The American Scene; Basis of Poetry

Good morning, this is Donald Smithburg for the Illinois Institute of Technology on the American Scene. This is the third in a series of programs in which we're dealing with the modern hospital. The modern hospital is a vastly different place, I think, than the hospital of 50 years ago. And as I've indicated in previous programs, and the guests have indicated has introduced a great many complications in modern life. Chicago, as most of you who are listening are aware, is one of the really great centers in the world for hospitals, for medical education, and for medical research. And I think it's appropriate that we discuss some of the problems in hospitals. In our first programs, we discussed hospitals in general, so to speak, and some of their changing characteristics. In the second program, we dealt with the vast proliferation of specialties that go into making up the hospital as a working organization. Today, we want to deal with still another aspect of the hospital problem, the relationship

between these very agitated specialties, which are all brought to bear on us when we go to the hospital as a patient. As I've tried to suggest in earlier programs, most of us that are speaking for myself, and perhaps for most of you listening, the hospital is a place where we come as a patient, usually a pretty sick patient, and we see it from the vantage point of the bed. We are not aware of the hubbub of activity going on behind the scenes, how it operates, what various people are doing, and how the whole thing ties into some kind of an integrated program, which gets us out of the hospital in due time. To discuss this problem of interprofessional relations and the problems of the great hospital, and its specialties, I have with my guest, Mrs. Margaret Ellsworth, who is the director of a special training project for the Illinois

Hospital Association in Cooperation with the Illinois League for Nursing. The other guest is Dr. Frederick Stan, who is a practicing physician on Chicago's South Side, and who also is an assistant professor of medicine at Northwestern University. Welcome to the program, Mrs. Ellsworth and Dr. Stan. I'd like to start the program by asking this basic question, how is the big hospital change, or how is the hospital changed, and what kind of complexities have we introduced? I have suggested that there are some, maybe you want to start with it, Mrs. Ellsworth. Well, as I was listening to you in your opening remarks, and you say that the patient views this from his bed, that made me think of one of the real changes, I think, that's come at least in my professional lifetime. And the fact that we have moved from multiple bed units to the, to bed or to the single bed unit, and there are lots of reasons why people prefer this. But

Fritz and I were talking about this earlier, it also causes one of the complexities, because when patients were in multiple bed units, then they saw those that were taking care of them, and they were busy with other people, and they still had that same feeling of assurance, and a week when you went by or a smile gave them a good deal of comfort to know that somebody was right on top of the situation. Now, when their door is closed, they're not as aware of what is going on behind the scenes, as you had indicated earlier. Well, I think that's true, certainly, as a patient in a hospital, I've punched that buzzer on the pillow, and sometimes it takes an awful long time for somebody to answer it, and I suppose you get a sense of irritation, you wonder, what are those people doing off -having coffee or? Exactly. If you cannot see, you do not know what it is. And even if there is somebody, there's whose sole job is to answer lights, then they have to go and do something about one, when it does come on, and while they're away

from the desk, maybe for a minute or two, another one or two or three, or maybe more. But do you want to come along? The patient is particularly impressed by the organization of the hospital institution. After he sent to the hospital by the doctor, he's pleasantly surprised to find that he's welcomed by a receptionist when he arrives at the hospital, and then brought to his room, and usually presented by a nurse who welcomes him or her, provides the bed, gives a brief explanation of what is to be done with the patient, and puts the patient at ease. And then shortly after his arrival in the hospital, after the nurse makes her study of the particular problem and notes her special observations, the intern comes in and takes the detailed history. First a history, then a physical examination, and comes to a specific diagnosis. He relates his diagnosis to the

attending man, and the attending man provides the therapy. Then after this is done, which usually is done within the first several hours after being in the hospital. The patient is surprised at the movement from one procedure to the next, which is applied to most all patients. That is the laboratory. Technician comes in to take the blood, take the sample of urine, and then the electrocardiographic department. Technician comes in to electrocardiogram, and then a technician may remove blood for chemical tests. The patient is presented shortly after with the technician who will bring the patient down to the x -ray department, x -rays be taken. After all these procedures are done, the patient is amazed at the organizational

