Raymond Chandler
Strand Magazine
October-February (2017-2018)
Issue 53
655 words
According to the Art:
In a 655-word short story, Raymond Chandler captures a range of problems in American health care of the late 1950s. Readers in the third decade of the 2000s will recognize a similar set of problems.
Synopsis:
The Strand Magazine is a source for “unpublished works by literary masters.” The October-February (2017-2018) issue includes a Raymond Chandler short story that has never before been published. Chandler wrote crime fiction for the most part, and the stories usually involved the fictional detective Phillip Marlowe. This story, however, written between 1956 and 1958, centered on how American health care fails people who need it when they can’t pay for it or look like they can’t pay for it.
In this story, a man who has been hit by a truck is brought into the emergency department at “General Hospital.” He arrives just before shift change and so the admitting clerk is already annoyed. The clerk checks the patient’s pockets for the required $50 deposit and finds nothing, so she could now send the patient to the county hospital, and that would be that. But, before she initiates the transfer, she asks a passing private attending physician to look at the patient. He sees that the patient is dirty, smells of alcohol, and would cost a lot to work up. Mindful of an admonition from a major donor that the “hospital is not run for charity,” the physician surmises the patient is “just drunk,” and agrees the patient should be moved to the county hospital. So off the patient goes.
The next day, the same admitting clerk at General Hospital gets a call from the county hospital. She’s informed that the patient they transferred had a head injury requiring surgery, and that the patient had $4,000 in a money belt inside his undershirt. The patient couldn’t be saved, however, because of the delay involved in the transfer to the county hospital. It’s all right—he only died.
Analysis:
Chandler gives us a view into what was going on in American health care during the latter half of the 1950s, or at least what was going on in hospitals. He shows us that even then money was a determinant in whether people could get health care services. This state of affairs apparently troubled him. He would probably be much more troubled and much more scathing if he had written the story at the time it was actually published.
Chandler would have seen his story played out over and over again in American health care. Scenes like the one in his story became so common that patients like the character in his story were sometimes given an institutional class distinction as “GOMERS,” which is an acronym for Get Out of My Emergency Room. GOMERS entered the medical vernacular in 1978 with the publication of The House of God, and its place in the vernacular has persisted. (I saw versions of this story take place on a regular basis when I worked in a large, private, university-based, referral hospital between the late 1970s and early 1990s. I often heard patients referred to as GOMERS, and fervently hope I never heard it from my own mouth, but fear I could have.)
Hospital personnel literally reaching into the pockets of unconscious patients to see if there’s enough cash for admission is not what Chandler would have witnessed, but he would see them still check for money in the form of an insurance card. Indeed, he would see that the scenario he described had progressed to a degree that people are moved around among different health care providers because of financial contingencies built into health care insurance plan designs (i.e., “restricted networks”).
Scenes like the one portrayed in this story have not gone unnoticed, and escalating negative reactions from patients, families, policymakers, news media, and health care providers themselves have led to the patient-centered care movement. This movement has produced important advances in health care practices, but as yet only spotty and still the exception. Perhaps patient-centered care advocates could add this story to their arsenal.
Chandler would not likely be satisfied with such an effort, even if successful, because he locates the problem where human folly meets money. In his author’s note accompanying the story, he uses the attending physician’s behavior to illustrate his point.
All he had done was disgrace himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long–acquired skill might help or save…Why should a doctor in such circumstances be better than other men? The answer is simply, that if he isn’t, he is not a doctor. The $4,000 would have made quite a difference in this case, wouldn’t it? Should it?
And, Chandler was able to give us all these insights on the ills of health care as they were when he wrote the story, and as they remained sixty years later, in a story of only 655 words (shorter than this review). Were that health care today was so effective and efficient; were that health care had since addressed the ills Chandler knew about long ago.
Also:
A version of this review is posted at the NYU Literature, Arts and Medicine Database
This story, along with the Chekhov’s short story, At the Pharmacy, and the novel, The House of God, were featured in an episode of the podcast, The Clinic & The Person, I cohost with Dan Albrant and with executive producer Anne Bentley.)
