Five Patients

Implicit in this is the notion that what the hospital now does, it does well. But it is not doing enough, and the times, indeed, are changing. To quote Galbraith, "One must either anticipate change or be its victim."



The hospital can no longer be a charitable refuge for the poor patients-the poor patient (or, rather, the patient whose bills can't be paid) is disappearing from the landscape.



The hospital can no longer act as a stronghold of technological, scientific excellence for a few patients, when the disparity between in-patient marvels and community horrors is ever-increasing.



Dr. John Knowles, director of the hospital, observes that "When I was recently the visit on the medical service, the first five patients presented to me all happened, by a curious coincidence, to have the same problem. And it serves to point up the incongruity of what we're doing here. All five were elderly, chronic alcoholics with massive GI bleeding and end-stage liver disease. All five were in coma and we were treating them vigorously, with everything medicine has to offer. They had intravenous lines, and central venous pressure catheters, and tracheostomies, and positive pressure respirators, and suction and Seng stocking tubes, and all the rest. They had house staff and students and nurses working on them around the clock. They had consultants of every shape and sort.



They were running up bills of five hundred dollars a day, week after week... Certainly I think they should be treated, just as I think that a large hospital like this is the place where this brand of complex medicine ought to be carried out. But you can't help reflecting, as you look at all this stainless steel and tubing and sophisticated equipment, that right outside your door there are people with TB who aren't getting antibiotics, and kids who aren't getting vaccinations, and women who aren't getting prenatal care... I think we have an obligation to these other people, as well."



The hospital's new objective is to spread its resources more widely, at the expense of its traditional passivity. The first step has been to begin an ambulatory care center in Charlestown, a depressed area of 16,000 people. This sort of "satellite clinic" is widely debated in medical circles today.



Dr. Leaf: "The Charlestown project is interesting to us, to see if we can begin to restructure the way we deliver care. I hear arguments from my colleagues in the medical school, saying that no satellite clinic has ever worked. They say the research interest isn't there, the way it is in a hospital. They say you can't find doctors to work in them. Well, then, we just have to get some new physicians who see their research as working in the community, devising ways to give better care, rather than being in the hospital and doing research on, say, gastric physiology."



Certainly the academic hospitals will have to abandon what Dr. Knowles calls "the present defensive isolation... in a bastion of acute curative, specialized, and technical medicine." The impact of this on the inner workings of the hospital itself may be extensive, and beneficial.



In 1896, the intern Harvey Gushing referred to the MGH as "this little world of ours"-and he meant precisely that. It was a little world, and it was "ours"; it belonged to the doctors, not to the patients. Doctors were a permanent fixture in this world. The patients were transients who came and went. (Patients are well aware that the hospital is for doctors, and not for themselves. They frequently report that they feel like "specimens in a zoo." Indeed, nearly every literate person who has recorded his experience in an academic hospital, from the late Philip Blaiberg on down, has mentioned this disturbing association.)



Initially the hospital was designed to be a little world for the patients, supplying all their needs. In those days, there were few resident physicians. But the hospital has evolved into a complete world for doctors as well. Indeed, it would be surprising if it did not, for there is one house officer for every four patients, and the house officers spend almost as much time in the hospital as the patients.



For a resident, the completeness of the little world-with its dormitories, libraries, cafeterias, coffee shops, chapel, post office, laundry, tennis and basketball courts, drugstore, magazine stand- combined with the intensity of training (the average resident spends 126 hours a week in the hospital) can have some peculiar effects. It is quite possible to forget that the hospital stands in the midst of a larger community, and that the final goal of hospitalization is reintegration of the patient into that community. In this respect, the hospital is like two other institutions which have a partially custodial function, schools and prisons. In each case, success is best measured not by the performance of the individual within the system, but after he leaves it. And in each case there is a tendency to view institutional performance as an end in itself.



This is true for both doctors and patients. The ideal of the physician-scientist, the clinician-researcher, is very much a product of academic hospital values. The educational process designed to mold this product has some paradoxical aspects. One may reasonably ask, for example, what is a medical student being trained to become?



Without doubt the answer is: a house officer in a teaching hospital. A good medical student graduates with all the necessary equipment: a background in basic science, some clinical experience, familiarity with the journals, and an academic orientation.



What, then, is a house officer being trained to become? The answer is, an academic physician specializing in acute, curative, hospital-based medicine [A student of my acquaintance, now a psychiatric resident, endeared himself to the house staff of hospitals where he was a student by doggedly asking each resident he met to define, in a simple sentence, the difference between neurosis and psychosis. He concluded that 15 per cent had some vaguely appropriate notion; the rest were appallingly wrong. The fact that a doctor does not know the difference between neurosis and psychosis does not necessarily mean he will be a poor physician; a doctor who cannot articulate these distinctions may conceivably handle them deftly in his practice. But it is a clear indication he has not had much training in behavior, and the question is whether he ought to have such training and whether his patients would benefit from the training]. This is heavily scientific and not very behavioral; it must be so. (As the visit said: "Tell me about his kidneys, not his marital troubles." And the visit was right: the hospital is geared to treat his kidneys, and not his arguments with his wife.)



But the great majority of house officers do not become academic physicians, at least not full time. They go out into the community to begin, in many respects, a totally different kind of practice from any they have ever seen. They are shocked to discover that 70 per cent of their patients have no identifiable illness; they are besieged and pestered by "crocks"; they have relatively few acutely ill patients, and relatively few hospitalized patients. They are, in short, called upon to practice a great deal of behavioral art and relatively little science.



