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The Arts and Medicine
October 15, 2019

Man’s 4th Best Hospital

Author Affiliations
  • 1NYU School of Medicine, New York
JAMA. Published online October 15, 2019. doi:https://doi.org/10.1001/jama.2019.16384

That afternoon Fats asked me to go with him to do attending rounds in the hospital. Our titles were “attending physicians.” Each of us would be responsible, a month at a time, for rounding and teaching. We were accountable for the care of the patients—and the screwups of the docs—on that particular medical ward. The team we would teach consisted of a resident, an intern, and BMS students doing their rotations in medicine. As interns in the House, we had been near the bottom of the ward team. At Man’s 4th Best, we were at the top.

With Fats and Humbo Parza—always at the side of the guy he called “Don Gordo”—I went into a skyscraper, up to floor 11, and out into a constricted view of the ocean and the city. Ward 34, our home base. Fats stopped, staring down the long hallway. Observing. He’d taught us that: first, observe—unobserved.

Image used with permission from Penguin Publishing Group.

A caravan of white coats, nine rolling keyboards of HEAL, parked at the nursing station and disappeared.

In civilian clothes, we met with the team in the house staff quarters, a two-bedroom on-call suite next to a large room filled to the gills with screens.

We introduced ourselves—“Hello! Hello! Hola! ”—with an enthusiasm that startled them. The resident in charge, avoiding our eyes, introduced himself. “Dr. Jack Rowk Junior.” Short, puffy around the chin and gut, balding, and tight faced. A large purple birthmark started out in the shape of Chile at his blond monk’s rim, fading to a pink iceberg calving down his cheek into small pink iceberg-ettes at his chin. Eyes flat blue. Sincere regimental tie, knotted. Tight. And why did he say “Junior” and list it on his name tag?

“Got a great case to present! A real puzzler, a toughie, in imminent danger. Going down the tubes!” Was he enthusiastic about this? “Patient of one of the Four Horsemen—”

“Is someone with her?” Fats interrupted.

Dr Jack Rowk Junior blinked. “I assume so. I mean, a nurse.”

“Find out,” said Fats. “Now.”

“Suresure.” He clicked his phone and in an e-moment got the answer. “Yeah, a nurse. The key to the case is that her physican is one of our Four Horsemen of the Apocalypse.”

“Meaning?” I asked.

“Agents of death. Book of Revelation. Bad docs. On their last legs. Still use paper charts, not HEAL. We clean up their messes with high-powered care. Mo Ahern here is our star senior med student doing her subinternship with us. It’s her case. Mo?”

Mo Ahern was a petite, fit-looking woman in a short white coat. Bright hazel eyed, on alert, sandy hair in a girlish ponytail. Her fear of “presenting” was revealed by her fingering a charm on a string necklace—maybe Mayan. Instead of an “I”-pad, she had handwritten notes on a stack of three-by-five index cards. Like what we’d used in the House? As Fats had said, “There is no patient that cannot be fitted on a three-by-five card.” Mo even had the same hand-drawn grid in which to put the crucial labs so they could be seen at a glance. I smiled at her, sent her a silent prayer: Don’t worry, Mo. At least me and Fats won’t rip you to shreds and we’ll keep you safe from Dr Rowk.

As she began, her voice trembled. How young she sounds. Like 14.

“Mrs. Burke is a seventy-two-year-old Caucasian married woman who was referred by her local doctor, who had been treating her for decades, with a chief complaint: ‘He told me to come in again, for my pacemaker infection.’”

Mrs. Burke had received one of the early types of cardiac pacemakers, where the wire was threaded through the abdomen and hooked on the outside of the heart, the pericardium. This was before pacemakers could be threaded up through a blood vessel, inside the heart. Occasionally the wire would get infected, her doc treating her successfully with an antibiotic, fluconazole, for fungal infection. 14 months ago she was admitted for a fever that the antibiotic was slow to clear up. Diagnosis: “Rule out septicemia.” On her second day in the hospital, a mild urinary tract infection was found, another antibiotic added. The fever did clear, but slowly, requiring three additional hospital days, an expense that, to Man’s 4th Best’s chagrin, was reimbursed at a lower rate than the first two days. The team suggested that her external pacemaker be replaced with an internal one. She refused, fearing surgery.

This admission, the source of infection again was the pacemaker. Fluconazole was continued, but her platelets began to drop precipitously. Bruises surfaced all over her body. Nobody knew why. All the tests for causes of thrombocytopenia had turned up nothing.

