The Patient Comes First


HOSPITALS, like the Sabbath, were made for man. The sole reason for their being is to provide a place where the sick person can be made whole, where he can be looked after by doctors, cared for by nurses, restored to health. Hospitals are provided for the sick and their doctors, not the sick and the doctors for the hospitals. This seems obvious, but it is sometimes forgotten in these days when hospitals are struggling financially for a precarious existence.

When we speak of a hospital we think of something more than a mere building. We think of the patients lying ill in it, of the medical and nursing staff working in it, of the operating rooms, laboratories, and equipment that it houses, and, if we are seriously thoughtful, of the administrative staff that makes the wheels of this complex organization go round. We think of it in terms of its function as a place of healing. This is as it should be, and the order of importance of the various parts of the organization is as they have been set down.

The first place goes to the patient. Hospitals, as well as doctors, would not exist if there were no sick people. Carry this reasoning a stage further, and the doctor occupies the second place in importance, for without him and the patient there would be no need for the hospital, which, at a pinch, both can still do without. The importance of the doctor, reduced to fundamentals, lies in his experience in treating the sick; the hospital building and its equipment provide him only with a better means of doing it.

The hospital, then, as a building with its administrative staff, takes only third place in our medical economy. This fact is not infrequently overlooked by the administrators. In their anxiety to find the means of supporting the building and their desire to make it function efficiently, they are apt to subordinate the end to the means and assume for themselves an authority to which they are not entitled. The function of the governing body is, or should be, to find money and look after the finances; of the administrative staff, to see that the nonmedical side is efficiently run. They should have no concern with or jurisdiction over the medical staff. That is the province of the doctors themselves through their Medical Board. Rules and regulations, which are necessary to the smooth working of any community, are made for one purpose only, efficiency, and not for the glorification of the administrative branch. This point of view is often accepted very hardly by boards of governors made up largely of business men accustomed to the principle that ‘he who pays the piper calls the tune.’ They forget that, though they may find the money, they do not pay the piper. The hospital doctor does his work for nothing.

As a result of this attitude a whole train of fallacies has arisen — that the bigger the building, the finer the hospital; the larger the staff, the better the work; the longer the rules, the greater the efficiency; and that all energies should be devoted to the task of keeping the machine running. Patients, doctors, and nurses are fed into its maw to that end, like pigs into a sausage factory. What comes out at the other end sometimes seems to be of less moment than the numbers which go in and the amount they can contribute. The administration rules the roost. The patient, instead of being the first consideration, tends to take second place, with doctors and nurses as also-rans. It is apt to be forgotten, in the exigencies of finance, that the reputation of a hospital depends upon the calibre of its staff, not upon the luxury of its housing.

Two major causes have produced this sad state of affairs. The increasing scope of modern medicine has led to the demand for more equipment and for more expensive equipment, while an appreciation of the evils of overcrowding in wards has necessitated an increased allowance of bed space per patient. The cost per patient has therefore increased by leaps and bounds. For this reason, during the period between the end of the first World War and the beginning of the Great Depression, when extravagance prevailed, many American hospitals piled up commitments which they found it difficult later to implement. If an institution has been planned without regard to expense, it is very difficult to reorganize it later on a less pretentious scale. Large and elaborate buildings are such solid obstacles. Poverty-stricken European hospitals were at least spared this extra burden, for they never had a chance to be extravagant. They were faced with bankruptcy from the start.


Big hospitals — by which I mean those huge aggregates of buildings housing half a dozen amalgamated institutions — have many and grave disadvantages. The argument for them is that they are more economical and more efficient. They are certainly impressive, but their economy and efficiency are more doubtful.

To one accustomed to the hospitals of Europe, these palaces are breath-taking. The visitor from that impoverished continent gazes in awe at the spacious halls and passages, the seemingly numberless elevators, the lavish equipment, the profusion of secretaries, helpers, orderlies, which combine to give an impression of luxury and wealth beyond his wildest dreams. Walking down the broad corridors and coming on drinking fountains at frequent intervals, he is quite disappointed to find that they gush forth only cool clear water, not some rare Tyrrhenian wine, for the effect is wholly Roman in its grandeur.

