Five Patients - Crichton Michael - Страница 31

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.