PERSPECTIVE PATENTS, PRO FITS, AND THE AMERIC From the Center for the History of Medi-(Technology Quarterly). December velopment: patents and technol cine, University of Michigan, Ann Arbor (http:/www.economist.com/node/14 3. Schacht WH. The Bayh-Dole Act: s 1996;82:1663-727 1. The University and Small Business Patent issues in patent policy and the cor 5. Stevens A). Th ent of Bayh-Dole. 1980.94Stat.3015 2012. ok:101056/NEMp1306553 2. Innovation's golden goose. Economist 4. Eisenberg RS Public research and private Copyright e 2013 Massachusetts Medical Society. "Good"Patients and"Difficult "Patients-Rethinking Our definitions Louise Aronson M. D our weeks after his quadru- ratory abnormalities, except that a daughter and leave the doctor- ple bypass and valve repair, the INR was above the target ing to others. But I had been 3 weeks after the bladder infec- range. The doctor guessed the holding a thought just beyond tion, pharyngeal trauma, heart trouble was a bit of dehydration. consciousness, and not just be- failure, nightly agitated confu- He would watch for a while, just cause I hoped to remain in my sion, and pacemaker and feed- to be safe assigned role as patient's off- ing-tube insertions, and 2 weeks My mother waited with my fa- spring. At least as important, I after his return home, I was help. ther. The rest of us filed in and didn ' t want to be the sort of fam ing my 75-year-old father off the out, not wanting to crowd the ily member that medical teams toilet when his blood pressure tiny room. Then my father's complain about. Now that I'd ap- dropped out from under him. As blood pressure dropped again. I parently taken on that persona, did his legs. old the and stayed out of there was no longer any point in held him up. I shouted for the way She silenced the alarm, suppressing the thought. Al- my mother. As any doctor would, upped ids, and rechecked though the differential diagnosis I kept a hand on my father's pulse, the blood pressure. It was better. for hypotension is long, my fa- which was regular: no pauses, no But less than half an hour later, thers heart was working well, accelerations or decelerations listened as the machine had adhered to the carefully cal- My mother was 71 years old scanned for a reading dropping culated regimen that we'd re- and, fortunately, quite fit. She from triple to double digits be- ceived for his tube feeds and free had been making dinner and said fore it found its mark. The num- water intake, and he did not have she dropped the salad bowl when bers flashed, but the silenced new medications or signs of in- I yelled for her. She took the stairs alarm remained quiet. I pressed fection. Those facts and his over- two at time. Something about my the call button, and when the ly thin blood put internal bleed- tone. she said nurse arrived I asked her to call ing like a neon sign at the top of Together, we lowered my fa- for the doctor. When ne the differential ther to the bathroom floor. I told came, I went to the nursing sta- I rested my hand on my fa- her to keep him talking and to tion and made my case to the ther's arm to get his attention call me if he stopped, and then assembled doctors and nurses. and said, "Dad, how much would I dialed 911 They were polite, but their un- you mind if i did a rectal o In the emergency department, spoken message was that they We doctors do many things ter some fluids, my father felt were working hard, my father that are otherwise unacceptable better. My mother held his hand. wasn't their only patient, and We are trained not only in how We compared this new hospital they had appropriately prioritized to do such things but in how to with the last one where we'd their tasks. I wondered how many do them almost without notic pent so many weeks but which times I had made similar assump- ing, almost without caring, at had been diverting ambulances tions and offered similar assur- least in the ways we might care elsewhere that evening. The doc- ances to patients or families in different circumstances or set- tor came in and reported no ECG After weeks of illness and tings. A rectal exam on one' changes and no significant labo- caregiving, it can be a relief to be father, of course, is exactly the ENGLJMED 369: 9 NEJM.ORG AUGUST 29, 2013PERSPECTIVE 796 n engl j med 369;9 nejm.org august 29, 2013 Patents, Profits, and the American People From the Center for the History of Medi￾cine, University of Michigan, Ann Arbor. 