All this is very well when you can afford it, though even so it savors somewhat of ostentation. Nowadays this lavishness hides an empty purse and a continual struggle against adversity. It is like the situation of a man who has made a reputation for himself by the splendor of his menage or built up his business on extravagant display — when difficult times come he cannot afford to give it up and he cannot afford to keep it up. Many hospitals are in just that position. Overheads remain, income is diminished. The extravagant organization planned in the plenteous years of the twenties has to be maintained in the lean years of the forties.

The idea, of course, was that the aggregation of many institutions in one building, or one group of buildings, the substitution of a single management and administration for many, would effect economies in working which would more than offset the extravagance of setting. But this has proved to be a delusion. Though it is true that big institutions are more economical to run than small, there are limits to economical expansion.

A hospital is not like a factory. Medicine cannot be mass-produced. Patients cannot be put on an assembly line and run through a series of consulting rooms and laboratories, to come out cured at the other end. Each patient is an individual problem whose diagnosis is a craftsman’s job, not an artisan’s. The process cannot be speeded up. Thus, while there is a certain basic requirement of laboratory facilities, X-ray equipment, operating rooms, and so forth, for any hospital, and it is uneconomical to provide for twenty what would equally well serve a hundred, there is a limit beyond which the process becomes simply one of multiplication, and economy ceases.

When that point is reached, difficulties begin to creep in. Administration becomes more complex, and its extra expense may easily eat up the savings. Nor is there of necessity a compensating increase in efficiency. It may be that to have a private printing shop in the hospital is an economy, though I doubt it, but it commonly takes considerably longer to have printing done there than it would if ordered from a commercial printer. A central splint room, with stocks of the more commonly needed splints, is a sensible provision; but when it is extended to supply any type of orthopaedic apparatus, from a heel pad to a molded jacket, and scaffold, it is very apt to become either a liability or a nuisance. The excuse for its existence is that it is on the spot, and special appliances can be made there and then. In practice there is often great delay because the splint room is busy with so many orders. Except in orthopaedic hospitals, such workshops are inefficient or extravagant.

So it goes throughout all these huge institutions. Everybody deludes himself into believing that it is more economical and efficient to be self-sufficient. Therefore everything is provided within the four walls. This is a delusion from which smaller institutions are immune because in their case it is so obviously false.

From the medical standpoint also, efficiency suffers in these big medical centres. Individual departments get so large that they begin to approach autonomy, to become more and more selfcontained. The medical centre is no longer a large general hospital, but an agglomeration of small special hospitals aggregated in one place, with all their objectionable features aggravated thereby.

The greatest of these is the one that applies to all specialism — the narrow viewpoint. In the general hospital of moderate size, all the staff know each other; they work together more as a family; there is a fusion into a homogeneous whole. Patient and doctor alike profit from the cooperation, the one from the broader view of his medical attendant, the other from the impact on his own of other brains in individual conclave. The organized official staff conferences of large hospitals are no substitute for the give-and-take of individual discussion.

It may be asked, is individual discussion not just as possible in a large as in a small hospital? Is it not practised in large institutions? Theoretically, yes; practically, less often. For one reason, the staffs arc so big that half of them do not know the other half. For another, the distances are too great; to get from one department to another in these vast buildings requires time and a passion for geography.

Not only do the doctors get lost, but so do the patients — and this is more serious. They become mere numbers in a great collection of sick humans: we treat not James Smith, but No. 267774.

However, like it or not, here are these large centres of medical science already in existence, and they, as well as the smaller hospitals, have to be kept going. They have needed money so badly that they have been prepared to adopt almost any means to get it, and a certain shadiness has, quite unconsciously, crept into the methods of their management. Patients and doctors alike are being used to maintain as a going concern institutions the original intention of which was to supply their needs. This is a Gilbertian reversal of their raison d’être.


In the matter of hospital economy a distinction must at once be drawn between municipal hospitals or institutions supported by public funds and those institutions maintained by private charity and subscriptions. The needs of the former, or at least their necessities, are provided for, and therefore they are not the victims of that compulsion which makes the starving man go to any shift to get bread. It is to the private hospitals only that the following paragraphs apply.

In recent years the private hospitals have seen their income from past endowments diminish and new endowments become fewer; they have seen their income from subscriptions and donations fall off to an alarming degree, while at the same time they have been faced with a steady increase in the cost of maintenance. This is a problem of common knowledge, and it has caused the managing boards of these hospitals many a headache in their efforts to solve it. One thing at least was obvious: that people must pay, so far as they could, for the actual out-of-pocket cost to the hospital of their maintenance as inpatients or their treatment as outpatients. I am speaking, of course, of people called nowadays the medically indigent, who cannot pay the whole cost of medical care, and not of the more well-to-do patients who use the private accommodation and pay their way.

