Nor do these figures tell the whole story, for even on the wards, patients with no financial resources for medical care hardly exist. At present, 85 per cent of all MGH patients have some form of "third-party" health coverage-and most of those who do are very wealthy patients, not poor ones.

Third-party payment, whether by insurance plan such as Blue Cross, state welfare, or Medicare, has revolutionized the position of the teaching hospital. Put bluntly, it is no longer possible to trade free care for teaching; nearly everyone can pay for his care, and can afford a private doctor, and a private or semi-private room.

The MGH is, at this writing, closing down its wards. Some other hospitals have already done so. Such structural changes are relatively simple, but a major dilemma remains. There are no charity patients left, and no private patient wants to be a "teaching patient," since this has disagreeable connotations.

What is the solution? There are, obviously, only two answers. Either teaching is halted or private patients are used for teaching purposes. The first solution is impractical, the second highly controversial. But it is clearly in the cards: someday, all patients in a teaching hospital will be used for teaching. Such a program has already been set up at another Boston teaching hospital, the Beth Israel. There, "ward" and private patients lie side by side, and all patients, whether they have private physicians or not, receive their in-hospital treatment from house staff.

Now all this may seem like a minor matter. After all, just 2 per cent of American hospitals are teaching hospitals. The rest have no such problem. But one may ask, if the teaching hospital truly delivers better medical care-if this claim is more than a rationalization for making private patients available for poking and prodding by medical students and interns-then shouldn't all hospitals adopt the methods of the teaching hospital? Shouldn't all patients have the benefits of the system?

There are some practical considerations, in terms of the availability of interns and residents, but we can ignore these and simply look more closely at the intrinsic quality, the advantages and disadvantages, of teaching-patient care.

Certainly there are some classic advantages. The fact that residents are literally that-individuals residing in the hospital-means there are more doctors around, day and night, to treat acute emergencies. A patient with the finest private physician in the world will not be consoled if his doctor is away in his office when the patient has a cardiac arrest.

Second, as the pace of medical development accelerates, the hospital's staff of academicians and researchers can claim up-to-date, specialized information of a depth and variety that other hospitals, and individual private physicians, cannot hope to match. The impact of this on patient care can be considerable in some instances. For most of medical history, it did not matter whether your doctor was up to date or ten years behind the times; now it may matter if he is only one year behind. Therefore, one of the great new appeals of the teaching hospital is the availability of the most recent knowledge in patient care.

Third, the academic orientation of the staff leads them to attack perplexing problems with unusual vigor, reviewing the medical literature, utilizing the laboratory and referral resources of the institution. Endless rounds and discussions among house staff and visits mean that a problem will receive the benefit of many opinions. Thus a patient with an obscure disease or a difficult diagnosis will get a great deal of attention-much more than any single physician could give him.

Fourth, because the hospital is structured to teach and do research, it is critical of all medical practice, including its own. Each physician has several others looking over his shoulder, and this tends to minimize mistakes. To that extent a teaching patient is "safer" than a private patient

All this is clearly evident when one looks at Mrs. Murphy's history. She is a patient with an uncommon, though not rare, disease-but a disease that manifested itself in an extraordinarily rare way. Mrs. Murphy first saw a private physician, who treated her complaint of swelling legs as if she had heart failure. She did not have heart failure. She did not improve. She then went to a community hospital, where more sophisticated tests were done. There, she was correctly found to have liver disease, GI bleeding, and hemolytic anemia. Each of these problems could have been discovered by her private doctor, with the help of a private clinical laboratory, but for reasons which cannot be assessed, he failed to do so.

At the community hospital, evidence was also found for pancreatic cancer. This evidence was incorrect. (Furthermore, important pathology unrelated to her primary disease was missed. This was not discussed in the earlier section, out of a desire to avoid complicating an already intricate story. However, in the report sent by the hospital to the MGH when the patient was admitted, a physical examination form clearly stated that a pelvic exam was normal. In fact, Mrs. Murphy had a cervical polyp the size of a large marble. It was easily felt and clearly visible. The only reasonable conclusion is that a pelvic examination was not, in fact, done at the other hospital.) And the only reason Mrs. Murphy was transferred to the MGH was because of this suspected diagnosis.

