The central problem of the modern hospital is trying to treat patients as human beings while efficiently using its technocrats -- doctors and others -- and its technologies.
Someplace in the process, the human being often gets lost. And the prospective patient has to be ready for this possibility.
Some experts on the subject -- and victims of the process -- tell their own stories.
Melvin A. (Mel) Glasser has been around the medical world much of his life. For 18 years he was the United Auto Workers' benefits director. He now directs the consumer-oriented Health Security Action Council in Washington.
"Two years ago," he says, "I had open heart surgery at a hospital here that specializes in heart surgery. When the medical students learned I was there, they asked if I'd lecture them on what it was like. I told them all the stuff in the medical literature about the mechanization of medicine is true -- but it's not true enough.
"For instance, I'd been there about a week, and when I counted up I found I'd been exposed to 14 doctors. I started thinking about how do I recognize each of them, and start talking to them about what I ought to do.
"But by the time I was well enough to recognize them, they were gone."
Next? "Like everyone else, I got tired of someone waking me at 6:30 every morning and making me get out of bed to weigh me, then telling me, 'Go back to sleep.' And 20 minutes later someone taking my blood pressure. So one night I got to talking to the nurse, and she said, 'You're right, it's crazy. We'll change some of these things.'
"I never saw her again. Two nights later I said to the supervisor, 'What happened to that nurse?' She said, 'We rotate the nurses, so they don't get too attached to one group of patients.'
"I said, 'What did you guys do, tear up all the books about patient relationships!' She said, 'Look, we're having trouble making ends meet. We contracted to give you good care and you'll get it, but we did not contract to give it from the same nurse.' "
On the day Glasser was to be discharged, he was, by hospital rule, required to wait while a nurse took him to the outer door in a wheelchair. But first he was asked, "Please go down to the business office on the first floor and take care of your bill."
"I said, 'Send the bill up.' They said, 'You have to go down there.' I said, 'You mean you're going to escort me to the door in a wheelchair, but I have to go down there and stand in line?' They finally sent an assistant administrator up to handle it.
"What's happened in hospitals, I think, is that there's been so much concern with mechanization and efficiency and costs -- and I know they're having a terrible problem with costs -- in the process someone has lost the patient again."
There are constant warnings about this in medical and hospital literature.
"The chart is not the patient," says a book that warns against the overwhelming "system." A noted surgeon wrote, "If the young surgeon is not careful, the patient may represent 'the common duct stricture' " or "the case in bed 4" rather than "Mrs. Thomas, mother of four children . . . Would any of us like to be known as 'a case'?"
Dr. John Talbott of New York Hospital and Cornell University Medical School is president of the American Psychiatric Association. In November 1981, while standing on the sidewalk, he was hit by a taxi ricocheting away from a collision and was left with a shattered left leg and lower spine.
"But in retrospect," he reports, "it was the way I was subsequently cared for . . . that sticks most in my mind."
He tells how, "despite all the teaching" about patient advocacy and about giving adequate doses of pain-killing drugs, "the fruits of those labors didn't reach me." His "medication was always minimal and wasn't prescribed in an overlapping manner, forcing me to beg for more every three hours."
Then: "Each morning a new nurse would bounce cheerily into the room, introduce herself and take a history. I assumed on the second day that my first day's nurse had the day off. But by the third or fourth day I realized that some bizarre rotational system ensured that no nurse would ever get to know me, my needs and my care, since I'd never see the same one twice.
"Also each morning the medical 'team' would arrive, four residents with an occasional medical student. Their purpose, I surmised, was to successfully set foot into and then out of my room in 20 seconds. Questions from me were discouraged . . ."
One evening he got no dinner. Calls to the kitchen by the nursing staff got no results, so he called, and "the nutrition person announced that . . . they were already immersed in setting up breakfast trays." He asked if he couldn't be fed, and she "blew up at me for not understanding all the pressures she was under." He did finally get fed.
As discharge approached, he was given no "comprehensive plan" for his future pain relief, home nursing and rehabilitation. He and his wife made the arrangements themselves.
"Going home," finally, "was no picnic with an enormous heavy cast and limited energy . . . but it was home, without the surly aides, constantly rotating nurses, inadequate medication, dashing house staff, uncoordinated treatment team, incredibly unappealing food and dehumanizing physicians."
Is all this a new problem in hospitals, caused by bigness, technology and increasing cost-controls? It is a bigger problem but not a new one. In 1927 Boston's great Dr. Francis Peabody wrote that "hospitals, like other institutions founded with the highest human ideals, are apt to deteriorate into dehumanized machines."
Dr. Robert Moser of Philadelphia is executive vice president of the American College of Physicians. In the Joint Commission on Accreditation of Hospitals' Quality Review Bulletin, he tells how his wife had heart bypass surgery last year in "one of the world's most distinguished hospitals."
"On the first day back in her room," he says, "after 72 hours in the recovery area, she was visited by 38 different people in 12 hours . . . All were cheerful and pleasant, and each had a job to do . . . but there was no evident coordination among them . . . To understand their cumulative disruptive effect, one need only count the total hours of uninterrupted rest possible (or impossible) for the patient.
"This episode occurred in a splendid, well-run hospital, and similar ones occur in every well-run hospital that I know of. It is a primary demonstration of 'process' becoming more important than health care's ultimate goal: the welfare of the patient."
It might also be called a demonstration of curing becoming so important that lack of caring interferes with the curing.
Can there be overemphasis on "caring"? After all, says Dr. C. Rollins Hanlon, director of the American College of Surgeons, "one of the most caring things you can do for an individual is to get him well."
I mentioned this to Mel Glasser.
"Yes, that's true," he said. "But you hear of the successful cases. Those who don't survive, maybe because of poor care, aren't in a position to complain."