Hospitals as They Are
I
‘THE best is none too good for the sick.’ A nice, comfortable precept. We complacently assume it to be the guiding principle of hospitals, until personal experience or observation makes us skeptical.
Hospital service has become as important a factor in community life as police and fire service. As medicine advances, it becomes more and more the application of complicated technique, requiring much machinery, by groups of doctors and associated workers. Hospitals offer superior facilities, in some communities the only facilities, for this kind of work.
If ‘ the best is none too good for the sick,’ this ought to mean all the sick. As far as essentials go, there ought to be no distinction between the poor, the moderately well off, and the rich. Poor patients get good food and nursing, and in some hospitals, as will be shown later, a little better average of medical service than pay patients. But they do not generally get the inestimable right of privacy. In the common type of semiprivate hospital, which takes both indigent and pay patients, we find, not the equality and privacy of a well-ordered prison, but as many class distinctions as aboard an ocean liner. In city, county, and state hospitals there may be but one class, the ward, corresponding to steerage; and some private hospitals are all first cabin de luxe, for the rich only.
The hospital ward where, in beds a few feet apart, a sensitive, pain-racked patient lies between one in the delirium of fever and another in the throes of a hard death; where sleepers are awakened when a screaming accident, victim is trundled in; where the most private functions of the body must be performed in public, or with no more seclusion than a bit of muslin screening affords, is a relic of mediæval brutality and caste distinction that has no proper place in modern life. Personal privacy is a fundamental part of civilized life; why blunt the morale of sick people by depriving them of it?
Hospitals with ward services have some facilities for isolating patients whose presence in a ward is frankly impossible, but too often such facilities are hardly adequate for extreme emergencies like delirium tremens, acute mania, or contagious disease developing after admission. If isolation space equals 20 or 25 per cent of ward space, it can be used to modify the bad conditions mentioned. This ought to be considered in enlarging existing hospitals. If a hospital with a hundred ward beds is adding twenty-five more, twenty-five small rooms, instead of ward space for the same number of beds, will take care of disturbing night admissions and provide privacy for ten to twenty patients who, for their own sake or that of others, need it most.
Some palients, mostly men not critically ill, profess to enjoy the companionship the ward affords; but their talk is hard to control and annoys those sicker than themselves. Social contact among hospital inmates is good or bad, according to their condition and the effect of their condition and behavior on others. When such contact is advisable, it should be intermittent, as in normal life, not constant. Sun parlors, roof gardens, and porches are the right places for getting together. When adequate in area, they can be used by a large proportion of patients, including some who cannot get up, if beds have large casters to permit easy wheeling.
The objections to herding adult patients in wards do not apply, in the same degree, to children. Their appreciation of privacy is not fully developed; they have more of the herd instinct than adults, and are not so profoundly affected by the proximity of suffering and death. A practical and pleasant arrangement for them is small wards of from three to six beds, the inmates to be carefully grouped, and single rooms in the proportion of one to each little ward.
I am opposed to large wards for patients of any age, for reasons not only of comfort and decency, but also of immediate safety. Drafts and dust, twin promoters of pneumonia, are harder to keep down to a minimum. My surgical work has been largely among elderly, debilitated men, and I have found these old gentlemen decidedly more apt to get post-operative pneumonia in wards than in private rooms.
The architectural changes are, for the most part, impossible at the present time. But their realization on a large scale in the near future is possible if the idea is kept, before the public, who will have to demand better accommodations for poor patients before the architectural and medical professions will concern themselves much about it. American hospitals, in normal times, grow so fast in size and number and, according to American standards, become obsolete so soon that, as economic conditions improve, we may expect much building of new hospitals and rebuilding of old ones. The ‘room for every adult patient’ plan does not mean that the cost of comfort, decency, and increased safety would be exorbitant. Narrow, built-in fixtures will reduce movable furniture to a bed and small bedside table. No space need be allowed for handling stretchers, because the use of portable beds will do away with them. The result of such economy of space will be rooms of practical size, yet so small that an average ward could be converted into them at a loss of not more than 25 per cent of its normal capacity. For obvious reasons, construction and operating costs will be somewhat higher. In hospitals, as elsewhere, what is worth having has its price.
