Five Patients

Five Patients Page 15

That same day, a radioactive liver scan was done to determine the size of the liver, since it could not be felt directly. The liver was found to be small and shrunken, suggestive of scarring from cirrhosis. The basis for this cirrhosis was unclear. Mrs. Murphy maintained that she was a non-drinker. She had no history of hepatitis in the past, and no occupational exposure to liver poisons. The cirrhosis was therefore labeled "cryptogenic," meaning of hidden cause.

For the next three days the question of cancer, or liver disease, or both, was widely discussed. As evidence of liver damage accumulated, cryptogenic [To an outsider, the tendency among physicians to call certain diseases cryptogenic or idiopathic-and then to discuss them as if they were well-defined, understood clinical entities-may be perplexing. But in fact it serves a purpose. For one thing, it excludes diagnoses: anyone who speaks of cryptogenic cirrhosis has excluded alcoholic or post-hepatitic cirrhosis. By implication, the term conveys more information than a simple "We don't know why." In the same way, idiopathic hypertension implies prior exclusion of the few known causes of this condition] cirrhosis became the favored diagnostic possibility.

Meanwhile, Mrs. Murphy began to feel better. She received a transfusion of three units of blood, and felt better still. She did not, however, receive any further therapy.

Everyone agreed that a liver biopsy would be useful, but the patient had a bleeding tendency- presumably secondary to liver disease-which made a biopsy impossible. Other diagnostic procedures were not helpful. Sigmoidoscopy and barium enema failed to determine the origin of gastrointestinal bleeding. A check for cancer cells in her abdominal fluid was negative.

On the seventh hospital day, she was seen by Dr. Alexander Leaf, who suggested thyroid tests as well as tests for collagen diseases. The following day, Dr. Nienhuis raised the question of whether this patient might have lupoid hepatitis, a rare and somewhat disputed clinical entity.

In the next forty-eight hours, two important pieces of evidence were obtained. First, an upper GI series was done, and it was normal. There was no sign of cancer of the pancreas.

Second, a re-examination of the patient's white cells revealed several with large, abnormal, bluish lumps imbedded within the cell substance. These cells are called LE cells, for they are virtually diagnostic of a collagen disease, systemic lupus erythematosus.

This is a disease of enormous interest to physicians at the present time. Once considered rare, it is now seen with increasing frequency as diagnostic tests become more refined. Classically it has been considered a disease of middle-aged women, characterized by protein manifestations-fever, skin eruptions, and involvement of many other organs, particularly joints and kidneys. However, as lupus is better understood, the classical description is changing: more males are now found with SLE, and the range of clinical manifestations has broadened.

Lupus is called a collagen disease because it shares with certain other diseases a tendency to alter blood vessels and connective tissue, and because it seems, like these other diseases, to be caused by some form of hypersensitivity (allergy). This question of causation is by no means clear, but patients with the disease certainly show a wide variety of biochemical disorders of the immune system; lupus is frequently called "the autoimmune disease par excellence."

Normally, the body's immune mechanism produces antibodies to fight agents, such as invading bacteria. This response is generally beneficial to the individual, although much recent work has gone into suppressing the response so that foreign organs can be transplanted.

However, it is now recognized that the body's natural rejection mechanism can sometimes be mistakenly directed toward the body itself. In some way the individual's capacity to distinguish what is native from what is foreign is disrupted; the patient attempts to produce immunity to himself-and proceeds to attack certain of his own tissues, leading to "a chronic civil war within the body."

In the case of lupus, the patient produces several sorts of antibodies against himself. One of these attacks DNA, the genetic substance of chromosomes. This damaged DNA is later ingested by white cells, producing the characteristic bluish lumps. However, SLE patients also produce other auto-antibodies, which are seen in other conditions. Thus Mrs. Murphy was found to have anti-DNA antibodies, increased gamma globulin, and antibodies against thyroid, as well as antibodies found in rheumatoid arthritis.

