized when I protested the budget cyclesbleeding out support of medical education infavor of the annual purchase of new scannersand surgical gizmos. I couldnt get anybodyfired up about patient safety. Retreating to the privacy of clinical medi-cine, I realized the other day that my real job isnot to diagnose, treat, and teach about diseasesanymore. My real job is to do everything in mypower to keep my patients out of the medicalcenter. I walk the halls now and dont recog-nize the institution I grew up in and came tolove. Everywhere I look, I see not magic andpromise, but dirt and danger. Im not a hospital guy anymore.

ADDRESS: Thomas F. Lansdale III, MD, 6535 North Charles

Street, Suite 500, Baltimore, MD 21204; e-mail ThomasLans-

daleMD@comcast.net.

REFERENCES 1. Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is

Human: Building a Safer Health System. Washington, DC:

National Academy Press, 2000.

My real job now

is to do

everything in

my power to

keep my

patients out

of the medical

center

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