“I,” Dr Rowk said, “and all the rest of us including the heme-onc and ID consults have now gone over all data—all twelve years of outpatient and inpatient data—in HEAL. The Horseman is not really computer savvy. Nothing’s turned up. A great case!”

“How low is it now?” Fats asked.

“Last hour’s bloods should be back.” He clicked his phone at the big screen in the conference room. HEAL awoke, had its latte, put on its face of 50 horizontal lines in four colors, flickered, and leaped into action—running between the seven or so stationary boxes containing short lines of bouncing data ricocheting off the corners of the screen, like bullets in a video war game. At Jack’s quick mouse caresses, layers of colored lines of data scrolled smoothly up and smoothly down. Pausing for breath, a line of HEAL moved from the left (the “Past”) to the right (the “Present”). Yes—the number of platelets in her blood.

“It’s one,” said Jack. “Per mil.”

“What?” Fats blurted out. “One little platelet?” We all knew the normal range was between 450 000 per ml and 150 000. This “one” was 149 999 below the lower limit of normal. Platelets are necessary for blood clotting, and life. This lonely “one” meant that she was about to bleed out internally and die. “Shit!” he cried. “She’s seventy-two. Young enough to die!”

“Suresure. Gotta be an error. I’ll check.” He searched the micro-ordered chaos on the big screen, found and clicked a “Question?” box. We waited. My thought? She’s bleee-ding. We waited more. Still bleeee-ding. A second box appeared, labeled: “Gotta be an error?” Jack clicked it. We waited more more. Please, HEAL, don’t freeze! Is the box locked?

Still waiting.

The box unlocked and answered, for some reason in Spanish: “Uno es correcto.”

“Let’s move!” Fats shouted, quickly up on his feet. “Mo?”

Mo led us into the room. Mrs. Burke was a thin, white-haired woman looking younger than 72, restless, fear in her eyes. The nurse was bending over the bed, putting pillows between arms and legs and bed rails. Wherever Mrs. Burke’s skin was in view, it was bruised black-and-blue. Her face looked like a loser’s in a prizefight.

“Hello,” Fats said, smiling, introducing himself, and then sitting on the edge of the bed so he was at black-eye level with her. “How we doin’, Mrs. Burke?”

“Not too bad.”

“You sure got a lot of bruises all of a sudden, eh?”

“Tell me something I don’t know,” she said quietly, shaking her head, then looking down into her lap. Her attention was focused inward, on her plight, on dying.

“Y’got me there!” he said, smiling. She glanced up at him, managed a grim smile, then, her lip quivering, looked back down. “Scared, huh?” She looked up, her eyes wet—and quickly looked away. And then, strangely, nothing happened—a lot of nothing, for what seemed a long time. Finally, Fats put his hand on one of hers, on the edge of a violet bruise shaped like Florida. “I’m sorry you’re scared, dear. We’ll take care of you.” A slight nod. He asked two or three pointed questions. No luck. “Okay, we’re gonna figure out why you’re all black-and-blue, get you outta here soon as we can. Anything we can get for you?”

“Yeah. Get this damn IV outta my arm!”

Fats paused. “What bothers you about it?”

“You ever had an IV?”

“Sure have. You’re right. They’re a pain.”

“I’ve always hated ’em. I want to go home.”

Fats nodded. Noticing that the small bruise beneath his hand had already spread toward another bruise—say, Cuba—he seemed to stroke it with a finger as if he could push the edge back, push it in, down, away, and then looked up at her. Holding her gaze for moment, he said, “I’m sorry. You still need the IV for now. We’ll get it out as soon as possible, and we’ll get you home.” He smiled at her and led us out, down the hall. “Anybody have any ideas?” No one had any. Someone asked if Fats had any. “I got only one. Slim chance. I need HEAL.”

He asked Mo to put up Mrs. Burke’s two recent admissions and the Horseman’s twice-a-year outpatient records in between. Even these few inquiries were cluttered up, entrapped in an avalanche of data that, I imagined, could have sent Mrs. Burke to Mars and back. For two years in the Indian Health Service, I had used the federal government E-GOV program, used also by Veterans Administration hospitals and clinics all over the USA. It was old and clunky, but friendly to docs and patients. It actually let you open up blank screens to write longer notes. Using HEAL was like deciphering the instrument panel of a 747. I wasn’t accustomed to these 50 or so lines of data streaming along, fast, those midget numerals. I soon got vertigo, had to look away. No particular number was highlighted—each onstage for a nanosecond, a poor player who struts and frets and then is swept away. No place to elaborate, write a note, highlight what really mattered in all that electronic mush.

