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Editorial The medical center, the patient and the clinician
J chr~n. Dis. 1963, Vol. 16. pp. 11l-l 13. Pergamon Press Ltd. Printed in Great Britain
Editorial
THE MEDICAL CENTER, THE PATIENT AND THE CLINICIAN DR. WALSH MCDERMOTT,Livingston Farrand Professor of Public Health at the Cornell University Medical College, presents in this issue of the Journal an eloquent and convincing statement concerning the scientific and humanistic beneficence available to the individual patient in the modem medical center. This point of view is timely and important for although much has been said about the highly developed skills in such centers, little reference has been made to the impact of the bigness of such institutions upon the overall management of the patient as a human being, burdened not only with illness but with its associated anxiety and fear. MCDERMOTT holds that the warmest aspects of the patientclinician relationship can and are fostered in the large medical centers. If it already exists in the hospital personnel, empathy and compassion will not disappear or be crushed by the enormous edifices of masonry. Nor will the glare from the highly polished, seemingly endless corridors blind the physician and his associates to the needs of any one sick person. The clinician’s efforts to make the patient feel somewhat the better for his visit will not vary inversely with the height of the hospital. There is little doubt that the development of the modem university-directed medical center, with the generous financial support from government and philanthropic agencies, has been the prime source of the spectacular growth of scientitic medicine. Each patient, whatever his economic or social background, is the recipient of this bounty. However, the question is sometimes raised whether the values so often extolled in the patient-doctor relationship, associated with the home call, the ofhoe visit, or the stay in the small community hospital, have deteriorated with the transition to the various departments of the gargantuan medical center. There is no easy answer to this question, but if it is remembered that the common denominator in this problem has been, is, and will always be the qualities of the attending physician, it is reasonable to conclude that the good doctor will continue to be the good doctor irrespective of the size of the institution in which he practises. The mutual trust between the patient and the clinician will not diminish and the better characteristics of each will be manifest. Although MCDERMOTThas made a sound case for the belief that the individual patient usually receives excellent care in the medical center, he might have wished to say more than he did about the impact of such institutions upon the individual physician or surgeon, particularly on his legs, his digestive apparatus, and his equanimity. It is true that the clinician’s immediate range of activities is usually restricted to only one or two floors of the gigantic building, but he must migrate frequently to many other areas in the growth hormone-stimulated hospital beehive for ancillary assistance and participation in a wide variety of committee meetings, conferences and consultations. He cannot avoid the long, long walks and he often has to decide 111
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DAVID SEEGALand LOUIS LASAGNA
whether to choose the ascent or descent of several flights of stairs or the emotional trauma associated with long, long waits at the elevators. Pedometric data on the mileage covered by the clinician in the medical centers are not available, but the figure must be impressive. A chemist at a well known medical center has stated that during an unusually active ten-hour day, his pedometer registered ten miles. Some less than sympathetic observers would suggest that the long walks offer a prophylactic measure against the velocity of coronary artery atherosclerosis, but the obituary columns of the Journal of the American Medical Association offer little support of this notion. But even if the long walks are ‘good for you’ it would be difficult to obtain a majority vote agreeing that it is also ‘good for you’ to engage in the polar bear dance waiting for the bradycardial, crowded elevators. The march ci petit pas performed before the sliding doors is associated with two new occupational diseases-‘elevator nystagmus’ and ‘lobby torticollis’. These pathologic processes derive from an attempt to survey, methodically and compulsively, the flashing lights reflecting the progress (sic) of the various elevators from floor to floor, so as to line up before the right one as it beats the others to your floor. In most institutions, there is further hazard in the form of apoplectic levels of catecholamines generated by the realization that one of the elevators is (as usual) out of order, straining the capacity of the remaining conveyances to the breaking point. It has been rumored that the ‘repair’ teams assigned to keep such elevators in fighting trim are a devilishly ingenious invention of ‘The Enemy’ designed to sabotage American medicine, but it is unlikely that the solution is as easy as all that. More reasonable explanations are: (1) The elevators are waging a successful war of attrition in the struggle of Machine vs. Man, and (2) the Benchley hypothesis. The latter ingenious theory, barely hinted at by the great seer in a neglected work, could account for much of the eccentric behavior of elevators. It assumes that certain elevators may go up to the top floor of one building, cross over and go down in another nearby buikiing. (Construction experts scoff at this theory, but people who can misplace whole floors, like the thirteenth, shouldn’t talk.) The emotional trauma associated with this experience may be compounded by queueing up for lunch as the self-service cafeterias continue to blossom in the modem medical center. Where, oh where, are the days when the clinician, after a full morning’s work, would quietly meander to an attractive dining room, be offered a linen napkin, rest his elbow on a tablecloth, and be served by a winsome waitress whose question might be: “Doctor, would you prefer the soft shell crabs or the hot roast-beef sandwich?” Those days have slipped away (except in the Heaven help the senior surgeon today dining rooms of the large Foundations). who, after o,perating for five hours, queueing up in the long lunch line, and selecting and eating some glutenous concoction from the steam table, fails to pick up his dishes and deposit the tray at the exit area. All these innovations at the modem medical center are trivial, however, when compared with the problem of parking. Administrators, harassed to provide space for the ever burgeoning offspring of Detroit, look upon the clinician’s automobile as his annoying junior metallic associate. CLARK KERR, the President of the University of California, had occasion to refer to this problem at the installation of the President of the University of Washington. He stated that he had been forced to change his mind regarding the nature of the duties which awaited him in Berkeley.
