ISSUE: Autumn 1985
If you were to take your automobile to a garage for an adjustment of the carburetor and have it returned with the carburetor working better but with heavy stains on the upholstery, several new dents in the body, and the paint badly marred, you would, I think, be vexed. If you then grumbled about these damages to the garage manager, and he said that was what you should expect when you have your carburetor fixed, your annoyance might well get out of control. Yet something comparable to this can happen to many patients admitted to hospitals today. People have come to tolerate mishandling of themselves in hospitals that they would not allow to happen to their cars in a garage. A patient admitted to a hospital—especially a university or a teaching one—may undergo a variety of extremely noxious experiences; no single one of these may be grave in itself, but taken together—as they must be—they often amount to a serious personal injury. We are gradually learning to check child abuse and wife-beating; now we are also beginning to check neglect and mistreatment in hospitals, the extreme forms of which may fairly be described as patient abuse.
If we are to do this, we must first clearly distinguish the usual concomitants of being seriously ill from the experiences that a patient undergoes solely from residing in a hospital. I shall therefore briefly describe some of the changes that accompany almost any major illness. First, and most obviously, anyone who becomes seriously ill usually has had unpleasant symptoms before he has even seen a doctor—especially pain and usually one or several of numerous other possible discomforts, such as weakness, loss of appetite, shortness of breath, or diarrhea. Just suffering from these is bad enough, but the sick person’s sufferings are not restricted to physical discomfort. He is necessarily unproductive and dependent on other persons; he becomes anxious about the outcome of his condition, and he may also become anxious about a loss of income that may occur or enormous medical bills that certainly will occur. If he is then admitted to a hospital, he will undergo a variety of uncomfortable and often painful diagnostic procedures and treatments; and he is separated from his familiar environment and the people he loves. All these unpleasantnesses are more or less inevitable given our present limited knowledge of disease. They seem to be unavoidable features of the condition of being seriously ill. If I become ill, I accept them as concomitants of my state of being ill—highly unpleasant, to be sure, but not warranting any complaint from me.
If what I have described were all that patients must endure, I would not be writing this essay. However, it is not; an ill person admitted to a hospital may undergo additional harmful experiences imposed on him by the procedures of the hospital and the attitudes of some of the staff. These experiences are not inevitable accompaniments of being ill; moreover, they are remediable, and they are slowly being changed to provide better medical care in the future.
Here I should introduce the distinction now commonly used in medicine between “curing” and “caring.” In the 16th century the great French physician Ambroise Pare said (of a soldier): “I dressed his wounds; God healed him.” Until as recently as one or two generations ago, Pare’s epigram summarized the little that doctors could contribute by drugs and surgery toward a patient’s recovery from most illnesses. They could relieve pain and modify the symptoms of some illnesses, but when a patient recovered he could nearly always attribute this to his own natural processes of healing instead of to the drugs or other visible treatments of his doctor. The curing side of medicine was negligible, its caring side almost everything. Now this has changed. Medicine has made important advances in the understanding of disease during the past two generations; and, although we still do not have cures for many diseases, we have developed measures for stabilizing and arresting some of them, so that patients who would formerly have died can now usually continue to live, often productively and happily. With other diseases, however, the technological advances have been far from satisfactory. The life that they sustain may be so miserable as to be not worth living. With more than a few diseases we can say without exaggerating that modern technological devices do not prolong life so much as they prolong dying. Meanwhile, our population is growing older, and old people are particularly liable to the multiple small disorders that can be patched up but rarely fully healed. An increasing number of patients cannot be cured but do need continuing care. Unfortunately, while we have been improving the curing side of medicine, we have been neglecting its caring side. Indeed, a patient needing only care is in some respects worse off today than one was with a similar illness 50 years ago. How can this be true?
