St. Jerome Teaching Hospital Case Study

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Question: I was recently in hospital to have some fibroids removed. It seemed there were a million people checking me out at each appointment! Who were all these people? I was told that it had to do with the fact that I was at a teaching hospital. What is a teaching hospital; does it mean a student might operate on me instead of the “real surgeon”?

Answer: You’re not the first person to ask this question. Many people feel uneasy about the thought of a novice involved in their care and treatment.

But studies show that patients at teaching hospitals receive care that’s just as good, and possibly better, than those treated at other medical centres.

Of course, it is true you may be asked the same questions by a lot of different people while you are at one of these hospitals. They’re the next generation of health care professionals at various stages of their training, and they include:

  • Medical students who are studying to be doctors. Most of those you see in the hospital will be in their final two years of medical school training.
  • Residents who have graduated from medical school and are now acquiring expertise to practise in their chosen fields such as family medicine, surgery or oncology. Residency training can last from two to five years, depending on the field.
  • Fellows who have completed residency training and are undergoing additional study in a sub-specialty of their discipline. For instance, a surgeon may decide to focus on the heart.
  • In addition to medical students and doctors-in-training, you will likely encounter students from other health-related professions such as nursing, physiotherapy, pharmacy and social work.

All trainees learn through an incremental process in which they are closely supervised at each step of the way. After they have demonstrated competency in a particular task, they are then permitted to do it on their own, says Dr. Mary Anne Cooper, a gastroenterologist who is director of undergraduate medical education at Sunnybrook Health Sciences Centre.

Medical students start off by learning basic skills, such as listening to a patient’s heartbeat with a stethoscope, or taking a blood pressure reading.

They don’t play a significant role in surgery until they have graduated from medical school and have begun working on their residency requirements.

“An undergraduate student is never participating in surgery alone without extensive oversight and supervision and their role would be to assist, not to conduct the actual surgery,” says Dr. Ari Zaretsky, Psychiatrist-in-Chief and Vice-President of Education at Sunnybrook.

“I remember when I was a medical student, I had to stand for hours scrubbed up and observing,” in the operating room, he recalls. The most responsibility he was given at that time involved holding a retractor – a tool used to pull back skin in order for the surgeon to gain access to underlying tissues and organs.

Surgery residents start their hands-on training by doing a small component of a much larger operation. As they master each skill, they are given more to do. By the time they have completed their residency – which takes five or more years – they are capable of performing an entire procedure without staff supervision.

It’s also important to keep in mind that surgery is a team effort and there are lots of experienced people in the operating room.

You may also be relieved to learn that doctors-in-training often practice on dummies and artificial body parts before cutting into a live human being.

Huge advances have been made in operating-room simulations in recent years. The artificial hearts and parts often look like the real thing. These training exercises are similar to the learning processes for commercial jet pilots who practice take-offs and landings on flight simulators.

Throughout their training, the residents, fellows and medical students work under the watchful eyes of staff clinicians who remain ultimately responsible for the patients.

“Obviously, they have their reputation and everything else on the line,” says Dr. Zaretsky. “They are not going to download responsibility without thinking. They are going to be very cautious.”

As they gain more experience, the residents assume a larger role in caring for patients admitted to hospital or recovering from surgery. It is the residents who you will often see working the grueling overnight shifts.

With the residents involved in daily patient care, staff clinicians can devote more of their time to research, says Dr. Cooper, who is an Associate Professor of Medicine at the University of Toronto.

In fact, one of the benefits of going to a teaching hospital is that the staff physicians are often at the forefront of medical innovation. They also tend to be the doctors who are willing to take on patients with complex conditions.

Over the years, researchers have done numerous studies that compared teaching hospitals with community medical centres. These studies are difficult to do properly because the patient populations are not always comparable. In particular, the teaching hospitals tend to be magnets for difficult medical cases.

“Despite the fact that teaching hospitals consistently take care of sicker patients, outcomes – including satisfaction outcomes – are typically as good as or better in teaching hospitals than community ones,” says Dr. Kevin Imrie, Sunnybrook’s Physician-in-Chief.

So, in general, you should expect to receive top-notch care at a teaching hospital.

But there is a catch: It may take a little longer to get through each procedure because there are additional people involved. Every patient examination is viewed as another learning opportunity for the group.

For instance, you likely saw a whole gang of trainees gathered around your bedside during morning rounds when the physician in charge of your care assessed your condition and drew up a treatment plan for the day.

Or, you have been questioned by a resident, and shortly thereafter, quizzed by a staff physician about the very same issues.

