Miracles and Mishaps: Closing the Quality Gap

For this broad survey of the remarkable medical technology that is available to some, but too few, Americans, Matt Clark, a 1951 graduate of Wesleyan University, drew on his thirteen years’ experience at writing about science and medicine. A winner of the Albert Lasker Medical Journalism Award and the Howard W. Blakeslee Award of the American Heart Association. he is medicine editor of NEWSWEEK magazine.

by Matt Clark

SOMETIME this month, the first of some 19 million persons over sixty-five will exercise a right wholly new in the American scheme of things. He will receive medical care ranging from a few diagnostic tests to major surgery and find most of his bill paid with government funds. His rights under Medicare, to be sure, were granted only after years of controversy between large segments of the medical profession and two presidential administrations. But the question whether Medicare is the first step down the dismal road of socialized medicine becomes academic.

There is hardly any doubt that governmentsponsored health care will be extended to all age groups in the long run. President Johnson has already mentioned a possible program of federally supported dental care for children under six. The immediate question posed by Medicare is whether the nation’s hospitals, on which the legislation is largely focused, are equipped, staffed, and organized to provide the kind of care that elderly Americans expect and the government promises. Medicare throws a spotlight on problems that have smoldered unresolved in hospitals in nearly every community in the country for decades. Not the least among Medicare’s benefits is the challenge it gives doctors, administrators, and everyone concerned with the future of American medicine to solve these problems.

The average layman may find it hard to believe that the modern hospital suffers from any serious deficiencies. In the popular mind, the widely publicized advances in medical technology have made the hospital a gleaming tower of hope in which new frontiers are crossed every day in the conquest of disease. There is considerable justification for this notion, for the hospital has changed dramatically in only a few decades.

Forty or so years ago, the hospital was the lugubrious last resort for patients too sick to be treated by their family doctors at home. One went to the hospital for surgery — which even in the case of a gallbladder removal might be touch and go — or to die of a lingering illness. But antibiotics, safer methods of administering anesthesia, and better blood transfusion techniques have drastically reduced the hazards of surgery and have given doctors the opportunity to develop skills undreamed of a generation ago. And these new skills have been matched by scores of new tools.

With a plastic and steel heart-lung machine to take over the job of maintaining the patient’s circulation, surgeons dare to slice open the human heart and repair defects inside. Heart valves scarred by rheumatic fever are replaced by artificial valves of wire and plastic; arteries in many parts of the body that have become clogged with the fatty deposits of atherosclerosis can be replaced with tubes of synthetic fabric. Thousands of men and women whose hearts cannot effectively pump blood because nerve centers controlling the heartheat have failed are being kept alive by miniaturized battery-powered pacemakers implanted in their bodies.

Nor are medical wonders restricted to heart disease. Orthopedists now replace shattered hip joints with plastic, and implant pieces of calf bone, prepared in assorted shapes and sizes, as substitutes for diseased human bone. Eye surgeons not only transplant corneas to overcome one form of blindness, but now use laser beams to reattach the inner lining of the eye and prevent blindness due to a detached retina. Medicine has profited from the atomic age. Radioactive isotopes injected into a patient’s bloodstream act as tracers, mapping, for example, the location of hidden brain tumors. Cobalt “bombs" and linear accelerators provide physicians with powerful new sources of radiation for the destruction of deep-seated cancers.

Thousands of lives are saved each year by artificial kidney devices, which rid a patient’s blood of toxic wastes until his own kidneys are able to function again. In fact, men and women whose kidneys have been permanently put out of action by disease are being kept alive by periodic treatment with the artificial kidney. They simply report to the hospital once or twice a week and are attached to the machine by means of plastic tubes implanted in the blood vessels of an arm or leg. While they sleep or read, the artificial kidney clears the toxic wastes from their blood.

Although having a baby may call for less exotic procedures than does open-heart surgery, obstetrics has made important advances. Doctors can now detect Rh incompatibility between a mother and child by inserting a needle through the mother’s abdomen and sampling the amniotic fluid surrounding the child to test for blood-destroying antibodies. Life-saving blood tranfusions can be given to the baby even before it leaves the womb.

