Five Patients - Crichton Michael. Страница 34

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.

How can one capitalize on this? At present, not at all. This is because, at the present time, patients are assigned to different parts of the hospital on the basis of only three criteria-financial resources, sex, and anticipated therapy. No other attribute of the patient matters, not even diagnosis. (Patients with ulcers, pancreatitis, or cancer, for example, will be assigned to medical or surgical floors depending on whether their treatment calls for operation or not.)

The various floors of the hospital operate with their own nurses, their own visits, their own house staff, their own stocks of supplies. This is the arrangement found in most American hospitals, and as a way of structuring, it has distinct advantages. For many years, it was thought to be the best way of matching the patient to the facilities he would most need.

However, each of the three criteria-sex, money, and therapy-has come under attack. Money, because third-party payment has made financial structuring obsolete; sex, because if everyone is in private or semi-private rooms, segregation by whole floors becomes unnecessary.

Anticipated therapy has also been questioned. Some even argue that the distinction between surgical and medical patients be abandoned in favor of distinctions based on severity of illness, and the need for close medical and nursing attention.

Under this system, medical and surgical patients would be intermixed in units that differed in the degree of care they provided-intensive care, recuperative care, minimal care, and so on. Patients would be moved about in the hospital as their illness became greater or less.

Some clear psychological benefits for patients are apparent. As they become healthier, they would be moved to new areas of the hospital, where they would be encouraged to be more self-sufficient, to wear their own clothes, to look after themselves, to go down to the cafeteria and get their own food, and so on. They would, at every point, be surrounded by patients of equal severity of illness. Their dependency needs would be fulfilled in a graded way, since the hospital would be providing a spectrum of care and close attention. To a degree, the hospital already does this, with its recovery rooms and intensive-care units [The hospital already has intensive-care units for respiratory care, cardiac care, neurological care, surgical care, medical care, transplantation patients, pediatric patients, and burns patients.]. But more could be done-and, indeed, one can predict that more will almost certainly be done in this direction. This will happen not because the hospital is preoccupied with the patient's psyche-it is not-but rather because graded care is economically more efficient. At the present time 30 per cent of the cost of a room goes to nursing care. For the average MGH hospital room, this amounts to some $22 a day. Although the percentage cost may not rise in the future, the absolute cost will. Ultimately it will be necessary to give patients no more nursing care than they really need; the present inefficiency in personnel use will become too costly to continue.

Among physicians, a restructuring could be more efficient as well. Consider anesthetists: in the last decade, they have emerged as the experts in the support of vital functions. They are called for every cardiac and respiratory arrest; they know more about drugs than anyone else; they are expert in the use of respirators. Most physicians would agree it is handy to have an anesthetist around any intensive-care unit, but at present the anesthetists are dispersed throughout the hospital. By restructuring on the basis of severity of illness, one important resource, anesthetists, would be made more available to patients who need them.

Indeed, "human resources" are just one argument for restructuring. Hardware and technology resources represent another. For example, the kind of electronic and mechanical equipment required for a patient with a heart attack and for a postoperative cardiac patient is very similar. As time goes on, and larger and more all-inclusive machines become available, it will be increasingly advantageous to bring patients with similar technological requirements together, so that they may share certain large machine capabilities and so that medical personnel trained in the use of these machines can be centralized.

The bringing together of patients, personnel, and hardware has certainly been valuable in cardiac intensive-care units; in some units immediate mortality from myocardial infarction has been cut as much as 30 per cent. We are already seeing a pro-

liferation of these specialized units, and we will certainly see more-and from there it is only a small step to complete reordering of the hospital along new lines.

Afterword

although it comes from an ancient tra-dition, the modern hospital, in fully recognizable form, is less than fifty years old.

At most it will last, in fully recognizable form, another decade or so. But by then, almost surely, what is different from the present will overshadow what is similar. And we may expect these changes to represent more than improved technology and differently trained personnel. For there will certainly be a change in the function of hospitals, just as there has been a change in function during the past half century.

During that period, the hospital evolved into a positive, curative agency specializing in highly technical, complex medical procedures. Very likely the hospital will continue to function in this capacity. But it will abandon certain other functions in the process. It will cease to be a convalescent facility, for example, as more specialized convalescent homes appear. It will curtail its in-patient diagnostic work to that which absolutely requires hospitalization. Its custodial function-whether.