Musing of a Contemporary Pathologist

Heartless hospitals – part 1

 

The first record of something that we might call a hospital, a specific place to bring sick people, may be in Ceylon in the Fifth Century. The Babylonian Talmud of more than three thousand years ago devotes considerable discussion to medical concerns (Medicine in the Bible and Talmud by Fred Rosner, KTAV Publishing, 1995) but does not describe what we might call a hospital. After Ceylon, records of other early hospitals were found in India, Caeserea, Lyons, Alexandria, and Constantinople. In 641 Hôtel Dieu was founded in Paris. A century later the Foundling Asylum began in Milan and St. Albans Hospital opened its doors in London. In the Fifth to Tenth centuries there were even specialized hospitals: Brephotrophia for Foundlings, Orphanotrophia for orphans, Ptophia for the hopeless poor, Gerontochia for the aged, and Xenodochia for poor and infirm pilgrims.

To a great degree hospitals were places to provide compassionate care to society’s incurables most often also with the intent of protecting those who were well by removing the sick from the community. As one example, Gregory of Tours, in 560, reports on a leper hospital. By 1225 there were approximately 19,000 hospitals for lepers in Europe. Increasingly state and/or church support helped maintain hospitals. We can appropriately consider that, when they started, hospitals were for the benefit of almost all of society by isolating those who could not be helped. Sadly, hospitals have evolved/devolved so that their main purpose today, at least in the United States, would seem to be to benefit the very few: increasingly unimaginative, uninspired and uninspiring and, too often, corrupt administrators as well as greedy health care providers who create large systems of minimize costs and maximize profits.

After the death of Charlemagne (748-814) state support for hospitals in Europe declined until 1198 when Pope Innocent III (1161-1216) initiated the great medieval hospital movement leading, in the coming years, to the establishment of hospitals at Montpelier, Paris, Reims, Bologna, Florence, Strasbourg, Madrid, Salpêtrière, Cologne, Arles, and so many other cities. A century later, in 1280, Mazriki founded the great hospital at el-Mansur Gilafun in Cairo. This might be considered the development of the template for the idealized hospital of today. Mazriki wrote: “I have founded this institution for my equals and for those beneath me. It is intended for rulers and subjects, for the soldiers and the emir, for great and small, freemen and slaves, men and women.”

Modern medicine did not develop until Andreas Vesalius (1514-1564) revolutionary contributions overthrew more than 1000 years of misinformation about human anatomy, after William Harvey (1578-1657), approximately a century after Vesalius, revealed the actual circulation of the blood in the human body using mathematic, rather than anatomic, studies, thereby establishing the scientific basis of human physiology, and, another century later, after Giovanni Batista Morgagni (1682-1771) reported on his life experience as a physician by correlating clinical events and findings with morphologic observations (‘clinical-pathologic correlation’), creating the discipline of Pathology.

Hospitals, or at least the great hospitals, soon became places for medical science to flourish, particularly in Europe. The great names in the history of medicine, and the great discoveries, often bearing those names (http://www.whonamedit.com), poured out of those centers. Now hospitals, in a sense, evolved from protecting all of society to a second stage where caring for sick, not necessarily incurable, patients was paramount and, soon after, a third stage where inspired doctors could engage in their chosen avocation of clinical and scientific research based on their vocation of caring for the ill; hospitals became the “playground” for bright, inquisitive and insightful physicians exploring the nature of diseases and making groundbreaking observations while also developing novel, at that time often surgical, therapies.

In 1800 there were two hospitals in the United States, the Pennsylvania Hospital, founded in 1752, and New York Hospital, found in 1771. Two hundred years later, in 1975, there were 7,100. Currently, there are approximately 5,500. The 20th century decrease in the number of hospitals, despite significant population growth, reflects, at least in part, the consolidation of hospitals into more financially resilient systems and networks, a trend that shows no evidence of slowing.

Arnold Relman (1923-2014), a highly influential medical researcher, physician, educator, and medical editor – particularly influential as editor of the New England Journal of Medicine from 1997 to 1991 – wrote about the “new medical-industrial complex” more than 30 years ago (New England Journal of Medicine, 1980, volume 303, pages 963-970), cautioning that the American health system was becoming a profit-driven industry that puts the interests of stockholders before that of the public. That clear warning has become unhappy truth, with the interests of hospital administrators and industry stockholders occupying the major positions in healthcare. Although every medical center proudly proclaims that patient care is primary the sad reality is that profits and reputations are primary. Magazines proclaim best hospitals and best doctors. Scoring high in the annual ratings by one or another periodical, ostensibly, but not necessarily, is promoted as a reflection of quality of care. Earning a high place in these ratings is vital not because anyone believes these ratings are scientifically accurate but because, if possible, they will, as if satisfying an alchemist’s dream, immediately transform into advertisements to bring in even more patients and more money.

The annual revenue for many medical centers is staggering, almost defying comprehension (http://www.statista.com/statistics/245033/top-us-hospitals-based-on-gross-revenue/ ), in many cases passing $10,000,000,000 (10 billion!) per year. Hospital executives as well as individual physicians can earn amounts in excess of $5,000,000 per year (Time magazine, March 4, 2013).