In the first place, a patient today is not nearly so likely to have a doctor as was one 50 years ago. This may seem strange to say when hospitals swarm with doctors and patients can expect to see ten or more of them within the first three days of a hospital stay. I am not talking about all these doctors; I am referring to one single doctor who assumes overall responsibility for the coordination of what all the others do or recommend; a doctor, moreover, who continues to exercise that responsibility whether the patient is in the hospital, staying in his home, or back at his work. Nearly every elderly patient, and many younger patients with serious illnesses, have disorders in several organs. In much of current medicine, different doctors handle each of these organs, and most of them have or show no interest in any of the others. What is worse, in hospital care each of them has usually only a transient position in the patient’s treatment. After a few days, or at most a few weeks, the doctors assigned to one group of patients are “rotated” to other patients; or (less frequently) they go off for weekends or on vacations. Other doctors succeed them only to be replaced, in their turn, a few weeks later by other new doctors. Still other doctors take over when the patient leaves the hospital. A patient whose course I followed closely had contact—on a modest reckoning—with more than one hundred different doctors during a ten-month period of illness.
II
Compared to the rest of the staff, however, the doctors looking after a patient are a compact and stable group. Nurses and other therapists have also become more and more technologically specialized. They are trained to work not with people, but with a variety of machines to which patients in hospitals are frequently attached. In addition, even nurses with general skills are rotated through different tasks on different days and different shifts. A patient during one shift may thus find himself being cared for by one nurse for medications, another for the changing of bed sheets, another for the measuring of his temperature and other “vital signs,” and yet another for assisting him to get out of bed and back in again. There may be still other nurses attending to other specialized matters. If any of the nurses needed for a particular function takes a break or goes for a meal, other nurses will come to the patient, who may, on a single shift, have six or eight nurses participating in his compartmentalized care. As many as 15 different nurses may be involved in the care of a patient during a single 24-hour period. The next day brings (nearly always) more new faces; the nurses are rotated in their daily assignments and they again change on weekends. The patient I mentioned above, who had more than a hundred different doctors during about ten months, must have had at least 200 different nurses during that same period. To the many different nurses must be added a bewildering number and variety of other therapists and technicians who come to draw blood or to give it, to attend to the oxygen supply, to weigh the patient, or to carry out on him some other procedure of diagnosis or treatment.
The patient’s need to adapt quickly to so many different people can impose a serious strain on him. It is known that changes in environment can precipitate a state of confusion and delirium in a person who is already seriously ill. In addition, the comings and goings of all the various individuals involved in the patient’s care deprive him of sleep or of rest when he is not sleeping. One patient (herself a physician) in a teaching hospital kept a record of the number of times her room was entered during a five-day stay in the hospital. The average was 56 entries per day, and she noted that the longest period during any 24-hour period in which no one entered her room lasted only two hours. This patient had a simple, uncomplicated condition affecting one part of her body; a patient with a more serious illness, or with several diseased organs, would have had many more interruptions.
Most of the hospital staff members coming to see the patient have to ask him questions, many of them ones he has already repeatedly answered. None of the staff—doctors, nurses, technicians—spend more than a few minutes at any one time with a patient. None ever takes a chair to sit and listen for a while to the patient. One hospital conducted a study of the time spent by the staff with the patients, and it learned that the women who cleaned the patients’ rooms spent more time with them than did the members of any other category of the hospital staff.
The conditions of hospital care that I have described so far can be explained and—some hospital administrators say— even justified. I shall consider the explanations and try to show their inadequacy later. Before doing that I wish to complete my catalog of unacceptable aspects of residence in a modern hospital.
It is perhaps unfair to expect in a hospital services that one would take for granted in a first-rate hotel—even when one is paying almost $300.00 a day or more—but why should the service so often fall to the level of a fourth-rate hotel? The food is usually tasteless, and it is served at hours that suit the convenience of the kitchen and serving staff; nothing remotely comparable to a good hotel’s “room service” provides for a patient’s individual needs and tastes. Appalling delays frequently occur between a patient’s requesting some special assistance or some relieving medicine and his receiving it. Except when he might be infectious to other persons, he loses all privacy and virtually all control over the conduct of his life. His room can be invaded by any member of the hospital staff at any time and sometimes also by individuals who are not on the staff.