II
There are two major defects in our hospital system. The first, herding in wards, already described, exists in practically all public and semiprivate hospitals. The second does not exist in the minority of hospitals that stand at the top. It does exist, in varying degrees, in the majority. It is lack of effective teamwork among the hospital physicians themselves, and between them and the nursing and administrative bodies. To understand this condition, we must trace its origin.
A community — anything from a prairie town to a neighborhood section of a big city — needs a hospital. The local doctors, or enough of them to assure medical support, having approved the project, a hospital organization is built up among the local public, with governing power vested in a board of trustees, if the hospital is to be nonsectarian, Protestant, or Jewish, on which doctors may or may not be represented. If it is to be Catholic, it will be governed by some order of nursing sisters. This governing body, whatever it may be, appoints the hospital doctors — must appoint them, in fact. During the formative period of the hospital there will be medical leadership of some sort, official or informal, and it will coöperate with the governing body in assigning doctors to the positions they are, presumably, best qualified to fill.
This is the semiprivate general hospital, the prevailing type in the United States, and the only one we need consider in detail. It operates as a private charity, doing the ordinary run of medical and surgical work, but excluding insane and highly contagious cases. It takes private, part-pay, and free patients. Part-pay and free cases outnumber private ones. To cover the cost of taking care of the former, the hospital depends on profit from the latter and various special services; local or other government help, usually inadequate, on a fixed appropriation or pro-rata basis; and income from endowment, if it has any. The almost certain result is a deficit, to be made up by periodical drives, bazaars, card parties, and other approved forms of benevolent extortion. This part of the financing is largely taken care of by auxiliary organizations, such as ladies’ guilds. Private patients are the most variable source of income, and one of the most important; hence the hospital’s efforts are constantly directed to getting more of them. But the methods used are, as I shall show, often damaging to the hospital’s scientific standing, and so defeat their own object.
In any general hospital, however small, five departments are essential: (1) general medicine, (2) general surgery, (3) eye, ear, nose, and throat diseases, (4) X-ray, and (5) laboratory. Other departments vary in number and scope according to the size and policy of the institution. Common ones are diseases of children, nervous diseases, skin diseases, bone and joint surgery, surgery of the female organs, surgery of the urinary organs, and maternity work. A department consists of one or more services, and each service is in charge of an attending physician or surgeon with one or more assistants who are eligible for promotion. The attending doctors and assistants constitute the attending staff. It is a common practice of hospitals to collect the charges for X-ray and laboratory work and pay the heads of those departments a salary or commission; in a few large hospitals, controlled by medical schools and used for teaching, some or all medical and surgical department heads have been put on liberal salaries on the same basis. With these relatively few exceptions, semiprivate hospitals do not and cannot pay their staffs.
The attending staff must treat ward patients free, with some exceptions. In liability cases covered by insurance, it is customary for the carrier to pay the established rate of medical charges as well as the hospital bill. In an average hospital service, the biggest part of the total work is free. This entails a sacrifice of time by attending staff members for which, since they work for a living, they must get indirect compensation. They get it from the prestige a hospital connection gives, from the facilities for study it offers, and from the right that goes with it to use the hospital for their private, pay patients.
The medical profession is not a body of mendicant monks. The abnormally unselfish, self-sacrificing medical drudge, pictured by complaisant clerical, judicial, or political orators at medical banquets, is practically, and fortunately, nonexistent. We are in business. It is not a highly remunerative business, and in obedience to economic law we are bound to give hospitals about what they give us. A hospital of one hundred beds may have enough work in its department of general surgery, for instance, to develop and keep in training two outstanding, 100per-cent surgeons, with enough income from private hospital cases to let them give their whole time to the study and practice of surgery and to hospital administrative details. Split the department into four services and there will be four 50-per-cent surgeons, whose income from hospital work is so limited that they must eke it out by doing general medical practice outside the hospital. Will the community be served best by two expert, full-time surgeons, or by four general-practitioner surgeons whose time for book study, case study, and needed rest is subject to the irregular and urgent demands of a family practice?
