Medicine's Fading Traditions of Generosity

What is the mission of a hospital?
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Sterilizing surgical supplies at Methodist Hospital in Indianaopolis, ca 1920 (Methodist Health Foundation)

It is difficult to fathom the dramatic changes that have taken place in hospitals over the past three-quarters of a century. Recently a friend shared with me a 70-year-old hospital pamphlet that was distributed to patients when they were admitted to Methodist Hospital of Indianapolis, which at the time was the sixth largest hospital in the United States. Its pages call to mind the remarkable progress that has taken place in medicine over seven decades, as well as painful reminders of some things that hospitals and their patients are losing.

Hospitals do well to look not only forward to a future of ever more sophisticated and remunerative care, but also back to a rich tradition of service and generosity.

On the upside, hospital care has been transformed by major scientific and technological advances in medicine. Thanks to MRI, CT, ultrasound, and endoscopy, physicians can now see much more clearly what is going on inside the body without cutting it open. A number of new therapeutic agents are available, such as ACE inhibitors for blood pressure, statins for serum lipids, and proton pump blockers for peptic ulcer disease. And new forms of surgery have been introduced, including cataract extraction and lens implant, hip and knee replacement, and organ transplantation.

The contemporary hospital experience also boasts far more creature comforts. Rooms are climate controlled and smoke free. Patients need not eat whatever is served to them, but can order from a full menu. Television and Internet access are available in each room. Hospitals now compete with one another in pampering their denizens, offering such amenities as high-thread-count sheets, concierge services, gourmet chefs, and on-site spa facilities. Some even boast that their staffs have been trained by the likes of the Disney Institute to deliver customer-pleasing service.

SHARK300200.jpgNurse Florence French at Methodist Hospital, ca 1925 (Methodist Health Foundation)

Of course, such opportunities come at a price, and increasing price represents one of the major drawbacks of the progress over the past 70 years. Back then, several types of accommodation were available, including a ward bed with a half-dozen or more other patients, a two- or three-bed room, a private room, or even a deluxe room with a private bath. The daily price for even the latter option was only $25, a private room varied between $6 and $8.50, and a ward bed cost just $3.50. These charges covered not just the room but also meals, nursing, house physician, and surgical dressings.

The dollar today not being what it was 70 years ago, of course these numbers need to be multiplied by at least 10 to put them into contemporary terms. Nonetheless, hospital care was a bargain compared with today, when a day in the hospital, not counting the fees for physicians, medications, and procedures, generally runs at least $2,000. And it deserves repeating that many of the services we now take for granted, including tests such as mammography, drugs such as SSRIs and newer antidepressants, and procedures such as laparoscopic surgery, were not available then at any price.

Another big change concerns the people running the hospital. Back then, the administrator in charge of day-to-day operations was called the superintendent, and he was a Methodist minister. The pamphlet bears a handwritten note from his desk, expressing the hospital's intention to provide the "very best care" and urging patients in need to phone his office, whose primary purpose was to minister to the sick. Today the administrator typically bears a business title such as CEO, and he or she is flanked by a CFO, a COO, and a legion of other staff whose degrees are far less likely to be in ministry than business.

The hospital also now employs large divisions of people in fields such as billing and coding, regulatory compliance, and marketing who barely existed 70 years ago. Whole new layers of management have been introduced, with the result that the hospital devotes a much smaller proportion of its much greater revenues directly to patient care.

When the superintendent was a clergy person, the hospital tended to be more focused on its religiously inspired charitable mission. It had been founded by people who saw service to the community not only as a duty but a privilege, and for whom business concerns were secondary. For example, the pamphlet states that "an entrance deposit is kindly requested (not demanded)," and "it is not our policy to disturb the patient regarding bills unless absolutely necessary." Patients were explicitly requested not to tip the staff.

Presented by

Richard Gunderman, MD, PhD, is a contributing writer for The Atlantic. He is a professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the Radiology Department, at Indiana University. Gunderman's most recent book is X-Ray Vision.

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