The patient is particularly vulnerable to unsatisfactory staff members with whom he may become intimately involved. Many nurses and technicians are kind and competent; but others are neither, and a few are downright negligent and heartless. Yet the patient has little redress against them. He obviously cannot fire them, as he might an office employee or a domestic servant; nor can he leave the hospital and go elsewhere; and if he (or a member of his family) complains, he risks reprisals of surliness and neglect by other members of the staff. Unlike patrons of a hotel or airline, a patient in a hospital is in a peculiarly exposed situation, and this is a principal reason why, I think, more inefficiency and impoliteness have been tolerated in hospitals than would be allowed in other institutions; slipshod service remains unreported, undetected, and hence uncorrected.
Finally, the patient may be subjected to a terrible battering of noise. While some hospitals try to reduce the noise outside hospitals, such as from traffic, little effort has been made to check it inside the hospital. One investigation of the noise in the bedrooms of a Veterans Administration Hospital showed that it reached or exceeded the noise produced by a vacuum cleaner; the noise was beyond what the Environmental Protection Agency considered desirable for healthy activity, let alone recovery from an illness.
Before finishing my inventory of what is wrong in many hospitals I need to make two further remarks. First, each of the insults I have mentioned could be endured, at least for a time; it is their collectivity that has such a cumulative damaging effect on patients. Second, the faults that need correction nearly all fall within different administrative provinces of the hospital. You could get rid of the dietitians— those masters of dull food—and replace them with chefs, as one hospital did with notable success, but that would not reduce the overall level of noise. You could stop the blurring rotation of nurses and assign one nurse to do everything a particular patient needs; but that would not improve coordination among the highly specialized doctors. Few hospitals have a member of the staff who sees the whole, unpleasant picture of what patients endure. Only a panoramic view could show the urgent need for widespread reforms.
A recent medical conference at which these topics were aired and in which I participated made me realize more keenly how extremely difficult it is for any one person to grasp the totality of unnecessary stresses to which patients are subjected in a modern teaching hospital. Several participants defensively extolled the medical professions for their high level of compassion; but such self-serving eulogies convinced me that the speakers had failed to see that the problems are mainly in the system and only secondarily in the personal failings of those who work within it. No doubt compassion is abundant among members of the medical professions; I certainly like to believe this myself. This, however, is clearly insufficient. Compassionate persons, franchised for the practice of modern technological medicine, can unwittingly engage in mistreatment of patients under their care.
III
Probably only one who has experienced the impact of hospital practice on himself, or on someone he loves, can fully appreciate all that needs remedying. Staff members who flit in and out of a patient’s room can never see more than a minute or two of what happens there during a patient’s entire stay in a hospital. We all wish to remedy the evils from which we suffer, but few of us suffer from the evils we have the power to remedy. This is why I have advocated the admission to a hospital (incognito; they can go to a hospital other than their own) of hospital administrators, doctors, and nurses. Nothing else could so quickly accelerate the reforms we need so badly.
Personal experience of the discomfort of living in a hospital seems to me particularly important for professors who are heads of clinical departments in medical schools and for senior hospital administrators. In the bloated bureaucracies of modern hospitals such administrators have become panjandrums who are largely engaged in the personnel management of the staff members immediately beneath them. Some of them seem appallingly ignorant of existing conditions in the everyday lives of patients. A senior hospital administrator was winkled out of his oak-paneled office and persuaded to participate in the conference I mentioned above. I expected him to stand on the defensive, and before the conference I had mentally resolved not to make my remarks appear to attack any individual person or group of persons. To my astonishment, this administrator unapologetically supported current hospital practice and even suggested that—with the further development of medical technology—we could expect the stressful conditions of which I complained to become even more pronounced than they now are. He seemed to accept them as an inevitable concomitant of expected advances in medicine. His attitude—not uncommon among hospital administrators—raises the questions of who is responsible for the present situation and who can change it.
