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clock. They had consultants of every shape and sort.
They were running up bills of five hundred dollars a day, week after week.... Certainly I think they should
be treated, just as I think that a large hos-pital like this is the place where this brand of com-plex medicine
ought to be carried out. But you can't help reflecting, as you look at all this stain-less steel and tubing and
sophisticated equipment, that right outside your door there are people with TB who aren't getting antibiotics,
and kids who aren't getting vaccinations, and women who aren't getting prenatal care.. . . I think we have
an obli-gation to these other people, as well."
The hospital's new objective is to spread its resources more widely, at the expense of its tradi-tional
passivity. The first step has been to begin an ambulatory care center in Charlestown, a de-pressed area of
16,000 people. This sort of "satel-lite clinic" is widely debated in medical circles today.
Dr. Leaf: "The Charlestown project is interest-ing to us, to see if we can begin to restructure the way we
deliver care. I hear arguments from my colleagues in the medical school, saying that no satellite clinic has
ever worked. They say the re-search interest isn't there, the way it is in a hospi-tal. They say you can't find
doctors to work in them. Well, then, we just have to get some new physicians who see their research as
working in the community, devising ways to give better care, rather than being in the hospital and doing
re-search on, say, gastric physiology."
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Certainly the academic hospitals will have to abandon what Dr. Knowles calls "the present de-fensive
isolation ... in a bastion of acute curative, specialized, and technical medicine." The impact of this on the
inner workings of the hospital itself may be extensive, and beneficial.
In 1896, the intern Harvey Gushing referred to the MGH as "this little world of ours" and he meant
precisely that. It was a little world, and it was "ours"; it belonged to the doctors, not to the patients. Doctors
were a permanent fixture in this world. The patients were transients who came and went. (Patients are
well aware that the hospital is for doctors, and not for themselves. They fre-quently report that they feel
like "specimens in a zoo." Indeed, nearly every literate person who has recorded his experience in an
academic hospital, from the late Philip Blaiberg on down, has men-tioned this disturbing association.)
Initially the hospital was designed to be a little world for the patients, supplying all their needs. In those
days, there were few resident physicians. But the hospital has evolved into a complete world for doctors as
well. Indeed, it would be surprising if it did not, for there is one house officer for every four patients, and
the house officers spend almost as much time in the hospital as the patients.
For a resident, the completeness of the little world with its dormitories, libraries, cafeterias, coffee
shops, chapel, post office, laundry, tennis
and basketball courts, drugstore, magazine stand combined with the intensity of training (the aver-age
resident spends 126 hours a week in the hospital) can have some peculiar effects. It is quite possible to
forget that the hospital stands in the midst of a larger community, and that the final goal of hospitalization is
reintegration of the pa-tient into that community. In this respect, the hos-pital is like two other institutions
which have a partially custodial function, schools and prisons. In each case, success is best measured not
by the per-formance of the individual within the system, but after he leaves it. And in each case there is a
ten-dency to view institutional performance as an end in itself.
This is true for both doctors and patients. The ideal of the physician-scientist, the clinician-researcher, is
very much a product of academic hospital values. The educational process designed to mold this product
has some paradoxical aspects. One may reasonably ask, for example, what is a medical student being
trained to become?
Without doubt the answer is: a house officer in a teaching hospital. A good medical student grad-uates
with all the necessary equipment: a back-ground in basic science, some clinical experience, familiarity with
the journals, and an academic ori-entation.
What, then, is a house officer being trained to become? The answer is, an academic physician
specializing in acute, curative, hospital-based med-
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icine.* This is heavily scientific and not very be-havioral; it must be so. (As the visit said: "Tell me about his
kidneys, not his marital troubles." And the visit was right: the hospital is geared to treat his kidneys, and not
his arguments with his wife.)
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 dis-cover 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 ratio-nale for
giving them the training they got, as prep-aration for the work they would be doing, was formerly couched
as "if they can handle the prob-lems they see in the hospital, they can handle any-thing." 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 con-cerning undergraduate, liberal arts colleges, where he
points out that professors of English or History are not training lib-eral humanitarians or anything else so
noble -they are train-ing future professors of English and History.
Underneath it all is a sense that modern, scien-tific 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 watch-ing the visit examine five or ten patients a week is a sufficient background
in how to deal with a pa-tient's psyche.
What a medical resident knows about science he has gotten from intensive courses, rounds, semi-nars,
and journal reading; what he knows about behavior, psychiatry, psychology, or sociology de-pends on what
he has managed to pick up as he goes along. This generally amounts to pitifully lit-tle.* 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 clin-ical clerk, social service and psychiatric
rounds as a house officer probably account for no more
*A student of my acquaintance, now a psychiatric resident, endeared himself to the house staff of hospitals where he
was a student by doggedly asking each resident he met to define, in a simple sentence, the difference between
neurosis and psychosis. He concluded that 15 per cent had some vaguely appropriate notion; the rest were
appallingly wrong. The fact that a doctor does not know the difference between neurosis and psychosis does not
necessarily mean he will be a poor physician; a doctor who cannot articulate these distinctions may conceivably
handle them deftly in his practice. But it is a clear indication he has not had much training in behavior, and the
question is whether he ought to have such training and whether his patients would benefit from the training.
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than 1 to 2 per cent of his total time; the extent of informal training is impossible to guess.
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