Research is currently under way which promises to make the American hospital the scene of even more spectacular capabilities. When the problem of tissue rejection between unrelated individuals is solved in the laboratory, the wholesale transplantation of healthy human organs to replace diseased ones will become routine. Physicians speak confidently of creating an artificial heart suitable for replacing worn-out human hearts within the next five years. In some types of cancer surgery, the laser beam may well replace the scalpel.

The promise of research and the sophisticated techniques and glittering gadgetry of current practice suggest that the American patient typically enjoys the best of modern hospital care. But in fact he does not. In some cases, the technological advances made in pioneering medical centers take too long to filter down to the community hospital. Intensive-care units for heart attack victims are a case in point. Many coronary patients admitted to hospitals die because the nerve mechanisms controlling the heartheat stop functioning properly. When such mishaps are detected soon enough, electric shock applied to the chest or cardiac massage can restore proper heart rhythm. If all community hospitals had coronary-care units, where heart attack victims were monitored around the clock by nurses and doctors skilled in resuscitation, an estimated 50,000 lives could be saved every year. But only a hundred or so hospitals currently have such facilities. A somewhat similar lack exists with regard to artificial kidney centers for periodic treatment of patients with otherwise fatal renal disease. Only about 300 persons are now receiving the benefits of such treatment, but if additional facilities were available, according to the U.S. Public Health Service, 3600 additional patients every year could be saved to lead normal lives.

Fortunately, more coronary-care units and artificial kidney centers are being established all the time. Far more serious is the problem posed by the shocking gaps in the quality of care offered by the nation’s hospitals. Heart-lung machines and artificial kidneys don’t make a good hospital. The true measure of a hospital rests on how well it meets the everyday medical demands of the community it serves, whether they include openheart operations or prosaic appendectomies. And in hundreds of communities, including the nation’s largest cities, the hospitalized patient isn’t assured of receiving care that meets the standards of twenty years ago.

THE kinds of gaps that exist are demonstrated in a study, carried out by Columbia University School of Public Health and Administrative Medicine, of the care members of the Teamsters Union and their families were receiving in New York hospitals. A staff of doctors representing the major specialties examined a random selection of 430 case records from 98 hospitals, judging the skill with which diagnosis and treatment were executed. The results were far from reassuring.

In 43 percent of the cases, the quality of care was regarded as fair to poor. In the category of “general medicine,” only one patient in three received good or excellent treatment. As for the rest, said the report, “all too frequently there was superficial therapy given to the most obvious complaint, with failure to study other signs of pathology which were contributing to the patient’s illness.” An unlucky sixty-five-year-old man ran a fever for twelve days, yet no one bothered to test his blood lor bacteria or take steps to confirm the discharge diagnosis: bronchopneumonia. When the patient was readmitted unconscious a few days later, doctors finally got around to doing a blood test, but, in the opinion of the surveyor, picked a poor drug to fight the infection. In the meantime, they failed to look for signs of a skull fracture, despite reports that the patient had had a serious fall. A “possible” stroke was listed as one of the causes of death in this bungled case.

Many of the records showed that diabetics had not been given adequate control therapy, that coronary patients were allowed out o( bed too soon, and that suspicious chest pains were not investigated by X ray or electrocardiogram.

Surgical patients fared better than their counterparts on the medical wards — 57 percent received optimal care in the opinion of the surveyors. Deficiencies were most glaring in major abdominal operations and hernia repair. In an operation for intestinal polyps, for example, the surgeon removed a normal part of the bowel and left the affected portion in place. The most tragic case involved a voung man who underwent a major lung operation in a hospital insufficiently equipped or staffed for such specialized surgery. “After a minimal amount of workup,” said the report, “major surgery of the chest was performed and patient died three days later. Both surveyors commented upon the lack of an experienced team approach.” An experienced chest physician would have recognized that the patient wasn’t in good enough physical condition to withstand chest surgery in the first place, the report noted.

There is good reason to believe that the Teamsters study isn’t just a special case. And what is most disturbing of all is the fact that the Teamsters aren’t an underprivileged group who would predictably receive inferior care. The union, on the contrary, has obtained for its members an excellent choice of health insurance programs as a fringe benefit.

