Published Spring 2017
In his essay “How the Poor Die,” George Orwell recounts a story from 1929, when he experienced a bout of severe pneumonia and was treated in a Paris hospital, which he simply calls the Hôpital X. The essay is a frightening, dark, but humorous tale of medical care — or the lack thereof — at the time.
A doctor, Orwell relates, typically dropped by later in the day with interns and medical students, and “there were many beds past which he walked day after day, sometimes followed by imploring cries.” But if a patient had an interesting illness or severe symptoms “with which the students wanted to familiarize themselves,” the doctor would stop and attend to the patient. The attention they paid Orwell because of his “exceptionally fine specimen of a bronchial rattle” was almost too much, with a whole group of students lining up to listen to his chest.
It was a very queer feeling — queer, I mean, because of their intense interest in learning their job, together with a seeming lack of any perception that the patients were human beings. It is strange to relate, but sometimes as some young student stepped forward to take his turn at manipulating you he would be actually tremulous with excitement, like a boy who has at last got his hands on some expensive piece of machinery…. You were primarily a specimen, a thing I did not resent but could never quite get used to.
Across from him, Orwell witnessed a patient undergoing a strange medical procedure: a match was lit inside a small glass, which was then “popped on to the man’s back or chest and the vacuum drew up a huge yellow blister…. It was something called cupping, a treatment which you can read about in old medical text-books but which till then I had vaguely thought of as one of those things they do to horses.”
Orwell also describes a patient (“Numéro 57 — I think that was his number”) with cirrhosis of the liver due to alcoholism. This man’s liver was so enlarged that he was often used as an exhibit for lectures. Numéro 57 died in the middle of the night, although no one knew it until the morning. “This poor old wretch who had just flickered out like a candle-end was not even important enough to have anyone watching by his deathbed. He was merely a number, then a ‘subject’ for the students’ scalpels.” As soon as Orwell gained enough strength, he fled the hospital.
Thankfully, medical care has come a long way since Orwell’s time. In the modern American health care system, patients enjoy tremendous autonomy, are generally treated with respect, and receive the best that modern medicine has to offer. They can regularly refuse lab draws, medications, or treatments. Patient advocates guide physicians, nurses, and ancillary staff to heed patients’ wishes. Patient satisfaction also plays a role in how much doctors are paid, as the government takes satisfaction surveys into account when making Medicare reimbursements. Cupping and many other old treatment methods are mostly a thing of the past (although cupping did make a surprising public reemergence with the U.S. swim team in the 2016 Olympics). Instead, physicians strive to prescribe medications and perform procedures that are supported by the latest scientific evidence. Consequently, Orwell’s experience seems far enough in the past that we don’t have to worry to the same extent about the ethical abuses or patient mismanagement that he witnessed.
All this should be reason to celebrate. More patient autonomy means higher demand for quality health care. More data from scientific studies and further efforts within hospitals to promote quality care means patients and physicians can make the right decisions and expect the right outcomes.
But in The Finest Traditions of My Calling, Dr. Abraham Nussbaum, an assistant professor of psychiatry at the University of Colorado School of Medicine, argues that these tenets of modern medicine may not always be as helpful for improving medical care as they seem. And so he proposes an addition to, if not a replacement for, these guiding principles — a change in the way doctors approach and think about the patient.