This principle of having the patient pay expenses, so obvious a device to obtain more income and on the face of it so unexceptionable, has led to many undesirable results which were not foreseen. It has led to an exploitation of patients and doctors which was not intended, and the extent of which is still not altogether appreciated; or, if it is, nothing is being done about it, probably because of the financial stringency.

Consider first the exploitation of the patient. Each patient, when he arrives at the hospital for the first time, goes through the social-service department, or its equivalent, to be assessed with regard to his ability to contribute. The few who can pay nothing are either passed in free or referred to a municipal hospital. The others pay a fixed rate or are rated according to their financial capacity, depending upon the particular method of the individual hospital. If a rating system is used, payments throughout the hospital, whether for clinic attendance, X-rays, medicine, or inpatient treatment, are based on the rating the patient has been given, and, in the case of the top rating, they may be pretty high. Theoretically, these payments are considerably below the ordinary fees of doctors in their offices, but there are times in actual practice when they approach such fees uncomfortably closely.

Moreover, there is apt to be a very careful grading of all services rendered and of the prices which have to be paid for them. It is rather like a fair — you pay to go in and you pay extra for all the side shows. For instance, take the case of a patient attending a clinic with some condition very simple to diagnose — let us say a sebaceous cyst on his head. After waiting, perhaps for a long time, he is dealt with in a moment because the diagnosis is obvious and he is told he should have the cyst removed, He pays a fee for the opinion; he returns another day and pays another and bigger fee for the small operation; finally he comes to the clinic to see that all is well, and pays again. He really pays a good deal for that very simple matter.

Or take the case of a patient who needs some small procedure which can be called surgical, if you are so minded, in order to establish a diagnosis — for instance, puncture of a nasal antrum to determine the presence or absence of infection. Now that is really a diagnostic procedure, but it is often classed as a minor operation and has to be paid for as such. In all probability that patient pays to the hospital a clinic fee, an X-ray fee for an examination which is indefinite in its results, and a minor operation fee to establish a diagnosis. It is too much. The last fee, at least, should be a clinic charge, not a minor operation charge, for the patient is going to have to pay for treatment, which may involve an operation and another, perhaps larger, operation charge. This sort of thing is simply money-making.

Or, again, the doctor may be particularly interested in some case and would like to follow it closely — unnecessarily closely, from the point of view of the patient. He would like to have some laboratory investigations made, X-rays taken, special treatment instituted — things unnecessary as far as the adequate care of the patient is concerned, but scientifically important in the discovery of new facts about disease. He would like many visits and many checks, unnecessary for the individual patient, necessary for science. This becomes expensive unless regulations can be waived

— and regulations are apt to be rigorously followed, for they mean money.

The private patient, too, has a complaint that seems valid. His complaint is that, for a price well within the range of hospital charges, he can get better accommodation, food, service, and general amenities in a first-class hotel than he can in a hospital. His personal tastes are catered for to a much greater extent in a hotel, and he is treated as an individual instead of simply one of a number of necessary evils, as he is sometimes made to feel. If a hotel can do that and make a profit on it, says he, why cannot a hospital? For in fact the private part of a hospital, divorced from its medical facilities,

— which are, of course, extra, and no more included than are the drinks in the bar, more’s the pity, — is no more and no less than a hotel. Now, granted that the circumstances which lead a person to a hotel are very different from those which lead him to a hospital, yet his essential requirements are much the same. He requires comfort, he requires consideration of his little personal idiosyncrasies, he requires, in short, service. He requires these things even more in a hospital than he does in a hotel, for the sick man is apt to be fussy. Actually he tends to get less of them unless he is prepared to hire a private staff to look after him, and even then the kitchen remains the same. It seems not unreasonable that a person paying the equivalent of firstclass hotel prices should expect the same first-class attention that he would obtain in a hotel. He does not always get it by any means. And this suggests that hospitals might be well advised to make more use of men trained in hotel work. The few that do are quite outstanding, and patients are loud in their praise. Moreover, these hospitals make money.


However, though the patient is sometimes made to pay more than seems just, his exploitation is on a minute scale compared with that of the doctor, under the conditions in which medicine is practised today. Yet everybody tolerates the evil, and, so long as no protest is made, naturally managing boards are not going to do anything which would reduce their already precarious income.

