The American Scene; The Frontier

Good morning. This is Donald Smithburg for the Illinois Institute of Technology on the American Scene. This is the fourth in a series of programs that we're doing on the modern hospital. The first program we considered the changing nature of the hospital, few I think of those of us who are not directly concerned with the medical profession or with the hospitals are aware of the fact that in the period from World War II on, there's been a very striking change in the character of hospitals and the character of hospital care and in the various aggregate of persons who make up the hospitals. In the second program, we took a look at the hospital as a complex organization. Those of you who have been in a hospital as a patient would be aware of a great bevy of people running around and doing a variety of things which you don't understand and we tried to look at some of the relationships between these people, the roles that they occupy, what they do. On the third program, we delved a little further into that problem, the role of the various professional

groups and the role that they play in the hospital. But primarily hospitals, of course, function in the interests of getting people well. And today, we want to look at the hospital from another angle, from the angle that you and I are, most of you, perhaps, who are listening to this program, would see the hospital from namely the position of the patient. To discuss this aspect of the hospital, I've asked is my guest, Dr. Daisy Atalia Kotso, who is formerly a project director, associate project director of patient care research at Presbyterian St. Luke's Hospital, and she is a sociologist by profession. Also, Dr. Mark Lepper, who is the professor of preventing medicine at the University of Illinois. Welcome to the program, Dr. Talia Kotso and Dr. Lepper. Well, let's look at the patient. Perhaps the best place to start out would be for you to

tell us something, Daisy, the kind of research you were doing at Presbyterian St. Luke's, into the patient. What did you find out and what was the reason for going into it? The reason for going into it, Dawn, was in part a background in literature about sick people in our society. There has been quite a bit written about the problems of the sick person and the reaction of people to their illness, but there has been very little written about what problems the sick person experiences and what are some of the really crucial experiences of the sick person as he becomes a patient. Now, we felt that being sick and being a patient are not entirely the same kind of experiences, particularly not if being a patient takes place in a very complex, very large organizational setting. So, what was our interest among others was to find out what patients

really felt meaning or being a patient implies. What did they consider their obligations? What did they consider their rights? What did they feel was expected of them by physicians, by nurses? And how difficult did they find it to adjust to these expectations? Again, we were interested in the kind of experiences which they picked out during hospitalization as important, as significant to them either because they found these experiences upsetting or because they found these experiences very satisfying and pleasing to them. Well, out of this experience, was there anything that would be beneficial to the physician? How does the physician, Dr. Lepper, view his role in the hospital situation? I believe that the physician today practices more in the hospital than he used to, doesn't he? That's correct. The hospital has become the center of therapeutic and diagnostic activity in the part of the

physician and the other forms of care which he rendered are integrated into the total picture, either preliminary observations which lead to hospitalization or follow -up observations after the patient is left the hospital and the hospital really has become the center of the medical activity in the community. I think the physician's interest in the work that is going on is genuine and is in part because they have realized for some time that there is need for understanding the problems in the terms that Dr. Talakaso is working on. We have realized that by and large patients have had pretty negative experiences as persons and hospitals. We realize that this has implications on the success of therapy. We realize that it has implications as far as

what patients will accept in terms of their care what type of stress they have to be under in order to accept hospitalization so that we do have to understand that person who comes into the hospital is not necessarily the same person behavior wise as he was the week before when he was not in the hospital. Well, isn't this then, Dr., an extension of this general concept that you hear bandied about so frequently these days, psychosomatic medicine, but psychosomatic medicine in a specific setting? Well, there are all kinds of terms. This would be nearer a somatocycic medicine that is psychosomatic is more or less restricted for certain diseases where it's felt the psychological problems have much to do with the causation, at least the symptomatology if not the whole process. Somatocycic is all those relationships and somatic disease in which the psychological aspects enter. I don't know that this type of difference makes a great deal of difference

except that we realize more and more that people are integrated whole and their current environment as well as their past environment is very important to the whole of the therapeutic and diagnostic relationships. Well, one of the things that interested me in what you said was that the patient as it goes into the hospital becomes a different person as you put it using medicine avenue jargon behavior wise. Daisy, do you want to elaborate on that? How does it roll change when it goes into the hospital? Well, in this sense, I think the patient is not much different from any other person who enters into a complex social situation. He becomes aware of this situation and along with it he becomes aware of the other people on whom he to a great extent depends. He becomes aware that these people have certain expectations of him and like in any other social setting to conform to these expectations is a very important matter. One day I would say that in the case