III
Here are illustrated two opposite policies for getting private patients.
The scientific policy: Attending doctors are appointed for ability only. The number of services is restricted to a minimum that gives each one adequate experience and a reasonable income from hospital work. They have full control of the medical administration, including the right to pass on applications for staff appointments, so that the control of technical matters is in the hands of a relatively small body of experts in the various branches of medicine and surgery whose interests are closely identified with those of the hospital. They make the hospital and the hospital makes them. Under such a system teamwork, the deciding factor in the makeup of a really first-class hospital, becomes a matter of routine, not of occasional emergency consultations, and diagnosis is a verdict based on the evidence of various experts. Assistants are properly trained and given reasonable opportunities to treat private patients, under supervision of their chiefs. The result is a loyal, cooperative staff and a high-grade, scientific institution which the local public, seldom fooled in such matters, appreciates and patronizes.
The salesmanship policy: The hospital depends mainly on the persuasive efforts of individual staff members to get private patients. The tendency of this policy is toward an overloaded senior staff, which, as has been shown, favors a lowered standard of scientific work and a lax medical administration. A hospital gets started on this course because the medical body lacks strong and progressive leadership. Its staff may represent as much potential scientific ability as that of one rated much higher; the organizing and directing ability to mould a group of average doctors into a cooperative scientific association, and to keep it going afterward, is what is lacking. Private medical practice does not tend to produce this sort of leadership. Involving personal responsibility for life and personal attention to an infinitude of details, it favors the development of minds which, though self-reliant and decisive in individual cases, are poorly qualified to direct the work of others on a large scale.
Most private patients are sent to hospitals by their personal or family doctors, who, when they lack authority or skill to give the needed special treatment, can refer their patients to any qualified staff member. Attending doctors take private cases at all times, whether their ward services are continuous or intermittent. The same right often extends to their senior assistants, often rated as associate or adjunct attending doctors. This means competition between staff members, never an ideal condition. But in a hospital conducted under the scientific policy, competition is dignified and restrained, and is not allowed to hamper cooperation, because control is in the hands of a few real specialists whose own reputations are at stake.
On the other hand, the salesmanship policy tends to make a hospital a competitive arena, where dissatisfied general-practitioner specialists who are economically embarrassed strive, like rival small-town business men, for such meagre pickings of private work as the mediocre reputation of the institution does not drive elsewhere.
Take a hospital of this type, with twice as many attending doctors as it needs, and a like number of senior assistants who have obtained the right to compete on equal terms with their chiefs, because they are good ‘feeders,’ as I have heard them quite shamelessly called, of private work — four times as many would-be specialists as the hospital can develop and provide adequate income for. The worst results of this unrestricted competition are, naturally, in the surgical departments, where the most profit is. Some of our best hospitals allow surgeons to go beyond the limits of their departments in private work, but the common sense and coöperative spirit of the staff keep the practice within reasonable limits. Under less favorable conditions, it may become a free-for-all scramble, disregarding the welfare of patients and making the hospital ridiculous. Thus, an assistant ‘specialist’ in the maternity department may compete, for tonsil operations, with the throat specialist!
The secret splitting of fees, by surgeons, with doctors who send them private work, is a natural product of such an economic environment. Despite efforts at suppression, it undoubtedly persists, and the salesmanship policy favors it. In its worst form, fee splitting is a racket from which political grafters and gang leaders could learn much. The surgeon or other specialist who pays for his cases this way is not the real racketeer; he is rather the victim of extortion which he is too weak, or too hard-pressed, to resist. On the other hand, the racketeer’s excuse is that, in diagnosing and referring the case, he renders a service for which the patient would not be willing to pay an adequate price, hence he must collect through the specialist.
