In the fall of 1980, in my final year of medical school, I sat in the main ward of Saint Vincent’s Hospital, Greenwich Village, Manhattan. Filling the vast space were twenty-four beds, in four rows, with twenty-four patients. The prow of the open nursing station thrust from one wall into the center. A high ceiling vanished above. Yellow light filtered through ancient rippled glass windows and distant fluorescent bulbs made skin colors strange.
To sit at the station was to survey the sight, sound, and smell of human suffering. Cancer, heart failure, mysterious infection, stroke, and just plain old, displayed in a zoo of disease. If you understood this room, you understood medicine.
I was shaking. My senior resident had just berated me for deserting Mr. Cooper, a 67-year-old bus driver with advanced cancer and pneumonia. There was a shortage of a critical antibiotic; it looked like we would run out. Therefore, I had stopped Mr. Cooper’s medicine “too soon.” I was concerned that if we ran out, then we would have nothing to treat the next “Mr. Cooper” who crawled into that ghastly room.
The resident had not concealed his contempt.
“Mr. Salwitz. Mr. Cooper is your patient. When you see Mr. Cooper, he is your only patient. If you are going to be a doctor … and I do mean if, then you will care only for that patient … that one patient in front of you. You will give medical care, one patient at a time. It is not your place to worry about the next patient, or the patient down the hall, or the patient in another hospital. It is not ethical, it is not moral, and it is not your job to worry about cost or shortages. That is the job of society. Of politicians! Your job … your only job, is to fight, with everything, for that one patient!”
So it was, and so it had been for thousands of years. A physician’s duty was to that one person, that one relationship, before him at that moment. The patient depended on the doctor to be the absolute warrior for their cause. No dedicated doctor worried about the other guy. Like an attorney, like a father, like a general in war, the doctor had only one “client,” one “cause” and that was one patient at a time.
The beauty of this argument, this belief, this calling, is that each patient has an absolute health ombudsman. In theory, it should work, not only for that one patient, but if every doctor across the country advocates for many “one patients,” it should create a balanced competitive environment, which ideally distributes resources. Free market medicine. The reality is that such a system, carried out across a nation, across the world for that matter, concentrates vital medicines in the hands of a loud few, gives the best care to those that shout, has the affect of emphasizing individual monetary gain, accelerates cost, and, most importantly, removes doctors from careful and compassionate discussion of how to distribute vital, but limited resources.
Therefore, ethics and reality are changing. The senior resident, who berated me 35 years ago for compromising care, looks at those 24 patients as a physician leader, and knows she is steward of all. Today, I might be castigated for giving the last of a vial of antibiotic to a man dying of cancer, and sentencing the next patient to greater suffering and perhaps death.
Physicians are beginning to understand about that there is a need to shift some of their focus of care from the one to all. When the United States spends 18 percent of GDP on health care and half of American families destitute themselves paying for medical treatment, it is not just a problem for the medical profession, but their fault. Therefore, we must balance, some would say ration, by true need, true availability, and maximum benefit. Build efficient systems. The best care for the many is the best care for the one.
The paradox is that there are no more wards. We do not see large groups of patients in one room, as a group, sort of natural population medicine. Now, the rooms are single. We jealously protect the health privacy of each patient. We talk about personalized and precision medicine responding to the needs of the individual. The patient is more private, but the doctor must see each in the context of a complex public world.
Medical students are beginning to learn that they will not practice in isolation, but that they are part of a great societal effort to improve health. Experienced physicians worry that this change, this sharp intrusion into the medical relationship and health care ethics, threatens each patient. Are we deserting our basic obligation as healers? Will the youngest clinicians come to believe that they serve not Hippocrates, but their employers, data metrics, and centralized care systems? Will the cheery insurance precertification phone line voice, be the only patient champion?
The best defender, the ultimate warrior for each patient, must be their physician. This healer understands not only illness, but the context of a patient’s life. The doctor knows how disease will change each patient and which treatment the patient will understand, tolerate and accept. This must remain a physician’s ultimate calling.
However, it is critical that doctors accept that the individual care they give affects the many, and that the resources expended to treat the many, affect the one. A broader view of real world health economics, a financial altruism, is required. Physicians must never again retreat into silos and allow any other part of our society, no matter how well intended, to make massive resource decisions without the professional medical voice. Part of being a doctor must be involvement at every level of government, finance, industry, and health leadership. We must have a commitment to the systems and institutions upon which health care is built.
Physicians have one patient to whom they must commit their lives, careers, and souls. That patient is us.
James C. Salwitz is an oncologist who blogs at Sunrise Rounds.
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