Five Patients Read online

  Five Patients

  Michael Crichton

  Michael Crichton

  Five Patients

  Health, as a vast societal enterprise, is too important to be solely the concern of the providers of services.

  William L. Kissick, M.D.

  Author's Note 1994

  Twenty-five years have passed since I wrote Five Patients. When I reread the book recently, I was struck by how much in medicine has changed-and also, by how much has not changed. Eventually I decided not to revise the text, but to let it stand as a statement of what medical practice was like in the late 1960s, and how issues in health care were perceived at that time.

  By design, the book is highly selective, and some of the most dramatic social changes in medicine were not anticipated in its discussions. This book was written before the great government interventions of Medicare and Medicaid; before the onslaught of malpractice litigation, which transformed medical practice; before the rise of group practices and HMOs; and before the entry of large numbers of women into the profession as physicians. At the time this book was written, abortion was illegal; patient rights were barely discussed; the right to die was only beginning to emerge as an issue for the future; and genetic testing was still an exotic, experimental procedure.

  At the same time, the description in Five Patients of life in the emergency room seems little different from the present day; the training of new doctors is largely unchanged; the influence of medical history on present attitudes remains as important now as it was then; and the struggle to master new technologies, and to mount new surgical techniques, seems entirely contemporary.

  Much of the book focuses on emerging technologies, and it is interesting to see how cutting-edge technologies in the 1960s have fulfilled, or failed to fulfill, their promises. The use of closed-circuit television for "remote doctoring" has not found wide application, but some observers think that this is because the technology is still emerging, and will reach fruition when a combination of robotics and virtual reality allow surgery to be performed by a surgeon thousands of miles away.

  Similarly, I was fascinated by the idea that the computer might provide a powerful diagnostic tool, but diagnostic computer systems have found little acceptance in medicine. Doctors don't trust them and patients don't like them; they would rather give case histories to a paramedic or aide. On the other hand, everyone accepts automated lab tests, which are quick, accurate, and inexpensive. But overall, the effect of automation in medicine has been mixed; for example, even the mundane use of computers for hospital record-keeping has proven unexpectedly problematic, as our society struggles with issues of accuracy and privacy in the era of electronic data.

  What was not foreseen by me, or by anyone else in the late 1960s, was that computers would soon become almost unimaginably cheap. A computer that cost ten million dollars in 1970 cost only a few thousand dollars in 1980, and only a few hundred dollars in 1990. Ubiquitous, cheap computer power has made possible a variety of non-invasive imaging procedures-computer assisted tomography, magnetic resonance imaging, and sonography- which have transformed the daily practice of medicine, and which seem, to someone from that era, almost magical in their results.

  As medical technology has proliferated we have gained more sophisticated understanding of its limitations. Indeed, one trend in medicine has turned away from technology altogether. The long-term improvement in statistics for heart disease is primarily credited to life-style changes in the population. Diet, exercise, and meditation are now solemnly prescribed where once they were laughed at. And the growing interest in psychoimmu-nology, the interaction of mind and disease, is shared by patients and physicians alike. (When I wrote Five Patients, the most famous doctor in America was probably Michael DeBakey, the Houston cardiac surgeon. Now, he may very well be Deepak Chopra.)

  It's also true that events in the larger world have upset the confident expectations for continuously improved health. Smallpox has been banished forever, but the appearance of Legionnaire's Disease, Lyme Disease, and particularly AIDS reminds us that new illnesses have always arisen throughout human history. During this past quarter century, we have come to know even more horrific pathogens, such as Eboli virus, which fortunately have not taken hold in Western societies. But the threat remains.

  Skyrocketing medical costs were an issue in the late 1960s, as they are today, although our concern about expenditures in that era now seems quaint. Back then, the United States spent 6 percent of our GDP on health care-about 50 billion dollars annually. I predicted that figure would reach more than 100 billion by 1975. (In fact, it was 132 billion in that year.)

  But no one back in 1969 would have foreseen the present astronomical level of expenditure: more than 800 billion dollars a year on health, more than 14 percent of our GDP, with no end in spending growth in sight. The reason was that, back then, nearly everyone imagined that the country would have long since moved to a national health plan, if only to contain costs. Our failure to do so has produced all sorts of unhappy consequences for our nation, ranging from diminished global economic competitiveness to new individual fears in the workplace. Half of all personal bankruptcies in America now result from health costs, and the need to maintain insurance coverage has transformed the work decisions of all Americans, greatly diminishing our once-prized personal mobility.

