Tuesday 23 March 2010

Teaching Hospitals

Where's the best place to get care? Where's the best place to work? Both are related questions; if you have a happy, motivated, enthusiastic, valued workforce then you're much more likely to have a better quality service and receive good care as a patient.

I've worked in many hospitals, through medical school training, then 2 more as a House Officer, then more whilst I trained as a GP, then more as I trained as a psychiatrist. Many different hospitals in different counties.

It's something that usually you come almost come across by mistake rather than by conscious design . . . do you favour working in a local district general hospital, or a big teaching hospital? At least as a professional I've the choice. For patients, especially if needing involved and ongoing care, we all invariably have to go with what the local service is. You might be referred to foreign parts for your specialist heart surgery or spinal cord stimulator or infectious diseases opinion, but if you're after a community mental health nurse, support worker, social worker, psychiatrist, pharmacist and psychologists' input a few times a week with ongoing contact over months/years, you're invariably not in a position to get that from far away. Private medicine doesn't do it well, either. You get to see a Consultant Psychiatrist (if not fobbed off) but how do you get input from the other disciplines? When a team contributes to care, so half a dozen folk add to it each week, it's a fearsome bill to generate each week in Private Practice. Having a menu from private companies and picking off just one bit (like a Consultant Psychiatrist or a CBT therapist) will work for some people some of the time, but isn't a sensible or coherent way to generate a service.

I don't do any private work so for me it's not an issue, but the point remains . . . for mental health care, usually it's only practical to have an NHS team involved and for this team to be local to you.

Is a teaching hospital a better place to be, then?

This issue is in my mind because, curiously, a family moved last month from their current city (and teaching hospital) 30 minutes up the road to my corner, specifically to have mental health care from our Trust. One relative needed appropriate dementia care (which they didn't think they were getting in the teaching hospital), one younger adult needed ongoing care in the management of a mood disorder. It's not uncommon that patients have strong views about their GP and seek to remain with good ones they trust (much as the Government seems to believe otherwise).

As well as a patient relocating to be under my care, I also had a supranumerary flexible trainee wish to work here. That surprised me anyway - how many bright young things are zealous to work in old age psychiatry?! But her rationale was seemingly sound. As an older graduate who was more reflective of her training scheme than most, she found that a teaching hospital usually wasn't.

She found that a teaching hospital, in striving to be a centre of excellence, had lots of people trying to gain experience so she was often displaced. More importantly, she'd found that a teaching hospital was driven by research, not by teaching. Teaching added nothing to the researchers' day, and indeed detracted from their research time. Jobbing clinicians were the poorer brothers to the Senior Lecturers and Professorial teams so had disproportionately larger workloads and couldn't find hours a week to teach. It's a valid point. Teaching hospitals usually are research hospitals and are not necessarily at all good at teaching.

Got me pondering.

Is a teaching hospital automatically a desirable place to train (when teaching can be scare), work (where publishing research competes with investing time in teaching/clinical care) or receive care?


sw2be said...

I've received care for bipolar disorder in a teaching hospital in the past, and now from a general hospital- I've observed 2 main differences in the care I receive.
In the teaching hospital, I had a permanent psychiatrist so there was continuity of care- however, there was usually a student in with her, so much of the consultation was taken with me- or her- explaining my past history & illness to the student.
Now however, in the general hospital, I have no continuity of care as they struggle to recruit and retain psychiatrists, so in the last 8 years I've rarely seen the same locum twice (I only attend every 6- 9 months for follow-up).
Now however, I don't end up explaining my history every time- I simply refuse to leave the waiting room until they have read my notes. Doesn't always go down well- but that's tough!
Care-wise, I've not noticed much difference in the quality, although I've not needed much intervention at all, just medication monitoring.

Unknown said...

Addenbrooke's in Cambridge has precisely this reputation. A couple of medical students I knew specfically transferred to London hospitals for the clinical parts of their training, MRC or no MRC.

Also, in psychiatry there, as I and friends have found out as patients, the ones doing the fancy research, as you say, don't bother dealing with patients. And some of the clinicians dealing with patients are sub-par by any standard (think uninterested by anything that cannot be cured by chlorpromazine, venlafaxine or a combo, and an acute ward where 90% of the patients at any one time are sectioned, not voluntary). I complained to my college and got transferred to an academic who was a dick, but was at least competent. Mind you, I wasn't very nice to him either.

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