1. The University and Small Business Patent Procedures (Bayh-Dole) Act of 1980. Public Law 96–517, 96th Congress. December 12, 1980. 94 Stat. 3015. 2. Innovation’s golden goose. Economist (Technology Quarterly). December 12, 2002 (http://www.economist.com/node/1476653). 3. Schacht WH. The Bayh-Dole Act: selected issues in patent policy and the commercial￾ization of technology. Washington, DC: Con￾gressional Research Service, December 3, 2012. 4. Eisenberg RS. Public research and private development: patents and technology trans￾fer in government-sponsored research. Va Law Rev 1996;82:1663-727. 5. Stevens AJ. The enactment of Bayh-Dole. J Technol Transf 2004;29:93-9. DOI: 10.1056/NEJMp1306553 Copyright © 2013 Massachusetts Medical Society. “Good” Patients and “Difficult” Patients — Rethinking Our Definitions Louise Aronson, M.D. Four weeks after his quadru￾ple bypass and valve repair, 3 weeks after the bladder infec￾tion, pharyngeal trauma, heart failure, nightly agitated confu￾sion, and pacemaker and feed￾ing-tube insertions, and 2 weeks after his return home, I was help￾ing my 75-year-old father off the toilet when his blood pressure dropped out from under him. As did his legs. I held him up. I shouted for my mother. As any doctor would, I kept a hand on my father’s pulse, which was regular: no pauses, no accelerations or decelerations. My mother was 71 years old and, fortunately, quite fit. She had been making dinner and said she dropped the salad bowl when I yelled for her. She took the stairs two at time. Something about my tone, she said. Together, we lowered my fa￾ther to the bathroom floor. I told her to keep him talking and to call me if he stopped, and then I dialed 911. In the emergency department, after some fluids, my father felt better. My mother held his hand. We compared this new hospital with the last one where we’d spent so many weeks but which had been diverting ambulances elsewhere that evening. The doc￾tor came in and reported no ECG changes and no significant labo￾ratory abnormalities, except that the INR was above the target range. The doctor guessed the trouble was a bit of dehydration. He would watch for a while, just to be safe. My mother waited with my fa￾ther. The rest of us filed in and out, not wanting to crowd the tiny room. Then my father’s blood pressure dropped again. I told the nurse and stayed out of the way. She silenced the alarm, upped the fluids, and rechecked the blood pressure. It was better. But less than half an hour later, we listened as the machine scanned for a reading, dropping from triple to double digits be￾fore it found its mark. The num￾bers flashed, but the silenced alarm remained quiet. I pressed the call button, and when the nurse arrived I asked her to call for the doctor. When no one came, I went to the nursing sta￾tion and made my case to the assembled doctors and nurses. They were polite, but their un￾spoken message was that they were working hard, my father wasn’t their only patient, and they had appropriately prioritized their tasks. I wondered how many times I had made similar assump￾tions and offered similar assur￾ances to patients or families. After weeks of illness and caregiving, it can be a relief to be a daughter and leave the doctor￾ing to others. But I had been holding a thought just beyond consciousness, and not just be￾cause I hoped to remain in my assigned role as patient’s off￾spring. At least as important, I didn’t want to be the sort of fam￾ily member that medical teams complain about. Now that I’d ap￾parently taken on that persona, there was no longer any point in suppressing the thought. Al￾though the differential diagnosis for hypotension is long, my fa￾ther’s heart was working well, I had adhered to the carefully cal￾culated regimen that we’d re￾ceived for his tube feeds and free water intake, and he did not have new medications or signs of in￾fection. Those facts and his over￾ly thin blood put internal bleed￾ing like a neon sign at the top of the differential. I rested my hand on my fa￾ther’s arm to get his attention and said, “Dad, how much would you mind if I did a rectal?” We doctors do many things that are otherwise unacceptable. We are trained not only in how to do such things but in how to do them almost without notic￾ing, almost without caring, at least in the ways we might care in different circumstances or set￾tings. A rectal exam on one’s father, of course, is exactly the