The various floors of the hospital operate with their own nurses, their own visits, their own house staff, their own stocks of supplies. This is the arrangement found in most American hospitals, and as a way of structuring, it has distinct advantages. For many years, it was thought to be the best way of matching the patient to the facilities he would most need.

However, each of the three criteria-sex, money, and therapy-has come under attack. Money, because third-party payment has made financial structuring obsolete; sex, because if everyone is in private or semi-private rooms, segregation by whole floors becomes unnecessary.

Anticipated therapy has also been questioned. Some even argue that the distinction between surgical and medical patients be abandoned in favor of distinctions based on severity of illness, and the need for close medical and nursing attention.

Under this system, medical and surgical patients would be intermixed in units that differed in the degree of care they provided-intensive care, recuperative care, minimal care, and so on. Patients would be moved about in the hospital as their illness became greater or less.

Some clear psychological benefits for patients are apparent. As they become healthier, they would be moved to new areas of the hospital, where they would be encouraged to be more self-sufficient, to wear their own clothes, to look after themselves, to go down to the cafeteria and get their own food, and so on. They would, at every point, be surrounded by patients of equal severity of illness. Their dependency needs would be fulfilled in a graded way, since the hospital would be providing a spectrum of care and close attention. To a degree, the hospital already does this, with its recovery rooms and intensive-care units [The hospital already has intensive-care units for respiratory care, cardiac care, neurological care, surgical care, medical care, transplantation patients, pediatric patients, and burns patients.]. But more could be done-and, indeed, one can predict that more will almost certainly be done in this direction. This will happen not because the hospital is preoccupied with the patient's psyche-it is not-but rather because graded care is economically more efficient. At the present time 30 per cent of the cost of a room goes to nursing care. For the average MGH hospital room, this amounts to some $22 a day. Although the percentage cost may not rise in the future, the absolute cost will. Ultimately it will be necessary to give patients no more nursing care than they really need; the present inefficiency in personnel use will become too costly to continue.

Among physicians, a restructuring could be more efficient as well. Consider anesthetists: in the last decade, they have emerged as the experts in the support of vital functions. They are called for every cardiac and respiratory arrest; they know more about drugs than anyone else; they are expert in the use of respirators. Most physicians would agree it is handy to have an anesthetist around any intensive-care unit, but at present the anesthetists are dispersed throughout the hospital. By restructuring on the basis of severity of illness, one important resource, anesthetists, would be made more available to patients who need them.

Indeed, "human resources" are just one argument for restructuring. Hardware and technology resources represent another. For example, the kind of electronic and mechanical equipment required for a patient with a heart attack and for a postoperative cardiac patient is very similar. As time goes on, and larger and more all-inclusive machines become available, it will be increasingly advantageous to bring patients with similar technological requirements together, so that they may share certain large machine capabilities and so that medical personnel trained in the use of these machines can be centralized.

The bringing together of patients, personnel, and hardware has certainly been valuable in cardiac intensive-care units; in some units immediate mortality from myocardial infarction has been cut as much as 30 per cent. We are already seeing a pro-

liferation of these specialized units, and we will certainly see more-and from there it is only a small step to complete reordering of the hospital along new lines.

 


Chapter

Afterword

although it comes from an ancient tra-dition, the modern hospital, in fully recognizable form, is less than fifty years old.

At most it will last, in fully recognizable form, another decade or so. But by then, almost surely, what is different from the present will overshadow what is similar. And we may expect these changes to represent more than improved technology and differently trained personnel. For there will certainly be a change in the function of hospitals, just as there has been a change in function during the past half century.

During that period, the hospital evolved into a positive, curative agency specializing in highly technical, complex medical procedures. Very likely the hospital will continue to function in this capacity. But it will abandon certain other functions in the process. It will cease to be a convalescent facility, for example, as more specialized convalescent homes appear. It will curtail its in-patient diagnostic work to that which absolutely requires hospitalization. Its custodial function-whether.

Afterword

Represented by a young couple "dumping" grandpa for the weekend, so that they can have a few days to themselves, or by the admission of alcoholics and derelicts who would otherwise have nowhere to go-has already been reduced and will soon be eliminated. One can say this with some confidence because in every case the rationale is economic, not philosophical. Hospitals are becoming so expensive that financial considerations will soon become the paramount determinant of function.

Less certain are those new tasks and responsibilities that the hospital will assume in the future. Here, the pressures are largely social, and their manifestations not easily anticipated. Perhaps the clearest-and most general-trend is the hospital's notion of an extended responsibility, which goes beyond the confines of its walls. A teaching hospital such as the Massachusetts General now sees its job as dealing both with the hospital patients and with the surrounding community. It defines this new role in two ways: discovering those patients who need hospitalization but are not receiving it, and treating other patients so that future hospitali-zations will be prevented.

But the hospital is going further. It is spreading its research and its knowledge beyond the local community to a broader population. In the past, it did this in the form of research papers printed in scientific journals. That form persists, but more directly the hospital now uses television and computer programs to disseminate its knowledge and its resources.

For the patient, something rather paradoxical is happening. Broadly speaking, the whole thrust of enlightened medical thinking is directed toward getting more care to more people. The problem is as enormous and as important as curing any specific disease process. In examining the situation, both doctors and patients express the fear that the individual may cease to be treated as a person, that he may become merged into some faceless, very lonely crowd. Yet at the same time, the hospitals, which have traditionally been the most impersonal elements in any health-care system, are more concerned than ever about tailoring the hospital so it treats every patient individually.

For medical education, the impact of changes in hospital function may be considerable. For the last half century, medical education has been almost exclusively in-patient education-the emphasis has been upon care of the patient who is in the hospital and not outside it. But as the hospital reaches outside its walls, so will medical education.

There is another point about medical education, not often considered in formal discussions. It is a problem, a fact of medical life, which can be dated quite precisely in terms of origin: it began in 1923, with Banting and Best. The discovery of insulin by these workers led directly to the first chronic therapy of complexity and seriousness, where administration lay in the hands of the patient. Prior to that time, there were indeed chronic medications-such as digitalis for heart failure or colchicine for gout-but a patient taking such medications did not need to be terribly careful about it or terribly knowledgeable about his disease process. That is to say, if he took his medicines irregularly, he developed medical difficulties fairly slowly, or else he developed difficulties that were not life-threatening.

Insulin was different. A patient had to be careful or he might die in a matter of hours. And since insulin there has come a whole range of chronic therapies that are equally complex and serious, and that require a knowledgeable, responsible patient.

Partly in response to these demands, partly as a consequence of better education, patients are more knowledgeable about medicine than ever before. Only the most insecure and unintelligent physicians wish to keep patients from becoming even more knowledgeable.

And when one considers a medical institution, such as the hospital, the importance of a knowledgeable public becomes still clearer. Hospitals are now changing. They will change more, and faster, in the future. Much of that change will be a response to social pressure, a demand for services and facilities. It is vital that this demand be intelligent, and informed.