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.

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.

How many contemporary patients, facing today's health-care costs, would even think of tipping the hospital staff? Now unless patients presenting to hospitals are suffering from an immediately life-threatening condition, they are unlikely to get much past the front door unless they prove their ability to pay for the facility's services. The first thing we biopsy is not the lesion but the wallet. Today it is sometimes truer to say that hospital are businesses whose product happens to be health care than health-care organizations that need to operate according to sound business practices.

The first motorized ambulance in Indianapolis, 1910 (Methodist Hospital Foundation)

In the past, hospitals were teeming with volunteers - pink ladies, candy stripers, the women's auxiliary. For example, 70 years ago the White Cross gift shop at Methodist Hospital was operated by the women's guild, an organization of over 2,000 volunteers. As the pamphlet states, "all receipts above cost go to the Free Bed Fund to pay for helpful service to the poor." Beyond raising money, the gift shop aspired to be "a happy place to visit, not just because it is most beautiful and served by the lovely White Cross women, but because it is an ideal of social helpfulness for the benefit of the sick."

Many contemporary hospitals - protestant, Catholic, Jewish, and non-sectarian - share such a charitable heritage. And in many, there are still volunteers manning the information desks, distributing reading materials, and shepherding patients and families around facilities. But the spirit of volunteerism in hospitals has diminished. Health care is now a huge business, generating more than 20 times its former levels of revenue in real dollars. Today people laboring in health-care institutions expect to be handsomely compensated for their work. If the work is truly important, many reason, the hospital will pay for it.

The Methodist Hospital pointed with special pride to its emblematic beacon, a lighthouse, perched atop its roof. It was intended "to remind every passerby that the hospital is a haven of safety, beaming out the truth of the unity of science, religion, and philanthropy to save humanity from its ills." In its past, the hospital espoused the view that medical science and technology can achieve their full fruition in patient care only if wedded to dedication to a higher calling and the belief that we exist not to enrich ourselves but to serve others.

These were noble sentiments then, and they are no less so today. The very word hospital comes from the same root as hospitality, and it was widely understood throughout most of the history of hospitals that their mission is to serve, to serve as a sanctuary and place of healing, and to serve as such a sanctuary above all for those in greatest need, regardless their financial circumstances. While the practical pursuit of such noble aspirations is in many respects more complicated and difficult today than 70 years ago, its worthiness has in no way diminished.

Hospitals administrators are often hired, fired, and rewarded according to their institution's number of beds, the sum of its net revenues, and its local and national rankings -- the sorts of measures that board members and community leaders find most readily comparable. At their best, however, hospitals are not merely successful businesses. They are service organizations, embodying some of the noblest human impulses of any age. As such, 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.