A hospital is a place where a sick individual and their loved ones are taken in and shoved up against a group of strangers – clinicians – with whom they develop a relationship which is hugely intimate and has difficulties on both sides.
Most of the patients now entering hospitals suffer from more than one physical problem; they are older, and have complex social circumstances that need to be addressed. A patient may have pneumonia that has stressed their heart, which has in turn affected their kidney and liver function. Many suffer delirium as a consequence of infection or pain, or simply from being moved from their usual surrounds. The ravages caused by life-long diabetes are starting to manifest. Diligently taking ten different prescribed medications has made them very sick. Their ability to cope at home is a precariously balanced tower of circumstance and luck.
What happens when these patients present to an emergency department? Who grants them entry to the institution and decides which bed, which ward, they end up in and which doctors will care for them? It may surprise you to hear that when your mother or your grandfather presents to a hospital, his or her arrival may set off a turf war. Doctors won’t fight to take care of him; they’ll fight not to.
In the last half of the twentieth century, as these “multi-morbid” patients became more common, medicine at the hospital level became more specialised. Cardiologists, respiratory physicians, neurologists, nephrologists and endocrinologists gradually replaced the generalist physician. Each organ had its expert, and if you came to hospital with a problem in that organ, its expert would welcome you. This specialisation contributed greatly to our knowledge of the workings of the human body, and to our knowledge of disease; it led to medical marvels such as organ transplantation. Greater knowledge, technology and expertise brought with it the super-specialists: cardiologists who only treat heart failure, or arrhythmias, or only do angiograms, or only treat patients with heart transplants. And if you have an otherwise robust body with an arrhythmic heart or you need a transplant, you should be glad the experts exist. If you come to hospital with florid thyrotoxicosis, you’ll be fine: an endocrinologist will look after your thyroid gland with punctilious attention.
But what if you come with two or three or four organs failing, and can no longer negotiate your stairs to go and buy food? What if your disease won’t fit into a fragment? Who will be your doctor?
Hospitals had become the institutions of a utopian world where medicine had the cure for every ill, for a human being split into organs that would fail in an organised fashion. The old general physicians, the in-hospital specialists who would treat the multi-organ failures, the decrepit and the mysterious, had been rendered obsolete. At the same time, the geriatricians – specialists in the care of the elderly – did not as a rule work in acute hospital units. They would consult on problems such as frequent falls and dementia, and run outpatient clinics and rehabilitation facilities, but they were rarely on the wards.
In 1997, from an English department in Melbourne, I applied to medical school at the University of Newcastle. I didn’t even know where Newcastle was, but I had heard they accepted arts students and taught them all the science they needed to become doctors. At the time, I wanted to be a doctor so I could become a Freudian psychoanalyst. To my great shock, they let me in.
In medical school I changed my allegiance from Freud to Oliver Sacks. I planned to be a neurologist and see all the patients who mistook their wives for hats. I knew a few general physicians. To my great shock, they were old guys; they could smell ketones and hear a heart’s gallop rhythm from the doorway. I remember one, mid-ward-round, swooping down to pick up a piece of rubbish in the hospital corridor. He held it in front of us and said, “You should take care of the hospital. The hospital is your home.” They were old-school dedicated. You know the kind of guys: they hadn’t seen their kids for forty-five years. There were not many young general physicians. If anyone had suggested I’d end up doing general and acute medicine, I would have taken it as an insult. By then, you only did that specialty unwillingly – if you didn’t get in to any other sub-specialty, if your English wasn’t too good, or if you wanted to live in the deep bush. General medicine had a bad reputation: it lacked prestige and was considered a dumping ground for the elderly. And who’d want to look after them?
By the time of my residency, the old generalists had retired and many general medicine units filled rosters by cutting deals with specialists: participate in our general medicine roster and we’ll give you a 30 per cent infectious diseases appointment. Other hospitals made do with a “physician of last resort.” If you wound up in the emergency department short of breath and with failing kidneys, the renal and respiratory registrars would fight not to take you. The respiratory registrar would say that kidney failure was not a respiratory problem. The renal registrar would say shortness of breath was not a kidney problem. The extremely busy emergency department doctor would ring around, and when everyone rejected you, they’d refer you to the day’s rostered physician of last resort – the specialist who for that day was not allowed to say no. Meanwhile, you’d be languishing on an emergency department trolley for ten, twelve, twenty-four hours, waiting to be admitted to a ward. No one was in a hurry; after all, you weren’t dying right then, you weren’t crashing – you were just slowly crumbling.
The House of God is a satirical novel published in 1978 which continues to sell in the tens of thousands. It tells the story of Roy’s first year as a doctor in the House of God hospital. There, elderly patients are called “gomers,” an acronym for “get out of my emergency room.” Throughout a year of sleep deprivation and horror, Roy learns the rules of medicine. Rule number one: gomers don’t die. Given their immortality and slow recovery, one sure way of getting the gomer off your patient list was to crank their bed up till it hovered six feet off the ground. From that height, the gomer was sure to fall out and break a hip – and then they’d be the orthopaedic team’s problem and off your list.