The study underscores the uneven quality of hospitals, including those that lie only a few blocks apart. The best care is obtained from teaching hospitals, institutions affiliated with medical schools, where virtually every case becomes the subject of critique and debate. These are also the hospitals where the leading specialists in their fields are found. At the other end of the quality scale are the so-called “proprietary” hospitals, often owned by physicians and operated with the intent of turning a profit. A good proprietary hospital is essentially a contradiction in terms. “A hospital simply cannot offer good modern medical care,” says a Boston surgeon, “and still make money.”

The surveyors conducting the Teamsters study were not entirely surprised to find that from 81 to 92 percent of cases treated in teaching institutions received optimal care, but only 44 percent of those in proprietary hospitals received better than fair management. Nine out of ten surgical procedures in teaching hospitals were rated good or excellent, but only six out of ten were considered optimal in proprietary institutions. In the field of general medicine, none of the care in the profit-making hospitals was considered optimal.

An important factor in the quality of care offered by any hospital is the level of training of staff physicians. The highest percentage of optimal care found in the Teamsters study was given by physicians who had undergone postgraduate training and taken the required examination for certification by one of the specialty boards, or who were members of a leading medical society in their specialty. Not surprisingly, most of the care in medical-school-affiliated hospitals was rendered by such qualified specialists. But only 45 percent of the surgical admissions and 16 percent of the nonsurgical cases were attended by similarly trained doctors in proprietary institutions.

Venality as well as incompetence is evident in studies of inadequate care given in American hospitals. A variety of reports seem to show that patients with health insurance have an unusual need for tonsillectomies and hysterectomies. Dr. J . Frederick Sparling of Johns Hopkins took a look at appendectomies performed in three Baltimore community hospitals and found that about half were unnecessary. As a group, patients with Blue Cross or some other form of insurance tended to undergo more unnecessary operations than did other private or ward patients.

SUCH findings point up the fact that American medicine is remarkable for its lack of formal regulation and discipline. A recent survey published in the Journal of the American Medical Association noted that only eighteen states have licensing laws that specifically provide for action in cases of incompetence on the part of a doctor, and of forty-seven state medical societies queried, only eight had a similar provision in their bylaws. The hospital, the report concluded, was the place in which disciplinary controls could be most logically exercised. But as the Teamsters study makes quite clear, almost any physician, no matter how incompetent, can find a hospital willing to accord him privileges.

Indeed, hospitals themselves operate in relative freedom from rigid controls on the quality of their services. The most important disciplinary agency in the field is the Joint Commission on Accreditation of Hospitals, sponsored by the American Medical Association, the American Hospital Association, the American College of Surgeons, and the American College of Physicians. To be accredited. hospitals must have more than twenty-five beds, must maintain adequate facilities for dispensing drugs, and must have X-ray departments and pathology labs to conduct clinical tests and study tissue removed at surgery. Hospitals are also expected to keep detailed records on their patients and conduct regular meetings of the medical staff to discuss the way cases are handled. In addition, the commission requires accredited hospitals to have staff “tissue” committees that discuss reasons for the removal of normal tissue by the hospital’s surgeons and curb unnecessary operations.

Hospital accreditation, although required of hospitals with AMA-approved intern and residency training programs, is voluntary: 4322 of the nation’s 7127 hospitals — slightly more than half — are accredited. Moreover, hospital authorities generally agree that the commission’s standards are a bare minimum for good modern hospital operation. The best hospitals exceed the standards automatically, while a mediocre institution will have no real trouble meeting them if it wants to. “You have to make sure the record of an electrocardiogram is signed,” a New Jersey physician notes, “but that doesn’t mean the EKG was correctly interpreted.” In a good many accredited hospitals, the tissue committees seldom hesitate to give the more influential surgeons on the staff the benefit of the doubt.

