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The Resident Patient



Shortly thereafter, the doctor acquired a new patient, a Russian nobleman with cataleptic fits. His grown son brought him in the evening while Mr Blessington was taking his usual walk. The son insisted on waiting out in the waiting room while the doctor saw his father. During the consultation, the patient had a fit, sitting bolt upright and going quite rigid. The doctor rushed for some nitrite of amyl for his patient to inhale, but upon returning, found that both his patient and his son had left.




The Resident Patient



Shortly after leaving, Holmes outlines to Watson his train of thought. He knows that two men, perhaps more, are out to get Blessington. The catalepsy was faked, just to keep Doctor Trevelyan busy so that he would not notice the other man going into Blessington's room. They did not wish to steal anything, as can be seen in their failure to rummage around in the room. They chose an appointment in the evening knowing that there would be no other patients in the waiting room. Holmes also knows just looking at Blessington that he is afraid for his own life, and deduces that he must therefore know who is after him, for no man could have such enemies without knowing about it. Also, it was only by chance that Blessington was not in both times that these two men came; they were obviously not familiar with Blessington's personal habits.


One of the characters in ''The Adventure of the Resident Patient,'' in fact, the resident patient, has a bit of his past creeping back up causing him to look over his shoulder. What do we mean? Read on to find out.


Our story opens not with the resident patient, but with Doctor Percy Trevelyan who presents to Sherlock Holmes with a problem. As he explains to Holmes and sidekick Doctor John Watson, he had been a good student, but a broke one. Sounds like most students, right? A graduate with a presumed ''distinguished career'' before him, Trevelyan nevertheless had no capital, or financing, to start up his own medical practice. That is, until a perfect stranger comes along.


The details of the deal were as such: Blessington would provide the location, staff, furnishings and necessities, and Trevelyan was to ''wear out'' his chair in the consulting room seeing patients. The doctor could keep a portion of his earnings and would provide a portion to Blessington for his investment.


Around the same time, the doctor finds a new patient, a Russian nobleman prone to ''cataleptic attacks.'' He arrives to see Trevelyan, with his strong, grown son assisting him. The pair arrive in the evening while Blessington is out and disappear just as quickly after the doctor leaves the patient's room to retrieve medication.


Lacking the capital but having the talent to open his own practice, Doctor Percy Trevelyan goes into business with the stranger, Mr. Blessington, who finances his operation with the promise of medical care and profits. Everything is going great until one day Blessington starts acting peculiarly. Around the same time, Trevelyan acquires a new patient. After two visits from this new patient and his son, Blessington announces that someone has been in his room, though not disturbed or stolen anything. The next morning, Blessington is dead.


Holmes concludes that he has been murdered rather than taken his own life. The new patient and his son are partly responsible. As it turns out, Blessington and the two men were in a bank-robbing gang. When caught, Blessington double-crossed them, sending two to prison and causing one to be killed. The men, once released from jail, came to exact their revenge.


Background: Continuity clinics are a critical component of outpatient internal medicine training. Little is known about the population of patients cared for by residents and how these physicians perform.


Objectives: To compare resident and faculty performance on standard population health measures. To identify potential associations with differences in performance, specifically medical complexity, psychosocial vulnerability, and rates of patient loss.


Setting and participants: Large academic primary care clinic caring for 40,000 patients. One hundred ten internal medicine residents provide primary care for 9,000 of these patients; the remainder are cared for by faculty.


Main measures: We compared resident and faculty performance on standard population health measures, including cancer screening rates, chronic disease care, acute and chronic medical complexity, psychosocial vulnerability, and rates of patient loss. We evaluated the success of resident transition by measuring rates of kept continuity visits 18 months after graduation.


Key results: Performance on all clinical outcomes was significantly better for faculty compared to residents. Despite similar levels of medical complexity compared to faculty patients, resident patients had significantly higher levels of psychosocial vulnerability across all measured domains, including health literacy, economic vulnerability, psychiatric illness burden, high-risk behaviors, and patient engagement. Resident patients experienced higher rates of patient loss than faculty patients (38.5 vs. 18.8%) with only 46.5% of resident patients with a kept continuity appointment in the practice 18 months after graduation.