of the patient his great dependency on others and his dependency as a result of illness sometimes involving life or death is much more intensified and as a result I believe the patient's desire to behave correctly becomes also very intense and I think that at least some of the problems which patients experience during hospitalization stem quite directly from their desire to conform to what they feel is the correct and the right behavior in this social setting. Sort of like people would feel it essential to adopt certain kinds of behavior patterns if they let's say went to church. It is very similar like as I say it's in any social setting the more less tried to conform however we have to remember that in the case of the patient conformity becomes an extremely crucial matter. Also because patients bring to the hospital certain ideas

for example I have found quite frequently that many patients feel that to be a good patient is more than of passing importance simply because they have the idea that good services form nursing personnel and this involves quite particularly the prompt response depends in part on their ability to make themselves acceptable. As a result they really are quite restrained in the expression of their desires of their needs also sometimes in the expression of their criticism for fear that they may be labeled complainers or that they may be labeled problem patients which is something that no patient would like to be called. Well how does this affect the physician as he ends his busy rounds in a hospital doctor lapper here he comes into the hospital has a number of patients there and can spend only a limited period of time with each patient. Well you know that brought out in the past of course the

physician's role in the hospital has changed so that he has relationships with the patients but there are a whole team of people who also have relationships with this individual and as we have found the more complex aspects of patient care we find that the physician has to depend more than he formerly did for even such things we used to call bedside manner. In other words the understanding of that his relationship to the patient and to the other person's taking care of the patient I would say this type of research is probably more important at this juncture to have the physicians and personnel understand patients and their problems and he is necessarily for a patient to try to conform to any ritualistic type of situation when you say people do all their behavior when they go to church this is true also there is quite a definite ritual and they know what is understood of them in their particular church and if you have an individual really go to some other church that has different rituals obviously they feel quite ill at ease unfortunately or fortunately and I think

it's fortunately we have no ritual to teach for any particular hospital and so the individuals react to a pre -formed notion and what the physician has to really understand is some of the mechanisms that the patients are using and to be able to understand these helps him not only to understand why the immediate behavior problem is there if there is one whether it's good or bad some good behavior so -called may be a bad problem it may be a denial of certain things that you not wish to visit and the patient was not denying but in any event the physician and the people taking care of the patient other than the physician need to understand the mechanisms because in this way they get insight into some of the patient's total problems as well as his immediate problems. Well you mentioned earlier Daisy that the patient brings to the hospital aspects of his behavior patterns that he manifests during his environment in the larger cultural scheme

let's say a man in our society who has given a certain role to play particularly a role in connection with let's say accepting pain with stoicism not complaining of being self -reliant and so forth does he carry that into the hospital as a patient or does he not? Yes he does and I think we have found in some of the case studies we did that the patients or the person's concept of the patient role in a sense may even reinforce this idea of what makes correct and right behavior for a male in our society for example most patients as male as well as female patients believe that it is very wrong in a hospital to be too demanding or too dependent this is a belief that is very firmly rooted and I think is reinforced very much by two things one is the patient's intense awareness of other

sick people most patients measure really their rights against a hierarchy of sickness in the hospital and they are very aware there may be other people who are sicker than they are therefore to be considered to be not demanding to be not dependent becomes very important secondly I have found that all patients regardless again of their sex are extremely impressed by the fact that both nurses and physicians are terribly busy and overworked and again they feel there must be considerate they cannot ask too many questions they cannot take the time of the physician often as because they seem to be constantly on the go now for male patients interestingly enough conformity to the good patient role as we call it very often comes in handy for example if you have been asked to be on bad rest but you feel that you really don't want to appear to be a sissy or appear to be too dependent because you are a man

you don't like to call people for every little thing you might get get up and against physicians orders do certain things which you're not supposed to do now the male patient can in a sense defend his behavior by saying well look there are other people who are sicker than I am I don't want to make myself a burden I don't want to be too dependent to demanding because after all I am a considerate patient so in a sense here the patient role reinforces his desire to represent himself to others as a man who still can perform independently and without being too demanding well this must complicate the physician's task does not matter yes I think of course these things have been inherent in the relationship between professional personnel and the patients all along and I would say that it doesn't complicate the task other than any time you introduce understanding at first the problem as you survey the scope tends to get wider and