Accredited or not, a hospital’s performance depends to a large extent on how its staff is organized. The pre-eminence of the teaching hospital comes, in part, from the fact that the major medical and surgical services usually are directed by salaried, full-time chiefs. Removed from the dependency on referrals for their practice, they are free to make the doctors on their services hew to the line. Full-time chiefs of service should also be the rule in most community hospitals. Without such supervision, many hospitals become the fiefdoms of private practitioners in the community, who use the institution as a personal workshop for their own convenience and profit. Controls, if any, must be imposed by a hapless administrator, frequently a layman, who may carry less weight with the board of trustees than the town’s more prominent doctors.

AN EXAMPLE of the extreme opposite of this unhappy hospital situation is the Hunterdon Medical Center, a 121-bed institution in Flemington, New Jersey, which serves an entire rural county of 65,000. The hospital is staffed by twenty-four full-time, salaried specialists, working in unparalleled harmony with the county’s general practitioners. The family doctors remain basically in charge of their patients’ care in and out of the hospital. But the specialists perform all surgery, are readily available for consultations, and assume responsibility when complicated medical or surgical problems arise.

Hunterdon’s director, Dr. Robert R. Henderson, admits that this happy arrangement was achieved without the usual town versus gown fight between specialist and GP because the center was “founded in a vacuum.” Until it opened, in 1953, the county had no hospital at all, and there were no qualified specialists in the community. The Hunterdon program was organized by the community as a whole, with the cooperation of the local medical society.

Hunterdon Medical Center has become a model community hospital, coordinating a variety of health services for the county. The institution offers a screening program to detect illness in apparently healthy men and women, thus assuming a role in preventive medicine. It supplies speech therapists for the county’s schools and maintains a home-care program and an affiliation with a local nursing home for patients who no longer require hospitalization. The center staff reviews the progress of each patient sent to the nursing home to ensure good continuity of care.

The center also provides inpatient and outpatient psychiatric care for the entire county, carefully following up on any patient who must be referred to a state hospital. Significantly, Hunterdon is the only county in New Jersey where admissions to the state hospital system have declined during the last ten years.

Although situated fifty miles from New York, Hunterdon is affiliated with New York University School of Medicine; its staff specialists have faculty appointments and are expected to spend one day a week in teaching or research at the medical school. The staff specialists, of course, form an educational bridge between the school and the family doctors, keeping them abreast of the latest developments in diagnosis and treatment. The center also has an arrangement with four other medical schools, including the University of Pennsylvania and Jefferson Medical College in Philadelphia. Students and residents from these schools may receive part of their training at Hunterdon; at the same time, patients from Hunterdon requiring such specialized care as open-heart surgery may be sent to one of the larger hospitals.

Hunterdon has done away with the charity wards common to teaching hospitals. Each patient is treated as a private patient, regardless of his ability to pay for care. Meanwhile, every patient is part of the hospital’s teaching program, and his case is studied by the resident staff.

Hunterdon Medical Center’s built-in quality controls may be a rarity, but even in New York, major steps have been taken, under protest to be sure, to rectify the most glaring deficiencies. During four years as hospital commissioner, Dr. Ray E. Trussell obtained regulations requiring proprietary hospitals to become accredited, and over and above that, forbidding unqualified physicians from handling complicated obstetrical cases or performing major surgery in these institutions. Moreover, indigent patients treated at city expense in voluntary hospitals must be cared for only on services approved for residency training or by qualified specialists. To improve the often shoddy performance of the city’s municipal hospitals, Dr. Trussell also put through a requirement that they become affiliated with teaching institutions, or voluntary hospitals. These measures, possibly unique in city hospital administration, grew out of the shocking revelations in such surveys as the Teamsters study.

IMPROVING the performance of doctors within hospitals is only part of the answer to developing a sound American hospital system; for the trouble is that American hospitals have sprung up across the country with no system at all to coordinate their services. “The public,” says Dr. Jack C. Haldeman, president of the Hospital Review and Planning Council of Southern New York, “insists that every hospital provide every possible medical service, that its hospitals be located convenient to everyone even though this means small and uneconomical institutions, and insists on using the hospital in a convenient fashion rather than in the most efficient fashion. However, in the next breath, the public, in increasingly louder tones, is expressing concern over the rapidly increasing costs of hospital care . . . those of us in hospital planning are damned if we do and damned if we don’t.”

