Michael Crichton - Five Patients

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."