Author: ExtreAdmin1-

The surgeon had no prestigious named professorship, no N.I.H. grant and no plum administrative position in the hospital’s hierarchy. But to the other surgeons-in-training and me, he was exactly who we wanted to be.

A decade or two earlier, he had started out like us, as a lowly resident in the medical center, but had finished his training elsewhere. When he returned to open a practice, the other doctors in town welcomed him back as one of their own. But they soon discovered that he had become a surgeon like few others. He finished in an hour operations that took most surgeons three or four and had few complications and enviable patient outcomes.

“I know whom I’d call if I ever needed a surgeon,” a friend said to me after watching the surgeon breeze through what we thought would be a particularly challenging case.

One night early in my internship, I received a frantic page for help from a fellow intern.

Seasoned nurses had been unable to draw a patient’s blood, which senior doctors had ordered be done if his fever spiked, so they’d called the covering doctor, the first-year resident on call. For more than an hour he had poked at the patient’s arms and legs, littering the floor with blood-stained gauzes, used alcohol swabs and crumpled syringe and needle packaging. When the patient finally kicked him out of the room, howling, “I’ll hit you if you come near me again!” he called the only people he thought he could: the other interns.

“We didn’t have to draw blood in medical school,” he confessed, his eyes red behind his Harry Potter spectacles. “My med school didn’t think it was important for us to learn.”

One of us did manage to get the required blood, but for the rest of the week, we were haunted by the feeling that any one of us could easily have been in the same situation.

We had all endured four years of medical school, and we believed that all our lectures, exams and national standardized tests had made us ready to be real doctors, or at least capable interns. But the reality was that in some cases, we were unable to carry out even the most routine duties.

The intern who did get the patient’s blood on her first try had had plenty of phlebotomy experience in medical school. But she confessed she didn’t know how to prepare a patient for surgery, and had had to ask another intern to write the pre-op checklist on an index card that she could keep in her white coat pocket. The intern who wrote up the checklist came from a medical school where students prepared a lot of patients for surgery but rarely did anything in the operating room. When asked to assist on a minor procedure during her first week, she had been so awkward and unsure of herself that the scrub nurse burst out laughing.

The elderly man lived alone in an apartment complex not far from the hospital. A younger neighbor, who’d watched him hobble down the building’s stairwell for nearly a week, insisted on taking him to the emergency room. Doctors there immediately diagnosed an infection in his painful toe and prescribed antibiotics for him to take at home.

But they also advised the man to be sure to take his diabetes medicine, since the infection could elevate his blood sugar to dangerous levels. And as the surgical consultant, I urged him to keep his foot up, check the toe once a day and come to our vascular surgery clinic in a week to make sure the infection was clearing up. He needed close follow-up to prevent serious complications, even the loss of his foot.

“Of course, if things get worse before the week’s up,” I said, raising my voice to be heard over the clatter beyond the makeshift curtain walls of the E.R. examining room, “come back here right away.”

Under the glaring fluorescent lights, there was no mistaking the blank look that passed over the man’s face. He was overwhelmed.

But so was the emergency room.

None of the staff members had been trained in coordinating the complex outpatient care this elderly patient needed. None knew of a way for the emergency department to check on him a day or so after discharge to ensure his care was proceeding as planned. And when a social worker from another department agreed to pitch in with outpatient care, the emergency room doctors and nurses became alarmed rather than relieved, because arranging such follow-up could take several hours. With patients spilling out of the waiting room and into the hallways, they were under pressure to either admit or discharge patients as quickly as possible.

An older nurse finally pulled me aside. “Just admit him,” she whispered. “It’ll cost more, but it’s the only way you’ll be sure he’s getting the right care.”

Not long ago, I heard a respected senior colleague recount to a group of medical students and trainees the story of a patient who had died under his care some 15 years earlier. Afterward, he had spent hours talking with the family, trying, he said, “to be as kind to them as I possibly could.” The family had been grateful for all his efforts, but my colleague still struggled even to tell the story.