Two points about this story should be made immediately. The first is that the MGH, by its very nature, sees a great many patients whose diagnoses have been missed. It is easy to gain the impression that all practicing doctors are inept, and all community hospitals incompetent. But, in fact, the great majority of patients who receive correct diagnoses and good care never show up at the MGH.

Second, no medical system is perfect. Teaching hospitals make mistakes just the way community hospitals and private physicians do. Each teaching hospital in Boston delights in getting the patients of others, and making diagnoses that were missed. The point of Mrs. Murphy's story, therefore, is not the glorification of the teaching hospital, but rather that this woman, with a complex disease and unusual manifestations, received nine days of the most intense academic scrutiny before a diagnosis was established. She was immersed in an environment geared to such scrutiny. A great many people-from students to the chief of medicine-saw her, examined her, and contributed suggestions concerning her care. And from that eventually came a diagnosis that might not have been made otherwise.

At the same time, there are some classic complaints about teaching-service care, from both patients and physicians. Patients dislike multiple examinations, and having to tell their story over and over again. Physicians complain that the academic orientation of a teaching service leads to excessive lab tests, too many diagnostic procedures, less briskly efficient care, longer in-hospital stays, and ultimately more expensive treatment. Without question, these complaints have some truth in them.

For example, it is relatively easy to dismiss the protests of a patient with an unknown disease who objects to many examinations by different people. It is in his own best interests to be examined by everyone, at least until a diagnosis is arrived at. However, it is less easy to shrug off the complaints of a patient who may have, unknown to him, a "classic case" of something that is neither rare nor unusual. An intelligent patient with a lucid history of ulcer may find himself visited by a large number of students who are directed to him by an instructor who tells them, "Mr. Jones has a good story and good findings." And worse, if the patient complains to a resident, the resident cannot evaluate the complaint. No one keeps track of how many students are visiting any given patient. It is impossible to know whether he is objecting to two visits or to twenty [Despite the above, most patients are not seen by many students. A fair percentage never set eyes on a student].

The question of excessive and unnecessary tests is difficult to evaluate. Everyone who works in a hospital sees patients who receive too many tests, under the guise of a "thorough work-up"; everyone has seen diagnostic procedures carried out where at least an element of motivation was the resident's desire to practice the procedure. These cases are rare, though they stick in one's mind.

Frequently, the issues can be subtle. They are polarized in the following verbatim exchange between a particularly obnoxious student and a particularly obnoxious visit. The patient under discussion was one who had documented obstructive lung disease with advanced emphysema. He was on the respirator full time.

visit: "Do you think we should do cardiac cathe-terization and get a pulmonary wedge pressure on this man?"

student: "No."

visit: "Can you think of any additional information we might get from the wedge pressure?"

student: "No."

visit: "In point of fact, we know that in emphysema, if we find the wedge pressure elevated, then the severity of the disease is increased."

student: "Will that change your course of therapy?"

visit: "I'm not sure mat's a valid consideration."

student: "There's a morbidity attached to pulmonary catheterization."

visit: "Yes, but it's very slight."

student: "It exists. If it won't change your therapy, how can you justify it?"

visit: "I don't think you can say it won't change our therapy."

student: "Then how might it change your ther-apy?"

visit "Over the long haul. For instance, in this lab we do VD/VT measurements, though similar labs do not. We've found it very valuable."

student: "This man has emphysema. He's seventy-three. He's dying."

visit: "We are nonetheless obligated to learn all we can about his disease."

student: "But it won't help him."

visit: "The Respiratory Unit has multiple functions. We are at once engaged in research and therapy."

student: "Will you tell the patient that the procedure won't help him, that it's just for the sake of curiosity?"

visit: "I wouldn't call it curiosity."

student: "Then you have a formal experiment going? A protocol? This patient is part of a defined study series?"

visit: "No, but we are gathering data. All patients are available for research here."

