Partitioning

As a tertiary care center, Stanford has many specialized services. There are primary teams for hematology, oncology, transplant, neurology, and cardiac patients. So when we are on general medicine wards at Stanford, we don't admit chest pain, strokes, or oncologic emergencies unless those teams have "capped" (filled up their quota of patients). This is in contrast to the VA where medicine handles everything nonsurgical. In any case, it is both good and bad. It means that those specialized patients get better care - a cardiologist primarily handles the heart attacks, a transplant specialist deals with the kidney rejections. But it also means my perception of medicine is skewed; I am less comfortable with strokes and seizures because I don't see as many.

The patients admitted to the general medicine wards are generally of two types. The typical emergency department admits include little old ladies with failure to thrive, run-of-the-mill pneumonias, patients at nursing facilities who aspirate, patients with liver disease. But at Stanford, we also accept transfers from outside hospitals (like the case described previously) that can be nightmarish. Those patients can be exceedingly complicated. Other types of complex patients are those with rare diseases or congenital malformations. In fact, one patient on my service was 20 years old and had 45 surgeries in the past. Though it is a good educational mix, it is also so overwhelming to a newly minted intern.