Six months before she came to the MGH, Mrs. Murphy, a fifty-five-year-old mother of three, began to notice swelling of her legs and ankles. This swelling increased and she became progressively weaker, until finally she had to quit her job as a filing clerk. She consulted her local doctor, who prescribed digitalis and diuretics. This reduced the swelling but did not eliminate it completely. She continued to feel very weak.
Finally she was admitted to a local community hospital where she was found to be severely anemic, to have bleeding in her gastrointestinal tract, to have chemical evidence of liver disease, and X rays suggestive of cancer of the pancreas. At this point, she was transferred to the MGH. She knew nothing of her suspected diagnosis.
On arrival she was seen by Edmund Carey, a medical student, and Dr. A. W. Nienhuis, a house officer. They found that she was slightly jaundiced and that her abdomen was distended with fluid. Her liver could not be felt because of this fluid. Her legs and ankles were still swollen. They confirmed the presence of blood in her stools.
Laboratory studies indicated a hematocrit of 18 per cent, which meant that she had less than half the normal number of red blood cells. Her reticu-locyte count, a measure of new-blood-cell production, was increased. A measurement of iron in her blood showed that she was iron-deficient. The total picture was thus consistent with chronic anemia from blood loss through the gastrointestinal tract, [The technical reader must excuse some simplification in this presentation] but the situation was more complex: A Coombs blood test was positive, suggesting that her body was also destroying red cells by an allergic mechanism.
A chest X ray and electrocardiogram and kidney studies were normal. Barium X-ray studies of the upper GI tract, to check the suggestion of pancreatic cancer, could not be done immediately. A bone-marrow biopsy was done, but it gave no further clue to the nature of the anemia. Her abdomen was tapped and a sample of fluid withdrawn for analysis. There was laboratory evidence to suggest liver disease and perhaps insufficient proteins in her blood, but this could not be immediately confirmed on the night of admission.
Mrs. Murphy thus presented a complex and puzzling problem. The first question was whether a single disease process could explain her three major difficulties, which Dr. Nienhuis summarized as anemia, gastrointestinal disease, and edema. As he noted, they could all be explained, in whole or in part, by cancer or liver disease, by invoking mechanisms that are quite complicated.
Implicit in his thinking was the notion that the body is constantly changing, and that those features of the body which appear static are really the product of a dynamic equilibrium. Thus the red-cell volume of the body, which usually appears fairly constant, is really the product of ceaseless creation and destruction of cells. The average red cell has a life span of 120 days; anemia can result from either inadequate production of cells or excessive destruction of cells. In Mrs. Murphy's case, production seemed actually increased, but she was losing cells through bleeding and allergic destruction.
Similarly, water, which normally accounts for 70 per cent of body weight, is carefully distributed in a healthy person-so much inside cells, so much outside cells. Individual water molecules are constantly shifting around the body, but the balance in each compartment is closely maintained. Edema, the pathological swelling of certain tissues with water, can be caused by a wide range of factors that disrupt the normal distribution of body water. The same effect can be produced by heart disease, liver disease, or kidney disease, each by a different mechanism.
Mrs. Murphy was admitted to the Bulfinch medical wards and passed an uneventful night. In the morning she was seen on work rounds by Carey, Nienhuis, and another resident, Dr. Robert Liss. Practical aspects of her condition were discussed, particularly the question of transfusion. It was decided to postpone transfusion since she appeared comfortable for the moment. Later in the day Mrs. Murphy's problems were discussed with the visiting senior physician on the wards, Dr. John Mills. He felt that "tumor in the abdomen was strongly indicated," but for a variety of reasons felt that lymphoma, a cancer of lymph glands, was more likely than pancreatic cancer.
That same day, a radioactive liver scan was done to determine the size of the liver, since it could not be felt directly. The liver was found to be small and shrunken, suggestive of scarring from cirrhosis. The basis for this cirrhosis was unclear. Mrs. Murphy maintained that she was a non-drinker. She had no history of hepatitis in the past, and no occupational exposure to liver poisons. The cirrhosis was therefore labeled "cryptogenic," meaning of hidden cause.
For the next three days the question of cancer, or liver disease, or both, was widely discussed. As evidence of liver damage accumulated, cryptogenic [To an outsider, the tendency among physicians to call certain diseases cryptogenic or idiopathic-and then to discuss them as if they were well-defined, understood clinical entities-may be perplexing. But in fact it serves a purpose. For one thing, it excludes diagnoses: anyone who speaks of cryptogenic cirrhosis has excluded alcoholic or post-hepatitic cirrhosis. By implication, the term conveys more information than a simple "We don't know why." In the same way, idiopathic hypertension implies prior exclusion of the few known causes of this condition] cirrhosis became the favored diagnostic possibility.
Meanwhile, Mrs. Murphy began to feel better. She received a transfusion of three units of blood, and felt better still. She did not, however, receive any further therapy.
Everyone agreed that a liver biopsy would be useful, but the patient had a bleeding tendency- presumably secondary to liver disease-which made a biopsy impossible. Other diagnostic procedures were not helpful. Sigmoidoscopy and barium enema failed to determine the origin of gastrointestinal bleeding. A check for cancer cells in her abdominal fluid was negative.
On the seventh hospital day, she was seen by Dr. Alexander Leaf, who suggested thyroid tests as well as tests for collagen diseases. The following day, Dr. Nienhuis raised the question of whether this patient might have lupoid hepatitis, a rare and somewhat disputed clinical entity.
In the next forty-eight hours, two important pieces of evidence were obtained. First, an upper GI series was done, and it was normal. There was no sign of cancer of the pancreas.
Second, a re-examination of the patient's white cells revealed several with large, abnormal, bluish lumps imbedded within the cell substance. These cells are called LE cells, for they are virtually diagnostic of a collagen disease, systemic lupus erythematosus.
This is a disease of enormous interest to physicians at the present time. Once considered rare, it is now seen with increasing frequency as diagnostic tests become more refined. Classically it has been considered a disease of middle-aged women, characterized by protein manifestations-fever, skin eruptions, and involvement of many other organs, particularly joints and kidneys. However, as lupus is better understood, the classical description is changing: more males are now found with SLE, and the range of clinical manifestations has broadened.
Lupus is called a collagen disease because it shares with certain other diseases a tendency to alter blood vessels and connective tissue, and because it seems, like these other diseases, to be caused by some form of hypersensitivity (allergy). This question of causation is by no means clear, but patients with the disease certainly show a wide variety of biochemical disorders of the immune system; lupus is frequently called "the autoimmune disease par excellence."