Immune disorders as a cause or complication of illness are now suspected for a great range of diseases, including rheumatic fever, pernicious anemia, myasthenia gravis, multiple sclerosis, Hashimoto's thryoiditis, and glomerulonephritis. Immune and auto-immune mechanisms are thus of considerable interest; investigation of these mechanisms represents one of the major thrusts of current medical research.

For systemic lupus erythematosus, however, there is no cure and no good information on prognosis. Patients have died within a few months of onset; others have lived fifteen or twenty years. For Mrs. Murphy, therapy consisted of diuretics, which resulted in loss of thirty-two pounds of fluid, and a cautious trial of corticosteroids to suppress some effects of the disease. She was discharged feeling well and returned to her job.

The case of Mrs. Murphy illustrates an important function of the ward patient in the university hospital that differentiates him from the private patient: the ward patient is there in part to help turn students into doctors. For the patient, this has its drawbacks as well as its advantages.

First, to clarify some terms:

A medical student is anyone with a bachelor's degree who is in the midst of four years of graduate work leading to the M.D. degree, but not yet to a license to practice. To be licensed, he must spend an additional year as an intern in a teaching hospital.

An intern is thus anyone with an M.D. who is in his first year out of medical school. An intern is licensed to practice only within the hospital. After a year of internship, he could theoretically leave and begin private practice, but practically nobody does. Instead, interns go on to become residents.

A resident is anyone who has finished his internship and is continuing with more specialized training in such areas as pediatrics, surgery, internal medicine, or psychiatry. A residency may be taken at the same hospital as the internship or at another; residencies last from two to six years, depending on the field.

Medical students are primarily responsible to the medical school, not the hospital; within the hospital they are referred to, somewhat ironically, as "studs."

Interns and residents, on the other hand, are hospital employees and are referred to as "house officers." Collectively the interns and residents comprise the "house staff," as distinct from the "senior staff," meaning the private physicians or academic teachers affiliated with the hospital.

This hierarchy is analogous to a university with its undergraduates, graduate students, and professors. There are departments within the hospital corresponding to university departments; these departments give courses for medical students and house officers, termed "rotations." Primarily, the teaching is informal, but there is also a heavy schedule of formal rounds, lectures, and seminars.

In the history of the teaching hospital, as in the university, the undergraduate (or medical student) appeared much earlier than the graduate student (or house officer). Indeed, the beginnings of the teaching hospitals are closely associated with the beginnings of medical schools in this country. This was clearly the case for the first three medical schools, and the first three teaching hospitals in America: in Philadelphia, New York, and Boston.

The Massachusetts General had Harvard students on the wards from its inception. There is no reason to believe the students made the hospital more appealing; Warren recalled that students in his day "were of the crudest character," and remembers that it was no recommendation to a landlady to say you were a medical student. Even a century later, Harvey Gushing grumbled that "students in a hospital, like children in a lodging house, are not an unmixed blessing." But despite persistent reservations, the teaching hospital has always taught medical students. What is new is the teaching of house officers.

Originally, medical students were required to take two years of academic courses, followed by a third year as an apprentice to a practicing physician. In those days the MGH had two house-officer positions-then known by the considerably more humble term "house pupils"-and these posts were acceptable substitutes for an apprenticeship. Beginning around the time of the Civil War, however, the hospital began to expand its house-officer posts; the greatest growth came at the turn of the century. In 1891, there were seven house officers; by 1901, fourteen; by 1911, twenty-one. As mentioned, there are now 304.

Part of this growth represents a simple growth of the hospital. As it became larger, there were more patients to care for, and to learn from, and more day-to-day work to be done by house officers.

Part of the growth represents the increasing role of the hospital as an acute-care facility. The hospital sees fewer patients with chronic diseases and more acutely ill patients who require continuous and careful management. This requires a larger house staff.

