Public and Private
And sick and well.

Medicine Mensch 5 is below. Enjoy!

MEDICINE MENSCH: A Tale of Two Hospitals
By Zackary Sholem Berger
May 13, 2005

Fancy Private Hospital is conveniently located in Upper Manhattan, a few blocks away from a subway stop. If you like, though, you can stroll to the main building along Madison Avenue, perhaps stopping at some of the boutiques you'll find along the way. A few other students and I took such a relaxed trip to FPH for a recent rotation. On our first day we went to a well-appointed office in an embassylike building of white stone, with an interior decorated in brass and wood. We settled into plush chairs and waited for the administrator. When she arrived, she gave us all a big smile as she handed out our orientation packets. "Welcome to Fancy!" she said. She gave us each a sheaf of meal tickets ("Hold on to these. They're just like money!") and told us where the swimming pool was.

Needless to say, we all had had somewhat different formative experiences in Raucous Urban Hospital, another one of the health care facilities operated by my university. There you're not so much welcomed as acknowledged. The elevators don't work, efficiency is not rampant and budgets are tight — but all this has come to be expected by the people who work there. Otherwise, it wouldn't be raucous and probably wouldn't serve as much of the public.

Both Fancy and Raucous are teaching hospitals where medical students (not yet doctors) and residents (doctors at the beginning of their training) learn to perform procedures and make diagnoses on real patients — you and me and our relatives. Everyone would love to be treated by the expert in whatever malady she's currently suffering from, but there aren't enough experts to go around. So people are treated by teams, the long chains of white-coated big-and-little-fish the patient sees snaking into and out of the room. Although a couple of people in that big group are more responsible for what happens to the sick person, no single person carries out all of a given patient's care over the course of a month.

That is, once in a hospital, every sick person realizes that he or she is one of dozens treated by a team of interlocking personalities. The patients at Fancy Private and Raucous Urban deal with this realization in ways that are superficially different. Some at Fancy Private, used to the best in everything in other areas of their lives (or merely the upper-middle-class certainty that they will be properly accommodated — be it at the hairdresser's, their favorite boutique or their local restaurant), will insist that they be treated only by their personal physician or at least an attending physician — no residents for them. Little does the patient know that when the attending physician gets word of this request, she'll probably roll her eyes, pick up the phone and have a good laugh about it with one of the residents, the ones she relies on to carry out the day-to-day work of patient care in a hospital with hundreds upon hundreds of patients. The Raucous Urbanites, on the other hand, tend to address everyone on the team — from lowly medical student to seasoned attending physician — as "Doctor," and impute to each of them the same level of training and responsibility. According to strict accuracy and ethical practice, the medical student should remind his patient that he is not, after all, a doctor. But how many times can you remind someone of this, especially when it's eminently possible that the person doesn't want to be reminded?

Public and private patients have something very basic in common: the wish to know who's treating them and the illusion that they have detailed control over their daily care. Of course they have control over the general decisions relating to their medical treatment: Informed consent is one of the pillars of current medical practice. (How "informed" this consent really is, however, is another matter entirely.) But once the patient makes a decision about medical care, then the team takes over, general decisions are transmuted into professional jargon like liters of lactated Ringer's solution, and a view of the forest is lost as trees are thickly planted at the patient's bedside.

That's why I try to introduce myself to every patient and have something approaching a conversation so that the patients at least have some personal contact with someone on their team, even if it's only the most insignificant and least important member. The Raucous Urban patients get my best doctor imitation, while the Fancy Private patients, if necessary, get my solemn oath that I won't go near their bed. Both of these behaviors are not quite in good faith, but they make everyone involved feel better. Perhaps one day I'll have all the public patients up to Fancy Private for lunch so that I can use up my leftover meal tickets.

Zackary Sholem Berger is a medical student at both public and private hospitals, depending on his rotation. He is doing surgery now, but don't worry — he won't be operating on anyone anytime soon.