It is evident that in a staff where such conditions exist there will be not only dissatisfaction, but discord, cliques, and intrigue. To paraphrase an old saying: when politics enters at the door, science flies out the window. The governing body, haunted by the everpresent spectre of a deficit, may take alarm and try to restore cooperation and order by forcing a change in the form of medical administration. This is usually a concentration of authority in a small committee or a single medical director. The director system works well when a strong, impartial director is backed by an efficient governing body; otherwise it is a gesture of despair in the face of democracy run riot.
To the bad results of overcompetition in attending staffs we must add those growing out of auxiliary or courtesy staffs. These are groups of doctors who do no ward work, but have the right to treat private cases. Some very good hospitals tolerate them in a restricted and carefully selected form; in others, the economic stress of recent years has encouraged the extension of surgical privileges to many poorly qualified operators.
IV
The reason why free patients sometimes get more scientific treatment than pay patients is that, in the wards, teamwork costs nothing, while for private patients it means paid consultations. Most private cases can pay only moderate medical charges, and an estimate of the total is often demanded. A surgeon in an overstaffed hospital, struggling to meet family and professional expenses which critics and idealists will not meet for him, is tempted to save from ten to a hundred dollars by handling the medical side of an operative case himself. The patient gets well, but a bad precedent is set, and some future patient, with an obscure heart defect that only a specialist in internal medicine can discover, pays the penalty.
The American Medical Association and the American College of Surgeons are rating hospitals on the basis of conformity to some very moderate requirements, and, as their approval is important, there has been a general improvement to that extent. This stabilizing influence has also kept well-meaning but inept governing bodies from trying to meet the present economic crisis by a medley of bizarre and futile experiments, the result of which would be a national tragedy. But these two’ organizations lack official authority, and must proceed by the slow methods of example and persuasion.
I have stressed the worst results of the salesmanship policy because this is a critical article. The average is not so bad. In the poorest hospitals, good work is done and lives are saved by doctors who carry on, under adverse conditions, often more from a sense of public duty than for the little profit involved. But the fact remains that a large proportion of our hospitals are not giving the public nearly what it is entitled to.
Objections to overloaded staffs apply mainly to attending doctors and senior assistants, and do not conflict with the principle, approved by medical organizations, that a hospital should be an educational centre for the doctors of its community. Any hospital service can take on and teach many more junior assistants than it actually needs to do the work, and no harm is done if promotions are not forced by improper influences.
Abolition of wards must come through an aroused public interest, demanding more decency and privacy. The general elevation of scientific standards is a more complicated problem, though already going on slowly, as I have shown. Most of the outstanding examples of scientific efficiency among our hospitals are public or semiprivate institutions whose services are controlled by universities and used, by their medical departments, for teaching purposes. It is quite true that American universities are not looking for added responsibilities at the present time. It is probable, however, that they would lend the occasional services of members of their medical faculties to a plan for extending their influence to the hospitals of their own and, in some cases, near-by states. The financing of such a plan would be mostly a matter of traveling expenses and clerical hire for a few persons, and would not be prohibitive for either state governments or private foundations; in the present state of American politics, financing by private agencies would undoubtedly be preferable. Eventually, the greater part of this work could be carried on by state and county medical societies, which are the component parts of the American Medical Association.
Our profession has its share of complacent reactionaries who will condemn this article as visionary, but who, if they gave away their real feelings, would say: ‘The present state of hospitals suits us because we don’t have to put on too much steam to keep up, and nothing shall be done about it if we can help it.’ They will have to learn that, when the economic policy of a group conflicts with public interests, the group must revise its policy.
This article is not pessimistic. It is written in the hope of accelerating the slow and painful progress of changes already going on, and of hastening the day when it will be recognized in fact, as well as in theory, that ‘the best is none too good for the sick.’