system that he meets as he is in the hospital, and it's rather impressive. I think it's impressive, but it may also be rather distressing. I think the thing that Margaret was bringing up was the patient who has poked at and felt at and checked on by a dozen different people, all of whom are looking at different aspects of him, and has a tendency to feel sort of lost and doesn't he? In the maze, because he really doesn't know what's going on, any more than I know when the doctor gives me a prescription for a medicine in his unseemly hieroglyphics, and I take it to the drug list. I don't know what he's giving me, but in the hospital, there's a shortage of explanation. Sometimes it seems to me, at least, again, as the patients, from the patient point of view, an explanation of what all this rigmarole add up to. What's going on here? Generally, the doctor explains to the patient exactly what he's going to do, and he states that we're concerned with making a specific diagnosis before therapy can be given,

and that the patient should be patient in undergoing the examination, because after all the data is in, a specific diagnosis will be arrived at, and then a specific therapeutic measure may be reached. For instance, an individual may enter the hospital with a sore throat. It's important to find out the exact organism or bacteria responsible for that sore throat, and so a culture is made, and after a culture report is returned, then the doctor is in the position to know exactly what drug is to be used. I'd like to come in on that moment, because I remember that on your last program that mortes Zimmerman from wasm memorial was on. I was thinking when you said that the doctor tells the patient what to expect with all of these tests, yes, he does, but sometimes he tells them in just the same kind of language that you used right then, and they don't always understand, or do they necessarily remember? And I remember that at WICE, that they have cute little

cards of patient reminders, you know, the doctor wants a portrait of your gallbladder, or you're going to join our operation club. Let me tell you about our operation club, that there are little reminders to help the patient know what's going to happen to the next, that you can't have any separate one night, maybe, or no fluids after midnight, or no breakfast. And I think that these help the patient who have still more assurance than they do from just hearing about it the first time. One of the things that Dr. Mauch was talking about on the last program that again seems to me to have some significance is that the nurse in the modern situation, we all think of a nurse as Florence Nightingale. The nurse has become more of an administrator than she has a person involved in patient care, and are these little reminders, so to speak, and just bureaucratic imitations of the empathy, which used to characterize the nurse patient relationship, or

is the nurse so busy filling out forms like O .W. Wilson's policeman, that she can't nurse. Is this coming to be a problem in the modern? This is the real problem we want to talk about. I feel it's the fundamental problem contending our country today. In view of the emphasis upon objectivity and upon materialism, we tend to push into the background the more sensitive aspects of the patient, namely the patient as a living, warm soul who wishes to be understood. In the first place the patient is fighting when he comes into the hospital, and he has deep fears as to the series of the problem before him, and he's seeking for a word of encouragement. The one who usually gives that is the nurse. We're very happy to have that assistance because the nurse makes it so much easier for us in our therapeutic

regime. But there's been an tendency of late. The nurse is so excessively busy with administrative work, not able to give of that for which are so well trained, namely in bedside compassionate characteristic. It seems to me when I was a patient last in the hospital, and this was one of Chicago's best hospital, the person I saw most frequently was a student nurse. They're in all the time, and they're the most cheerful little girls I've ever seen in my life. And they made your life very happy, but it seemed to me that I very seldom saw an RN. I think the perhaps you've put your finger on it there within the public mind as well as within nursing and within medicine. That generic term nurse means many different things. Actually, there is more hours of nursing care available, per patient

now than there ever was before. But granted that much of this is given by people who have had less preparation than that we normally associate with what we call the RN. That is, you know, the legal terminology for the person who has completed a rather extensive informal program in nursing. Now, I grant you that they are not there, and because they are not there in such large numbers, then they are using the licensed practical nurse and the nursing aid to assist them as what we would call supportive care when you agree. And so that the nurse must be in the position to perhaps make that initial visit to the patients, to make the determinations of the patients need for nursing care, and then to assign it to those other people who can do it best. But she must always be there watching how the job is progressing, teaching, supervising, and of course, always then making the evaluation

of how the care has been. It's important, though, that she'd be there, Margaret, because we worry sometimes that the floor nurse, the supervising nurse of the floor may not make her presence available. We find the patients are delighted. In fact, reassured when they can see the chief nurse of the floor, it gives them a great deal of courage to know that they're coming along. It's all right with the nurse's aids. They do a very fine job. The practical nurses do it next and job, but the patients would be delighted to have an opportunity of having at their side from time to time to the day the head nurse. In fact, one patient told me the other day that she could only wish that the head nurse of the floor could bring in her food, a char that's done only by the nurse's aids. Not so much for the food, but really the presence of that.