Normally, the body's immune mechanism produces antibodies to fight agents, such as invading bacteria. This response is generally beneficial to the individual, although much recent work has gone into suppressing the response so that foreign organs can be transplanted.
However, it is now recognized that the body's natural rejection mechanism can sometimes be mistakenly directed toward the body itself. In some way the individual's capacity to distinguish what is native from what is foreign is disrupted; the patient attempts to produce immunity to himself-and proceeds to attack certain of his own tissues, leading to "a chronic civil war within the body."
In the case of lupus, the patient produces several sorts of antibodies against himself. One of these attacks DNA, the genetic substance of chromosomes. This damaged DNA is later ingested by white cells, producing the characteristic bluish lumps. However, SLE patients also produce other auto-antibodies, which are seen in other conditions. Thus Mrs. Murphy was found to have anti-DNA antibodies, increased gamma globulin, and antibodies against thyroid, as well as antibodies found in rheumatoid arthritis.
Immune disorders as a cause or complication of illness are now suspected for a great range of diseases, including rheumatic fever, pernicious anemia, myasthenia gravis, multiple sclerosis, Hashimoto's thryoiditis, and glomerulonephritis. Immune and auto-immune mechanisms are thus of considerable interest; investigation of these mechanisms represents one of the major thrusts of current medical research.
For systemic lupus erythematosus, however, there is no cure and no good information on prognosis. Patients have died within a few months of onset; others have lived fifteen or twenty years. For Mrs. Murphy, therapy consisted of diuretics, which resulted in loss of thirty-two pounds of fluid, and a cautious trial of corticosteroids to suppress some effects of the disease. She was discharged feeling well and returned to her job.
The case of Mrs. Murphy illustrates an important function of the ward patient in the university hospital that differentiates him from the private patient: the ward patient is there in part to help turn students into doctors. For the patient, this has its drawbacks as well as its advantages.
First, to clarify some terms:
A medical student is anyone with a bachelor's degree who is in the midst of four years of graduate work leading to the M.D. degree, but not yet to a license to practice. To be licensed, he must spend an additional year as an intern in a teaching hospital.
An intern is thus anyone with an M.D. who is in his first year out of medical school. An intern is licensed to practice only within the hospital. After a year of internship, he could theoretically leave and begin private practice, but practically nobody does. Instead, interns go on to become residents.
A resident is anyone who has finished his internship and is continuing with more specialized training in such areas as pediatrics, surgery, internal medicine, or psychiatry. A residency may be taken at the same hospital as the internship or at another; residencies last from two to six years, depending on the field.
Medical students are primarily responsible to the medical school, not the hospital; within the hospital they are referred to, somewhat ironically, as "studs."
Interns and residents, on the other hand, are hospital employees and are referred to as "house officers." Collectively the interns and residents comprise the "house staff," as distinct from the "senior staff," meaning the private physicians or academic teachers affiliated with the hospital.
This hierarchy is analogous to a university with its undergraduates, graduate students, and professors. There are departments within the hospital corresponding to university departments; these departments give courses for medical students and house officers, termed "rotations." Primarily, the teaching is informal, but there is also a heavy schedule of formal rounds, lectures, and seminars.
In the history of the teaching hospital, as in the university, the undergraduate (or medical student) appeared much earlier than the graduate student (or house officer). Indeed, the beginnings of the teaching hospitals are closely associated with the beginnings of medical schools in this country. This was clearly the case for the first three medical schools, and the first three teaching hospitals in America: in Philadelphia, New York, and Boston.
The Massachusetts General had Harvard students on the wards from its inception. There is no reason to believe the students made the hospital more appealing; Warren recalled that students in his day "were of the crudest character," and remembers that it was no recommendation to a landlady to say you were a medical student. Even a century later, Harvey Gushing grumbled that "students in a hospital, like children in a lodging house, are not an unmixed blessing." But despite persistent reservations, the teaching hospital has always taught medical students. What is new is the teaching of house officers.
Originally, medical students were required to take two years of academic courses, followed by a third year as an apprentice to a practicing physician. In those days the MGH had two house-officer positions-then known by the considerably more humble term "house pupils"-and these posts were acceptable substitutes for an apprenticeship. Beginning around the time of the Civil War, however, the hospital began to expand its house-officer posts; the greatest growth came at the turn of the century. In 1891, there were seven house officers; by 1901, fourteen; by 1911, twenty-one. As mentioned, there are now 304.
Part of this growth represents a simple growth of the hospital. As it became larger, there were more patients to care for, and to learn from, and more day-to-day work to be done by house officers.
Part of the growth represents the increasing role of the hospital as an acute-care facility. The hospital sees fewer patients with chronic diseases and more acutely ill patients who require continuous and careful management. This requires a larger house staff.
Partly, too, the growth represents a shift away from the old personal apprentice system toward an "institutional apprenticeship." In the 1930's and 1940's, it became clear that house officers who remained in the hospital were better trained than those who left early and linked up with private practitioners. This observation finally led to virtual abandonment of the personal apprenticeship. Thus, formerly, surgical residency was three years, followed by two years of apprenticeship under a private man; now it is five years (including internship), and the only reason for joining a private surgeon at the end of that time is to build a practice, not to gain more experience.
All this means that the structure of patient care is quite different today from what it was when the hospital first opened. In 1821, patient care was essentially in the hands of private, senior men who donated their time to the hospital and agreed to take students around with them on the wards. But between student and senior man there has sprung up a large body of individuals who are now essential to the functioning of the hospital. The MGH could cheerfully dispense with its medical students, but it would come to a grinding halt in a few hours if deprived of its house staff.
It is no exaggeration to say that the house staff runs large areas of the hospital, with senior men advising from above, and students looking on from below. One may applaud this system for providing a spectrum of competence and responsibility, allowing students to move up the ladder to internship, then junior and senior residency, in easy stages. But in fact the emergence and proliferation of house officers has another, much harsher rationale. For the hospital, they provide a source of trained, intelligent, hard-working, very cheap labor.
This has always been true. In 1896, when Gushing was an intern, he noted that "house officers are about as hard worked men as I have ever seen. Every day is twenty-four hours long for them with a vengeance."
The modern house officer generally works an "every other night" schedule, meaning roughly thirty-six hours on duty, and twelve off. In practice this means arriving at the hospital at six thirty or seven in the morning, working all day and probably most of the night, continuing through the following day until late afternoon, and then going home to sleep-until six thirty or seven the next day. Payment for this effort, which is sustained over many years, was until quite recently nonexistent. Some hospitals were so bad that they worked their house officers at this pace, paid them nothing, and charged them for laundry and parking.