Fats seemed solid in these rapids, looking carefully at the admission four years ago, staring at something, and then to the team’s amazement writing it down on paper in his FMC leather notebook. He then went to the admission from a year and a half ago, at a certain point shouting, “Stop! Freeze-frame, Mo!” Squinting, and then walking even closer until he was big-nose-to-none with the teensy-weensy pixie pixel numerals, he wrote something else down. Finally, he did the same with the current admission.

“Y’got a blackboard here?”

“A whiteboard, suresure,” said Jack, “a dry board. With erasable Magic Markers!”

“We gotta move, pronto. I’ll be brief.” On the whiteboard in CAPS, he charted a grid with the values for each of two admissions: platelet count versus antibiotic, and the Horseman’s outpatient blood values in between—all normal. On the most recent admission, 14 months ago—with the urinary tract infection—by the end of her stay, there had been a small drop in the platelets, with which she had been discharged. She had recovered soon after. There was no note from her resident about that small drop—because, even if it had been noticed, there was no place in HEAL to write a note as to why. This time, the same antibiotic had been given, and the huge drop was about to kill her.

“The answer’s right there,” Fats said. “Anybody else see it?” Nobody did. “Mrs. Burke told us what it is.” Blank. “What’s the difference between her treatment outside the hospital and inside the hospital?” No one knew. “Think.” Think we did. Nothing. “Okay. A hint. What’d she say was bothering her?”

“The IV,” several of us said.

“Good. So, both outpatient and inpatient she gets the same antibiotic, fluconazole. But outside it’s pills. Inside it’s IV. She’s suffering a rare side effect of the flucon that’s seen only in IV administration. Believed allergic. Sensitized via beta-four-y-immunoglobulin. Reversible.”

The fingers of the team members flexed Googley to look up the citation.

“Stop! Heads up!” Shocked, all stopped. “How ’bout before we google her, we save her life? Jack, write the order to stop the IV stat—and keep transfusing her platelets.”

Jack clicked in the orders. And sat back. “Ja-a-ck,” Fats said, “now you go and tell the nurse in person.” Jack did not move. “Junior? Move!” Startled and astonished, Jack left.

Fats referenced two articles, with the admonition: “Do not look at ’em now. Look at, and listen to, Fats.” All did. “So we got bad news and good news. The bad news is that we almost killed her with our ‘care’; the good news is that we saved her from our care. It’s called iatrogenica imperfecta. So, why’d we miss the diagnosis? One: she didn’t point any of you toward it when you spoke with her, right?” Nods. “Even though, deep down, she may have had a sense that somethin’ bad was coming through the IV. There’s no note written that she complained before—’cause HEAL has no box to click for that. Two: I’m all for data, but there’s so much data on HEAL that no human, except for the hint we got, and the ‘think’ we did, could possibly see what was right before our eyes: outside, pills; inside, IV. Nobody noted the big clue from her previous admission, the platelet drop. Again, even if someone had noticed and wanted to note it for future interns, Boss HEAL does not want to deter us from its appointed nanosecond rounds. On screens of one med school’s electronic record, I created ‘blurbs’: heart-shaped circles rimmed in hot scarlet that ‘pulse’ on-screen to get attention, inside of which there’s room for docs to write brief thoughts, understandings—to tell the next doc what to be alert to in this person. Here, if there’d been space for just one highlight blurb: ‘Unresolved why platelets started down before discharge—find cause.’ Bingo! It’s top of the problem list upon her next admission! If we’d’a had that, she wouldn’t’a had this.” He sighed. “So with everybody looking carefully at the screen, what didn’t happen?”

“Keeping it simple,” said Mo.

“Exactly. What didn’t happen was, simply, a pause. To muse. To think. We gotta think to pause, and we gotta think to think. None of us took that space of time and relief from this million-pixel mishegas to think. It was all here. We all technically saw it, but it didn’t sink in, so we didn’t see it. No time to understand it. You can’t click into the same stream twice. And don’t forget, the one clue came from what?”

“Suresure,” said Jack, back, “listening to the patient. But everybody hates IVs.”

“Uh-huh, but there was something else in her as she told us—a feeling. Anybody get that?” Mo and another med student nodded. “And why’d she show us that feeling? Because she felt connected, with me, with us.” He paused. Others nodded. “I picked up, in my body, a sense. As a doc, sometimes your instrument is your own body, your own heart—the one thing that you can’t screen out.” He blinked, smiled. “But hey, let’s not blame ourselves. In the face of all that big data, it would take a genius to use common sense, to think to think, and understand. Blame the electrical engineering grads, isolated out in Cheese Country, Wisconsin, who designed HEAL with one primary goal. Which is? Med students only.”

“Having all the data at your fingertips?”

