Faculty Bibliography

President Bill Clinton's plan separates doctors only by specialty. It makes no allowance for a doctor's experience or motivation. A great many of us still see ourselves as healers, driven by compassion and altruism rather than greed. Yet the president's plan will punish the doctors who are not now overpaid. Is a patient justified in resenting a doctor for profiting for his or her dependency? Contrary to popular belief, most of us are not golf-playing land barons. The question is: Will I be able to maintain the same interest under the proposed system of government curtailment and control? And will reducing my income somehow cure the problem? Patient A is an AIDS patient who lost his medical insurance three years ago when he was deemed 'high risk' by his insurance carrier. I continued to treat him without charge, although he was a difficult and abusive patient. After countless narrow escapes with death, Patient A has now developed a regard for me that is matched only by the gratification I feel at taking care of him. He has also acquired Medicaid, which means that I can charge him a whopping $7 a visit if I choose to do the paperwork. Under the proposed new system of health care, Patient A may no longer be able to choose me for his doctor at all

For example, Patient A was on a respirator in my hospital's Intensive Care Unit for many weeks. She suffered from severe emphysema and pneumonia, yet she wrote frequent notes of her desire to resume playing poker. The pulmonary consultant believed that one day she would be able to do it. Meanwhile, I was prevailed upon by fiscal pressures to transfer her to a less aggressive institution and free up an ICU bed. Soon I learned that Patient A had died. I shudder to think that this sort of transfer will soon become a daily occurrence. Patient A's poker bluffs may not be reducible to the terms of managed care. A hasty conversion to universal health coverage may also dilute the quality of care without significantly improving the quality of a patient's life. Patient B was a jobless man who slept in a Manhattan alleyway and froze to the pavement in the middle of winter. I treated him in the emergency room of the local public hospital; when he woke up, the nurses brought him food. His old clothes were burned. He was given clean clothes and several sandwiches to take back to the street with him

With AIDS afflicting many patients no older than ourselves, many of us continue to cringe at every fever, unremitting cold or peculiar headache we experience. Recent surveys among house officers in New York and California have shown a significant concern about acquiring AIDS from patients, despite the fact that the actual risk appears to be small. Twenty-seven cases of conversion to HIV positive following a needle stick have been documented worldwide, with 19 of these in the United States, two of which have progressed to full-blown AIDS. The latest statistics from the Centers for Disease Control suggest a conversion rate to HIV positive of 0.4 percent (1 out of 250) for every stick from a needle known to be contaminated with AIDS blood. Other factors, such as depth of the needle stick, have yet to be studied

I WAS STANDING in the middle of the big room, watching the paramedics bring in another patient on a stretcher. Like so many other trauma victims, survivors of motor vehicle accidents, this one was taped to a board, her neck in a hard collar to protect her spine. Her body was powerless against the confinement imposed by the heavy tape. As with all the others, I could see the panic in her eyes. But there was one difference: On the stretcher beside her lay a [Stephen King] novel. The poor trauma patient hadn't seen any of this; the apparatus of her confinement held her gaze to the ceiling. As I began to examine her for signs of injury, I couldn't resist questioning her about the apparent theft. Her face was so taped up she could barely speak, but her eyes showed surprise. Illustration by Brad Hamann-Cover of Stephen King book `ER'

One such gentleman was Appleby, a huge blonde man with a scraggly beard, who would sit, self-contained at his post, quiet and smiling, until his name was called. Instead of just 'Hospital Police to the big room,' it would be 'Appleby to the big room.' And there he would come upon a howling junkie rising up off his stretcher, about to assault one of the nurses. With a sudden move of scarcely any effort, Appleby would flick his giant shoulders, and the patient would be flat on his back, docile. [Louden] wasn't the physical specimen that Appleby was, but he was a strong man, and he had a certain look that made people back down rather than cross him. But Louden was also easy to talk to, a people's person, and there was a feeling there that he'd go to bat for you, if you ever needed him for anything. His range was such that one moment he'd be talking down a menacing patient who was screaming obscenities at a doctor, and the next moment he'd be stooped over, walking a lost old lady laden with shopping bags to the information desk

In the relatively short time I've been a doctor, I've wondered countless times about the ideal approach to a patient. Some want to be told everything, some don't. Some appreciate a breezy professorial manner and appear to gain confidence from it. Others look for directness and take it for as a sure sign of empathy. But there are no hard and fast rules. Truly humane physicians may appear aloof, and there are jocular, kibbitzing ones who couldn't care less. Assuming a role as a patient is, for many, very difficult. For others it is a respite from the cares and concerns of daily living. I am reminded of the husband of a woman I was seeing for a mild case of nausea. He came to my attention because he was asking the nurses for nitroglycerin for his chest pain. When I approached him, he insisted he was all right - he couldn't afford to be sick, he had to look after his wife. It took pointing out to him repeatedly that he would be useless to her unless he himself was okay before he would agree to even an electrocardiogram. But as soon as he donned a hospital gown a transformation occured; he became docile and gave himself over completely to my care

One night in the emergency room, there was a psychotic patient with a split lip. The psychiatrists were up in arms because the surgical resident on duty had sent him their way without stitching him up. But the surgeon said he wasn't about to risk life and limb trying to sew a moving target, and besides, the guy didn't want it. The psychiatrists replied that the patient's judgment was impaired - he was more worried about an imaginary eye problem than anything else. The surgeon insisted that the lip problem was minor, but the psychiatrists insisted it be treated. Weeks later, the same internist was seeing a different patient for a routine conjunctivitis, and the ophthalmologist on duty recommended eyedrops the internist was not familiar with, known as 'Sulf-10,' or 'Bleph-10.' Mumbled through a swollen lip, 'Bleph-10' had been 'Bluff ten,' or so it had seemed to a beleaguered internist one night in the emergency room

''The guy's a jerk,'' he said. ''I told him what it was like here. I told him to go to a hospital in Brooklyn where he lives. Instead, he puts himself in a taxicab, chest pain and all, and drives all the way into Manhattan.'' I confronted the patient on the middle stretcher. ''What are you so damned happy about?'' I asked him. ''Traveling all the way to this madhouse from Brooklyn with a heart problem?'' The patient paused and gave me a knowing look. ''What are you talking about?'' he said. ''You think this place is something? You should see what the hospitals in Brooklyn look like.''

I WAS CROSSING First Avenue at 58th Street one drizzly evening when I saw a man lying flat on his back. I decided I should do something, so I bent down over him. I called out, but he didn't respond. I felt for his pulse - it was strong - it was regular. I saw that he was breathing, his wet lips hidden beneath the fur of a ragged beard. Droplets of rain or sweat were suspended there. The stethoscope was in my hands. I knelt close to the body and felt for his chest. The crowd seemed to move with me. Listening for a heartbeat, the stethoscope was the lifeline. And all at once he came to life, coughing and howling and pounding at the pavement, swearing in his delirium, as the crowd took a panicked step backward. The sounds, amplified through my stethoscope, nearly deafened me. To look at him was to see a snarling drunk, with tattered coat and wretched woolen pants, and an unknown assortment of holey sweaters. He smelled as if he'd been drinking for days. Still, he'd complained of chest pain and then fallen to the pavement. It was his heart I was concerned about

Marc K. Siegel reviews 'In Sickness and in Wealth: American Hospitals in the Twentieth Century,' by Rosemary Stevens