Others would provide a few meals, and perhaps an honorarium fee of twenty-five dollars a year. At the MGH, a senior man recalls that as recently as ten years ago, "I was chief resident in surgery, eight years out of medical school, having spent two years in the army; I had a wife and four children; I was responsible for the conduct of an entire surgical service-and I was paid just under two thousand dollars a year."
Such a situation requires either an independent income or a great tolerance for debt; one wonders whether the modern stereotype of the private physician as crassly avaricious can be traced back to these years of early, absurd financial hardship. Fortunately, the salaries of house officers have climbed sharply in recent years. In many hospitals an intern now receives six thousand dollars, a senior resident eight or nine. Many factors are responsible for the increase: the effect of Medicare, which permits the hospital to charge patients for the services of a resident; the fact that the G.I. bill has been extended to cover residency training; the realization among medical educators that you cannot get and keep good people in an affluent society without paying them.
As the house officers have become more numerous and more skilled, the position of the medical student has changed. House officers are licensed to practice medicine; students cannot practice by law. A student cannot write orders, even for something as simple as raising a patient's bed, without having them countersigned by a house officer.
Legally, a student is permitted to employ nothing other than diagnostic instruments, and then only for the purpose of diagnosis. In practice, this ruling is stretched to mean that a student can, under supervision, perform a lumbar puncture, a thoracic or abdominal tap, or a bone-marrow aspirate; he can suture wounds in the emergency ward; he can also mix medicines, start intravenous infusions, inject medicines intravenously, and give a blood transfusion. Additionally, he is expected to have competence in a variety of laboratory procedures and tests.
The medical student's officially sanctioned functions thus lie somewhere between those of a doctor, a nurse, and a laboratory technician. It is not surprising that no one knows what to call him. Instructors with a group of second- or third-year students will often introduce them to patients as "doctors in training" or "these young doctors." Fourth-year students, seeing patients alone, will introduce themselves as "doctor." Until a few years ago, the students even wore name tags which said
"Dr.," but this practice was abandoned
after the hospital was advised it constituted misrepresentation that might have legal consequences. Student name tags now give only their names; those of interns and residents say "Dr."
It is not clear why medical students are called doctors in front of patients, especially since so few patients are fooled by the appellation. One can view the whole business as a harmless convention,
in which the hospital pretends that its students are doctors, and the patients pretend to be taken in.
Why bother? Instructors say that this small white lie comforts the patients, who would be upset to learn they were being examined by students. Something of the same sort happens with interns, who occasionally pass themselves off as residents in the belief that this soothes patients. It is true that the folklore-and the mass-media image-of the medical student and the intern is distinctly unfavorable, and these negative connotations persist until residency. (Dr. Kildare, that charming, all-knowing physician, was a resident who spent much prime time dealing with neurotic, guilt-ridden, fumbling interns and students.) "Even now," according to George Orwell, "doctors can be found whose motives are questionable. Anyone who has had much illness, or who has listened to medical students talking, will know what I mean." In a single, paradoxical stroke, he dismisses the motivations of some doctors, but all medical students.
The position of the medical student is thus peculiar, and occasionally comical. In society at large, he finds himself eminently marriageable and a good credit risk, thus enjoying the approval of those two bastions of conservative appraisal- matrons and bankers. In the hospital, however, those same matrons and bankers want nothing to do with students, and nearly every student has had the experience of examining a woman who grumbles and complains throughout the history and physical and then politely asks if the student is married.
In the end, one suspects that the practice of labeling students as doctors is misguided. Patients ought to be told explicitly who the students are; a moment's reflection shows many advantages to such a practice.
For one thing, most patients coming into a teaching hospital are already apprehensive about being used as guinea pigs. They have heard vague reports that "You'll be in the hands of students and interns," and this is not really true. Patients entering the hospital-already sick and afraid-are almost always unfamiliar with the hierarchy of decision-making that provides careful checks on junior men. Against this background of apprehension is added the fact that everyone introduces himself as a doctor, while the patient knows perfectly well that some of those doctors are students. Thus, failure to identify students increases anxiety instead of relieving it.
Further, it is a common observation on the wards that students are popular with patients. Students have more time to talk to patients; hospital life for a patient is boring; patients like the attention. (Frequently they will rank the house staff according to warmth and attentiveness. A friendly student who has had the experience of working with a brusque resident knows how often patients
conclude that the resident is a student, and vice versa.[This implies that patients associate brusqueness with professional ineptitude, and that may be valid])
Finally, it is explicit in the bargain any teaching hospital makes that a patient will receive better care, but in return must put up with teaching. The teaching function might as well be identified as such. In any case, as Frederick Cheever Shattuck said many years ago, "Before swerving from or denying the truth we should ask ourselves the searching question, 'For whose advantage is this denial?' If it is in any measure for our advantage, or seeming advantage, let us shame the devil."
How do students, house officers, and senior men combine to produce the ward teaching system? As exemplified by Mrs. Murphy's experience, the system works as follows.
When the ward is notified that a new patient is being admitted, the student goes down to the EW and examines the patient. On occasion, he has to hurry to beat the house officer, but students learn to do this, and the best house officers will go to great lengths to allow the student to perform the initial examination. The reason for this is that with each succeeding history and physical, the patient becomes more accustomed to the routine of delivering his story in an orderly but unnatural manner. Fresh patients are the most difficult to get a history from, and therefore the most prized.
After a student has examined the patient, the resident conducts a second examination, and then comes out to talk to the student about the case. The resident generally has only three questions: "What did you find?" "What do you think he has?" "What do you want to do for him?" Interestingly, these are the only really important questions in all clinical medicine.
A discussion of diagnosis and treatment follows; if the resident agrees with the student, he will let him write the orders, then countersign them. Diagnostic procedures such as lumbar puncture, bone-marrow biopsy, and so on are usually done by the student under the resident's supervision. By tradition, patients are expected to be "worked up" as much as possible on the day (or night) of admission. This means that in addition to the history and physical, the ward team is supposed to look at the blood morphology, do a white-cell count, a hema-tocrit, an electrocardiogram, urinalysis, review the chest X ray-and whatever other, more sophisticated, tests are necessary, all at the time of admission.
The student may do much or all of this, but he really has no control over the patient's care. Most of the decisions-decisions at the time of admission, and all later decisions-are made by the admitting house officer. This is why the medical service regards "admitting a patient" as directly equivalent to the surgeon's "doing a case." In each instance, only one person can have the responsibility of decisions on patient care. And while it is valuable to look on, it is not the same thing as doing it yourself. The experience of responsibility is not transferable.
