My father's friend was Sy Axelrod. Sy
was a doctor like my Dad. Their third doctor friend was George
Silver, and all three were Lefties from Philadelphia who trained in
the 30's and 40's when the most basic ideologies had yet to be
settled. Sy established the University of Michigan School of Public
Health and the field they called “medical care,” to distinguish
it from things like sanitation and epidemiology. “Medical care”
was about the organization of medical care services. Most of the
Medical Careniks wanted socialization of medical care, but they never
got that far. As far as they could get was prepaid care, which
became HMOs, which entailed large organizations instead of small
offices.
Sy had a bracelet he wore, which said,
“In case of illness, take me to the nearest teaching hospital.”
That was the best way he thought one could deal with the variation of
health care quality one finds in the field. Or, as my father used to
say, “Every family needs at least one doctor in each generation, to
protect them from all the bad care out there.”
Sy was a good Dean; he looked out for
his professors and his students. He had a sense of mission, and he
realized that the products that he sent forth would be his legacy.
One of his professors was Avedis Donabedian, who devoted himself to
the issue of quality of care; no one had done much on this until
Donabedian. I remember Sy saying, “He's got his handle on this
now; he finally understands it.” It was Donabedian who
distinguished three levels of quality ascertainment: structure,
process, and outcome. Without the structure – like properly
trained clinicians – you were unlikely to produce good medical
care; without good processes – doing a strep test before you decide
whether or not to treat – you were unlikely to be producing good
results; but of course the ultimate value of care was in the outcome,
but that was very hard to measure.
They believed that the pinnacle of
excellent medical care was at the great teaching hospitals; for them,
it was the University of Michigan University Hospital. They had all
the structural elements necessary to produce great care. Their
professors were excellent and did great research. They were
intelligent people who could discuss concepts and who agreed with
Donabedian's concepts of quality. The house staff were highly
selected and motivated. Everything was in place at the University of
Michigan.
Then Donabedian got sick. I forget
what his affliction was, but he was cared for at, naturally, the
University of Michigan. What he found there as a patient was a
disaster. Every element of process quality that he defined was
violated. Coordination? Forget it. Continuity? Non-existent.
Etc. He and Sy were vexed and bemused, but it was too late in their
careers to think much more about it.
My Dad, on the other hand, had left the
University of Pennsylvania setting early in his career, unhappily so.
He was told that there was no room there for a Jew, and he found his
place elsewhere in Philadelphia, getting his revenge by living well,
and getting research grants and heading a teaching program
independently. He bacame a world-renowned neurosurgeon with an
attitude problem. Like, he thought all the NIH grants went to
friends of the reviewers, although my Dad got his share.
Nonetheless, he was right, there is a problem of safety-first with
peer-reviewed grants. He also got his revenge by having a CT scanner
before the less-nimble University got theirs, and giving them middle
of the night appointments.
One time, my Dad was brought in as
visiting professor in neurosurgery at the Cleveland Clinic for a
week. He came back and said, “That's where you should go if you
get sick!” Their secret? “They don't have any residents!”
All they did was focused on patient care; that was their proclaimed
goal, not the traditional three-legged academic medicine stool of
teaching, research, and (lastly) patient care. As a clinician, my
Dad's opinion differed from Sy's. My Dad got his coronary bypass
operation at the Episcopal Hospital where he had led the staff for
years, and got his atrial ablation at the Lankenau Hospital outside
Philadelphia, and his aortic valve fixed there as well. His final
caretaking institution was the long term care unit right in his
retirement home. No academia for my Dad.
My Dad was a sensitive and
argumentative sort, and very much the neurosurgeon. Sy on the other
hand, had pride in his academics. Sy thought my Dad didn't
understand all the relevant points, and my Dad wasn't going to take
any shit from an academic. They parted ways in acrimony. It was
really a shame; the three couples, the Axelrods, the Shenkins, and
the Silvers, had spent many good times together, and it just ended
like that. Dad said how can you take my views so unseriously and
disrespect me, and Sy said if you're going to say mean things, how
can we be friends. It ended.
Now, years later and here on the West
Coast, you would think the medical care issues would be different,
but they're not. My wife's ex-husband Bruce, the father of my
step-children and the grandfather of Lola, a very nice man who has
been an attentive father and grandfather and a thoughtful ex-husband,
unfortunately has esophageal cancer. After local oncologic treatment
he had his surgical excision at UCSF in an eight hour procedure. I
have no doubt that the surgery was excellent, but five out of ten
nodes were positive for cancer, and there was local invasion. Such a
disappointment.
He went home and lost weight, and then
after a few weeks started retching uncontrollably. He went for care
back to UCSF and got … a resident, wouldn't you know. A pompous
resident. A resident who didn't see why he had to be admitted; after
all, it wasn't something that needed an operation right away, I guess
he thought. A resident who while he talked turned away from Sara,
Bruce's daughter, who is the physician for this generation of the
family. It was hard to contact the attending physicians who had
operated on Bruce; they were signed out to the residents.
But Bruce was eventually admitted,
after spending an interminable time in the dark interior holding area
next to the ER, with curtains separating four patients, the others
having to listen to Bruce's retching. After two days, on Friday no
one rounded on him. Sara discovered by looking at the chart that his
sodium was down to 130, too low. She tried to contact the residents
who were taking care of him but was unsuccessful. Today on Sunday
the sodium is down to 128 and he had not been rounded on by the time
Sara finished her own rounds on her patient. Sara had the nurse on
the floor page the residents three times and they finally responded
that they had 40 patients to round on, had been going since 6:30 AM,
and he just wasn't their highest priority. The nurses told Bruce's
wife that he might be discharged today. Sara told them not to accept
discharge with a sodium so low. Besides which, Bruce has a jejunal
tube inserted for feeding and no one has taught his wife how to use
it. And of course there is still little discussion of a diagnosis –
why is he retching? There appears to be no game plan. Bruce had
been scheduled to see the oncologist at UCSF to see if any further
chemotherapy would be helpful, but that was the day he was admitted,
and there has been no contact from that office.
American medicine is sick, clearly.
The system is unarticulated. UCSF doctors are great in what they do,
for the most part, but as an institution they don't take care of
patients very well. My Dad had it right – we need more Cleveland
Clinics. There are calls for “centers of excellence,” and they
would be great. But large institutions can go off on their own
tangents for their own purposes and lose track of the individual
mission of medicine. Residents need to be trained, but throwing them
in the pool as asking them to swim might not be the best training
regimen. I could go on about academic institutions, I guess, by why
do that? Just to say, my Dad probably had it right, and here we are
with the same problem all these years later. I feel so bad for
Bruce, and for all the other patients who have to endure the ill
effects of poor organization.
Budd Shenkin