Poor planning and duplication not only waste money but reduce the quality of care. Only selected medical centers with well-trained teams should have heart-lung machines, yet many hospitals have bought them as institutional status symbols, to the possible jeopardy of prospective heart surgery patients. A cardiac surgery team needs constant practice to achieve good results. But in a survey of 348 hospitals with open-heart surgery facilities, a Johns Hopkins researcher found that 74 percent of the institutions were averaging less than one operation a week.

A classic example of wasteful duplication occurred a few years ago in Westchester County, New York, when four community hospitals announced plans to buy cobalt radiation units for cancer treatment. Dr. Haldeman’s council approved one unit as being entirely sufficient for the needs of cancer patients in the county.

One of the major duplication problems, however, is the national multiplicity of small hospitals. In Texas a few years ago there were fifty-five towns with two or more hospitals of 100 beds or less, and forty communities with two or more hospitals of fifty beds or less. Sound planning would have put these beds under one roof for the sake of efficiency and quality of care. A delivery in a 400-bed hospital, for example, requires twelve personnel hours, as compared with seventeen in a 100-bed facility; pharmacists at the larger hospital will prepare twenty-five prescriptions per man-hour as compared with fourteen in the smaller institution. In the larger institution, Haldeman notes, employees have less idle time, personnel are more likely to work within specific areas of specialization, and the hospital itself will tend to attract doctors with special qualifications.

TO PROVIDE Americans with enough hospital beds, the federal government twenty years ago embarked on a program to aid hospital construction, the so-called Hill-Burton Act. States, with federal support, have invested more than $6 billion to provide more than 300,000 new beds, and 2000 laboratories, diagnostic and treatment centers, and other health facilities. Although hospitals are perilously overcrowded in such rapidly growing areas as Arizona, Texas, and parts of Long Island, the supply of beds is no longer an acute national crisis.

The emphasis under Hill-Burton was new construction in rural areas; the urgent need now is modernization of medical facilities, particularly in the cities. Probably the most exhaustive study ever made of hospital obsolescence was published recently by the Hospital Review and Planning Council of Southern New York. Forty-seven of New York City’s 130 general hospitals were found to be so unsuitable that the council recommended total replacement; all the rest needed at least some modernization, and twenty-four needed major renovation. In fifty-eight voluntary hospitals, only one in five had surgical facilities considered adequate for good operating technique and sterility. In some instances, doctors and nurses had to walk through nonsterile areas in their scrub suits to reach operating rooms, or had to walk through operating rooms in their street clothes to get to their lockers.

More than a third of the clinical laboratories in these hospitals were so crowded or badly placed, said the report, as to “contribute to inaccuracy and compromise patient care.”Nearly hall the hospitals had no emergency power sources, and only 17 percent met the standards for fire safety recommended by the U.S. Public Health Service.

Most experts agree that similar conditions can be found in the hospitals of most major cities, although Washington, D.C., and Columbus, Ohio, are among certain outstanding exceptions. Using beds as a unit of measurement, Dr. Harold M. Graning, of the U.S. Public Health Service, estimates that 13,000 beds across the country are becoming obsolete each year; the bill for replacing them will come to almost $10 billion in the next decade. President Johnson has called for a program of government-guaranteed loans amounting to $1 billion in this year’s health message.

Despite talk of a bed shortage, many hospital spokesmen doubt that Medicare beneficiaries will impose a crushing burden on most hospitals this summer. Unquestionably, many men and women over sixty-five have postponed nonurgent operations until after July 1. However, elderly patients account for only a quarter of the total days Americans currently spend in the hospital. Therefore, even if the hospitalization rate among persons over sixty-five should increase by 20 percent, the overall rise in demand for bed space would be only 5 percent.

In the long run, Medicare will take a major burden off hospitals through its provisions for convalescent care in nursing homes or in the patient’s own home. Extended care and home care are concepts long neglected in American medicine, and many patients occupy beds in hospitals simply because their doctors have no other place to put them. A hospital planning agency in Rochester found that 15 to 20 percent of patients in the city’s hospitals didn’t require bed care. As a result, a program to provide new hospital facilities was altered to include three extended-care units and a home-care program.