Each house officer thus has a series of "his patients" on the ward; these are the patients he originally admitted, and he feels primary responsibility for them throughout their hospital stay. He is expected to know more about his patients than anyone else, though others must know enough to handle details of care when the resident is off duty. The sense of individual responsibility is so strong that it is couched in possessive terms. One house officer may ask another, "Is Mr. Jones your patient?" and be told, "No, he's Bob's."
The student's role in all this is to pretend that he is the admitting house officer, and to continue pretending so throughout the hospital stay. A student generally works closely with one intern or resident, keeping the same hours, following him along. Among students there is an active grapevine to keep everyone informed about which house officers are good to work with and which not. A good house officer is one who is confident of his skill (insecurity is catching); willing to take time to teach the student; and unwilling to delegate all routine work, termed "scut," to the student.
On the morning after a patient's admission, during "work rounds" from 7:45 to 9:00, when the ward team goes from patient to patient, the student is expected to summarize informally the history, physical, and lab tests for the benefit of those team members who were off duty the previous night. A formal discussion is given by the student during "visit rounds" later in the day, when he relates the details of the case to the visiting physician, usually just called "the visit." The visit is a staff member of the hospital, assigned to the wards for a month, and legally responsible for all the patients on the ward.
The student's formal discussion is known as "presenting." To present a patient means to deliver the salient information in a brief, highly stylized form. The student is expected to do this from memory. A presentation begins with events leading up to admission for the present illness; then goes on to past medical history; then a review of organ systems; family and social history; physical findings beginning at the head and working down to the feet. Laboratory data is then presented in a specific order: blood studies, urine studies, cardiogram, X rays, and finally more specialized tests.
The entire process is not supposed to take more than five minutes.
A good presentation is difficult, for along with summarizing positive findings, the student is expected to include certain "pertinent negatives" from among the almost infinite number of symptoms and signs the patient does not have. These pertinent negatives are intended to exclude specific diagnoses. Thus, if a patient has jaundice and a large liver, the student should state that the patient does not drink, if this is the case.
Aggressive students can be quite abstruse in their negatives, hoping that the instructor will interrupt and ask (for example): "What were you thinking when you said the patient had never danced in Tibet?"
To this the student can triumphantly name some obscure disease that vaguely fits the situation, such as "the Kurelu Dancing Syndrome, sir." He thus appears well read. The game can be dangerous with a knowledgeable visit, however, for he is likely to shoot back: "The Kurelu Dancing Syndrome never occurs in males under forty, and your patient is thirty-six. If you want to do some reading, I refer you to the Kurelu Medical Journal, volume ten, number two." This is a signal for the student to crumble; he has lost the round-unless, of course, he has a rejoinder. There is only one acceptable form: "But, sir, in the Mauritanian Journal of Midwifery last week there was a report of a case in a ten-year-old boy." This may, or may not, work. The visit may reply, "The what journal? Wasn't that the one which reported that skimmed milk caused cancer?"
That ends the discussion.
Among students, visits are classified into two groups-"benign," and the others. It depends on how the visits treat students. Generally the visit sits in silence throughout the presentation; he then begins by pointing out all the things the student forgot to mention; and then proceeds to ask questions. He is entitled to ask questions on anything he likes, so long as it vaguely relates to the case at hand. He can, if he wishes, keep the student hopping.
For example, a typical discussion about a case of stress duodenal ulcer might have the visit first asking the anatomy of the four parts of the duodenum; then the arterial supply to the stomach; the common complications of duodenal ulcer; the factors that classically increase and decrease ulcer pain; the features that distinguish ulcer pain from the pain of acute pancreatitis, gall bladder disease, or heart attack; the four indications for surgical intervention; the reasons for measuring serum pancreatic amylase and serum calcium; the mental changes one might expect with GI bleeding in the presence of liver disease, and the reason for the change; the other causes of upper GI bleeding; the way to distinguish upper and lower GI bleeding; and so on.
Furthermore, the visit can shift to a related topic at any point. If he asks about serum calcium and the student correctly answers that there is a relation between parathyroid disease and ulcer, the visit may go on to ask how calcium fluctuates in parathyroid disease; the associated changes in serum phosphate; what changes might be seen in the electrocardiogram; what mental changes are associated with increased and decreased serum calcium, in adults and in children.
Thus a student who began talking about ulcer disease is effectively shunted to calcium metabolism. And, at any time, the visit can turn around, demand to know six other conditions associated with ulcer, [Such as chronic lung disease, cirrhosis, rheumatoid arthritis, burns and strokes, pancreatitis, and the effects of certain drug therapies, especially steroids] and go on to discuss each of them. Visit rounds are two hours long. There is plenty of time.
For the most part, interns and residents are exempt from grilling; it is considered too undignified. The visit treats house officers as colleagues, but not students. A house officer who asks a question of the visit will get an answer. A student who asks a question will most often get a question back, as in "Sir, what does the serum calcium do in Chicken Little disease?" "Well, what do the plasma proteins do in Ridinghood's Macro-globulinemia?" If the student fails to see the light, he will get another hint, also in the form of a question: "Well, then, what about the serum phosphate in Heavyweight's Syndrome?"
This is a form of a game which is repeated over and over again in medical teaching. It is a game useful to the conduct of medical practice. A very simple example of the game is the following:
student: "The patient has a rash and fever."
visit: "Has he ever been to Martha's Vineyard?"
student: "No, he does not have Rocky Mountain spotted fever."
The point is that the student sees the implication behind the question-that each year one or two cases of Rocky Mountain spotted fever are contracted on Martha's Vineyard. Such deductive processes are precisely those important to the conduct of medicine, and therefore represent a useful teaching method. In the extreme, this can lead to a leap-frog interchange which is almost beyond the understanding of the casual observer:
student: "The patient has kidney disease consistent with glomerulonephritis."
visit: "Was there a recent history of infection?"
student: "Anti-streptolysin liters were low."
visit: "Was there a facial rash?"
student: "LE prep and anti-nuclear antibodies were negative."
visit: "Were there eyeground changes?"
student: "Glucose-tolerance test was normal."
visit: "Did you consider rectal biopsy?"
student: "The tongue was not enlarged."
This is jumping from mountaintop to mountain-top, skipping the valleys. In translation, the visit is asking, first, whether the glomerulonephritis was caused by streptococcal infection; second, whether it is due to lupus; third, to diabetes; and finally, whether due to amyloidosis. The student is denying each diagnosis by presenting negative data. Neither teacher nor student specifies the diagnosis; the game is to figure out what each is talking about without saying what it is.
This Socratic tradition of teaching medical students dates back to the days when medicine was an apprenticeship in the strictest sense. The Socratic method has the virtue of informality: on work rounds, the resident can ask the student in passing, "How will we know when Mr. Jones is adequately digitalized?" and the surgeon can pause in his operation to ask the student, "What would happen if I cut this nerve here?" It is a good way to keep the student constantly recirculating his knowledge through his brain, and by and large it works well.