I have noted that we could excuse some of the inadequacies of the hospital staff because they work within a defective system. But we must not forget that although a system may seem to authorize harmful behavior on the part of some participants, the system itself is created by the decisions and attitudes of human beings.(This surely is the lesson learned—if learned it has been—from the history of slavery and concentration camps.) The higher administrators of hospital practice must be held responsible for what we want altered; and we must ask them either to change conditions or to give place to those who will. The world will never become a better place in which to live if we allow everyone to exculpate himself by appealing to the systems in which they work.
Readers fortunate never to have been a patient in a hospital, or to have had a close relative who was one, may ask whether the deficiencies I have listed are important enough to require correction. They may be annoying, but are they really harmful? Several lines of evidence show that they are.
Consider first the effects of depriving a patient of sleep and of allowing many strangers to ask him questions, often the same ones. These are, in fact, two methods employed by torturers of political prisoners in countries where this still occurs. In order to break a victim’s will to resist the demand for information or “confessions,” torturers deliberately exploit the damaging effects of sleeplessness and of the confusion produced by many unfamiliar people asking the same questions. Of course, in a hospital no one expressly tries to deprive the patient of sleep or to get him confused; each person interrupting or questioning the patient thinks he has a good reason for doing so, and perhaps has. Unfortunately, none seem to be aware of the activities of the others and of the total effect of all the interruptions and interrogations on the defenseless patient.
A second source of sometimes serious harm arises from the frequent incoordination among the different members of the staff involved with a patient. As I have said, each doctor (or group of doctors) treats the organ of a medical specialty, but too often no one coordinates their activities. They go their separate ways in a manner far worse than that of an orchestra without a conductor. The situation in some hospitals reminds me of what we should expect in the performance of a symphony if the separate sections of the orchestra—strings, woodwinds, brass, and percussion—were all put into different soundproof rooms and told that they must nevertheless play together harmoniously.
An example of how badly a patient’s treatment can be jeopardized without a single doctor coordinating his colleagues’ efforts came to my attention recently. A patient with severe diabetes was diagnosed by a neurologist as having a brain tumor, and a neurosurgeon had agreed that it should be removed surgically. An internist was to have prepared the patient for the operation, but he was not available, and so the neurologist handled the preparation by himself. No one told him, or he forgot, that the patient had diabetes, and he prescribed a drug that was appropriate for the pre-operative preparation but that happens to have adverse effects on diabetes. The patient’s diabetes became seriously uncontrolled, and before this was appreciated and corrected he had lost so much fluid that he developed kidney stones and intestinal obstruction as well. The doctors involved in this bungling were competent physicians within their own small domains. In this case we might reasonably say that the fault was not in them, but in the system in which they work; but this kind of mishap is all too common and will continue until we stop the practice of leaderless medicine.
A third harmful effect of the repeated changes in the medical staff concerned with a patient is the loss of the staffs ability to individualize treatment and care. Doctors like to say that they treat patients, not diseases. However, diseases resemble each other much more than do patients. It takes time to learn about a patient’s individual sensitivities and needs. I am ashamed to say something so obvious, but you cannot individualize treatment unless you know the individual you are treating. The constantly changing staff can never adequately learn (or communicate to each other) the particularities of individual patients. In principle, they would like to modify treatment to suit each patient, but in the absence of personal knowledge about the patient they cannot do this; so they end up treating the disease. At the level of nursing and technical care the individual needs of the patient are rarely even considered. A few rapidly fired perfunctory questions about allergies seems to be all that anyone wants to know about a patient’s idiosyncracies. He is expected to submit docilely to the “regulations”—a vast codebook of tradition that justifies forcing the patient to adapt to the needs of the staff.
IV
I now come to the aspect of hospital practice that I consider most baneful. I said earlier that up until as recently as one or two generations ago doctors could claim almost no credit for the drugs or other visible treatments that they could offer their patients. In saying this, however, I did not mean that doctors had no effect on the course of an illness. On the contrary, they often profoundly influenced the outcome of one. This influence, however, came from their conveyance of faith, hope, and love to the patient. These are powerful healing forces, and we are only now beginning to learn just how powerful they are.