In the first place, the doctors on the staff of a hospital give their services — a fact which many patients do not realize. Often the patient believes that some of what, he pays goes to the doctor, as in truth it should. The practice of doctors’ giving their services for nothing goes back to the days when hospitals were entirely supported by charity and their inmates were the sick and needy who paid nothing for the care they received. It has always been the privilege of the medical profession, part of its code, to care for the sick poor without question of payment. But what is sauce for the goose is sauce for the gander. If the hospitals find times difficult, so do the doctors. If the hospitals demand contributions from patients for their services, a proportion of those contributions belongs to the doctors for theirs. Hospital authorities seem to forget that what they give to the patients would not be much good without what the doctors give; that medical care is as much what the patient is paying for as hospital care. Many patients believe this is true, as I have said, and are surprised and even indignant when they find that it is not.

That brings us to the next point, the exploitation by the public of hospital facilities, which include medical services. It is the part of the hospitals to see that this does not happen, and to a large extent they do. Every patient who applies for hospital treatment is put through the sieve of the social-service department to determine his financial status and his eligibility. The trouble is that the meshes of the sieve are too large and some of the big fish get through. To some degree this is inevitable. There are always people who will manage to take advantage of privileges, and perfection is impossible of attainment. Nevertheless, it is well known to all who work in hospitals that there is a great deal of abuse, that many of the people who make use of hospitals could well afford to pay private fees — certainly if those fees were adjusted to suit their means. I do not know the doctor who is not prepared to adjust his charges. In fact, I think it is true to say that doctors in these days are more often agreeing to modified fees than receiving unmodified ones.

A practice connived at and even encouraged by some hospitals is the use of their out-patient facilities for consultations. A doctor not connected with the hospital has a case about which he wants an opinion regarding diagnosis and treatment. He sends the case to the hospital with a letter asking for this. The patient is sent to the appropriate department with his chart marked ‘Consultation Only.’ This means that the specialist who sees the patient is to give his expert opinion on the case. A letter is then written to the referring doctor embodying the results of the consultation, and the patient is returned to him to be taken care of. Now if the referring doctor is prepared to treat his patient as a hospital case without payment for his own services, there can be no objection, but usually the private doctor obtains for his patient the benefit of a consultation with a specialist for nothing. However, if that patient can afford to pay his family doctor for treatment, he can afford to pay the specialist something for a consultation. He should, in fact, be sent by his doctor to the specialist’s office for a consultation at a reduced fee. The reason why this is not done is due partly to the doctor’s reluctance to ask, as he thinks, a favor, and partly to the grudging attitude of some consultants towards reducing their fee. Both attitudes are regrettable and unfair to the patient.

However that may be, the practice of allowing such consultations in a hospital is a pernicious one which should not be countenanced. The patient whose case is difficult enough to require specialist diagnosis very probably also requires specialist treatment, treatment which, for want of facilities or experience, the outside doctor is not in a position to give. At any rate, the only person who is competent to decide is the specialist who sees the patient. What the hospital is doing in such a case is turning itself into a cheap diagnostic centre at the expense of its unpaid staff, and arrogating to itself the right to dictate by whom the patient shall be treated, regardless of the interests of the patient. The only reason I can imagine why anybody stands for it is that no one has troubled to consider its implications, or at least to voice them.

These are not the only devices used by hospitals to increase their income at the expense of the medical man. In the last twenty years it has become the practice in some institutions to employ a certain number of full-time salaried physicians whose duties are largely teaching and administrative. Instead of refusing to see private patients, or refusing fees if for some reason they are compelled to, these whole-time physicians often take fees and turn them over to the hospital, which applies the money towards its general expenses. Every consultation fee so taken by a whole-time man maintained by an institution is one less available to outside consultants who are dependent upon private fees in order to live.

On a par with this practice, though less obvious, is the practice of offering special all-in rates for obstetrical services, provided that the resident or some paid member of the hospital staff performs the delivery, or the supplying of resident or nurse amnæsthetists at cut rates. In each of these cases the individual physician is put into the position of competing against a large concern which can offer special rates, like the individual trader who has to compete with the chain store. It is a state of affairs that merits serious thought, especially from those doctors who are averse to any form of socialized medicine, for many hospitals are practicing the latter already under the guise of voluntary service. The menace of socialized medicine, if it is a menace, comes from within as well as from without.

