AS I WAS DRIVEN to the hospital not at all confident about my future, and feeling more ready for the scrap heap, I said to the friend who was driving me, "There is one thing about being a journalist at moments like this: We always find something to write about whatever happens to us."
"You mean that we use it as a form of transcendence," said my friend. (He is a literary critic, and can be relied on to dignify my most commonplace ideas with words like that; he probably uses them at breakfast.)
The longer I lay in the hospital, which is a fresh experience for me, the more I thought of what we had said. Our point can be made of others than journalists. A watchful and detached curiosity about what is going on around one is an inexhaustible resource on which to draw to avoid dwelling on one's own wretched condition. There is in the hospital a cosmos to watch. One has only to use one's eyes and ears, and quickly one is taken out of oneself.
I watched and listened to the other patients -- especially to the five who, one after the other, occupied the second bed in my room -- and it was disturbing how few of them have this resource.
This is not their fault. They simply have not been reared to be curious. They are not really interested in the world except in how they are affected by it, and so grow only more absorbed in themselves. What is other than them is strange and frightening. Just as outside they feel at the mercy of the big bureaucracies, public and private, so now they feel at the mercy of the hospital which is caring for them. Much that happens to them is just not understandable. These people are in fact deprived.
What is most distressing of all to see, they feel at the mercy even of their own ill health. It is a wonder that they are not more superstitious and paranoid than they are, like the man in the bed opposite me who believed that every hospital was torturing him. Yet now he wanted to go to Johns Hopkins.
In fact, I became more and more convinced that, in this age of reason and science, we have all become superstitious about our health. We are so convinced that we should all be wondrously well all the time that we are no longer able to think of ill health as normal. This determines what we expect of our medicine. We increasingly expect our physicians to be not healers but witch doctors. We look to our hospitals not for treatment but for exorcism. There is no cost we will not pay to have the devil thrown out.
Many suits for malpractice may be brought only by the greedy, not least by the lawyers today who are no better than the ambulance chasers in the past, but the awards of the courts reflect our superstition.
But there is another effect. As a friend who visited me in the hospital put it, we have all been made to feel guilty about ill health. There is so much emphasis today on what I can only describe as violent good health that we are marked down as back-sliders if we happen to be ill. Again we do not go to a hospital to be made better, we go to have the devil cast out and be made perfect.
Hospital costs are determined largely by our own expectations. We think that our doctors should have the royal touch. We lie under the huge and expensive machines, but what we are really looking for is a laying on of hands.
Two of my roommates were sent home after brief stays. Two were whisked away, both in the dead of night, to the intensive care unit. How quickly one's attention is diverted to the new arrival in the bed opposite. One is naturally assuming the importance of the hospital itself. The bed is stripped and remade, within an hour or two the new occupant is wheeled in, the memory of the first is erased. He might almost have never been there.
Only an enthusiastic student nurse asked one morning after one of the patients who had disappeared during the night. Her inquiry was considerate, but it seemed out of place. She will learn.
The routine of a hospital has much to teach, not only to a big bureaucracy like the telephone company, but also to us who are often so impatient with routine. All routine is meant to be predictable. But the routine of a hospital is predictable so that it may deal with the unpredictable. It gears itself to an emergency, not by a flurry of improvisation, but by still following the rules.
We are too suspicious these days of routine, thinking that if we are treated uniformly it must be impersonally, that we have been reduced to mere units. It is important to see how in a vast organization it is the routine which makes possible any individual attention at all. It is often not the routine of a bureaucracy of which we should complain, but the lack of routine which enables it to change step in an orderly way.
A patient's bed in a good hospital today is like the bridge of an ocean liner, with the battery of equipment and sockets and dials. When one presses one's button, one knows that the ship will respond.
An inefficient bureaucracy must depend on the exceptional willingness of some member of its staff; the routine of a hospital makes one member of its staff as dependably willing as the other. Whenever I felt the need of some attention in the hospital, I knew that it would come and come promptly, not because one nurse or doctor was unusually caring, but because the routine enables them all to be caring.
It may be said that I was fortunate to be in a good teaching hospital in Washington. When I was praising the nurses, one of the doctors said as much. I should go and look at some of the other hospitals in the area (he mentioned two by name). At first one thinks that this means only that the funds available for hospital care are inadequate and unevenly distributed. But it is more difficult than that.
As one who has an egalitarian impulse in my blood, I often sadly wonder if there is not a limit to providing a good education to all, simply because there are not many potentially good teachers to be found. How many good doctors and nurses are undiscovered?