Why not just state the fact, as a declarative statement, for the edification of the student? There is just one major reason: most medical students are tired. At any given moment, a lecture to a medical student is a signal to click off, to tune out, to go to sleep. Partly, this is a learned response. It is common, during the first two years of medical school, to have four hours of lectures and five hours of laboratory work in a single day. Students who are studying late into the night on top of this schedule learn to sleep during lectures with great facility. The pattern carries on into the clinical years. One can observe lectures to medical students and house staff in the hospital in which 20 to 50 per cent of the class is slumped over in their chairs. The lecturer pays no attention. To a lecturer, it is not an insult, but a fact of life. Everybody accepts it; everybody expects it.
The only way to beat the dozing off is to ask questions. Supposedly this makes the learning experience more active, less passive. But, as anyone who has ever attempted to put together a programmed text knows, teaching by questions is extraordinarily difficult. The ideal set of questions is graded, going from fact to fact, leading the student from information he knows well to the reasoning out of information he does not know. On the other hand, the usual unplanned set of questions just draws a blank look and a guess.
For some reason, the question-and-answer teaching method is a peculiarity of professional school instruction. It is common in law, medicine, and business, and practically unknown in other graduate fields. The best teachers can employ it to great effect; most teachers are hopeless at it.
The system is most likely to succeed when applied to an individual-and almost certain to fail when applied to large groups. I have watched a specialist in diabetes walk into a room full of third-year students, rub his hands together, and say: "All right. Let's suppose you've gotten your diabetic patient. He has a blood sugar of three hundred. What kind of diet are you going to put him on?" Nobody in the room had the faintest idea what kind of diet to put him on. "How many grams of carbohydrate do you want to give him?" the instructor demanded. Nobody knew; nobody said anything. Finally he pointed to a student and insisted on a figure. "Ninety grams?" the student said. "Wrong!" said the instructor, and went around the room until somebody finally guessed one hundred grams, the figure he wanted to hear. "Now then, how much insulin do you want to start him with?" the instructor asked, and the game began again.
It would be pleasant to think such examples atypical of medical education, but in fact they are more the rule than the exception. Considerable dedication is required of students to learn medicine in the face of such teaching; one often has the impression that medical education works despite itself.
Useful changes can be made in all elements of the process^-changes in the students, changes in the teachers, changes in the teaching methodology. Of these, only one appears very likely: the traditional routine of every-other-night for clinical students and house officers is dying. Many hospitals are shifting to an every-third-night schedule, which makes a considerable difference. The student or house officer sleeps through his first night off, but he is able to read during the second night; and during the day he is more alert, more awake. This helps to remove one of the oldest paradoxes in medical education-namely that the hospital claims to provide an excellent learning environment, while systematically depriving its students of sleep.
A change in teachers is less likely. Clinical teaching posts have status attached to them; a private man likes to be able to say he "spends some time with the students." At the same time, teaching hasn't got much value as a way to be promoted within the academic hierarchy; medicine, like every other field, puts its emphasis on published research. This leads to a multitude of rather casual teachers who may spend only a few hours a year with the students. These people-like the diabetes expert, who comes to the hospital once every three months to deliver his little talk-are most pernicious. They do not care enough about teaching to attempt to do it well; they don't have enough experience with students to know how to direct their talk; they have never received any training in exposition and attach no significance to a good delivery.
Having dismissed these people, one should say that medicine does indeed correctly sense that private, experienced practitioners have accumulated practical knowledge that ought to be communicated to students. Unfortunately, this is not the way to do it.
Methods of teaching require considerable revision. You can be assured that this is taking place-it is always taking place and always has been. Curricula change, new courses spring up and others die, grand lectures on education are given citing Gushing and Osier, but somehow the fundamental quality of medical education remains the same.
The methodology continues to be perplexing. The notion that the subject should be suited to the manner of teaching; the idea that certain things are best taught in lectures, others in seminars, others individually; the understanding of those qualities that distinguish the lecture from the slide from the
printed page from the visceral experience-all these things are traditionally lacking in medicine.
Future medical educators, for example, will probably look back on the teaching hospital and shake their heads at the way "patient material" was used. One can argue that this use, at the present time, is highly inefficient. The individual patient in a teaching hospital is not intensively used for teaching. A bizarre case may be seen by fifty or sixty people, but the average ward patient is seen by many fewer, particularly if his problem is common and his stay in the hospital is short.
The need to see patients firsthand is an important part of medical education; one must have experience with many ill individuals, exhibiting many different manifestations of disease. This is necessary because there are both many diseases, and many forms that a disease will take in different people. To obtain the proper depth and breadth of experience requires a long time; a student or house officer must remain in the hospital at all hours for many years. Otherwise, he is going to miss vital experiences.
However, a number of ways of "saving the patient for future reference" are now possible. Teaching collections of X rays have existed for several years, enabling students to gain broad radiological experience without waiting for the patients actually to come in. But this is only the beginning: one can record a patient's appearance and important physical findings on video tape; one can even record an interview and history-taking. By such techniques literally hundreds of students can, over a period of years, have some experience with a given p;
And one can go further. For example, one n most severe limitations of modern clinical tea is that the student cannot really use the pati«"practice on." While mistakes are an imp* part in any learning process, in the hospita are discouraged and guarded against-and n so.
What is needed, of course, is a disposable tient, for whom mistakes do not matter. In the one can argue, the disposable patient was pro by society in the form of the charity case (at this was the popular belief); but this requiu can now be provided by technology. Anesti have developed a lifelike plastic dummy i for students to practice on; this dummy can allergic reactions to anesthesia, cardiac and n atory arrests, and a variety of other serious ci cations. The student can practice on the di«with impunity. So far, the only analogous sin is that provided by the post-mortem patient used for practice of surgical procedure. B» will see much more in the future.
For example, a teaching program can be pii a computer, enabling the student to ask ttu tient" questions, and get back replies. On th-. of such an interview, the student can make a nosis and institute therapy. The computer car inform the student of the consequences of hi scribed regimen.