Another widespread practice that is generally accepted, though it is difficult to see why, is that of working the pathological laboratories and X-ray departments deliberately at a profit — the charges are such that income is higher than expenses. The difference, or the profit, goes into the funds of the institution. As it was put very truly in a medical paper not long ago, ‘The arithmetical difference between the total cost of operation and the total profit derived ... is certainly represented by the individual services of the medical personnel’; but funds which represent professional training and specialist knowledge are diverted from the doctors to the institution.

The pharmacist too has a justifiable complaint against the hospitals. The wholesale drug houses all have a special hospital rate for drugs that is considerably below even the wholesale price the outside pharmacist must pay. The hospital pharmacy is thus enabled to dispense medicines to the poor at a very low rate, which is well and good, but to the better-endowed patients they charge a price approaching and sometimes even in excess of what would be paid outside. Thus both wholesalers and retailers are being forced to contribute, willy-nilly, to hospital funds.

In view of facts like these, which cannot be disputed, there is every reason for the feeling, widespread among thoughtful and farseeing members of the profession, that the doctors are not only held responsible for the medical care of patients but also relied upon to contribute to the financial support of the hospitals. Indeed, ‘forced to contribute’ might be the better term, for he who kicks against the pricks does so at the peril of being turned off the staff and refused the entree to an institution designed originally to help him. The hospitals are very powerful vested interests. They are using the prestige built up for them by their honorary staffs under different circumstances to get away with practices today which verge on the dishonest. After all, in everyday life you do not surreptitiously put your hand in another man’s pocket and then tell him, when found out, that he should be proud to contribute to your difficulties. At least you ask first. And yet from time to time some earnest administrator may be heard descanting largely upon the ethical concepts of his hospital. I fear the ethical concepts are apt to make a bad showing against present expediency.

All this boils down to the fact that the hospitals are abusing their position. Nobody cavils at the work they do, but many cavil at the means they adopt to do it.


It is to be hoped that there will be no more of these huge structures, costly to build and costly to maintain. The functional life of hospitals is rapidly lessening. Buildings erected two hundred years ago fulfilled their function efficiently for one hundred and fifty years; those that succeeded them are already out of date and cannot be efficiently patched. The life of a hospital building today — the functional life — is estimated at no more than twenty-five to thirty years, and may soon be less than that if the rate of medical progress continues. What good, then, to put up palaces? Rather erect as economically as possible structures that will last efficiently their allotted span and can without compunction be torn down when their usefulness has ended.

Furthermore, let them be smaller, and let there be more of them, scattered at many strategic points rather than congregated at one. With the exception of a few special hospitals, the policy should be decentralization. Not only would patients have shorter distances to travel, since each hospital would cater for its own area, but the waste of time in overcrowded clinics would be diminished. The objection from the doctor’s point of view would be the time taken in getting to and from the different institutions, a serious consideration in a large city; but this could be eliminated by limiting the number of hospitals to which a doctor might be appointed. Such a stipulation would be a great help in several ways. At the present time in any large city the temptation is for a man to be on the staff of several hospitals, and his energy is frittered away among many rather than concentrated upon one. He, his work, and the hospitals all suffer. Hospitals should be scattered and staffs concentrated, small staffs doing more work in fewer institutions.

Some special hospitals must remain, for special reasons. Patients with acute infectious diseases are obviously not suitable inmates of the ordinary general hospital, even though it is perfectly possible, if need arises, to nurse them there without risk to others. Bed isolation, however, is a troublesome business and requires careful training and attention to detail. Tuberculosis will remain segregated in country sanatoria for everybody’s benefit. Mental diseases require special buildings because of the special difficulties of their care, though probably these should be attached to general hospitals in order that all facilities may be readily available for the investigation of their manifold problems. Radium and radiation therapy must be concentrated in the larger institutions or sometimes in one special hospital which may serve a large area, and this not only because of the high cost of apparatus and the limitations of its applicability, but also because of the special techniques required for its handling and its grave dangers in inexperienced hands.

Such, then, is a general view of the hospitals, their plight and the reasons for it, with some suggestions for the future. The views expressed will undoubtedly horrify some, disturb many, but perhaps be given consideration by a few. One thing, however, admits of no dispute, and that is that the hospitals are in a parlous state and something very soon will have to be done about it. Half-hearted measures are of no use. The time has come for the large view, for the facing of facts even if unpleasant, for drastic measures.