Chapter 12

Perhaps the most common criticism of the academic service is that "the doctors are not interested in patients, only in diseases," a harsh complaint, and an old one. Oliver Wendell Holmes said in 1867 that he did not want a researcher-clinician for his doctor: "I want a whole man for my doctor, not half a one." (As a teacher, Holmes could be brutal about academic medical instruction: "What is this stuff with which you are cramming the brains of young men who are to hold the lives of the community in their hands? Here is a man fallen in a fit; you can tell me all about the eight surfaces of the two processes of the palate-bone, but you have not had the sense to loosen the man's neckcloth, and the old women are still calling you a fool.")

Certainly the researcher-clinician has split loyalties and conflicting interests. A GI consult who sees a patient is specifically called in to give advice about the patient's abdomen; and to some extent, the consulting physicians are more interested in the patient's stomach than the rest of him. The consequence of this may be to surround the teaching patient with many people interested in his problems, but less interested in the patient himself. The patient gets excellent but impersonal care-if that is not a contradiction in terms.

The idea that an orientation toward disease can ever lead to poor care is furiously denied by academicians. But it is disturbing to note, for instance, that Death Rounds at the MGH, which once reviewed a deceased patient's hospital course with a view to discussing whether anything more could have been done for him, are now almost entirely given over to academics: the patient's disease is discussed, not the patient. (This is only true on the medical service. Surgical Death and Complication Rounds still deal with the patient's course. In general, the surgical service is more pragmatic and less academic than the medical-a point of some friction between the two groups.)

Eventually, one comes to the conclusion that care on a teaching service is not so much better or worse as different. Some patients will benefit from these differences more than others. A patient with an obscure malady can do no better than a teaching service, where he will be fussed over, considered, and reconsidered endlessly; a patient with a common, well-understood complaint may get quicker, more practical treatment from a private doctor in a nonacademic setting.

This would seem an excellent argument for transforming the teaching hospital into a referral institution, and that is what has happened to many of them. But there are two reasons to deplore the change.

First, it means that research on the most common-and therefore, one might argue, the most important-diseases stops. This is unwise; there are many times in medical history when a researcher has "gone over old ground" and come up with something new and important. Reginald Fitz went over "perityphlitis" and came up with appendicitis, thus changing the course of surgical history.

Second, it ignores the community in which the hospital stands. The community is likely to sense this rapidly, and resent the fact that although the hospital personnel did a great job for Uncle Joe's unpronounceable Latin ailment, they could hardly be bothered with Sally's ear infection.

What is the hospital's responsibility? Originally, the answer was quite clear-it was built to care for any needy person in Boston who had the initiative to seek it out. With the passage of time, its community became not the entire city, but a part of it, the so-called North End. This is a community of working-class Italians and Irishmen, with areas of considerable poverty.

But the hospital has never lost its passivity, a tradition that can be traced all the way back to Greece. Patients are expected to come to the hospital, and not the reverse. And while the hospital will never turn anyone away from its doors, neither will it actively seek out illness in the community. Furthermore, the impact of technology over the last twenty years has been to make the hospital even more passive, as it becomes more preoccupied with acute established disease, to the almost total neglect of preventive medicine.

But the role of the hospital is going to change, as public expectations for medical care change. According to Alexander Leaf, Chief of Medicine, "For a long time-since Hippocrates-we have not attached any broader social obligation to the physician's education. You went through your training program whether in school or as an apprentice, and men you hung out your shingle and treated whoever could pay you. But now that is unacceptable to society, which is making other demands from physicians." He says, further: "I think we have to restructure the functions of the hospital if it is to survive for the next twenty years."