Partly, too, the growth represents a shift away from the old personal apprentice system toward an "institutional apprenticeship." In the 1930's and 1940's, it became clear that house officers who remained in the hospital were better trained than those who left early and linked up with private practitioners. This observation finally led to virtual abandonment of the personal apprenticeship. Thus, formerly, surgical residency was three years, followed by two years of apprenticeship under a private man; now it is five years (including internship), and the only reason for joining a private surgeon at the end of that time is to build a practice, not to gain more experience.

All this means that the structure of patient care is quite different today from what it was when the hospital first opened. In 1821, patient care was essentially in the hands of private, senior men who donated their time to the hospital and agreed to take students around with them on the wards. But between student and senior man there has sprung up a large body of individuals who are now essential to the functioning of the hospital. The MGH could cheerfully dispense with its medical students, but it would come to a grinding halt in a few hours if deprived of its house staff.

It is no exaggeration to say that the house staff runs large areas of the hospital, with senior men advising from above, and students looking on from below. One may applaud this system for providing a spectrum of competence and responsibility, allowing students to move up the ladder to internship, then junior and senior residency, in easy stages. But in fact the emergence and proliferation of house officers has another, much harsher rationale. For the hospital, they provide a source of trained, intelligent, hard-working, very cheap labor.

This has always been true. In 1896, when Gushing was an intern, he noted that "house officers are about as hard worked men as I have ever seen. Every day is twenty-four hours long for them with a vengeance."

The modern house officer generally works an "every other night" schedule, meaning roughly thirty-six hours on duty, and twelve off. In practice this means arriving at the hospital at six thirty or seven in the morning, working all day and probably most of the night, continuing through the following day until late afternoon, and then going home to sleep-until six thirty or seven the next day. Payment for this effort, which is sustained over many years, was until quite recently nonexistent. Some hospitals were so bad that they worked their house officers at this pace, paid them nothing, and charged them for laundry and parking.

Others would provide a few meals, and perhaps an honorarium fee of twenty-five dollars a year. At the MGH, a senior man recalls that as recently as ten years ago, "I was chief resident in surgery, eight years out of medical school, having spent two years in the army; I had a wife and four children; I was responsible for the conduct of an entire surgical service-and I was paid just under two thousand dollars a year."

Such a situation requires either an independent income or a great tolerance for debt; one wonders whether the modern stereotype of the private physician as crassly avaricious can be traced back to these years of early, absurd financial hardship. Fortunately, the salaries of house officers have climbed sharply in recent years. In many hospitals an intern now receives six thousand dollars, a senior resident eight or nine. Many factors are responsible for the increase: the effect of Medicare, which permits the hospital to charge patients for the services of a resident; the fact that the G.I. bill has been extended to cover residency training; the realization among medical educators that you cannot get and keep good people in an affluent society without paying them.

As the house officers have become more numerous and more skilled, the position of the medical student has changed. House officers are licensed to practice medicine; students cannot practice by law. A student cannot write orders, even for something as simple as raising a patient's bed, without having them countersigned by a house officer.

Legally, a student is permitted to employ nothing other than diagnostic instruments, and then only for the purpose of diagnosis. In practice, this ruling is stretched to mean that a student can, under supervision, perform a lumbar puncture, a thoracic or abdominal tap, or a bone-marrow aspirate; he can suture wounds in the emergency ward; he can also mix medicines, start intravenous infusions, inject medicines intravenously, and give a blood transfusion. Additionally, he is expected to have competence in a variety of laboratory procedures and tests.

The medical student's officially sanctioned functions thus lie somewhere between those of a doctor, a nurse, and a laboratory technician. It is not surprising that no one knows what to call him. Instructors with a group of second- or third-year students will often introduce them to patients as "doctors in training" or "these young doctors." Fourth-year students, seeing patients alone, will introduce themselves as "doctor." Until a few years ago, the students even wore name tags which said