These doctors suffer from what Grossman calls "acute organically trained syndrome." The rationale for giving them the training they got, as preparation for the work they would be doing, was formerly couched as "if they can handle the problems they see in the hospital, they can handle anything." It is obviously untrue, except for those diseases that are scientifically understood and medically treatable; patients with other complaints may get a more sympathetic ear from their next-door neighbor.



*This same argument has been made by Peter Drucker concerning undergraduate, liberal arts colleges, where he points out that professors of English or History are not training liberal humanitarians or anything else so noble-they are training future professors of English and History.



Underneath it all is a sense that modern, scientific medicine can be taught, but the vague, amorphous "art" cannot be taught in the same way. This is true, but it does not mean it cannot be taught at all. Nor does it mean that simply watching the visit examine five or ten patients a week is a sufficient background in how to deal with a patient's psyche.



What a medical resident knows about science he has gotten from intensive courses, rounds, seminars, and journal reading; what he knows about behavior, psychiatry, psychology, or sociology depends on what he has managed to pick up as he goes along. This generally amounts to pitifully little.* It is hard to estimate the amount of time a doctor spends studying behavioral science during his years as a student, intern, and resident. Formal training-lectures as a student, rotations as a clinical clerk, social service and psychiatric rounds as a house officer-probably account for no more than 1 to 2 per cent of his total time; the extent of informal training is impossible to guess.



There is now a growing movement within medical education to provide more formal training in behavior, but there is also formidable opposition. As John Knowles has pointed out, medicine gained acceptance within the university as a valid discipline not because of its advances as a social science, but because of its discoveries as a natural science. For nearly a century, natural science has been the paydirt, and the behavioral art has taken a subordinate position. Reversing the trend of a century will take some doing.



Of course, the hospital has an out-patient department and emergency ward, where the interface of hospital and society is more sharply seen. But the addition of community clinics, separate from the hospital, will almost certainly change the psychological set of doctors working within the physical setting of the hospital itself.



It is too early to know whether the satellite clinics are going to work. The question of physician acceptance is one problem; the question of community acceptance another. But if they do not work, something else must be found, and at this time it appears social pressures are sufficiently intense to guarantee such a search for new delivery systems.



The concept of a "patient-oriented hospital" is fashionable at the moment. The phrase is widely used, though the idea is shopworn. People have recognized for a long time-at least twenty-five years-that hospitals are designed for the patient's needs only when those needs do not conflict with the doctors' convenience. Nor is there any mystery about why this is so. Whenever a new hospital is built, it is the doctors who are consulted on design requirements, not the patients.



All this has produced a great deal of talk among doctors, architects, patients, engineers, interior decorators, and innumerable other people-but very little innovation, very little experimentation. For the majority of hospitals, and the majority of new hospitals, the classic complaints still hold true:



The hospital is difficult to adapt to. It brings in individuals from outside, and plunges them into a totally new existence, with new schedules, new food, new rules, new clothing, new language, new sounds and smells, fears and rewards. For the patient entering this foreign environment, there are no guides or guidebooks available to him. A person visiting Europe can get better advance information than a person entering the "foreign country" of the hospital.



The hospital building disregards physical factors that might promote recovery. Colors are bland, but instead of being restful, are more often depressing; space is badly distributed, so that a patient may be stranded in a large room, or crowded in a small one; private and semi-private patients often feel isolated in their rooms. (A Montefiore Hospital study concluded that while families of ward patients were eager to see their relatives transferred to private rooms, the patients wanted to stay on the wards, where they would have more contact with other people.) Windows are badly placed, and the view most often shows an adjacent large hospital building or a parking lot.



The hospital makes psychological demands that may retard recovery. According to Stanley King, these include dependence and compliance with hospital routine; a de-emphasis on external power and prestige; tolerance for pain and suffering; and the expectation that a patient will want to get well. These can easily work at cross-purposes. For example, a proudly self-reliant man may find his passive role as threatening as his illness. Or a person may become so dependent, and regress so far toward a child-like state, that he becomes more petty, complaining, and intolerant of pain than he would be otherwise. Or he may find his dependent role so satisfying that he loses his desire to get well.



One may immediately object that despite all this, the majority of patients adjust well to the hospital, recover, and go home. That is true, but as an argument it is a little like saying that the world got on perfectly well without electricity, which is also true.



But assuming these complaints have validity-assuming that patients would really recover more swiftly in a better designed environment-how should the new environment be designed? There is a spectrum of proposals, ranging from minor adjustments to quite radical innovations.



Perhaps the most radical, and the most interesting, comes from a simple observation: the modern hospital is best suited to a severely ill person. These people are most tolerant of hospital routine and its indignities, irritants, and difficulties.



On the other hand, persons recovering frequently become less tolerant as their physical condition improves. The phenomenon is so well known that doctors notice when a previously compliant patient begins to grumble about the food or the noise at night. These gripes are interpreted as a sure sign the patient is improving. Related to this is the so-called "lipstick sign," referring to the fact that as women begin to feel better, they start wearing lipstick and combing their hair in the morning. Essentially, all this means that the patients are acting in ways not demanded by the environment (lipstick) or else positively condemned by the environment (griping). Such activities are more appropriate to the outside world, and they are a signal that the patient, in his own mind, is preparing to leave the hospital for the outside.



How can one capitalize on this? At present, not at all. This is because, at the present time, patients are assigned to different parts of the hospital on the basis of only three criteria-financial resources, sex, and anticipated therapy. No other attribute of the patient matters, not even diagnosis. (Patients with ulcers, pancreatitis, or cancer, for example, will be assigned to medical or surgical floors depending on whether their treatment calls for operation or not.)