There are times when we recommend that the head nurse do this. The chief carry some breakfast trays, for instance, because this is a time when she can assess the patient's needs without the patient being aware of it. You know, the way he lies in bed, he holds his hands, the way his eyes look. But I have, as you know, been visiting hospitals throughout this date of Illinois now, ever since the day after Labor Day. Actually, there is a head nurse and one other nurse usually on the average hospital unit of the RN as you would color. Now, when these units are average between 40 and 60 beds in size, then we have to perhaps rather formalize the visits that she makes to the patient. Yes, we do want her to make rounds early in the morning so that she sees each patient before she begins to make rounds with you when you come and the other physicians when they come. Would you make a statement about the quality of

care as you see it given in the hospital today? In view of the great need there is for personnel in the ward and in the floors of the hospital. What would you say about that? Well, strangely enough, because I think that many, the point that I'm going to make is perhaps in contrast, the way the average member of the general public feels about hospitals today. I think sometimes that they feel that nurses are lacking in warmth, that they are not as concerned about their physical needs and their emotional needs. But as I have visited hospitals in Illinois, I have been more concerned about the lack of emphasis on meeting the patient's medical needs, the role that the nurse plays in assisting the physician in this way. I think that most nurses are very much aware of the patient's fright, their fear, their need for support, and

the need for, well, all of those needs that a patient brings to the hospital with them because they're people. I'd like to ask you a question from a standpoint of the practicing physician. The practicing physician today is probably not the horse and buggy duck or the kind of thing that characterized the country in the old GP of 50 years ago. He has 40 -50 patients a day streaming in and out of his office, and then he goes to the hospital and visits to what extent can he and how can we provide the doctor -patient relationship, which will satisfy these emotional needs you were talking about just a few minutes ago when we have, when each physician not to mention the specialties, but each internist, let's say, has a workload like he does. He can spend 10 minutes with this patient and 10 minutes with that one. That question is just the very question that disturbs us down. The

doctor finds himself in the position of being quite overworked. He has a large office practice, and he has many patients to see in the limited period of time during which he makes rounds, but he tries to get as close to the patient during the brief period that he's at her side. He wished he could do more, but the circumstances prevent him. It's for that reason that we lean so much upon the skilled trained nurse. The aid to be true, practical nurse to be true, but the professional nurse is the one on whom we mainly lean. We see the importance of keeping the nurse abreast of the very best going on within the field of medicine so that she can properly interpret the orders we give. You bring up the problem here down of cooperation with the nursing profession. This is the real critical problem that we're having throughout the country.

The specialization has affected every discipline, has affected every aspect of knowledge and no differently nursing in medicine, and we find ourselves so deeply involved in our specialized fields that we dare not enter into the interest of the adjacent field. I feel that we have lost a real opportunity by not cooperating with the nursing profession as closely as we might, because after all, nursing and medicine are one. I don't see them as two. It's just like class 10s, they're one. The doctor cannot function without the nurse, the nurse without the doctor, and it's probably the best way of illustrating the importance of the nurse. I don't know you would have been able to disagree with me on this. I look upon the situation in the hospital environment very much like a football team. The doctor is the coach, but you know who carries the

ball? The nurse. These are the people who are on the fighting line. They're with the patient constantly during their eight -hour service, and we physicians may already come in for just a few minutes, perhaps for two, at most two times a day. And that period during which we observe the patient is very, very little. It's for that reason that we must develop a close relationship with the nurse and prefer to have her make rounds with us so that we can take advantage of her specialized knowledge that she's observed in the course of her contact. Isn't there a problem here and I'd like to ask you, Mrs. Zelsworth on this, because I think there's an enormous status gap between the physician and the nurse. And maybe the place we got to start is raising nurses' salaries or doing something along that line, to try and bring the nurse up to a level of status cognizant or commensurate with her responsibilities in this area of specialization. And