  When I wrote Five Patients, a room at the Massachusetts General Hospital cost $70 a day. Now it costs more than $700. The hospital's annual operating budget was then $35 million a year. Now it is $732 million, far exceeding the rate of inflation for that period.

  The need to control costs, while ensuring health care for all Americans, now dominates every discussion about the future shape of medicine in America. This country must finally adopt some form of national health insurance, as every other industrial country in the world has long since done. It is a complex and a difficult issue, even without its political dimension, which often seems to render it almost insoluble.

  But while the systems of other countries are not without their problems, the fact is that other industrialized nations spend less on health care and get more for their money. At the moment, our national debate on health care is in the phase of blame and recrimination. We are told that doctors are paid too much, or that lawyers and litigation cost too much, that pharmaceutical companies charge too much, and so on. But the truth is that everyone works within the constraints of the present system-and it is the system itself that must be changed.

  One can draw an analogy to the earlier complaints about the cost and quality of American automobiles, which at one time were blamed on American workers. But the reality is that workers on the assembly line are prisoners of a system designed by others. Individual effort cannot significantly affect the outcome of the system. Only by changing the assembly line itself-by changing the way cars are designed and made-can a better product result. And given a better process, American workers have proven that they are as productive and efficient as anyone else.

  Similarly, American medicine has grown up as an unplanned entrepreneurial system of individual providers. The current system does many things well, but at high cost. A growing proportion of that cost derives from legislation passed by American politicians, who are not accountable for costs they impose. Indeed, freedom from political accountability is one of the worst features of the present American system.

  Changing the American system will confront us with far more difficult decisions than how much doctors or lawyers or drug companies are paid. The real battleground will be over coverage-what treatments the system will pay for, and under what circumstances. This in turn will bring to the fore all the ethical issues created by modern medicine in this century. Here especially we will need the expertise of physici
ans. It is unfortunate that the most recent tendency among politicians has been to exclude physicians and other health-care workers from planning the new system. One can only imagine this is a temporary phase, similar to the temporary phase when Detroit tried to design better cars without the help of workers on the line. That didn't succeed for automobiles, and it is unlikely that the current strategies in Washington will succeed any better for health care. There are signs that the public is disenchanted with politicians, and as our national debate continues, we can at least hope for a system that controls costs while preserving the innovation, vitality, and excitement that has always characterized American medicine.

  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.

  The emergency-ward residents attended these rounds, for in the early morning the EW is least busy. A short distance away, however, the acute psychiatric service was in full swing. The APS always gets a group of patients in the morning; they are the people who, for one reason or another, have not been able to sleep the previous night.

  In one of four interview rooms in the APS, a nineteen-year-old girl, separated from her husband, chain-smoked as she described her uns
uccessful attempts to kill her three-year-old daughter: first by hanging, then by suffocation with a pillow, and finally by gas asphyxiation. She explained that she wanted to stop the child from crying; the crying was driving her crazy. She came to the APS, she said, because "I wanted to talk to somebody. I mean, it's not natural, is it? It's not natural-a kid that keeps crying that way."

  In another room, a forty-year-old accountant was running down a list of eight reasons why he had to divorce his wife. He had written out the list so he would be sure to remember everything when he talked to the doctor.

  In a third room, a college student living on Beacon Hill explained that she was depressed and troubled by a recurrent sensation that came to her during parties. She said she would have the impression that she was invisible and that she was watching the party from across the room, from a different viewpoint. She had attempted suicide two days before by swallowing a bottle of aspirin tablets, but she had vomited them up.

  In the fourth room, a husky fifty-one-year-old construction worker discussed his fear that he was going to die suddenly. He knew the fear was groundless but he could not shake it, and his work was suffering, since he was afraid to exert himself and lift heavy objects. He was also bothered by sleeplessness, irritability, and bad headaches. On questioning it developed that his father had died of a stroke almost exactly six years before; the patient remembered his father as "a cold fish that I never liked."

  In the lobby of the APS were three other people waiting to talk to the psychiatrists. One woman was crying softly; another stared vacantly out the window. A middle-aged man in a tuxedo and ruffled shirt smiled reassuringly at everyone else in the room.