One evidence of the healing effect of these positive emotions comes from studies of the markedly increased incidence of illness and mortality among widows and widowers during the first year or two after they have lost a spouse. The increased ill-health of those in a state of bereavement probably has several causes. For example, after the death of a partner, they may eat less nutritious food and otherwise neglect themselves. It seems likely, however, that the main factor in their increased susceptibility to illness comes from the survivor of a good marriage no longer having the opportunity to give and receive love in an intimate relationship. Numerous observations—both in the laboratory and in everyday life—show that negative emotions, such as fear and anger, adversely affect the functioning of our bodies. It follows that maintenance of the positive emotions, such as love and hope, helps to sustain and improve our health; and widows and widowers are, for a time, without these healing forces.
Studies of the pharmacologically inert tablets or capsules known as placebos have given us further information about the healing effect of faith, hope, and love. A placebo has no chemical activity on the body; its effect depends entirely on the patient’s belief that he has been given an effective remedy. Placebos frequently produce startling improvements in patients. These are often substantial enough to have forced off the market drugs of marginal value that could not produce in competition a benefit equal to that evoked by the suggestive effect of a placebo. Unfortunately, many members of the medical professions have interpreted the effects of placebos to discredit patients. They say that if a patient responds to a placebo this proves that he needs less pharmacologically active medication than he thought he needed. They fail to see that what it really shows is that patients need less medication when we give them faith, hope, and love. This brings me back to the role the doctor had in former times—one that he will resume in the improved medical climate of the future.
The effect of a placebo is not automatic; it depends on the person who gives it to the patient and on the trust the patient has in this person. The stronger the bond of trust between the giver and receiver the greater the effect. Strong emotional links, however, can only develop with time. We are not born, it seems, with automatic trust of other people; if anything, we may have an innate distrust of them until they have gained our confidence. The doctor of former times usually had this confidence. He had earned it by knowing a patient throughout many years and by staying with him when he was ill for many hours at a time. When I was a medical student, a popular print—distributed, I think, by a drug company with a calendar—showed a doctor sitting by the bed of a sick child. It was understood that the doctor was staying with the child until it went through the crisis, the passage of which indicated— in the days before antibiotics—whether a bacterial infection would overwhelm and kill the patient or whether his defenses would conquer the disease. I remember that in those days I thought this print almost cloying in its sentimentality, too idealistic of a generation of physicians who were rapidly dying out. Now, however, I think that it embodied a great truth about healing. I believe the doctor sitting by the sick child’s bed had a real influence on the outcome of the illness, just through his being there. If a picture of a doctor actually seated in a chair beside his patient shows how out of date the scene is, I can only say that in this respect we need to retrace our steps.
Not many doctors—if any—could play that role today, and few would even consider it time well spent if they were to try. A doctor of today may barely know his patient’s name, and if he knows that he often knows little else. I know of one instance in which a doctor, from reading results of tests printed on slips of paper, directed a patient’s treatment without ever having once met the patient. Such a doctor may prescribe treatment that will influence a patient’s metabolism, but his patient could never benefit from the equally powerful effect on that metabolism of a personal relationship with a doctor.
Perhaps I can best illustrate the emotional chasm that now separates most doctors from their patients with a brief digression on touching. We know that touching, hand-holding, and caressing by a loving person can be both pleasurable and healing to the person touched. A few doctors have discovered this again and are even investigating the healing effects of touching. Who, however, should touch us? Most of us do not wish to be touched by a stranger, and we may positively dislike this—even resent it. A person must, in a sense, earn the right to touch us by his earlier expressions of love in some other form. Today’s doctors know this, and few of them touch their patients—at least to communicate love and hope. At most, the patient may receive a patronizing pat on the back of the hand; and not many patients today expect or want more in the way of touching from the strangers who have become their doctors.
My favorite, admittedly somewhat trite, definition of a psychiatrist is that he is a good doctor who spends time with his patients. Certainly few members of other medical specialties spend time with patients any more. Doctors are now largely paid for procedures, all listed for them on insurance forms. Listening to a patient or trying to advise him does not figure in the list of compensated procedures (except in psychiatry), and it is not surprising that most doctors of other branches of medicine spend little time at such financially unrewarding activity.