Where does this money go? Certainly, dollars are necessary to support the most sophisticated (but not necessarily the most effective or equitable) medical care in the world. But some details of the finances of hospitals are often known only to the select few. The obvious expenses are well documented: how much for patient care, how much for employees, how much for supplies. But how much money is for legal expenses above and beyond that needed to defend against sometimes-frivolous medical malpractice charges? How much money is spent for lawyers defending hospitals against charges of unfair practices by physicians, about a variety of alleged employment and contractual issue including allegations directed at improving hospital safety (http://articles.latimes.com/2010/apr/06/local/la-me-cedars-sinai6-2010apr06). Approximately two decades ago the Institute of Medicine in its study To err is Human pointed to preventable hospital-based errors that lead to morbidity and mortality. Much has been done to try to correct that, with some successes, but recent data suggests that the problem still exists and may even be magnified (New England Journal of Medicine, November 25, 2010).

The 1980 graduating class of the Mount Sinai School of Medicine invited Jack Klugman, an actor then portraying “Quincy,” a television forensic pathologist, to give the commencement address. In 1974, Klugman’s laryngeal carcinoma was evaluated at a prestigious Los Angeles hospital where a total laryngectomy was recommended, a procedure which would unequivocally end his career. He sought the advice of one of the nation’s outstanding ENT surgeons, Maxwell Som, at Mount Sinai. Som, in turn, had the biopsy slides reviewed by Mamoru Kaneko, Mount Sinai’s legendary surgical pathologist. Kaneko, although agreeing that the tumor was malignant, did not agree with key portions of the first pathology report and advised Som that a total laryngectomy would not be necessary. Som performed a partial laryngectomy; Klugman continued his career and lived another 38 years.

Klugman’s simple message to the graduating students, recounting both his own experience and that of his father who had recently died, was, “Listen to your patient.” He said they should take the time to sit and hear what the patient wanted to say. At one time all medical students were taught to perform a careful “H&P” – history and physical – with strong emphasis on the taking of a detailed history. The art of the H&P is already lost – few of today’s young physicians are able to carry it out effectively. This is not because it is not taught in medical school but because it is not practiced in their internships and residencies where ordering any of a variety of sophisticated and expensive, and potentially lucrative for physicians and/or hospitals, procedures is routine – despite the fact that the history and physical can provide the diagnosis in many cases. But the purpose of this is not to decry the wonders of modern technology but rather to illustrate how the human elements are disappearing from medical care. Senior physicians make rounds with house staff (interns, resident, fellows) and listen to the younger doctors summarize the case, look at the images (x-rays, scans, MRIs, etc.), review the laboratory test results, but may not ever see the patient – may not listen. Surgeons increasingly use robotics to operating, perhaps themselves never actually touching the patient (Gordon LA. Out of touch. General Surgical News, Apr 14-15, 2014)

Busy. Everyone in medicine is busy. But, increasingly, physicians devote their energies to business concerns, to making more money than ever before, to purchasing luxury automobiles, yachts and other symbols of their earning power. The system is off balance.

Danielle Ofri, an outstanding internist at NYU’s medical center and editor of Bellevue Literary Review, recently wrote about her experience in struggling to get insurance coverage for her patient’s medications, after years of effort to find the right combination of drugs to handle his stubborn hypertension (“Adventures in ‘Prior Authorization,’ New York Times, August 3, 2014). Standard therapy was not effective. It had taken her years to find the balance of medications that could help manage a man with highly labile blood pressure, a regimen that just did not match the insurers guidelines. There is nothing, on the surface, wrong with challenging a physician’s judgment but, if you read Ofri’s commentary, you can appreciate how ludicrous it is for a doctor to spend hours upon hours trying to convince a series of well-meaning but essentially uninformed clerks about the nuances of trying to care for a difficult to manage patient. Surely, hundreds of physicians across the country experience the same frustrations, the same waste of time, each day. Many, I suspect, are not as committed to doing the right thing as Dr. Ofri, accepting the realities of an increasingly business-driven, patient-blind, system and, unhappily, will too often sacrifice the needs of the patient for some less optimal, but easier to obtain, choice.

Relman, in his last article (“A Challenge to American Doctors,” New York Review of Books, August 14, 2014), paints a bleak (to use his own word) picture of American health care in the coming years. Although we spend more per person on medical care than any other country, we spend a much smaller portion of our GDP on social services that ‘undoubtedly contribute to improved national and personal health,’ including support for maternal and child care, disease prevention, nutrition and environmental safety, as well as housing, unemployment benefits and education. Political know-nothings (in the 1850s the know-nothing movement, including Millard Fillmore, vainly tried to ‘purify’ American politics by promoting religious intolerance) of today fail to understand how decreasing support for these necessary activities ultimately contributes to greater health care expenses and increases the deficit.

And affects human beings.

To be continued …

 

 

 

 

 

One Response to “Heartless hospitals – part 1”

  1. Joel Bernstein says:

    Thanks for so well articulating what I have long suspected about hospital priorities.

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