nursing is not a very hybrid profession in terms of its training, is it? Well, nursing is a much better paid profession than it was a few years ago, and of course that much of that is due to the efforts of our professional organization. But I don't know that it's a status symbol entirely. I think that Hans has seen some facts in his study that it was a status one. But I think it's perhaps a preoccupation as the physician is there for only two or three minutes a day. And he is so dependent upon the nurse and remember that the relationship of a physician to his patient is a one -to -one relationship. And he sometimes forgets. And I think purposely so and has to forget that the nurse must play one of these men against the other in a way so that the needs of the patients of maybe

a dozen or 20 different physicians will be met. I think sometimes we tend to forget that and that's why we do need to make every effort to be with you and you make your rounds. But there may be three or four other men that are coming on the floor at exactly the same time. The nurses generally are so much better prepared in the field of cycle social relations than the physician. Largely through to the excellence of the teaching and to the emphasis placed upon those fields during the early training period. We're beginning to see the importance of that training amongst our medical students now and amongst our interns and our taking advantage of the special knowledge of the nurses. I want a method that we have been employing in order to incult this way of thinking is to study a patient with a team

idea such as bought up a short while ago. Namely a specific patient is discussed at conference at which sit not alone at the conversation and the resident and the intern but also the nurse of the floor, the specific nurse in charge of the patient and the social worker and perhaps the psychologist or psychiatrist. And if the case be a surgical case or a case requiring the attention of a specialist in any particular field that specialist is brought forward. Each to discuss from their viewpoint the specific problem at hand thus enriching each other's experience. And we find in our conferences that the nurses have come forward rather strongly with this aspect the the psychosocial aspect that is amazing to us the depth to which they've learned field. And in fact it's impressed upon that upon us so much that the suggestions been offered that perhaps

our students in medical school sit in with nursing classes in the field of psychosocial studies. I wonder about the role of the resident and the intern. Again I speak only from the standpoint of a patient. The intern is there the resident comes in once in a while but the patient really doesn't know where they fit into the picture very well. What is the or maybe I ought to phrase the question this way. The intern and the residents in a hospital are primarily students they're learning or they're at least partially students. And can we coordinate the patient care function with the educational function? Do the things mesh? Maybe yes they do down there one the the purpose of that system of of

doctor resident and intern is for education and for service that double double function. The man in which it operates is that the attending man gives specific orders. The resident carries out those orders through the intern who serves under him. So the intern is responsive to the resident the resident to the attending man. Unfortunately a misunderstanding sometimes occurs where the the several interns and several residents may themselves attach themselves to one patient making it very confusing to the patient as who is his real doctor especially when the doctor himself does not emphasize his own personality upon that patient. It can be confusing but the doctor solves the problem by explaining very clearly to the patient that the manner in which his care will be taken care of is through this group of workers. I wonder if there's

anything we could suggest as to the shape of the future. We've mentioned the fact that there are great many specialties have emerged. What do you foresee? And this is all to the future as far. Certainly as far as nursing is concerned. We know that we're going to continue to attract more and more young people into it and we hope that perhaps from programs such as this that more people will be interested in the health field. But the change for nurses themselves will probably lead to more practice in depth in some clinical area because the whole field is so broad and just as medicine has begun to specialize in clinical areas we will certainly see that coming in nursing. I am sure that we will get nurses who are skilled in the care of the patient with heart disease for instance and they will not only use these skills in

assessing a particular patient's need for care but they will be teaching the other people and they might move throughout a whole hospital area or maybe throughout a whole hospital guiding the regular staff but then they will still be there with a patient. Dr. Standee want to take this from the standpoint of the physician what is happening and what is likely to be the future in relationship between the physician, the attending physician and the hospital. Is this changing? Well the direction is in a direction of a search. The direction all over the country goes more and more in a direction of understanding more about the very nature, the pathogenesis we call a disease and it is not sufficient for the physician to be content in the hospital with

the knowledge we have known during the past 10 years but for himself to be engaged in research or to be aware of the best developments going on research all over the world so that he can direct his energies in that particular field but I am convinced that the real energies of the future will be in the in a direction of close cooperation with all the various disciplines within the hospital. I'm afraid I'm going to have to interrupt there because we're running out of time. I would like to suggest that those of you who are interested in hospitals come back next week we're going to consider patient care at that time. Thank you very much for coming.