Five Patients - Crichton Michael. Страница 28

A resident is anyone who has finished his internship and is continuing with more specialized training in such areas as pediatrics, surgery, internal medicine, or psychiatry. A residency may be taken at the same hospital as the internship or at another; residencies last from two to six years, depending on the field.

Medical students are primarily responsible to the medical school, not the hospital; within the hospital they are referred to, somewhat ironically, as "studs."

Interns and residents, on the other hand, are hospital employees and are referred to as "house officers." Collectively the interns and residents comprise the "house staff," as distinct from the "senior staff," meaning the private physicians or academic teachers affiliated with the hospital.

This hierarchy is analogous to a university with its undergraduates, graduate students, and professors. There are departments within the hospital corresponding to university departments; these departments give courses for medical students and house officers, termed "rotations." Primarily, the teaching is informal, but there is also a heavy schedule of formal rounds, lectures, and seminars.

In the history of the teaching hospital, as in the university, the undergraduate (or medical student) appeared much earlier than the graduate student (or house officer). Indeed, the beginnings of the teaching hospitals are closely associated with the beginnings of medical schools in this country. This was clearly the case for the first three medical schools, and the first three teaching hospitals in America: in Philadelphia, New York, and Boston.

The Massachusetts General had Harvard students on the wards from its inception. There is no reason to believe the students made the hospital more appealing; Warren recalled that students in his day "were of the crudest character," and remembers that it was no recommendation to a landlady to say you were a medical student. Even a century later, Harvey Gushing grumbled that "students in a hospital, like children in a lodging house, are not an unmixed blessing." But despite persistent reservations, the teaching hospital has always taught medical students. What is new is the teaching of house officers.

Originally, medical students were required to take two years of academic courses, followed by a third year as an apprentice to a practicing physician. In those days the MGH had two house-officer positions-then known by the considerably more humble term "house pupils"-and these posts were acceptable substitutes for an apprenticeship. Beginning around the time of the Civil War, however, the hospital began to expand its house-officer posts; the greatest growth came at the turn of the century. In 1891, there were seven house officers; by 1901, fourteen; by 1911, twenty-one. As mentioned, there are now 304.

Part of this growth represents a simple growth of the hospital. As it became larger, there were more patients to care for, and to learn from, and more day-to-day work to be done by house officers.

Part of the growth represents the increasing role of the hospital as an acute-care facility. The hospital sees fewer patients with chronic diseases and more acutely ill patients who require continuous and careful management. This requires a larger house staff.

Partly, too, the growth represents a shift away from the old personal apprentice system toward an "institutional apprenticeship." In the 1930's and 1940's, it became clear that house officers who remained in the hospital were better trained than those who left early and linked up with private practitioners. This observation finally led to virtual abandonment of the personal apprenticeship. Thus, formerly, surgical residency was three years, followed by two years of apprenticeship under a private man; now it is five years (including internship), and the only reason for joining a private surgeon at the end of that time is to build a practice, not to gain more experience.

All this means that the structure of patient care is quite different today from what it was when the hospital first opened. In 1821, patient care was essentially in the hands of private, senior men who donated their time to the hospital and agreed to take students around with them on the wards. But between student and senior man there has sprung up a large body of individuals who are now essential to the functioning of the hospital. The MGH could cheerfully dispense with its medical students, but it would come to a grinding halt in a few hours if deprived of its house staff.

It is no exaggeration to say that the house staff runs large areas of the hospital, with senior men advising from above, and students looking on from below. One may applaud this system for providing a spectrum of competence and responsibility, allowing students to move up the ladder to internship, then junior and senior residency, in easy stages. But in fact the emergence and proliferation of house officers has another, much harsher rationale. For the hospital, they provide a source of trained, intelligent, hard-working, very cheap labor.

This has always been true. In 1896, when Gushing was an intern, he noted that "house officers are about as hard worked men as I have ever seen. Every day is twenty-four hours long for them with a vengeance."