In Australian hospitals, gomers are known as “crumbles” and “acopics” (not coping at home); they are “granny dumps” (popular during holiday seasons), “bed blockers” or “gen med specials.” As a registrar, you’d do anything to avoid accepting this kind of patient under your unit’s bed card. They had too many problems, were too difficult, probably required family meetings or even a social worker and, worst of all, didn’t have problems you could cure. We were all overworked and didn’t do medicine to deal with all of that; we did medicine to stick catheters and cameras in people’s organs, give drugs that dissolved a patient’s problem, perform complex transplants and make it onto the front page of the newspaper.
The House of God is both horror story and black comedy. It paints all the underlying frightfulness of practising medicine, all the unspoken assumptions and prejudices, in full colour. Some medical schools in Australia give copies of this book to their students as a graduation present.
Six years after finishing medical school, the terrible specialist medical exams behind me, and finally about to start my neurology training program, I admitted to myself that despite what Oliver Sacks had led me to believe, no one came to a hospital or clinic claiming they’d mistaken their wife for a hat. So I accepted a last-minute job as a trainee in nuclear medicine – interpreting fuzzy scans and injecting radioactive isotopes – but I missed talking with flesh-and-blood patients, regretted leaving the wards. And yet there was no organ system or disease I wanted to dedicate my life to.
My supervisor asked me, “Have you considered general medicine?”
I had not.
“Don’t do it!” an endocrinologist friend warned me. “No one will respect you.”
Why would caring for a ward full of patients with multiple problems deserve less respect than caring for a ward full of the freshly angiogrammed? I once posed this question to a sub-specialist and he said, “There’s less at stake.” I asked what he meant. He said, “If you fuck up, it’s not such a big deal … so I guess the thinking goes that a lesser physician can do the job.”
Half the patients in an acute care hospital are over the age of sixty-five. Study after study has shown that the frail elderly do better in wards dedicated to their care – wards with nurses and doctors and allied health practitioners who know how to care for them. The single most important aspect of care is to have clinicians who want to look after this cohort. Generalists, geriatricians, sub-specialists who’ve crossed to the dark side … it doesn’t matter who they are, as long as they have a desire to care for the elderly and feel there is a lot at stake. The frail elderly need clinicians who can look around a ward and see individuals, rather than a mass of cast-offs who’ve somehow snuck into an ivory tower for a bit of inappropriate, grudgingly given treatment.
I am lucky that I work in a well-funded general medical unit staffed by a group of dedicated, full-time general physicians, supported by a tight-knit team of committed nurses and allied health practitioners. I think we are thus able to offer above-average care to our patients, the old and the young. But I have worked in numerous hospitals across three states of Australia and know this to be uncommon. Many general medical units (where they exist) are overstretched, underfunded and caring for far too many patients with a skeleton staff.
One reason aged patients do poorly in hospital is that they become malnourished. They are too weak to eat, too debilitated to negotiate tiny plastic sealed packets of margarine and “fruit salad,” and have no one with the time or inclination to feed them. Everyone on every ward in Australia recognises that this is a major problem, but assisting patients to eat is no longer anyone’s job. “I didn’t go to university for four years to spoon-feed demented patients,” I once heard a nurse say. So who does feed our patients? Some hospitals have volunteers, some patients are lucky enough to have families to assist them – many of whom complain that no one is helping their loved one eat, that if they weren’t there, they’d starve. And often it’s true.
The elderly are inappropriately prescribed far too many drugs. If we follow international treatment guidelines for each disease in the average frail patient on my ward, they receive upwards of twelve drugs a day that need to be taken at five different times of day with the risk of at least ten serious adverse effects. Many elderly patients come to hospital with these kinds of medication regimens. Twenty to thirty per cent of all hospital admissions in those over the age of sixty-five are related to illness directly caused by their prescribed medications. Due to incomprehensible institutional requirements and service fragmentation, upon discharge back to a nursing home, patients have to continue their pre-hospital medications (sometimes the cause of their hospitalisation in the first place) until a GP visits the home, perhaps days later.
All general medical departments are under enormous pressure to treat and discharge patients as soon as possible. They have such a large number of patients that extending each patient’s stay by even a single day would cause emergency departments to choke up. However, elderly patients are complex and time is needed to offer them the care they need, to talk to them about their wishes, listen to their experiences of their illnesses, and together forge ways to make their lives bearable. Patients need properly trained nursing staff, quiet rooms with clocks and familiar items, family-friendly visiting hours, assistance with eating, and soothing touch. To do well, patients need to eat, move and remain mentally active in hospital – three things the hospital environment specifically hinders.
ALSO FROM QUARTERLY ESSAY