But the great majority of house officers do not become academic physicians, at least not full time. They go out into the community to begin, in many respects, a totally different kind of practice from any they have ever seen. They are shocked to discover that 70 per cent of their patients have no identifiable illness; they are besieged and pestered by "crocks"; they have relatively few acutely ill patients, and relatively few hospitalized patients. They are, in short, called upon to practice a great deal of behavioral art and relatively little science.
These doctors suffer from what Grossman calls "acute organically trained syndrome." The rationale for giving them the training they got, as preparation for the work they would be doing, was formerly couched as "if they can handle the problems they see in the hospital, they can handle anything." It is obviously untrue, except for those diseases that are scientifically understood and medically treatable; patients with other complaints may get a more sympathetic ear from their next-door neighbor.
*This same argument has been made by Peter Drucker concerning undergraduate, liberal arts colleges, where he points out that professors of English or History are not training liberal humanitarians or anything else so noble-they are training future professors of English and History.
Underneath it all is a sense that modern, scientific medicine can be taught, but the vague, amorphous "art" cannot be taught in the same way. This is true, but it does not mean it cannot be taught at all. Nor does it mean that simply watching the visit examine five or ten patients a week is a sufficient background in how to deal with a patient's psyche.
What a medical resident knows about science he has gotten from intensive courses, rounds, seminars, and journal reading; what he knows about behavior, psychiatry, psychology, or sociology depends on what he has managed to pick up as he goes along. This generally amounts to pitifully little.* It is hard to estimate the amount of time a doctor spends studying behavioral science during his years as a student, intern, and resident. Formal training-lectures as a student, rotations as a clinical clerk, social service and psychiatric rounds as a house officer-probably account for no more than 1 to 2 per cent of his total time; the extent of informal training is impossible to guess.
There is now a growing movement within medical education to provide more formal training in behavior, but there is also formidable opposition. As John Knowles has pointed out, medicine gained acceptance within the university as a valid discipline not because of its advances as a social science, but because of its discoveries as a natural science. For nearly a century, natural science has been the paydirt, and the behavioral art has taken a subordinate position. Reversing the trend of a century will take some doing.
Of course, the hospital has an out-patient department and emergency ward, where the interface of hospital and society is more sharply seen. But the addition of community clinics, separate from the hospital, will almost certainly change the psychological set of doctors working within the physical setting of the hospital itself.
It is too early to know whether the satellite clinics are going to work. The question of physician acceptance is one problem; the question of community acceptance another. But if they do not work, something else must be found, and at this time it appears social pressures are sufficiently intense to guarantee such a search for new delivery systems.
The concept of a "patient-oriented hospital" is fashionable at the moment. The phrase is widely used, though the idea is shopworn. People have recognized for a long time-at least twenty-five years-that hospitals are designed for the patient's needs only when those needs do not conflict with the doctors' convenience. Nor is there any mystery about why this is so. Whenever a new hospital is built, it is the doctors who are consulted on design requirements, not the patients.
All this has produced a great deal of talk among doctors, architects, patients, engineers, interior decorators, and innumerable other people-but very little innovation, very little experimentation. For the majority of hospitals, and the majority of new hospitals, the classic complaints still hold true:
The hospital is difficult to adapt to. It brings in individuals from outside, and plunges them into a totally new existence, with new schedules, new food, new rules, new clothing, new language, new sounds and smells, fears and rewards. For the patient entering this foreign environment, there are no guides or guidebooks available to him. A person visiting Europe can get better advance information than a person entering the "foreign country" of the hospital.
The hospital building disregards physical factors that might promote recovery. Colors are bland, but instead of being restful, are more often depressing; space is badly distributed, so that a patient may be stranded in a large room, or crowded in a small one; private and semi-private patients often feel isolated in their rooms. (A Montefiore Hospital study concluded that while families of ward patients were eager to see their relatives transferred to private rooms, the patients wanted to stay on the wards, where they would have more contact with other people.) Windows are badly placed, and the view most often shows an adjacent large hospital building or a parking lot.
The hospital makes psychological demands that may retard recovery. According to Stanley King, these include dependence and compliance with hospital routine; a de-emphasis on external power and prestige; tolerance for pain and suffering; and the expectation that a patient will want to get well. These can easily work at cross-purposes. For example, a proudly self-reliant man may find his passive role as threatening as his illness. Or a person may become so dependent, and regress so far toward a child-like state, that he becomes more petty, complaining, and intolerant of pain than he would be otherwise. Or he may find his dependent role so satisfying that he loses his desire to get well.
One may immediately object that despite all this, the majority of patients adjust well to the hospital, recover, and go home. That is true, but as an argument it is a little like saying that the world got on perfectly well without electricity, which is also true.
But assuming these complaints have validity-assuming that patients would really recover more swiftly in a better designed environment-how should the new environment be designed? There is a spectrum of proposals, ranging from minor adjustments to quite radical innovations.
Perhaps the most radical, and the most interesting, comes from a simple observation: the modern hospital is best suited to a severely ill person. These people are most tolerant of hospital routine and its indignities, irritants, and difficulties.
On the other hand, persons recovering frequently become less tolerant as their physical condition improves. The phenomenon is so well known that doctors notice when a previously compliant patient begins to grumble about the food or the noise at night. These gripes are interpreted as a sure sign the patient is improving. Related to this is the so-called "lipstick sign," referring to the fact that as women begin to feel better, they start wearing lipstick and combing their hair in the morning. Essentially, all this means that the patients are acting in ways not demanded by the environment (lipstick) or else positively condemned by the environment (griping). Such activities are more appropriate to the outside world, and they are a signal that the patient, in his own mind, is preparing to leave the hospital for the outside.