Conclusions: In this large academic practice, resident performance on standard population health measures was significantly lower than faculty. This may be explained in part by the burden of psychosocial vulnerability of their patients and systems that do not effectively transition patients after graduation. These findings present an opportunity to improve structural equity for these vulnerable patients and developing physicians.


Doctors make the worst patients, but he wasn't nearly as insufferable as I would've imagined from him. He was astute enough to realize that if they chose to do so, from AJ and Conrad to Kit, they could've made his life hell. He knew he wasn't warm and fuzzy with him, and he's butted heads with everyone there.


"Closed eyes mean cut away, no need to wait for the attending." It was at that precise moment, I snorted. Cain's residents treating him as they would any other patient on the table and ignoring the fact that Kit's OR rules are different was some poetic justice.


Every day patients walk through the doors of Chastain with different needs, and our staff is ready. Our doctors and nurses work tirelessly, care deeply, sacrifice willingly. This hospital is a cornerstone of this community and a center for medical innovation, and that's why I'm so proud to call Chastain Park Memorial home.


He flew to Atlanta, helped save her life, and then told her he was willing to give up his entire life so that he (and his dog) could join her in WitSec. It's up there with some of the show's best patient love stories.


One evening in October, Sherlock Holmes and Dr. Watson return to their Baker Street apartment to find that a client is waiting to see Holmes. The client is a doctor named Percy Trevelyan. He has come on behalf of his resident patient, a man named Blessington.


During his student days, Percy Trevelyan was recognized as having great potential by his professors. He won a prize for a paper which he wrote and hoped to become a well-known specialist in catalepsy. To become an acknowledged specialist, a doctor needs to set up a practice in the West End of London. This requires renting and furnishing a house, employing servants and keeping a smart-looking horse and carriage. Percy Trevelyan did not have enough money to do any of those things. A few years ago, Dr. Trevelyan was approached by Blessington, a man whom he had never seen before. Blessington offered to help Trevelyan set up a practice. He said that he would rent and furnish a house in the West End for Trevelyan, pay the servants and even give trevelyan some pocket money. In return, Blessington would take three quarters of all the money which Trevelyan made and stay with him as a resident patient. Blessington said that he required constsnt medical supervision due to his weak heart.


Two days before he went to see Holmes, Dr. Trevelyan received a letter. According to the letter, a Russian nobleman suffering from catalepsy would come to consult Dr. Trevelyan at 6:15pm the next day. The Russian nobleman arrived accompanied by a muscular young man, who said that he was the man's son. The young man said that he would wait outside while his father consulted Dr. Trevelyan. During the consultation, the Russian appeared to suffer from a cataleptic attack, he fell silent and stared ahead blankly. Dr. Trevelyan went to get some gas to revive his patient. When he returned, the Russian nobleman and his son had both gone. Trevelyan's page, a boy who had not been in his service for very long, claimed that he had not seen anyone leave. Blessington returned home from his pre-dinner walk shortly afterwards.


The American College of Graduate Medical Education (ACGME) mandates that at least 33% of internal medicine training occur in the outpatient environment.1 This training occurs primarily in resident continuity clinics, where residents manage the primary care of a limited panel of patients under faculty supervision. The ACGME outlines the importance of practice-based learning and improvement as a core competency, whereby residents must demonstrate facility in assessing their own care of patients in order to provide them with experience in self-evaluation and life-long learning.1 Similarly, primary care has incorporated the principles of population health management, with individual and group performance measurement becoming a primary feature of continuous quality improvement and reflective practice. The American Academy of Medical Colleges outlined a series of key features of high functioning primary care training environments. Among these is a focus on population health management, facilitated by efforts to retain patients within the practice and data-driven quality improvement. 041b061a72


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