Even the best has a downside

As I recently alluded, I’m on staff at a children’s hospital.  It is an absolutely wonderful place to work, and I am aware of the privilege of working there every time I step through the doors.  The chance to be an attending physician there was no small part of my decision to take my current job.  I’ll stop with the encomium now, but it seemed important to clarify my admiration for the institution from the get-go.

As one might expect from an institution of its caliber, it offers expertise in just about every area and for almost any diagnosis or condition imaginable.  (I was almost proud of myself when I wanted an opinion about a certain obscure disorder and found out that there wasn’t an expert on it there.)  The place pullulates with specialists and sub-specialists and sub-sub-specialists.  No organ system or biological function is without its own team of consultants, clinics and support staff.  To quote one of the premier bards of the early 90s, if there’s a problem, yo… they’ll solve it.

In addition to the above, the place is loaded with residents.  It is, after all, a premier teaching institution.  While the residents take care of the patients’ medical management, they interact with all of those various experts, ordering and interpreting all of the recommended tests and interventions and learning about diseases both common and abstruse.  This is wonderful in many ways, and I am happy to report that thus far (*knocking vigorously on wood*) I’ve yet to interact with a resident there who didn’t live up to the place’s stellar reputation.

However, being ensconced in a setting like this also has some downsides.  First of all, it is incredibly comforting to have every imaginable sub-specialty consultant just a page away, and this can easily increase one’s reliance on them.  For my own part, I already know that it would be incredibly hard to go from a situation where I can look up any given disease in the hospital’s directory and contact the head of the department using the internal e-mail system to one like the last job I had, where it could take months to get a patient in to see a gastroenterologist or hematologist, all of whom were an hour’s drive away.  Residents “raised” in this kind of environment are likely to seek out jobs in similar settings, contributing to the problem of over-saturation in well-served populations and leaving underserved areas continuously bereft.

Which leads to another problem.  After politely inquiring from a couple of residents, I learned that there is really no rotation offered outside of the hospital itself.  Residents have essentially no exposure to a clinical environment where all of these tests and consultants aren’t readily available.  This is an intellectual problem, in that it fosters over-reliance on diagnostic testing at the expense of history-taking and physical examination.  It really only equips pediatricians thus trained to manage patients with these extraordinary resources at their fingertips.

I wonder if the residents who graduate from the program at this top-tier, world-class institution are, ironically, a little bit short-changed by their experience.  As amazing as it may be to work there, it’s not the kind of environment where the vast majority of pediatricians work.  (I suspect that the same could be said about other similar institutions and specialties.)  Wouldn’t we want the doctors leaving the country’s best residencies to be capable of practicing anywhere, including places where there is no cardiology fellow two floors away to come to their rescue?  (There were plenty of situations in my old job where I was the cavalry in a pediatric emergency.)  A short time away from the ivory tower would probably provide a learning experience unlike any their going to find inside it.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


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