Aside from its immediate financial benefits to the elderly, Medicare will play an unprecedented role in implementing the philosophy of continuous patient care. In a symposium published in Hospitals, Dr. William H. Ford, president of Blue Cross of Western Pennsylvania, put it this way: “This country is moving toward a complete health care system. The question is whether the leadership in the voluntary hospitals of this country is going to measure up to this concept.”

Inevitably, Medicare will also raise the quality of medicine practiced in the nation’s hospitals. For one thing, the law requires hospitals to establish “utilization review” committees. Made up of staff doctors, these committees will check on admissions to make sure they are necessary, and they will curb overstays. For another, the federal government established standards for Medicare hospitals similar to those of the joint commission. At the very least, Medicare means that hundreds of previously unaccredited hospitals will be subject to minimal controls, including regular staff meetings, tissue committees, and maintenance of explosion-proof operating rooms. State and local boards, moreover, can set even higher standards, and in New York, the state health department is expected momentarily to impose regulations similar to those which Dr. Trussell obtained for the hospitals in New York City.

Medicare’s standards for nursing homes will go far toward assuring Medicare patients of care by skilled personnel. The law requires that nursing homes qualifying for Medicare payments must employ a full-time registered nurse and have, at the least, a practical nurse from a state-approved school on duty at all times. At present, only about 250,000 of the nation’s 700,000 nursing-home beds are in homes that meet these standards.

ANOTHER new piece of legislation, Public Law 98-239, although less widely publicized than Medicare, may have as much ultimate effect on the future of the U.S. hospital. The law grew out of the recommendations of the President’s Commission on Heart Disease, Cancer, and Stroke, appointed in 1964 to plot a broad attack on these major killers. Among the commission’s main requests was establishment of regional medical complexes built around large medical centers. The law, written broadly enough to cover virtually all diseases, provides appropriations of $340 million over the next three years to plan ways to establish such regionalized medical care by linking medical schools and large clinical centers with smaller hospitals on a geographic basis.

Such an arrangement would, of course, give patients needing specialized care easier access to the large facilities best equipped to provide it, would reduce wasteful duplication of facilities, and would help keep doctors at the local levels better informed of new developments coming out of medical-center laboratories and clinics.

The Hunterdon Medical Center already represents aspects of such regional planning. An even earlier model is the Bingham Associates program, begun in the early 1930s to link Tufts-New England Medical Center in Boston with some fifty-eight hospitals and clinics scattered throughout Maine. Local doctors in Maine refer their patients to Boston for management of complex diagnostic and treatment problems, keeping fully informed of how their cases are handled. The center sends senior residents on brief tours of the small hospitals to apprise community physicians of new developments in medicine. The educational program includes closed-circuit television between the clinics and operating rooms of the Boston center and the Maine hospitals. Finally, the Bingham project has encouraged well-trained specialists to practice in communities where they are needed and has established consulting services between the hospitals in the program, making for more efficient use of diagnostic facilities.

The much-talked-about American hospital crisis is not the need for new technological advances, but the necessity of finding the best ways to use the tools already at hand. And with the onrushing development of ever new weapons against disease, the need for efficient organization of hospital services becomes urgent.

Not every hospital will, or should, offer the most specialized care; but every patient, no matter where he lives, must have ready access to everything that medical science has to offer. This means planning along regional lines in the construction and staffing of hospitals. Some institutions may become totally specialized, providing, for example, all the radiation therapy and X-ray diagnosis for an area. The general hospital will remain in the front line, as the hub of health care for the entire community. Its staff will not only assume responsibility for the patients within its walls but coordinate the care of patients in nursing homes and other extended-care facilities.

Recent federal legislation lays down a framework for a true American hospital system. A hospital network not only ensures a flow of new knowledge from the largest medical centers but challenges the physician in the smallest community to use these developments with imagination and skill. How well the physician and hospital administrator rise to this challenge will largely determine how strong outside controls, including government regulations, over medical practice will become. Americans, well aware of how good medical care can be, won’t settle for less than the best.