Community hospital

This month, I'm rotating through a small community hospital that is affiliated with the academic center where my residency program is based. For residencies based in well-staffed, well-resourced academic centers, the point of having their residents rotate through a community hospital is to expose them to the real world of medicine. A significant proportion of the hospitals in this country are community hospitals, and because these facilities have little to none of their budget devoted toward research, they often have far fewer specialty services and facilities than academic hospitals do.

This doesn't make their care any less good than that of academic hospitals--it just makes it less specialized. At a community hospital, you could probably get a perfectly good laparascopic cholecystectomy, or maybe a course of intravenous antibiotics for a bad pneumonia, but you might not get an experimental treatment for breast cancer, or a cardiac catheterization for a heart attack.

All that said, the rotation I'm in at my local community hospital--I'll call it the Sixth Portal of Hell, or SPOH for short--is, to me, harder than any rotation I've done yet, either in medical school or in the short span of intern year that has passed. It's not because the hours are longer, although they are--it's because medical care at the SPOH is incredibly inefficient; startlingly subject to the whims of human error and carelessness; and perpetrated by administrators and clinicians who are shockingly variable in their giving of a shit about the consequences of all of this to patients and families. I don't think I'm the only person who feels discomfited by the place; there's a higher-than-average level of passive-aggressiveness among the secretaries and nurses, and I wonder how much it is produced by their sense of being part of something below par.

For better or worse, my tolerance for bad systems (my own personal ones excepted) is pretty low, and yet I have no status and no influence in this particular system. My job at the SPOH is to put up and shut up, and when I see so much dysfunction around me, that's a very hard thing to do.

Our general medicine service is, at the moment, full of pretty sick people with an abundance of social issues. There's a deaf man with metastatic rectal cancer who bounces between shelters here and in a metropolis 5 hours away; and a cocaine addict with poorly controlled diabetes, a kidney infection, and the expectation that we will find her an apartment before she leaves the hospital. I'm in the hospital to round on my 11 patients earlier than ever, and I leave the hospital later than ever and feeling beat down in a way I haven't before. I'm beginning to understand what people mean when they say intern year sucks.

Complaining is not something that's encouraged in my profession. We are doers, all of us, and when things aren't so good, we suck it up at work, bitch to our loved ones at home, and keep our noses to the grindstone. I'm not sure whether this is the reason that so many people have told me they actually enjoy working at SPOH, or whether there is some hidden magic about the place that I'm missing.

On my first day at SPOH, I had a sudden, terrible, unprovoked thought while waiting for the elevator: "I am going to unwittingly do something wrong and with awful consequences at this hospital in the next month." I'm not much into magical thinking, so I shook it off and resolved to consume more coffee before coming in. And yet I now feel even more confident that I will make a bad mistake while at SPOH, and it will negatively affect the health of one of my patients. The foreboding isn't just a sense any more; I know that the web of quality control that protects patients from our mistakes just isn't there. It scares me.

One way or another, I'm spending 75 hours a week in a place that is supposed to be somehow cozier and more tightly knit than the Big House, and yet I feel less connected to people and more worried for my patients than I have before.

Some community.