more complex and what you have been ignoring before now becomes a concern to you but I don't know that fundamentally the task is any more difficult I think what we're doing is trying to find ways of coping with a problem that has always been there well does the physician ask this question I don't know that the physician go to the nurse let's say on the floor and find out from the nurse these various aspects of the behavior of the patient so he can get them were comprehensive diagnosing it varies with the circumstance there are different types of illnesses in which the need for this sort of thing is quite different some of our acute illnesses the patient is in and out so rapidly that he barely finds out what's going on and people barely get to know him and it's all over favorably and he's discharged however with the changing nature of disease towards the chronic disease requiring extensive rehabilitation working with people these factors become increasingly

important now their importance has been met in some very specialized situations by having special rehabilitation teams here of course there is constant interchange between all of the personnel it's one of the main reasons for having a team and so that they do keep their signals straight and at least the team presents to the patient a uniform understanding the problem rather than everyone making up his own mind about this particularly individual as we have more and more of these things that are not complex enough to go to the teams and yet they are more complex than some of our simple illnesses then we have patients who do not seem to be doing well and at this point one group of the professional personnel of the other will take the initiative to talk to the other about it sometimes it's a nurse who approaches the physician sometimes it's a physician who approaches the nurse it depends really upon which one gets an insight first that things are not going as well as they should

frequently it's the junior physician for instance the house officer who has this brought to his attention it's not a representing a third party and he brings the attention of the attending physician Dr. Lampert before we went on the air you brought up an anecdote which I think that would be a great interest to the listing audience in connection with sometimes matters which seem to be irrelevant and in connection with treatment which actually assume a relevancy when you consider the situation in its total complex and I'm referring particularly to the visits of the dentist to the rehabilitative patient do you want to tell us about that yes well this gave us some insight into the type of reactions patients have the patients we were trying to rehabilitate had been through a very life threatening situation and they were indeed still being patients who had had polyomyalitis interfered with their breathing were still dependent really on machines and the

emphasis of the team and this was a team center effort the emphasis of the team was on having the patients adjust to the machines adjust to this situation on a chronic basis and having the families also adjust and learn to participate so that they could go back home and all of our efforts in this area in the meantime more or less by chance it was found to greet many of these patients because their acute illness and lack of dental care during it had very poor dental hygiene so we arranged for dental care this became a symbol to the patient that we were really serious about the fact that they were going to have a prolonged period of relatively good health in spite of their limitations and on the basis of this it improved the morale considerably just simply the fact that we were concerned enough about their future to worry about their dental health and I think that's a fascinating notion because

very often these are factors which fall outside the traditional to the traditional definition of medicine and I suppose your field doctor leopard preventive medicine is something that is itself a relatively new concept in American medicine is well I think preventive medicine as we know and vision it has been concerned with the environmental host relationship that will allow optimal function and optimal longevity for each individual is quite a new concept it's a post -war concept it grows obviously out of the roots of the tremendous preventing medicine efforts that conquered the communicable diseases or almost conquered them at least in the pre -war era actually rehabilitation you see ties in because it's sort of the focused point of the very severely disabled patient and tailor making an optimal environment for optimal function for this individual now we can envision

all individuals have certain types of strong points and weak points and the task of preventing medicine is to try to fit the environment to groups of people who have certain demonstrable limitations which we now label under the field of early diagnosis which is one of the big fields in preventing medicine well Daisy I suppose the sociology as a field of knowledge also is relatively new as applied not only to hospitals but as to the whole concept of medicine itself isn't it it is where did the what kind of insights have we developed in terms of the associate sociological analysis of what I suppose we might call a definition of the situation if that's not too complex in terms with specifically we it reverence to the general hospital I'm afraid relatively little as yet much of the sociologically interest in the last years has focused on mental hospitals patients who were emotionally disturbed and we have only recently I think entered the field of the