In fact, such methods are already in usual Board Examinations, Part III-the section to interns prior to certification. The exam imong other things, film clips of patullowed by questions about the patient's It also contains a most interesting section if brief histories, followed by specific such as "What would you do immedi- iiis patient?" After each question is a :ssible answers, such as "Begin intrave- :eplacement," "Start antibiotics," "Give iid so on. And following each answer is 'lit space.
nt selects the therapy he wants and er- acked-out space to reveal the conse- his choice. If he has chosen correctly, i will be encouraging: "Patient im- Hut if he is wrong, the answer is likely to Patient dies."
se techniques, it is possible to give the posure to rare clinical situations he r see otherwise. It is also possible to ulent exposure in depth to a problem. iiki program the differing clinical histories patients with hyperthyroidism, for ex-let the student work through them all, idea of the differences from case to nt this will ever replace experience at the it it will certainly supplement that and very soon. There are two reasons L-chniques will gain rapid acceptance.
is a slowly simmering rebellion against the length of medical education. In this country the average physician is almost halfway to the grave before he is prepared to start practice-and the trend is toward even longer educational periods, not shorter ones. At the same time, there is a demand for more physicians, and the suggestion that this demand can be met, in part, by faster education. There is also a growing suspicion that in affluent America some of the best young men shun medicine because the educational period is so long.
As an educational process, medicine has suffered the full effects of the scientific outpouring of information; the response of medical educators has been simplistic-to lengthen the period of formal training as the body of knowledge has increased. This cannot go on indefinitely, and specialization-breaking up knowledge into smaller and smaller areas-will not provide the whole solution.
As a stopgap measure, medical schools have kept the total number of years constant, but have lengthened the per-week teaching load. Thus medical students at Harvard attend twice as many hours of classes per week as law or business students. Of necessity, this makes medical education a very passive business and deprives the student of the single most important thing he desperately needs to learn while at school-how to initiate the educational process for himself, later on, when he is a practitioner.
For medical schools there are only two solutions: to teach less or to teach more efficiently.
Medicine has been reluctant-sometimes wisely, sometimes not-to teach less. Curriculum changes are a traditional sport, but they occur slowly (John Foster notes that "it is easier to move a graveyard than to change a medical curriculum") and never seem to make manageable the total information to be mastered. The current administrative structure of medical schools appears incapable of curtailing the curriculum. Educators must therefore devise ways to teach faster. It is the only solution.
If it is hard to be a student, it is much harder to be a good visit, for a visiting physician has the most difficult teaching job in the world. His "class" of students, interns, and residents is small, but their depth of knowledge is dissimilar, and the visit must endeavor to teach everyone. His subject matter is all of medical knowledge; he must act simultaneously as adviser, librarian, lecturer, and, at the bedside, as a direct example in dealing with patients. The best visit is a marvel to watch. In an hour he can listen to the student, quiz him, arrive at a diagnosis, proceed to deliver a ten-minute extemporaneous lecture on some aspect of the diagnosis, throw in one or two humorous anecdotes, see the patient and elicit more information than the students and house staff were able to obtain, in the process demonstrate an obscure physical sign, then step into the hall and summarize the entire situation in a few minutes.
And then go on to the second patient of the day.
The whole act depends on vast knowledge, clear organization, boundless energy. But it is also the final check in the long system of built-in checks- the intern checks on the student, the resident checks on the intern, and the visit checks on everybody.
What does all this mean for the patient? Most teaching hospital physicians believe it produces better patient care. According to Dr. Robert Ebert, dean of Harvard Medical School, "It is far easier to check on the mistakes of an incompetent intern than the mistakes of an incompetent private physician. It is one of the ironies of our system of medicine that a very sick charity patient in the ward is likely to receive better and more constant medical attention than his counterpart on the private side of the hospital."
These considerations lead Dr. Ebert to talk of "the privileges of being used for teaching." This is an idea foreign to most private patients, yet our definition of the "teaching patient" is in the midst of drastic revision for that most fundamental of reasons, money. The financial structure of the hospital is changing, and with it, everything else.
Originally, the Massachusetts General and hospitals like it were founded to care for the sick poor. Patients entering the hospital agreed to be used for teaching, in exchange for medical care they could obtain no other way. At this time, there were virtually no private patients in the hospital. Any individual of means preferred to be treated- and to be operated on, if necessary-in his own home. Even at the turn of the century, the hospital was no place for the wealthy. When the Peter Bent Brigham Hospital was built in Boston in 1913, its planners made no provision for private patients.
Soon thereafter things began to change. The development of anesthesia made operations more common, and the use of Listerian antisepsis did much to reduce cross-infection and epidemics of "hospitalism." The hospital emerged as a place for all severely ill patients, private or charity cases alike. In 1917, the MGH built a pavilion entirely for private patients, and in 1930, another. By 1935, 40 per cent of hospital beds were occupied by paying patients. By 1955, it was nearly 50 per cent. In 1967, some 60 per cent of patients admitted to the hospital went to private pavilions.
Nor do these figures tell the whole story, for even on the wards, patients with no financial resources for medical care hardly exist. At present, 85 per cent of all MGH patients have some form of "third-party" health coverage-and most of those who do are very wealthy patients, not poor ones.
Third-party payment, whether by insurance plan such as Blue Cross, state welfare, or Medicare, has revolutionized the position of the teaching hospital. Put bluntly, it is no longer possible to trade free care for teaching; nearly everyone can pay for his care, and can afford a private doctor, and a private or semi-private room.
The MGH is, at this writing, closing down its wards. Some other hospitals have already done so. Such structural changes are relatively simple, but a major dilemma remains. There are no charity patients left, and no private patient wants to be a "teaching patient," since this has disagreeable connotations.
What is the solution? There are, obviously, only two answers. Either teaching is halted or private patients are used for teaching purposes. The first solution is impractical, the second highly controversial. But it is clearly in the cards: someday, all patients in a teaching hospital will be used for teaching. Such a program has already been set up at another Boston teaching hospital, the Beth Israel. There, "ward" and private patients lie side by side, and all patients, whether they have private physicians or not, receive their in-hospital treatment from house staff.
Now all this may seem like a minor matter. After all, just 2 per cent of American hospitals are teaching hospitals. The rest have no such problem. But one may ask, if the teaching hospital truly delivers better medical care-if this claim is more than a rationalization for making private patients available for poking and prodding by medical students and interns-then shouldn't all hospitals adopt the methods of the teaching hospital? Shouldn't all patients have the benefits of the system?
There are some practical considerations, in terms of the availability of interns and residents, but we can ignore these and simply look more closely at the intrinsic quality, the advantages and disadvantages, of teaching-patient care.
Certainly there are some classic advantages. The fact that residents are literally that-individuals residing in the hospital-means there are more doctors around, day and night, to treat acute emergencies. A patient with the finest private physician in the world will not be consoled if his doctor is away in his office when the patient has a cardiac arrest.
