I will start this note by clearly stating my bias about where the highest quality healthcare is delivered, particularly for complex problems -- teaching hospitals. It would never occur to me to seek care at any other type of hospital for a serious condition. Here are some of the reasons why I believe that higher quality care is delivered in teaching hospitals:
- Multiple layers of physician oversight (i.e., senior residents over junior residents; faculty over senior residents) provide checks-and-balances that can help guard against both procedural and judgmental errors.
- Staff physicians at teaching hospitals generally derive the bulk of their compensation from fixed salaries. This form of compensation tends to decrease the incentives for unnecessary surgery or medical procedures.
- There are strong incentives for the faculty physicians in teaching hospitals to keep abreast of current research and technology because such knowledge can lead to greater success in academic medicine.
Because of these factors, it came as no surprise when I came across an article in the The Annals of Thoracic Surgery indicating that lung surgery for cancer was associated with a mortality rate 17% less in teaching hospitals than in non-teaching hospitals (see: Are Surgical Outcomes for Lung Cancer Resections Improved at Teaching Hospitals?). It may also be the case that the more complex patients tend to gravitate to teaching hospitals in which case the lower mortality rate is even more impressive Below is an excerpt from the article (boldface emphasis mine):
Results: Of 46,951 lung resections (5,651 segmentectomies, 37,027 lobectomies, 4,273 pneumonectomies), 56% were performed at TH [teaching hospitals]. Overall mortality was significantly lower at TH versus non-TH (3.2% vs 4.0%; p < 0.001)....On multivariate regression, overall odds of death was independently reduced by 17% at TH versus non-TH .... At TH, odds of death for pneumonectomy and lobectomy were significantly reduced independent of surgical volume, except for the latter at the highest hospital volume strata.
Conclusions: In-hospital mortality is reduced for patients undergoing lung cancer resections at teaching hospitals, with results prominent at all but the highest volume institutions. Lower mortality rates persisted at GSTH [general surgery teaching hospitals] and TSTH [thoracic surgery teaching hospitals]. Understanding and disseminating the processes of care associated with these settings may improve quality of care for lung cancer patients, and decrease patient bias against teaching hospitals.
The only thing that surprised me in this article was the assumption of the authors, contained in the last paragraph, that there is a "patient bias against teaching hospitals." I do understand that patients tend to rebel against becoming "guinea pigs" in teaching hospitals. However, many of the patients that I have interacted with over the years in teaching hospitals have commented to me that this is "just the price one pays" for the higher quality care that they receive in such hospitals. I wonder, then, if it is correct to assert that there is a general bias in the U.S. population against teaching hospitals. Perhaps one of the readers of this note can comment on this specific issue.
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