“Streamlining patient care?”

“Maximizing safety and quality of care?”

“Real-time response to changes?”

“Nope,” said Fats. “A hint: clicking boxes. By the way, how many of you like having to click on those cute boxes—”

The team began screaming. Two nurses rushed in, were told, and started screaming. Others came, and others, and soon we all together were screammmmming!

“Ohhh-kay, team!” Fats said. “High fives!”

A lot of high fives.

“Those boxes are a pain in the ass. Why? Because new good studies show they don’t improve patient safety, or quality of patient care. With each of us doing eight thousand clicks a shift, mistakes are inevitable—and sometimes deadly! In fact, they don’t have much to do with good patient care at all.” He paused. “And what do they have everything to do with?”

“Billing! Money! Cash! Profit! Money laundering!” etc.

“Yes, yes,” Fats said sagely. “Finally. The Wisconsin cheesers want money. For us docs to find the key clinical-care data in that cheesy machine is hard! Starling’s law: the more data, the less understanding.” He rose. “Fun, eh?” Nods. “Basch, Humbo, and I will follow Mrs. B with interest. Come visit the FMC, do a rotation. We love med students.”

“Hold on,” said Jack. “There’s no need, in front of these young physicians and top med students, to be so cynical, to trash high-tech Electronic Health Records and HEAL.”

“Cynical? Me? I feed on ideals, on ideal care. I’m so idealistic, to you I sound cynical! And I do not call ’em Electronic Health Records, ’cause they don’t help with health, and may well harm it. With a screen between you and your patient, you get distracted, right? A lotta medical mistakes are made—errors in dosages, wrong data entered. Real harm is done to patients. Lots of accidents. It’s like texting while driving. We docs are distracted.”

He paused to let this sink in.

“So, to remind us of the danger, let’s call ’em EMRs, the ‘M’ for ‘Medical.’”

“A distinction without a difference,” Jack said. “Face it. Without HEAL’s recording everything, like the outpatient data, you wouldn’t’ve been able to crack the case, and—”

“The case? You don’t mean that sweet Mrs. Burke, do you?”

Jack steamed. “Whatever. You and her woulda been nowhere without HEAL.”

“Really? Without it, I woulda paged her doc stat, had a chat, worked it through quick. Or leafed through the written charts—brief, thought-through notes passing along not only the info or knowledge, but un-der-stan-ding. What we docs value and are valued for. Y’can forget information and knowledge; y’never forget what y’understand. And now? Understanding? Lost somewhere out on a cheese farm in Wisconsin.”

He checked his watch—pricey, the workings visible amidst a coral reef of gemstones.

“I love great tech. It could be dynamite for docs. I design tech for my clinical venture in Silicon. But I can’t stand monetized crap tech like HEAL—even if it trumps EPIC.”

“Excuse me, sir.” Clearly a med student. “What can we do to heal?”

“HEAL the machine, or heal the patients?”

“The patients.”

“Any of you ever rotate through the veterans hospital, use those computers?” Nods all around. “What’d you think of ’em? I mean, compared to HEAL.”

“Really good,” said Mo. “A lot easier to use.”

“Yeah,” said a student, “they even let you free-write notes on your patients. You can click to get a clear screen to write in. HEAL won’t let us do that.”

“Jack?” Fats asked.

“Yeah,” he said surlily. “More friendly user interface. Everybody knows that.”

“And,” I said, “the VA and the Indian Health Service are all connected to each other. You can get on every other VA or IHS computer in America, in a flash.”

“Which HEAL and the others can’t do,” said Fats. “So why’s the VA much better?”

Silence. Then Mo spoke up. “Because there’s no billing, no profit. Like Medicare.”

“Exactly. Nobody’s makin’ money offa it. So we all gotta get together and unhook care from billing. So nobody makes an obscene profit offa the sick.”

Jack was turning red, up toward his birthmark. “You want government insurance? Where’ll you get the money? Eat the rich—” He got redder. “I mean, tax the rich?”

“Works for me,” I said, “works for the civilized world.”

Fats mused for a moment, actually mused. “No wonder America’s left with Velveeta Health.” His eyes got hot. “New law: Learn your trade, in the world.”

Blank looks from the team.

“What’s that mean?” Mo asked.

“The patient is never only the patient—the patient is the world. The family, the friends, the housing, the food, the toxins, where the water comes from, where the garbage goes, the politics, the government, the ailing climate. The world’s in the room now. We can’t screen it out! The earth is in the room. We and our patients are the earth—made of dirt and seventy percent water, with a thin membrane of skin between, right?” Nods. “Dust to dust, ashes to ashes. None of us are here for long. We and the patient are the world.” He beamed out Fat Man Gratitude. “You all did good—you listened, about why you couldn’t listen to Mrs. B. Don’t blame yourselves. We’re all at the mercy of the Man and his Machine.” He tried to get up from his chair and failed. He grimaced, tried again. Succeeded.

