Internal medicine training in Nijmegen and Boston: observations from an American trained physician

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M.V. Seiden
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Ned Tijdschr Geneeskd. 1993;137:153-4
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In July of 1992, I had the opportunity to spend two weeks at the University Hospital in Nijmegen to observe the training of internal medicine residents as well as the delivery of health care in the Netherlands. This visit occurred at the completion of my clinical specialty training in internal medicine at the Massachusetts General Hospital in Boston. My visit at the University Hospital in Nijmegen involved attending numerous clinical conferences, work rounds, teaching conferences and interacting with many residents and staff physicians. One of my first impressions was that both institutions place a very high priority on educating their residents to become outstanding physicians while helping these residents to deliver first rate health care to the patients. Nevertheless, the means to realizing these goals are often different, and at times these differences were dramatic.

Health care

The health care system in the Netherlands seems to be better organized and considerably less chaotic than the U.S. system. Good insurance, primary health care, and a strong social support system have spared the Nijmegen Hospital much of the medical problems seen in urban hospitals in Boston. At the Massachusetts General Hospital, the Emergency Department may have visits from a few hundred patients each day. These visits will include motor vehicle accidents, gun shot wounds (several a month), and myocardial infarctions, as well as chronic back pain or other less acute medical problems. Many visits are from patients who do not have a general practitioner. The acutely ill patients obviously stress the emergency facilities. Meanwhile, patients with chronic problems, aside from the obvious inefficiency and misuse of the emergency facilities, place a significant strain of manpower in the Emergency Department. The department currently requires almost 20 residents over a 24 hour period to handle the large number of patients. This large number also leads to significant chaos on the in-patient services since many of the daily admissions are emergency admissions of clinically unstable patients who require urgent attention. At the Nijmegen Hospital, many of the patients were referred or transferred into the hospital from general practitioners or regional hospitals, for specialized procedures or evaluations. These patients are generally more stable and an initial evaluation and opinion have allready been formed on the patients‘ problems and complaints.

Resident training

One of the most obvious differences between Nijmegen and the Massachusetts General Hospital is the responsibility and patient demands placed on the residents in training. In general, more responsibility and work are placed on more junior physicians at the Massachusetts General Hospital. As mentioned above, admitted patients are often acutely ill and have had no previous medical evaluation. Residents are responsible for quickly developing a differential diagnosis and a treatment plan. Hence, much of the clinical medical education at the Massachusetts General Hospital is structured on differential diagnosis. Errors or omissions can be catastrophic and much of our formal and informal training is used to emphasize uncommon manifestations of common diseases (e.g. syncope with pulmonary embolism) or common complaints seen with uncommon entities (e.g. back pain with aortic dissection). Although the primary goal of this education is to thoroughly train young physicians, a secondary goal is to minimize the chance of physician error which might lead to litigation against the physician or the hospital. This is reflected not only in the more liberal use of laboratory tests and diagnostic procedures, but also in the amount of written documentation: A patient requiring a one week admission for a myocardial infarction will often generate a chart of over 100 pages of documentation at the Massachusetts General Hospital while creating only 10-20 pages of documentation at the Nijmegen Hospital.

Although the Massachusetts General Hospital and the Nijmegen Hospital have similar numbers of hospital beds, the Massachusetts General Hospital has three times more internal medicine residents. This is partially explained by increased patient acuity at the Massachusetts General Hospital and coverage of the hospitals‘ Intensive Care Units and busy Emergency Department. In contrast, the smaller number of residents in Nijmegen has served them well. I was impressed with the personal attention residents received at the Nijmegen Hospital from staff physicians and it seemed residents benefited from the one-on-one attention. The U.S. system also has significant input and education from staff physicians, but particularly the more senior residents are expected to train the junior residents at bedside and at clinical rounds and conferences.

Patient care

In general, patient care seemed similar in both institutions. The patients‘ expectations and interactions with the health care system and the physicians, however, are notably different. Specifically, the typical patient in the Netherlands seemed more likely to accept his physician's comments, diagnosis, and treatment plan with complete trust. The patient in the U.S. is becoming an educated health care consumer. Articles on breast cancer, magnetic resonance imaging (MRI), tumor markers, and mammograms are now commonplace in the lay press. Patients will often ask for a MRI or CA-125. A recent car bumper sticker reflects the new U.S. sentiment’ ‘Keep abreast, get a second opinion’. Second opinions are common in the U.S. and many insurance companies now require second opinion prior to non-emergent surgical procedures. Residents are required to respond to these patient requests and if tests or diagnostic procedures are not performed and a problem is missed the resident may face future repercussions. This does not mean that most patients dictate the exact nature of their medical care. Nevertheless, the dissemination of medical information to the U.S. patient, as well as the risk of costly litigation, has led to noticeable differences in patient care and patient-physician interactions at the Massachusetts General Hospital as compared to Nijmegen.

The most noticeable difference in patient demographics between the two institutions was the relative paucity of HIV related disease in Nijmegen. Although it is fortunate that Nijmegen has not been heavily impacted by the HIV epidemic, it did lead to a somewhat laxed approach to universal precautions in the Nijmegen Hospital as compared to the Massachusetts General Hospital.

Conclusions

Clearly, both systems deliver quality health care and provide quality training for young internists. However, each system can learn important lessons from the other.

The residents at the Nijmegen Hospital were enthusiastic, well trained, and considerably better rested than their Massachusetts General Hospital counterparts. Decreasing work weeks and extending training periods would improve the quality of life of U.S. residents and probably benefit the overall quality of their training. Unfortunately, however, most U.S. physicians in training do not complete their internal medicine training until 29 years of age and their subspecialty training until 32 or 33 years of age. It is now common for students to carry more than 50,000 in college and medical school debt and repayment of this debt usually begins in residency and subspecialty training. In addition, there has been a worrisome trend away from Internal Medicine as a carrier choice for recent medical graduates. Also, hospitals are under pressure to minimize the costs associated with recidency training and indeed government reimbursement of training program costs may be curtailed or possibly discontinued. All of these factors place significant pressure on not extending training periods in the U.S. despite the obvious potential benefit.

Finally, it would be naive to assume that the well educated citizens of the Netherlands will not become more medically sophisticated regarding health care technology, thus scrutinizing the quality of care they receive. The challenge to the citizens, government, legal profession, and physicians of the Netherlands is to learn from the current problems in the U.S. system and hopefully avoid them.

I would like to thank dr.R.H.Rubin and prof.dr.J.W.M.van der Meer for making this exchange possible. In addition thanks are extended to the residents in internal medicine at the University Hospital in Nijmegen, with special thanks to L.B.Hilbrands and ms.V.Mattijssen for engaging discussion, their time, and patience.

Auteursinformatie

Massachusetts General Hospital, Dept. of Medicine, Fruit Street, Boston MA 02114, USA.

Dr.M.V.Seiden, internist.

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