In addition to this, much of the day-to-day treatment and care of patients is now delegated to nurses and technicians. Doctors are becoming increasingly like generals in a map room, far behind the people engaged in fighting. Unfortunately, the people who are more in contact with patients have usually had little or no training in the subtleties of human relationships. They are often completely unaware of the exquisite sensitivity of anxious people—and most patients are anxious—to the slightest remark that a member of the medical professions may make. Moreover, many are so technically oriented and so single-minded in their determination to correct a diseased organ that they behave as if they did not want patients around, just as the garage mechanic does not wish to have an automobile’s owner watch him while he repairs the vehicle.
If some of the foregoing arguments seem too abstract and inconclusive, my contentions may receive more support by comparing the results of treating patients with the same diseases in a hospital and in their homes. It is not easy to be sure that the groups in such comparisons are otherwise similar and properly matched. Nevertheless, two studies of this type give cause for concern, if not alarm. One investigation compared treatment at home and in the hospital for patients suffering severe kidney disease requiring dialysis; the other compared patients who had had heart attacks. In both studies the patients treated at home did as well as those admitted to the hospital. In comparisons of this type the hospital has the great advantage of equipment and staff that are not available in a home; this being so, any adverse change in the patient’s condition can be more quickly detected and remedied in a hospital than in a home. It follows, therefore, that the hospital—in these comparisons—must have had some harmful effect that canceled the advantage it had in technological facilities. I have tried to describe some of the causes of this effect, and I turn next to suggest how the present conditions of medical care in hospitals arose.
I think these conditions have two main sources. The first is economic. It goes back to the foundation—sometimes a century or more ago—of many of our modern hospitals as eleemosynary institutions. For many decades hospitals were mainly supported by philanthropy and staffed by volunteer or unpaid workers—nuns, for example. Even when a hospital of this early period charged the patient something for his treatment, he rarely paid the entire cost; and often he paid nothing. He was, however, regarded as a supplicant, lucky to be taken in, and without any right of complaint. I think one can see this attitude of hauteur on the part of the staff persisting in our hospitals at the present time, even though they are now financed quite differently. Today most patients pay for their medical treatment, either through taxes or through insurance. Unfortunately, the indirect methods of payment make it difficult for the patient to see himself as a consumer with rights that he can affirm. Furthermore, lack of competition among hospitals reduces most patients’ options and, correspondingly, their assertiveness. A customer of a hotel or an airline expects quick service with a smile, and because hotels and airlines have competition, he usually receives it. On the other hand, a university teaching hospital may have a monopoly (in its region) of advanced technology. If it has no effective competition, patients needing its facilities cannot go elsewhere. This situation may generate attitudes of carelessness and indifference—sometimes even of callousness—on the part of the hospital staff, and it can also shelter managerial inefficiency.
The second source of the condition of modern hospitals derives from the almost unchallenged concept that most doctors today have of the nature of man and his diseases. This is that human beings consist only of their physical bodies; these are machines, and when they become diseased they need to be repaired like other machines. I deliberately opened this essay with the metaphor of an automobile needing repair because the concept of the human body as a machine dominates modern medicine, and the automobile is our most familiar machine. The analogy has its merits; the human body has numerous organs just as an automobile has different parts. Some mechanics know more about transmissions than others, who, in turn, know more about cylinders; similarly, some doctors know more about hearts, others more about kidneys. Nor is the analogy of a human body to a machine without some value in treatment. If you can get a stone out of the urinary tract, the urine will again flow just as water will flow again through a drain that was blocked and then unstuck. Nevertheless, you can quickly reach the limit of usefulness of this analogy, for two reasons. First, automobiles and other machines have no reparative processes of their own that a mechanic’s efforts can help or hinder; and second, they have no central self that provides control and coordination for the different parts as our brains do for the different organs of our bodies. A doctor adopting a purely mechanical approach to medicine can fail to help a patient use his natural healing processes; indeed, he can seriously interfere with these. The theme of this essay is that much of what patients experience in hospitals can have such an adverse effect and thus works against both the patient’s self-healing and the intended effects of a doctor’s treatment.