“How can we be sure, sir,” said a med student, “that this won’t happen to her again?”

“Be creative. And be deft. Find a way to make a note in HEAL that will be noticed by future docs, but not by the HEAL Police. Hey—her next admission, how ’bout going around the hospital and writing it in crayon on all the HEAL screens?” We all laughed. “Seriously. Try to put a noticeable note in HEAL. Mo? Can you find a way to do that?”

“No. I’m only a med student.”

“Hey—nobody’s ever ‘only’ anything, okay? And because you’re so fresh, you’re a gift.” She blushed. “Jack? Your thoughts?” Jack sulked. Fats smiled, put his arm around his shoulder. “Jack? Jah-ack! This ain’t a contest. We’re all in the same boat—it’s called learning. We all used to do a lot of it, when we were kids. Remember?”

Jack struggled, then grinned, turning back into Jah-ack. “Yeah. Okay.”

“Good. Basch, Humbo—vamos.”

“Wait,” I said. “Someone has to explain to her what happened, tell her she’ll be fine.”

“Tell her the IV med was an error?” said Jack—going from Jah-ack back to Jack.

“You can’t not,” I said.

Jack looked at Fats, who nodded. “Okay. But d’ya know she’s gonna be fine?”

“Telling her she’ll be fine—and meaning it—will help her be fine. Read the literature—good news maximizes good results. Bad news, delivered badly, screws people up. Morbidity and mortality rise, confirming the bad news. And when a doc says, ‘You have only X months to live’? It crushes people. People die sooner.”

“Oh, boy,” Jack said with contempt. “The placebo effect, suresure.”

“What’s wrong with an effect without side effects?” I said. “Better than most meds.”

“Great—go ahead and give ’em false hope.”

“How can you know it’s false?” I asked. “Belief in something beyond yourself isn’t false. It’s a touch of the spirit smacking up against the medical machine. Hope is sacred. Try it.”

“Sí, sí,” chimed in Humbo. “The very church miracle is done with the plachaybos.”

“Did y’see the new research paper on placebo, Jack?” Fats asked. “They found the enzyme, a COMTgene variant—and guess what turns it on. Good human connection. Being with.

Jack had dived back into his “I”-pad. Clearly these words didn’t compute.

“Oooh-kay,” Fats said. “So who’s gonna tell her she’ll be fine?”

“May I do it?” asked Mo. “I really like her. We talk a lot. I’m the only one who has time to talk. Because med students aren’t allowed to click on the billing boxes.”

The Fat Man reached into his shirt pocket and came out with a neon orange plastic fork that had on the other end a spoon, and along one side serrations of a knife. Waving it as a Day-Glo magic wand over Mo, he intoned, “Since you didn’t forget to say ‘May I?’, by the power vested in me by the Attending Woman Doctor in the Sky in the Big White Bathrobe and Beard, I hereby appoint you”—he squinted at her name tag—“‘Mocha’ . . . ?!”

“I know,” she said. “It’s weird—they met over coffee at Peet’s and—”

“Weird hell. Delicious.” He cleared his throat, a royal “Ahem.” “I hereby appoint Dr Mocha Ahern to sincerely tell the truthful and even really good news to that cute Mrs. Burke and bless your heart.”

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Article Information

Corresponding Author: Samuel Shem is the pen name for Stephen Bergman, MD, DPhil, NYU School of Medicine (sshem@comcast.net).

Published Online: October 15, 2019. doi:10.1001/jama.2019.16384

Conflict of Interest Disclosures: Dr Bergman reports receipt of royalties from books, plays, and other works.

Additional Information: Excerpt from the book Man’s 4th Best Hospital by Samuel Shem, to be published on November 12, 2019, by Berkley, an imprint of Penguin Publishing Group, a division of Penguin Random House LLC. Copyright 2019 by Samuel Shem.

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    1 Comment for this article
    Can't Wait!
    Yasser Abdullah, MRCS Ophthalmo Edinburgh | University of Edinburgh
    Revolutionary, as it's expected to be. Your House of God changed my life, my career and my choices. I lived through similar experiences in my internship and residency. I lost faith in Medicine until I read it. I hope this sequel will be a warning, a pre hoc reflection and an inspiration of how we will make choices in our future practice.
    I can't wait to read the book.