Here’s a review I wrote for the Journal of Palliative Medicine on a book by Julie Salamon called Hospital: Man, Woman, Birth, Death, Infinity, plus Red Tape, Bad Behavior, Money, God, and Diversity on Steroids.

The discipline of palliative care emerged from careful observation and consideration of modern health care.  Pioneers such as Dame Cicely Saunders and Balfour Mount studied how people were being treated at the end of their lives and asked if there was a better way.  In this tradition, palliative care practitioners continue to monitor and try to make sense of how contemporary technological, economic, social, and political forces are shaping modern medicine.  For anyone performing this reflective task, Julie Salamon’s Hospital may be an illuminating resource.  The book is a journalist’s account of a year spent in Brooklyn’s Maimonides Medical Center with unrestricted access to the hospital and its personnel.  Searching for the universe in a grain of sand, Salamon hopes the story of this large urban hospital will help tell the larger story of American medicine at the beginning of the twenty-first century.

The story that emerges is one of ever increasing industrialization.  While Maimonides’ staff clearly strives to do what is best for their patients, the institution’s driving ethos is efficiency and financial success.  As the hospital’s chief of surgery explains to Salamon, “It’s all about patient turnover.  The more you can get in and out, the more times that cash register rings.  It sounds like business and it is business. . . We’re not kicking them out.  But if you get them out two days later, for every discharge you lose, you’re losing ten thousands bucks.”  Like a factory mass producing a standardized product, the care at Maimonides relies upon treatment protocols  derived from evidence-based medicine that applies to the everyman of population studies rather than the individual patients of the real world.  In its growing emphasis on medical specialization, the hospital incorporates the basic industrial principle of division of labor.  Finally, just as the industrial revolution saw the rise of a managerial class to organize and maximize production, so Maimonides has an administrative superstructure headed by its chief executive officer Pamela Brier, a business-savy MBA.

The industrialization of American medicine exemplified in Salamon’s portrayal of Maimonides has clear merits.  To remain financially solvent enough to carry out their mission of patient care, hospitals must pay close attention to efficiency and the bottom line.  Treatment protocols derived from evidence-based medicine promote consistency and quality of care.  And with the logarithmic growth of medical knowledge, more and more specialization is necessary to effectively bring scientific developments to bear on patient treatment.

But as Salamon’s book shows, medicine’s industrial shift comes at considerable cost.  It is the cost of the alientation that pervades the pages of Hospital.  At Maimonides, physicians and patients often feel estranged from the healing physician-patient relationship that has traditionally been the heart of medicine.  As one physician tells Salamon, “The past few decades, patients have been saying, ‘I feel I’m just a machine, a widget on the assembly line.’  But lots of doctors are now beginning to experience that, because of the medical industrial complex that treats doctors as another widget.  It’s all interchangeable parts, and the chief virtue becomes efficiency rather than caring compassion.  Lots of physicians are feeling a sense of emptiness, alienation:  ‘Is this why I went into this? Is this what it’s about?. . . Is there more than just thinking about how many colons I can put a scope up per day and how many polyps I can remove and how fast I can be and how few complications I can get?”

The character of Davey Gregorius shows how medical industrialization has shaped the next generation of physicians’ views of their profession.  Gregorius is a first-year resident in emergency medicine at Maimonides who harbors no quixotic aims for his career after finishing his training.  He plans on a job in an emergency department in the Colorado mountains, where he can work two to three shifts a week to finance a life of plentiful skiing and fishing.

Gregorius spends the majority of his time during emergency department shifts in front of a glowing computer screen monitoring patient test results and documenting his work.  Rather than learning about patients’ conditions through listening to their stories and physically examining them, most of Gregorius’ diagnostic information comes through a battery of labs and imaging tests he has ordered.  We see here how modern medicine’s ever-growing diagnostic technology sometimes alienates patients and physicians from each other.  We also see how much time the modern American physician spends breaking down her care for patients into artificial units of value that a third-party payer has devised to determine compensation.  But none of this seems to bother Davey Gregorius.  He does not romantically long for a bygone era in which medicine was a deeply meaningful, even noble profession.  Gregorius instead pragmatically views being a doctor as interesting shift-work that provides adequate compensation to pursue his true passions.  

In contrast, Allan Astrow is determined to preserve the idea of medicine as a deeply moral enterprise.  Astrow in an oncologist whose formative years as a physician were spent in the 1980s and 1990s treating AIDS-related malignancies in a Greenwich Village hospital. Over against the idea of health care as a commodity, he believes that medicine is a covenant between the practitioner whom society has entrusted with the power of healing and the sick person who is in a uniquely dependent, vulnerable, and anxious state.  Astrow has come to Maimonides to take over as associate director of its medical oncology department.  It is an administrative position in which he’ll have to concern himself with efficiency and the bottom line, something seemingly ill-suited for this idealistic man.  But as an outspoken critic of medicine’s industrialization, Astrow feels a duty to get involved in the muck of the system to try to improve it.  It is an admirable, but deceptively perilous endeavor.  Will a position where success is often measured in financial terms distract Astrow from his commitment to medicine’s higher calling?  Will the system change him more than he is able to change it?

His dilemma is akin to one that palliative care faces as it searches for its place in twenty-first century American medicine.  Should the field see itself as comfortably fitting into the industrial division of patient care into component tasks?  Is our place at the end of the health care conveyer belt, taking over patient care at the end of life from hospitalists who were handed the care baton from internists upon hospital admission?

Or should palliative care consider itself a protest against medicine’s industrial trend?  After all, as medicine becomes more and more specialized, palliative care self-consciously takes a holistic approach to patient care.  As futuristic medical technology becomes today’s reality, palliative care’s special procedure is effective interpersonal communication.  As medical research promises scientific certainty and miracle cures, palliative care embraces the art and limits of medicine.

Ultimately, of course, palliative care must continue to seek integration into America’s modern health care system.  Doing so is necessary for the field to have its greatest possible impact.  But palliative care must also intentionally and rigorously guard against attempts to downplay or alter its core commitments in the name of medicine’s infinite quest for maximal efficiency.  For these core commitments are what gave birth to the field and remain its most valuable contribution to medicine.