Some of my colleagues may think that I and the increasing number of doctors who share my concern about these matters are a new type of Luddite wanting to discard the technological advances of modern medicine. That is far from being my stance. I think we can have a medicine that is both technologically advanced and attentive to the needs of the individual patient as a person. These two aspects of medicine need not be rivalrous. They only seem so to a generation of hospital staffs that has become overawed by the technical side of medicine.
The present state of hospital practice is not likely to last long. Radical changes are already occurring. Patients are becoming more articulate in requesting an end to impersonal and indifferent attitudes on the part of hospital staffs. Many of them are avoiding when they can the university hospitals and going instead to the smaller, community hospitals, where the idea of the patient as a person still lingers. Even the medical journals, which are ordinarily devoted single-mindedly to the technical side of medicine, are now publishing a swelling number of comments (by doctors themselves) about deficiencies in the care of patients in hospitals.
These complaints and comments are stimulating changes. For example, some hospitals are reducing and even abandoning rotation and specialization in nursing care; they are returning to the practice of having one single nurse take care of all of an individual patient’s needs (during one shift of duty). Others are experimenting with entire wards and nursing units run for the convenience and comfort of the patients instead of for those of the staff. Still others are experimenting with the effects of good food and better courtesy. And a few hospitals are even making all these improvements at the same time.
When I have discussed the deficiencies of patient care in hospitals with colleagues, I have often heard them say (as the hospital administrator I mentioned earlier had said) that we have to accept these conditions in modern hospitals, and especially in the teaching hospitals that provide so-called tertiary care, that is, those having advanced technology not available in smaller hospitals. I could not agree that this needs to be so, and I have therefore found it especially gratifying that some university hospitals have shown leadership in improving the care of patients while not sacrificing anything in the most advanced treatment of diseases.
Many doctors also are changing their attitudes and concepts. They are beginning to appreciate the insufficiency of the model of a machine in understanding and treating human disease. Teaching hospitals are showing increasing efforts to bring care of patients back into medicine. Medical schools are trying to attract students who are versed in the humanities as well as in science. The last change derives from the belief that the study of philosophy, history, and other forms of literature may inculcate humility and compassion in ways that the study of science alone does not.
Nevertheless, I think the necessary changes in the conditions of hospitals are going to come mainly through economic incentives. Already shareholder-owned hospitals have taught us that medical institutions can, after all, provide prompt, efficient service that is also friendly. Some of them have additionally shown that improved management can reduce costs.(It is not clear that the patient as consumer always receives the financial benefits of these savings; but that is another matter.) In addition, the high costs of hospital care (and a current surplus of doctors) are forcing, encouraging, and permitting more patients to be treated at home instead of being admitted to the hospital. One can foresee that with the increasing miniaturization and mobility of medical equipment many patients will be able to remain at home and yet have their conditions monitored as closely—and treated as expertly—as would be possible in a hospital. One can even imagine a future medical care in which patients will be admitted to hospitals only for certain tests requiring heavy, immobile equipment and for major surgery.
An incidental, but priceless feature of the return to home treatment will be the restoration of individualized care for patients. Patients will again have their own doctors. The doctor in charge of a case may call in consultants and technicians, but they will handle specific assignments and will not preempt control of particular organs to the neglect of other aspects of the patient. If a homebound patient needs nursing care beyond what members of his family can provide, he will have the same nurse or at most three or four nurses, not an ever-changing succession of new ones. He can have tasty food when he wants it and medication without delay when he needs it. Best of all, he need not be deprived of the love that members of his family can give him, nor do they need to be deprived of his love. It will be ironic perhaps if economic necessity restores the best of the medicine of a former period while enabling us to keep the benefits of the medicine of today without its present horrors. This, however, is the revolution in medical care that is now occurring.