The Medical Center, the Patient
and the Clinician
113
To his surprise he found that he was spending considerable time on three activities: athletics for the alumni, the sex quandaries of the students, and parking for the faculty. The clinician is, therefore, not alone in wrestling with the problem of where to deposit his automobile. Thus, it seems that although MCDERMOTT has presented convincing evidence that today’s medical center is proving a blessing to the individual patient, a plaintive word might be whispered about the vexed, often tired clinician in the same milieu. He will accept these difficulties as he has others in the past, and if he complains about some of the discomforts noted above, it will be in modest and usually ineffectual tones. Despite his dog-tired legs, his muted roar at the closed elevator door, his grimaces in the cafeteria, his ‘Barney Oldfielding’ towards the last parking space in the lot or the frustrating slow cruise around the neighborhood in search for an unoccupied macadamized plot, he will continue to play his expanding role in practise and research, no matter how large the modern medical center becomes. For despite any weariness he may experience, the doctor cannot ignore the impetus of the medical center on the advances in medical practice he sees about him. He will generally reach the conclusion that Parkinson’s Third Law: “Expansion means complexity and complexity, decay” may hold for some business corporations but not necessarily for the large hospital-medical school combines. But if some of the inconveniences of the increasing bigness of the hospital and medical school enterprises become too burdensome there may be the possibility that he can negate Pope’s dictum that “Whatever is, is right”. Since medical societies of many varieties are being formed at an alarming rate, the clinician in the medical center can join this rush by becoming a charter member in the inauguration of: The Society for the Amelioration of TLEW-CQOP (pronounced tloo-kwop) (Tired legs, elevator waiting, cafeteria queueing, and no parking). DAVID SEEGAL LOUIS LASAGNA
Editorial
THE MEDICAL CENTER, THE PATIENT AND THE CLINICIAN DR. WALSH MCDERMOTT,Livingston Farrand Professor of Public Health at the Cornell University Medical College, presents in this issue of the Journal an eloquent and convincing statement concerning the scientific and humanistic beneficence available to the individual patient in the modem medical center. This point of view is timely and important for although much has been said about the highly developed skills in such centers, little reference has been made to the impact of the bigness of such institutions upon the overall management of the patient as a human being, burdened not only with illness but with its associated anxiety and fear. MCDERMOTT holds that the warmest aspects of the patientclinician relationship can and are fostered in the large medical centers. If it already exists in the hospital personnel, empathy and compassion will not disappear or be crushed by the enormous edifices of masonry. Nor will the glare from the highly polished, seemingly endless corridors blind the physician and his associates to the needs of any one sick person. The clinician’s efforts to make the patient feel somewhat the better for his visit will not vary inversely with the height of the hospital. There is little doubt that the development of the modem university-directed medical center, with the generous financial support from government and philanthropic agencies, has been the prime source of the spectacular growth of scientitic medicine. Each patient, whatever his economic or social background, is the recipient of this bounty. However, the question is sometimes raised whether the values so often extolled in the patient-doctor relationship, associated with the home call, the ofhoe visit, or the stay in the small community hospital, have deteriorated with the transition to the various departments of the gargantuan medical center. There is no easy answer to this question, but if it is remembered that the common denominator in this problem has been, is, and will always be the qualities of the attending physician, it is reasonable to conclude that the good doctor will continue to be the good doctor irrespective of the size of the institution in which he practises. The mutual trust between the patient and the clinician will not diminish and the better characteristics of each will be manifest. Although MCDERMOTThas made a sound case for the belief that the individual patient usually receives excellent care in the medical center, he might have wished to say more than he did about the impact of such institutions upon the individual physician or surgeon, particularly on his legs, his digestive apparatus, and his equanimity. It is true that the clinician’s immediate range of activities is usually restricted to only one or two floors of the gigantic building, but he must migrate frequently to many other areas in the growth hormone-stimulated hospital beehive for ancillary assistance and participation in a wide variety of committee meetings, conferences and consultations. He cannot avoid the long, long walks and he often has to decide 111
112
DAVID SEEGALand LOUIS LASAGNA
