Reviews

Teaching hospital teams

We meet in the morning for consulting rounds. "How is Mr Jones ?" I ask. "Oh, he is Irene's patient, and she is in the clinic," answers another resident.

We go to see Mr Jones. Manuel, the intern on the primary care "team," has the day off. The resident cannot present the patient because he was off last night. The student who worked up the patient is at a lecture. "Jones really belongs to Manuel, and we are only covering for him," says another resident. Later we communicate with other "teams" on equally vague terms.

After lunch, the clinic. Some 50 patients are waiting. Irene is here, but three other residents are missing. Joan has her own separate "continuity" clinic. Joe has been assigned to escort a residency candidate around the hospital. Larry was on-call last night and, according to regulations, has to be off that afternoon. We finish late.

At weekends Irene covers the service. But only until 5 pm. Then comes another resident, who does not know the patients. He will endorse them the next morning to Joan, who at 5 pm will endorse them to Manuel, who will endorse them to the "team" on Monday.

After one month most residents leave the service. They endorse the patients to a new "team" and move on to another one month rotation, an awkward arrangement made necessary by the multitude of regulations promulgated by the residency accrediting boards. As a result some service chiefs now have to orient new residents 12 times a year, constantly issuing handouts and curricula to inexperienced house officers whom they hardly have time to get to know.

Monthly rotations have also spawned an "evaluations industry," with forms being constantly sent out, filled in, signed by everybody concerned, sometimes lost, then traced and filed.

All these arrangements are made in the name of better education and patient care. But for continuity of care they do very little. Ask a patient who was his doctor in a teaching hospital and he will tell you there were so many that he couldn't tell. But there is more to come. A well meaning representative has introduced another bill in Congress. There will be more regulation, more patient "protection." Residents will have to have at least 10 hours off between shifts. And more patients will be lost in the system.

George Dunea, attending physician. 

Cook County Hospital, Chicago, USA