Second, as the pace of medical development accelerates, the hospital's staff of academicians and researchers can claim up-to-date, specialized information of a depth and variety that other hospitals, and individual private physicians, cannot hope to match. The impact of this on patient care can be considerable in some instances. For most of medical history, it did not matter whether your doctor was up to date or ten years behind the times; now it may matter if he is only one year behind. Therefore, one of the great new appeals of the teaching hospital is the availability of the most recent knowledge in patient care.
Third, the academic orientation of the staff leads them to attack perplexing problems with unusual vigor, reviewing the medical literature, utilizing the laboratory and referral resources of the institution. Endless rounds and discussions among house staff and visits mean that a problem will receive the benefit of many opinions. Thus a patient with an obscure disease or a difficult diagnosis will get a great deal of attention-much more than any single physician could give him.
Fourth, because the hospital is structured to teach and do research, it is critical of all medical practice, including its own. Each physician has several others looking over his shoulder, and this tends to minimize mistakes. To that extent a teaching patient is "safer" than a private patient
All this is clearly evident when one looks at Mrs. Murphy's history. She is a patient with an uncommon, though not rare, disease-but a disease that manifested itself in an extraordinarily rare way. Mrs. Murphy first saw a private physician, who treated her complaint of swelling legs as if she had heart failure. She did not have heart failure. She did not improve. She then went to a community hospital, where more sophisticated tests were done. There, she was correctly found to have liver disease, GI bleeding, and hemolytic anemia. Each of these problems could have been discovered by her private doctor, with the help of a private clinical laboratory, but for reasons which cannot be assessed, he failed to do so.
At the community hospital, evidence was also found for pancreatic cancer. This evidence was incorrect. (Furthermore, important pathology unrelated to her primary disease was missed. This was not discussed in the earlier section, out of a desire to avoid complicating an already intricate story. However, in the report sent by the hospital to the MGH when the patient was admitted, a physical examination form clearly stated that a pelvic exam was normal. In fact, Mrs. Murphy had a cervical polyp the size of a large marble. It was easily felt and clearly visible. The only reasonable conclusion is that a pelvic examination was not, in fact, done at the other hospital.) And the only reason Mrs. Murphy was transferred to the MGH was because of this suspected diagnosis.
Two points about this story should be made immediately. The first is that the MGH, by its very nature, sees a great many patients whose diagnoses have been missed. It is easy to gain the impression that all practicing doctors are inept, and all community hospitals incompetent. But, in fact, the great majority of patients who receive correct diagnoses and good care never show up at the MGH.
Second, no medical system is perfect. Teaching hospitals make mistakes just the way community hospitals and private physicians do. Each teaching hospital in Boston delights in getting the patients of others, and making diagnoses that were missed. The point of Mrs. Murphy's story, therefore, is not the glorification of the teaching hospital, but rather that this woman, with a complex disease and unusual manifestations, received nine days of the most intense academic scrutiny before a diagnosis was established. She was immersed in an environment geared to such scrutiny. A great many people-from students to the chief of medicine-saw her, examined her, and contributed suggestions concerning her care. And from that eventually came a diagnosis that might not have been made otherwise.
At the same time, there are some classic complaints about teaching-service care, from both patients and physicians. Patients dislike multiple examinations, and having to tell their story over and over again. Physicians complain that the academic orientation of a teaching service leads to excessive lab tests, too many diagnostic procedures, less briskly efficient care, longer in-hospital stays, and ultimately more expensive treatment. Without question, these complaints have some truth in them.
For example, it is relatively easy to dismiss the protests of a patient with an unknown disease who objects to many examinations by different people. It is in his own best interests to be examined by everyone, at least until a diagnosis is arrived at. However, it is less easy to shrug off the complaints of a patient who may have, unknown to him, a "classic case" of something that is neither rare nor unusual. An intelligent patient with a lucid history of ulcer may find himself visited by a large number of students who are directed to him by an instructor who tells them, "Mr. Jones has a good story and good findings." And worse, if the patient complains to a resident, the resident cannot evaluate the complaint. No one keeps track of how many students are visiting any given patient. It is impossible to know whether he is objecting to two visits or to twenty [Despite the above, most patients are not seen by many students. A fair percentage never set eyes on a student].
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The question of excessive and unnecessary tests is difficult to evaluate. Everyone who works in a hospital sees patients who receive too many tests, under the guise of a "thorough work-up"; everyone has seen diagnostic procedures carried out where at least an element of motivation was the resident's desire to practice the procedure. These cases are rare, though they stick in one's mind.
Frequently, the issues can be subtle. They are polarized in the following verbatim exchange between a particularly obnoxious student and a particularly obnoxious visit. The patient under discussion was one who had documented obstructive lung disease with advanced emphysema. He was on the respirator full time.
visit: "Do you think we should do cardiac cathe-terization and get a pulmonary wedge pressure on this man?"
student: "No."
visit: "Can you think of any additional information we might get from the wedge pressure?"
student: "No."
visit: "In point of fact, we know that in emphysema, if we find the wedge pressure elevated, then the severity of the disease is increased."
student: "Will that change your course of therapy?"
visit: "I'm not sure mat's a valid consideration."
student: "There's a morbidity attached to pulmonary catheterization."
visit: "Yes, but it's very slight."
student: "It exists. If it won't change your therapy, how can you justify it?"
visit: "I don't think you can say it won't change our therapy."
student: "Then how might it change your ther-apy?"
visit "Over the long haul. For instance, in this lab we do VD/VT measurements, though similar labs do not. We've found it very valuable."
student: "This man has emphysema. He's seventy-three. He's dying."
visit: "We are nonetheless obligated to learn all we can about his disease."
student: "But it won't help him."
visit: "The Respiratory Unit has multiple functions. We are at once engaged in research and therapy."
student: "Will you tell the patient that the procedure won't help him, that it's just for the sake of curiosity?"
visit: "I wouldn't call it curiosity."
student: "Then you have a formal experiment going? A protocol? This patient is part of a defined study series?"
visit: "No, but we are gathering data. All patients are available for research here."
Perhaps the most common criticism of the academic service is that "the doctors are not interested in patients, only in diseases," a harsh complaint, and an old one. Oliver Wendell Holmes said in 1867 that he did not want a researcher-clinician for his doctor: "I want a whole man for my doctor, not half a one." (As a teacher, Holmes could be brutal about academic medical instruction: "What is this stuff with which you are cramming the brains of young men who are to hold the lives of the community in their hands? Here is a man fallen in a fit; you can tell me all about the eight surfaces of the two processes of the palate-bone, but you have not had the sense to loosen the man's neckcloth, and the old women are still calling you a fool.")
Certainly the researcher-clinician has split loyalties and conflicting interests. A GI consult who sees a patient is specifically called in to give advice about the patient's abdomen; and to some extent, the consulting physicians are more interested in the patient's stomach than the rest of him. The consequence of this may be to surround the teaching patient with many people interested in his problems, but less interested in the patient himself. The patient gets excellent but impersonal care-if that is not a contradiction in terms.