The modern house officer generally works an "every other night" schedule, meaning roughly thirty-six hours on duty, and twelve off. In practice this means arriving at the hospital at six thirty or seven in the morning, working all day and probably most of the night, continuing through the following day until late afternoon, and then going home to sleep-until six thirty or seven the next day. Payment for this effort, which is sustained over many years, was until quite recently nonexistent. Some hospitals were so bad that they worked their house officers at this pace, paid them nothing, and charged them for laundry and parking.

Others would provide a few meals, and perhaps an honorarium fee of twenty-five dollars a year. At the MGH, a senior man recalls that as recently as ten years ago, "I was chief resident in surgery, eight years out of medical school, having spent two years in the army; I had a wife and four children; I was responsible for the conduct of an entire surgical service-and I was paid just under two thousand dollars a year."

Such a situation requires either an independent income or a great tolerance for debt; one wonders whether the modern stereotype of the private physician as crassly avaricious can be traced back to these years of early, absurd financial hardship. Fortunately, the salaries of house officers have climbed sharply in recent years. In many hospitals an intern now receives six thousand dollars, a senior resident eight or nine. Many factors are responsible for the increase: the effect of Medicare, which permits the hospital to charge patients for the services of a resident; the fact that the G.I. bill has been extended to cover residency training; the realization among medical educators that you cannot get and keep good people in an affluent society without paying them.

As the house officers have become more numerous and more skilled, the position of the medical student has changed. House officers are licensed to practice medicine; students cannot practice by law. A student cannot write orders, even for something as simple as raising a patient's bed, without having them countersigned by a house officer.

Legally, a student is permitted to employ nothing other than diagnostic instruments, and then only for the purpose of diagnosis. In practice, this ruling is stretched to mean that a student can, under supervision, perform a lumbar puncture, a thoracic or abdominal tap, or a bone-marrow aspirate; he can suture wounds in the emergency ward; he can also mix medicines, start intravenous infusions, inject medicines intravenously, and give a blood transfusion. Additionally, he is expected to have competence in a variety of laboratory procedures and tests.

The medical student's officially sanctioned functions thus lie somewhere between those of a doctor, a nurse, and a laboratory technician. It is not surprising that no one knows what to call him. Instructors with a group of second- or third-year students will often introduce them to patients as "doctors in training" or "these young doctors." Fourth-year students, seeing patients alone, will introduce themselves as "doctor." Until a few years ago, the students even wore name tags which said

"Dr.," but this practice was abandoned

after the hospital was advised it constituted misrepresentation that might have legal consequences. Student name tags now give only their names; those of interns and residents say "Dr."

It is not clear why medical students are called doctors in front of patients, especially since so few patients are fooled by the appellation. One can view the whole business as a harmless convention,

in which the hospital pretends that its students are doctors, and the patients pretend to be taken in.

Why bother? Instructors say that this small white lie comforts the patients, who would be upset to learn they were being examined by students. Something of the same sort happens with interns, who occasionally pass themselves off as residents in the belief that this soothes patients. It is true that the folklore-and the mass-media image-of the medical student and the intern is distinctly unfavorable, and these negative connotations persist until residency. (Dr. Kildare, that charming, all-knowing physician, was a resident who spent much prime time dealing with neurotic, guilt-ridden, fumbling interns and students.) "Even now," according to George Orwell, "doctors can be found whose motives are questionable. Anyone who has had much illness, or who has listened to medical students talking, will know what I mean." In a single, paradoxical stroke, he dismisses the motivations of some doctors, but all medical students.

The position of the medical student is thus peculiar, and occasionally comical. In society at large, he finds himself eminently marriageable and a good credit risk, thus enjoying the approval of those two bastions of conservative appraisal- matrons and bankers. In the hospital, however, those same matrons and bankers want nothing to do with students, and nearly every student has had the experience of examining a woman who grumbles and complains throughout the history and physical and then politely asks if the student is married.

In the end, one suspects that the practice of labeling students as doctors is misguided. Patients ought to be told explicitly who the students are; a moment's reflection shows many advantages to such a practice.