Some patients may find this repetition a bit annoying. But it is part of the teaching process and, to some extent, it is one of the safeguards to make sure nothing is missed.

In my time at Sunnybrook, I have had an opportunity to follow some doctors on their morning rounds and the experience has bolstered my confidence in how the teaching system works. The trainees are eager to do their best. And, I think, senior staff benefit from the stimulating discussions with the students, residents and fellows. When they are reviewing a patient’s case, all the care options are carefully weighed and considered. It’s fascinating to watch.

I hope this explanation of a teaching hospital puts your concerns to rest. You may still feel tempted to ask the senior staff physician to perform your entire surgery – and not let the trainees touch you.

However, if you make such a request at a teaching hospital, don’t be surprised to encounter some resistance.

“Teaching is part of the mandate of our hospital,” says Dr. Cooper. “This is what we do here.”

Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog Personal Health Navigator  is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to and follow Paul on Twitter @epaultaylor


With this casebook, students have the opportunity to apply finance principles and concepts to a setting that simulates an actual work environment. Thus, this book creates a bridge between academic learning and applied practice.Each of the 30 finance cases presents a comprehensive picture of the organization, along with a relevant financial-management challenge that you must solve. The majority of cases are accompanied by spreadsheet models to help you perform analysis and calculations.Also provided are six mini ethics cases to provoke thought about financial situations with ethical implications.Click here to see case descriptions:Attention students: Access the student spreadsheet models by clicking on the Student Resources tab above.Changes to this edition:The marginal cost pricing analysis case now includes both underlying cost structure and current profitability information.The pay-for-performance case now includes the three areas of performance (productivity, financial, and quality.)The clinic valuation case now includes the use of free operating cash flow as a valuation approach in addition to valuations based on free cash flow to equityholders, number of physicians, and revenues. Also, debt financing has been added to the clinic’s capital structure.The receivables management case includes two additional customers each with a different receivables pattern. Also, the cost of carrying receivables has been added to the model.The organization in this capitation and risk sharing case has been recast as a new Physician Hospital Organization (PHO.)


  • Contents
  • Preface for Instructors
  • Preface for Students
  • Case Descriptions
  • 1 Riverview Community Hospital (A): Assessing Hospital Performance
  • 2 Chesapeake Health Plans: Assessing HMO Performance
  • 3 Rio Grande Medical Center: Cost Allocation Concepts
  • 4 Apple Valley Family Practice: Cost Allocation Methods
  • 5 Blue Pointe Healthcare: Premium Development
  • 6 Columbia Memorial Hospital: Break-Even Analysis
  • 7 Palisades Mental Health Clinic: Variance Analysis
  • 8 Alpine Village Clinic: Cash Budgeting
  • 9 Boston Transplant Center: Marginal Cost Pricing Analysis
  • 10 Denver Health Network: ABC Analysis
  • 11 Maitland Family Physicians: Pay for Performance
  • 12 Pensacola Surgery Centers: Time Value Analysis
  • 13 Southeastern Specialty, Inc.: Financial Risk
  • 14 Atlantic Healthcare (A): Bond Valuation
  • 15 Atlantic Healthcare (B): Stock Valuation
  • 16 Southern Homecare: Cost of Capital
  • 17 RN Temp Services, Inc.: Capital Structure Analysis
  • 18 Portland Cancer Center: Leasing Decisions
  • 19 Palms Hospital: Traditional Project Analysis
  • 20 American Rehabilitation Centers: Staged Entry Analysis
  • 21 Cook County Health System: Make or Buy Analysis
  • 22 St. Jerome Teaching Hospital: Merger Analysis
  • 23 South Beach Health Partners: Joint Venture Analysis
  • 24 Bloomington Clinics: Practice Valuation
  • 25 University Faculty Practice: Physician Extender Analysis
  • 26 Johnson Memorial Hospital: Competing Technologies with Backfill
  • 27 Commonwealth Pharmaceuticals: Receivables Management
  • 28 Clear Lake Hospital: Inventory Management
  • 29 Riverview Community Hospital (B): Financial Forecasting
  • 30 Copperline Healthcare: Capitation and Risk Sharing
  • 1 Trigson Blue Cross/Blue Shield: Copayments
  • 2 Deal of a Lifetime: Corporate-Owned Life Insurance
  • 3 Bayview Surgery Center: Pricing/Billing of Surgical Services
  • 4 Jefferson General Hospital: Mergers, Acquisitions, and Agency
  • 5 Front Street Hospital: Uninsured Charges and Collections
  • 6 Westwood Imaging Centers: Payment for Referrals
  • About the Author
  • About the Contributor

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