general hospital they have been some studies on the organization of general hospitals they have been some studies on the patient for example one study trying to illustrate some of the reasons why some patients may be more reluctant to leave the hospital than others but they have not been too many studies that have focused on the patient in a general hospital and I think one reason of course is that it is not easy to study much of the really important experiences of patients are in interaction with physicians and nurses now the patient today in a general hospital is already confronted with so many different types of people and has to meet so many new faces that it is naturally not easy as a sociologist to be present at all times to observe the interaction but I think what really is needed today most of all is

to really try to understand better what goes on between patient and physician what is it that the patient finds most difficult to express in this relationship and I think our study gives some hints in this direction one of the previous guests I believe it was Dr. Monk talking about the problem that has arisen because of the development of the semi -private room and the private room where the patient gets into a situation where he is in physical isolation and he can't adjust to the situation for that reason as against the ward have you found that to be we have some hints again and at least our study raises some very interesting questions for example for many patients it's very difficult to know what they are really entitled to in every organization you try to know the rules of the game so to speak and a patient who comes to the hospital and

enters into a private room misses the advantages of a patient who enters into a ward in a ward there are other people who have been already in the hospital who can tell the patient what it is he can do what it is he can ask for there may even explain certain technical aspects about how to move a bed or how to use in communication system the patient in the private room cannot learn that easily and as a result and I think more research has to be done here he may find it much more difficult to express himself without fear that he may ask for too much again a patient in a ward has always a nurse walking in and out to take care of other patients it's much easier to stop a nurse and say look what you are in here could you do something for me while I have found that many patients in private rooms particularly when they were not very seriously ill would say well you know I don't want to call her just for that to come to me I thank the lamp where you

were talking earlier about the symbolic process of processes in the hospital I believe Daisy was suggesting the importance of a smile while hospitals do not have formal ritual in the sense of of established behavior that's passed down from generation to generation as in a church nonetheless there's an highly symbolic process going on isn't there well I think you're right of course this has been referred to by many comedians as the bedside manner and it is distinctive enough that it can be characterized by them quite successfully at times and it is handed down or has in the past at least been handed down from generation to generation by more or less the preceptorship method of the younger physician studying with the older physician and observing how he copes with certain situations which do arise and obviously this is part and parcel of the same thing I think what we're seeing now

in these studies is to try to put some of this so -called art of medicine into a more scientific domain it that therefore allows you to teach somewhat more effectively because I'm sure we have passed along almost as many bad things in our preceptorship since we have good things and I think the other repercussion of course is hospital organization when you talk about wards versus private rooms and whatnot one of the things that is apparent is the value of the group particularly in prolonged things and identification of people who have somewhat similar problems also I think that we are now seeing hospitals beginning to move along lines of organization by degree of need of care so we have intensive treatment areas these usually are combined areas for some of the reasons you say that it saves the nurses time to be right in the room with three or four people with similar problems as they get better we then can put them in areas where the patient can move to other patients and it doesn't necessarily mean

that they need to be a private room into these circumstances might be quite fitting for certain individuals because they can then have the solitude when they want it but they can get out and communicate in community areas for patients at other times but I think we are seeing the hospital even the structural relationships change in response to some of this data one comedian who was talking about comedians who was telling a physician who built a house in the country named it bedside manner to quite extend his bedside manner that is the art of medicine still an important factor and does it become more an important factor because of the intense specialization of function well I think perhaps Daisy can answer this better than I can because she's looked at it more objectively some of the studies that we have had in our rehabilitation center studying the physician and patient relationships from the viewpoint of both of them with different observers observing different people and trying to put the picture together indicate that indeed this is very

important to to the patient and the way the patient will respond to a given individual and I think that it is important to recognize that most or not most but a great deal of the successful bedside manner is sort of empirically discovered as being the best way to handle certain problems therefore it's persistent I'm afraid I'm going to have to interrupt there because we're coming to the end of our time next week we want to spend our time discussing medical education and I think some of the same problems will come up at that time I want to thank you very much for coming in and helping us look at the hospital from the standpoint of the patient thank you thank you this has been the American scene today's discussion the modern hospital the fate of the patient had his guests Dr. Daisy Talucoto sociologist and Dr. Mark H. Lepper professor and head of the Department of Preventive Medicine University of Illinois

we have to interrupt there because we're coming to the end of our time you