M.C.
Foreword
there has recently been a lot of fool-ish talk about something called "the new medicine." To the extent that it implies a distinction from some form of old medicine, the phrase has no meaning at all. Medicine has crossed no watershed; there has been no triumphant breakthrough, no quantum jump in science or technology or social application.
Yet there is, within medicine itself, a sense that things are different. It is difficult to define, for it is not the consequence of change, but rather the fact of change itself.
The first time I began to look at the Massachusetts General Hospital in the spring of 1969 I had the uneasy feeling there was too much flux, too much instability in the system. I felt a little like an interviewer who has come upon his subject at a bad time. Only later did I realize that there would never be a "good" time, and that change is a constant feature of the hospital environment. The true figurehead of modern medicine is not Hippocrates but Heraclitus.
To trace a history of change, one must go back about fifty years, to the time when organized research began to produce major new scientific and technological advances. Medicine has been revolutionized by those advances, but they have not stopped. Indeed, the pace of change has increased. Within the past ten years, social pressures have been added to those of science and technology, producing a demand for a new concept of medical care, a new ethic of responsibility for the doctor, and a new structuring of institutions to deliver broader and better care.
As a result, medicine has become not a changed profession but a perpetually changing one. There is no longer a sense that one can make a few adjustments and then return to a steady state, for the system will never be stable again. There is nothing permanent except change itself.
From this standpoint, the experiences of five patients in a university teaching hospital are most interesting. It should be stated at once that there is nothing typical about either the patients described here or the hospital in which they were treated. Rather, they are presented because their experiences are indicative of some of the ways medicine is now changing.
These five patients were selected from a larger group of twenty-three, all admitted during the first seven months of 1969. In talking to these patients and their families, I identified myself as a fourth-year medical student writing a book about the hospital. As they are presented here, each patient's name and other identifying characteristics have been changed.
I chose these five from the larger group because I thought their experiences were in some way particularly interesting or relevant. Accordingly, this is a highly selective and personal book, based on the idiosyncratic observation of one medical student wandering around a large institution, sticking his nose into this room or that, talking to some people and watching others and trying to decide what, if anything, it all means.
M.C.
La Jolla, California
November 15, 1969
Acknowledgments
I am greatly indebted to the employees and medical staff of the Massachusetts General Hospital for a kindness and patience that went beyond any reasonable expectation.
I would also like to thank Drs. Robert Ebert, Hermann Lisco, Joseph Gardella, and Mr. Jerome Pollock, all of the Harvard Medical School, for encouragement and advice in planning the book; Drs. Howard Hiatt, Charles Huggins, Hugh Chandler, Ashby Moncure, James Feeney, Joel Alpert, Edward Shapiro, Josef Fisher, Michael Soper, Jerry Grossman, and Miss Kathleen Dwyer for their suggestions at various points in my work; Drs. Alexander Leaf, Martin Nathan, Jonas Salk, and Mr. Martin Bander for their review of the manuscript at different points; Mr. Robert Gottlieb and Miss Lynn Nesbit for ongoing, tireless work on the project; and finally Dr. John Knowles, whose influence is everywhere in this book, as it is in the hospital he directs. With all this help, the book ought to be flawless, and to the extent that it is not, I am to blame.
Acknowledgments
The late Alan Gregg once quoted a former teacher as saying, "Whenever you say anything explicitly to anyone, you also say something else implicitly, namely, that you think you are the guy to say it." Such sentiments trouble all but the most egotistical writers; the others recognize that their sense of enfranchisement is a gift of the people around them, whom they can only hope not to disappoint.
Ralph Orlando. Now and Then
In the early morning, The Massachusetts General Hospital was notified by Harvard University that some students, at that time occupying a university building in protest of ROTC, might be brought to the hospital for treatment of injuries after their forcible removal from the building. This occurred at 5 a.m., and although some fifty students were reportedly injured, none were brought to the MGH.
At 5:45 in the morning, the last of the emergency-ward residents got to bed, sleeping fully clothed, sprawled on a cot in one of the treatment rooms. Taped on the door to the room was a piece of paper on which he had written his name and "Wake at 6:30." Across the hall in another treatment room, two surgical residents were sleeping; in a third room, one of the interns.
Even without the Harvard students, it had been a busy night. Shortly before midnight, the EW had admitted two college students with pelvic fractures from motorcycle accidents, and both had been taken to surgery; later on, they had also admitted a forty-one-year-old man suffering from a heart attack, an eighty-year-old woman with congestive heart failure, and a thirty-six-year-old alcoholic with acute pancreatitis. An elderly man with meta-static carcinoma and renal failure had died at 3 a.m.
There had also been the usual number of patients with sore throats, coughs, abrasions, lacerations, foreign bodies inhaled or swallowed, bruises, concussions, dislocated shoulders, earaches, headaches, stomachaches, backaches, fractures, sprains, chest pains, and breathing difficulties.
At 6:30, some of the junior residents and interns were up, doing lab studies and checking on the patients who had been admitted for observation to the overnight ward, adjacent to the emergency ward. The ONW limited patients to a three-day stay; it was designed for patients who required a period of observation longer than a few hours, such as those with suspected gastrointestinal bleeding or those with severe concussions. However, in practice it was also used for patients who were severely ill but could not get a bed at the time they arrived, because the hospital was full.
At 7 a.m., surgical rounds were made in the ONW. Six patients were discussed during half an hour, but most of the time was given over to a fifty-four-year-old woman with a recurrence of bleeding ulcer. This was her second day in the hospital and her condition was now stable; she had received five units of blood the day before. Normally she would not be a surgical candidate, but on two previous admissions she had shown the same pattern of massive, unexpected bleeding, followed by stabilization in the hospital after transfusion. The residents were afraid that if this happened again, she might bleed to death before she got to the hospital.