As I watched them in Georgetown University Hospital, much of their efficiency and ability and willingness to care was obviously due to their training, but all of them also seemed to be moved by a spark of their own. The nurses could all have been highly paid receptionists in a lawyer's office, but it was not just imagination to detect in them also a sense of calling. Are there all that many who have it?
A thought slid through my mind. The nurses are still called nurses. They have not asked to be known as medical assistants. Their pride is in what they do. They nurse. They do not need a fancy name.
Then the doctors, the old and the young. We read so much these days of malpractice and misconduct and mismanagement that we forget the skill and dedication of most of the physicians and surgeons in a hospital. There may be doctors who deserve our criticisms, especially among those in private practice. But not here, by and large, not in the hospital. At least not in this hospital.
With what infinite patience they explain one's illness, trying to gain the cooperation of the patient, without which even their skills cannot do their good. They seem to have all the time in the world, until they scurry to the next patient.
One can measure the depth of concern in what they do by the admiration with which the young doctors talk of the skill and involvement of some of their elders. The head of the department of cardiology at Georgetown, Dr. Proctor Harvey, was described to me as one of the deans of cardiology in America. The man is a born teacher. He cannot stop teaching. cHe talked to me as if I were a pupil. His actual pupils talk of him with affectionate awe.
On Thursday evenings he conducts a siminar for all the cardiologists in the area, so that they may present and discuss any interesting new case. Late on a Thursday evening after a full day in hospital, 90 cardiologists gather in an auditorium to discuss and learn.
I am used to cardiologists jumping with excitement when they listen to my heart. Aha! what a specimen. I always have to put up with a trail of students who come to examine me. At one moment I rebelled. One of the young doctors whom I had already marked down as officiously no good asked to take a rectal examination at 8:30 p.m. "Why are you the only doctor," I asked, "who wants to take a rectal examination at 8:30?" He suggested that I should do the thing myself and I never saw him again.
But Dr. Harvey was teaching and most of the students were practicing what I had first observed in a great cardiologist in London. "Use your fingers and your ears; and use also your eyes," he added. "You can learn a lot just by looking," and he pointed out some irregular movement in my neck. For all the machines now available, it is the fingers which as a patient I trust.
You can go through the extraordinary operation of a cardiac catheterization, when they feed wires into one's arteries in one's groin, and then one can eerily watch them fish about one's heart. But the next morning it is most reassuring to feel the fingers again, and it is with a final use of the fingers and ears that one is sent home. In the hospital at least, man is still in charge of his machines.
It is no wonder that Plato so often takes medicine as the example of an education in something like an art, and again I wondered how many there are who could benefit from and then use the training in such skills.
It is also no wonder that hospital care is expensive. The machines are massive and numerous and costly, but they are not frills, and it is not they which are the main source of the expense. We are paying for the individual attention of skills which are the result of not only a complicated but a lifelong training, just as the established cardiologists still give up a Thursday evening to go on educating themselves. We are paying for a training more elaborate than that of lawyers, yet complain more of health than of legal costs.
The only way to bring down the costs of health care is for us to use our hospitals more intelligently. There are malingerers among the patients in a hospital, and costly they are, but they are not as costly as our own expectations of a hospital.
If we were satisfied with the real but limited benefits of healing, and did not expect to be made whole and rejuvenated, we would significantly reduce the costs of health care in a trice. It is our own attitudes to health and ill health that need revising. The more advances there are in medical science, the more superstitious we get of what it should do, for we really do expect miracles of it.
When one is lying under one of those great machines, it brings one down with a bump to look at the names of the manufacturers, such domesticated names as General Electric and Sanyo, and think of how one's dishwasher and television set work at home. One stops expecting a miracle.
As I watched it seemed that much of what we now expect of our medicine is really no more than cosmetic. We are not only to be made well, we are to be made beautiful and even young.
Yet the good American hospitals, if they are allowed to attend to their proper business, are themselves enough of a miracle. When I was mentioning my experiences to one of the most independent-minded of former senators in Washington, he said at once that "we must not do anything to damage our hospitals." He then muttered that he did not know what could be done about costs, but my experiences suggest that we could say more often, "Patient, heal yourself."
When one of the doctors showed an unusual impatience with one of the malingerers, he said, "We need the beds for those who are waiting to come in with heart attacks and strokes." And indeed each bed is filled as soon as it is emptied; it is we ourselves who could help to empty them.