The idea that an orientation toward disease can ever lead to poor care is furiously denied by academicians. But it is disturbing to note, for instance, that Death Rounds at the MGH, which once reviewed a deceased patient's hospital course with a view to discussing whether anything more could have been done for him, are now almost entirely given over to academics: the patient's disease is discussed, not the patient. (This is only true on the medical service. Surgical Death and Complication Rounds still deal with the patient's course. In general, the surgical service is more pragmatic and less academic than the medical-a point of some friction between the two groups.)
Eventually, one comes to the conclusion that care on a teaching service is not so much better or worse as different. Some patients will benefit from these differences more than others. A patient with an obscure malady can do no better than a teaching service, where he will be fussed over, considered, and reconsidered endlessly; a patient with a common, well-understood complaint may get quicker, more practical treatment from a private doctor in a nonacademic setting.
This would seem an excellent argument for transforming the teaching hospital into a referral institution, and that is what has happened to many of them. But there are two reasons to deplore the change.
First, it means that research on the most common-and therefore, one might argue, the most important-diseases stops. This is unwise; there are many times in medical history when a researcher has "gone over old ground" and come up with something new and important. Reginald Fitz went over "perityphlitis" and came up with appendicitis, thus changing the course of surgical history.
Second, it ignores the community in which the hospital stands. The community is likely to sense this rapidly, and resent the fact that although the hospital personnel did a great job for Uncle Joe's unpronounceable Latin ailment, they could hardly be bothered with Sally's ear infection.
What is the hospital's responsibility? Originally, the answer was quite clear-it was built to care for any needy person in Boston who had the initiative to seek it out. With the passage of time, its community became not the entire city, but a part of it, the so-called North End. This is a community of working-class Italians and Irishmen, with areas of considerable poverty.
But the hospital has never lost its passivity, a tradition that can be traced all the way back to Greece. Patients are expected to come to the hospital, and not the reverse. And while the hospital will never turn anyone away from its doors, neither will it actively seek out illness in the community. Furthermore, the impact of technology over the last twenty years has been to make the hospital even more passive, as it becomes more preoccupied with acute established disease, to the almost total neglect of preventive medicine.
But the role of the hospital is going to change, as public expectations for medical care change. According to Alexander Leaf, Chief of Medicine, "For a long time-since Hippocrates-we have not attached any broader social obligation to the physician's education. You went through your training program whether in school or as an apprentice, and men you hung out your shingle and treated whoever could pay you. But now that is unacceptable to society, which is making other demands from physicians." He says, further: "I think we have to restructure the functions of the hospital if it is to survive for the next twenty years."
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.)
The various floors of the hospital operate with their own nurses, their own visits, their own house staff, their own stocks of supplies. This is the arrangement found in most American hospitals, and as a way of structuring, it has distinct advantages. For many years, it was thought to be the best way of matching the patient to the facilities he would most need.
However, each of the three criteria-sex, money, and therapy-has come under attack. Money, because third-party payment has made financial structuring obsolete; sex, because if everyone is in private or semi-private rooms, segregation by whole floors becomes unnecessary.
Anticipated therapy has also been questioned. Some even argue that the distinction between surgical and medical patients be abandoned in favor of distinctions based on severity of illness, and the need for close medical and nursing attention.
Under this system, medical and surgical patients would be intermixed in units that differed in the degree of care they provided-intensive care, recuperative care, minimal care, and so on. Patients would be moved about in the hospital as their illness became greater or less.
Some clear psychological benefits for patients are apparent. As they become healthier, they would be moved to new areas of the hospital, where they would be encouraged to be more self-sufficient, to wear their own clothes, to look after themselves, to go down to the cafeteria and get their own food, and so on. They would, at every point, be surrounded by patients of equal severity of illness. Their dependency needs would be fulfilled in a graded way, since the hospital would be providing a spectrum of care and close attention. To a degree, the hospital already does this, with its recovery rooms and intensive-care units [The hospital already has intensive-care units for respiratory care, cardiac care, neurological care, surgical care, medical care, transplantation patients, pediatric patients, and burns patients.]. But more could be done-and, indeed, one can predict that more will almost certainly be done in this direction. This will happen not because the hospital is preoccupied with the patient's psyche-it is not-but rather because graded care is economically more efficient. At the present time 30 per cent of the cost of a room goes to nursing care. For the average MGH hospital room, this amounts to some $22 a day. Although the percentage cost may not rise in the future, the absolute cost will. Ultimately it will be necessary to give patients no more nursing care than they really need; the present inefficiency in personnel use will become too costly to continue.
Among physicians, a restructuring could be more efficient as well. Consider anesthetists: in the last decade, they have emerged as the experts in the support of vital functions. They are called for every cardiac and respiratory arrest; they know more about drugs than anyone else; they are expert in the use of respirators. Most physicians would agree it is handy to have an anesthetist around any intensive-care unit, but at present the anesthetists are dispersed throughout the hospital. By restructuring on the basis of severity of illness, one important resource, anesthetists, would be made more available to patients who need them.
Indeed, "human resources" are just one argument for restructuring. Hardware and technology resources represent another. For example, the kind of electronic and mechanical equipment required for a patient with a heart attack and for a postoperative cardiac patient is very similar. As time goes on, and larger and more all-inclusive machines become available, it will be increasingly advantageous to bring patients with similar technological requirements together, so that they may share certain large machine capabilities and so that medical personnel trained in the use of these machines can be centralized.
The bringing together of patients, personnel, and hardware has certainly been valuable in cardiac intensive-care units; in some units immediate mortality from myocardial infarction has been cut as much as 30 per cent. We are already seeing a pro-
liferation of these specialized units, and we will certainly see more-and from there it is only a small step to complete reordering of the hospital along new lines.
Afterword
although it comes from an ancient tra-dition, the modern hospital, in fully recognizable form, is less than fifty years old.
At most it will last, in fully recognizable form, another decade or so. But by then, almost surely, what is different from the present will overshadow what is similar. And we may expect these changes to represent more than improved technology and differently trained personnel. For there will certainly be a change in the function of hospitals, just as there has been a change in function during the past half century.
During that period, the hospital evolved into a positive, curative agency specializing in highly technical, complex medical procedures. Very likely the hospital will continue to function in this capacity. But it will abandon certain other functions in the process. It will cease to be a convalescent facility, for example, as more specialized convalescent homes appear. It will curtail its in-patient diagnostic work to that which absolutely requires hospitalization. Its custodial function-whether.