“Were you afraid of getting sued?” one of the students suddenly asked.

My colleague’s eyes widened, and he answered slowly, the tone of his voice shifting from grieving to professorial. “In medicine, malpractice isn’t something we just think about when a patient dies. Malpractice is always in the back of your mind.”

The handful of senior doctors in the room nodded in grim agreement. Every one of us either had been named in or knew of a colleague embroiled in litigation. That evening we all urged the aspiring clinicians to be the best and most compassionate doctors they could be. We knew all too well how much easier it is simply to order more tests and procedures than necessary and to overtreat in hopes of avoiding a lawsuit.

But a study published earlier this year in the American Journal of Obstetrics and Gynecology has revealed that a group of doctors at Yale-New Haven Hospital has been quietly working to change the culture of “defensive medicine” that so many have come to accept as inevitable.

Beginning in 2003, the hospital’s department of obstetrics and gynecology, in collaboration with their malpractice insurance carrier, initiated a series of reforms to improve care. Those in charge had no illusions. Obstetrics was, and remains, one of the most legally embattled specialties, accounting for the highest proportion of malpractice payouts over $1 million. Their goal was only to make a small dent in adverse patient outcomes.

“He’s back?” my colleague asked, eyes widening as she passed the patient’s room. “He’s in the hospital again?”

Slender, pale and in his late 60s, the man had first been admitted nearly a year earlier with pressure in his chest so severe he had trouble breathing. When his heart stopped, doctors and nurses revived him by injecting the latest life-saving medicines into his veins and applying the newest electrical defibrillator paddles to his chest.

Within minutes, the cardiology team arrived, but when the blockage in the arteries of his heart proved too extensive for even their state-of-the-art techniques and equipment, they handed him off to the waiting surgeons. The surgeons, in turn, cooled down his heart until it stopped beating, sewed in bypass conduits with threads finer than human hairs, restarted the heart with a few well-placed jolts of electricity and then transferred the patient to the cutting-edge intensive care unit to recover.

The man survived. Sort of.

Weakened by this string of emergencies, he required a breathing machine for several days. When excess fluid in his lungs caused shortness of breath, he needed intravenous diuretics. When his heart began beating erratically, he was obliged to take a finely tuned cocktail of heart medications. And when his chest wound became infected, he had to return to the operating room.

Finally, after nearly two months in the hospital, he was discharged to a skilled nursing center. But then a urinary tract infection made him dizzy and confused, and he went right back to the hospital, beginning a cycle of discharge and re-admittance that would persist for almost a year.

To many of us who had cared for the man, it seemed as if he had spent more days in the hospital than out.

“What kind of life is that?” my colleague asked as we stood in the hallway and watched the man’s wife help him once again put on his hospital gown and pack away his street clothes. “You’ve got to wonder,” she whispered, “did we really do him a favor when we ‘saved’ him?”

Birdlike and in his 80s, the patient had come to the hospital complaining of a new cough. But it was not he whom my colleagues and I found most disquieting.

It was his middle-aged daughter.

With a practiced dexterity, she had managed to wheel her father in the clinic, hoist him on to the examining table, smooth his hair, wipe his brow and tuck blankets around his legs to keep him warm without pause as she simultaneously fielded nearly a dozen calls and texts on her cellphone.

Still, every time her cellphone rang, buzzed, gurgled or popped, she jumped and sometimes even clutched her chest. After examining her father, I asked if she was O.K.

The woman’s eyes widened; she looked as if she was going to cry.

Her father, she began to recount, had moved in with her and her husband a few years earlier to help with their young children. But over the last few months, his health had begun to fail, and she found herself spending more and more time taking care of him. An occasional doctor’s appointment escalated into frequent emergency room visits and missed workdays so she could watch over him at home. Now, with her own sick days used up, her vacation day stockpile dwindling and the goodwill of her colleagues and boss dissipating, she tried to do as much work as she could by phone.