whether to choose the ascent or descent of several flights of stairs or the emotional trauma associated with long, long waits at the elevators. Pedometric data on the mileage covered by the clinician in the medical centers are not available, but the figure must be impressive. A chemist at a well known medical center has stated that during an unusually active ten-hour day, his pedometer registered ten miles. Some less than sympathetic observers would suggest that the long walks offer a prophylactic measure against the velocity of coronary artery atherosclerosis, but the obituary columns of the Journal of the American Medical Association offer little support of this notion. But even if the long walks are ‘good for you’ it would be difficult to obtain a majority vote agreeing that it is also ‘good for you’ to engage in the polar bear dance waiting for the bradycardial, crowded elevators. The march ci petit pas performed before the sliding doors is associated with two new occupational diseases-‘elevator nystagmus’ and ‘lobby torticollis’. These pathologic processes derive from an attempt to survey, methodically and compulsively, the flashing lights reflecting the progress (sic) of the various elevators from floor to floor, so as to line up before the right one as it beats the others to your floor. In most institutions, there is further hazard in the form of apoplectic levels of catecholamines generated by the realization that one of the elevators is (as usual) out of order, straining the capacity of the remaining conveyances to the breaking point. It has been rumored that the ‘repair’ teams assigned to keep such elevators in fighting trim are a devilishly ingenious invention of ‘The Enemy’ designed to sabotage American medicine, but it is unlikely that the solution is as easy as all that. More reasonable explanations are: (1) The elevators are waging a successful war of attrition in the struggle of Machine vs. Man, and (2) the Benchley hypothesis. The latter ingenious theory, barely hinted at by the great seer in a neglected work, could account for much of the eccentric behavior of elevators. It assumes that certain elevators may go up to the top floor of one building, cross over and go down in another nearby buikiing. (Construction experts scoff at this theory, but people who can misplace whole floors, like the thirteenth, shouldn’t talk.) The emotional trauma associated with this experience may be compounded by queueing up for lunch as the self-service cafeterias continue to blossom in the modem medical center. Where, oh where, are the days when the clinician, after a full morning’s work, would quietly meander to an attractive dining room, be offered a linen napkin, rest his elbow on a tablecloth, and be served by a winsome waitress whose question might be: “Doctor, would you prefer the soft shell crabs or the hot roast-beef sandwich?” Those days have slipped away (except in the Heaven help the senior surgeon today dining rooms of the large Foundations). who, after o,perating for five hours, queueing up in the long lunch line, and selecting and eating some glutenous concoction from the steam table, fails to pick up his dishes and deposit the tray at the exit area. All these innovations at the modem medical center are trivial, however, when compared with the problem of parking. Administrators, harassed to provide space for the ever burgeoning offspring of Detroit, look upon the clinician’s automobile as his annoying junior metallic associate. CLARK KERR, the President of the University of California, had occasion to refer to this problem at the installation of the President of the University of Washington. He stated that he had been forced to change his mind regarding the nature of the duties which awaited him in Berkeley.
The Medical Center, the Patient
and the Clinician
113
To his surprise he found that he was spending considerable time on three activities: athletics for the alumni, the sex quandaries of the students, and parking for the faculty. The clinician is, therefore, not alone in wrestling with the problem of where to deposit his automobile. Thus, it seems that although MCDERMOTT has presented convincing evidence that today’s medical center is proving a blessing to the individual patient, a plaintive word might be whispered about the vexed, often tired clinician in the same milieu. He will accept these difficulties as he has others in the past, and if he complains about some of the discomforts noted above, it will be in modest and usually ineffectual tones. Despite his dog-tired legs, his muted roar at the closed elevator door, his grimaces in the cafeteria, his ‘Barney Oldfielding’ towards the last parking space in the lot or the frustrating slow cruise around the neighborhood in search for an unoccupied macadamized plot, he will continue to play his expanding role in practise and research, no matter how large the modern medical center becomes. For despite any weariness he may experience, the doctor cannot ignore the impetus of the medical center on the advances in medical practice he sees about him. He will generally reach the conclusion that Parkinson’s Third Law: “Expansion means complexity and complexity, decay” may hold for some business corporations but not necessarily for the large hospital-medical school combines. But if some of the inconveniences of the increasing bigness of the hospital and medical school enterprises become too burdensome there may be the possibility that he can negate Pope’s dictum that “Whatever is, is right”. Since medical societies of many varieties are being formed at an alarming rate, the clinician in the medical center can join this rush by becoming a charter member in the inauguration of: The Society for the Amelioration of TLEW-CQOP (pronounced tloo-kwop) (Tired legs, elevator waiting, cafeteria queueing, and no parking). DAVID SEEGAL LOUIS LASAGNA