Michael Crichton - Five Patients

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?"