Ch 4 ~ Two problems, one solution, a big win for society at the expense of healthy childbearing women
From Dr. JWW’s perspective, as former chief of obstetrics and Dean of a famous American medical school, the biggest and difficult problem was the desperate lack of “general” hospitals able to provide “comprehensive” services in the United States. These are large regional hospitals, like Johns Hopkins in Baltimore, were equipped to provide comprehensive medical and surgical care to patients of all ages, all stages of life, and across the spectrum of serious illnesses and injuries.
He wanted to solve both of these problems and do so without depending on government funding in any way, as the medical profession and American Medical Association believe was a “slippery slope” that would inevitably lead to unwanted government interference, which was just a polite way to say, government interference in what the AMA characterized as the “sacred doctor-patient relationship”.
But without access to comprehensive medical and surgical services, husbands with a limb mangled in a piece farm equipment, women having an pregnancy-related emergency, babies with convulsions and a high fever and elderly relatives having a heart attack would likely die before they could be transported by car or the open bed of a truck to the nearest well-equipped general hospital that was 50 to 400 miles away.
What was obviously and desperately need was nationwide system of fully-equipped, fully-staffed general hospitals.
This brings our story back to Dr. JWW and his dream of finding or inventing a way to privately fund the modernization of these the 8,000 or so small privately-owned hospitals and eventually develop a significant number of them into a nationwide system of acute-care “general” hospitals.
An audacious plan for modernizing small private hospitals without depending on any government funding
Dr. JWW saw this as a gradual process in which each hospital would be able to slowly upgraded or remodeled the hospital building and its facilities, as well as purchasing new or better equipment and generally improving their technological capabilities.
He believed that a significant number of these small and medium-sized hospitals would gradually, over the course of a few decades, grow into a well-equipped general hospital that would be able to provide “comprehensive” medical and surgical services to patients of all ages and all kinds of medical problems in their geographical area.
But first, it helps to understand the basic nature of hospital care during the hundreds of years long pre-scientific era
A brief trip in the Wayback Machine, when hospitals were little more than medical hotels providing “hospitality” and palliative services
Prior to the modern development of medicine as a science, the services provided by hospitals had little or nothing to do with “curing” diseases. With a few exceptions such as setting broken bones, “medical cures” had yet to be invented. Hospitals were in essence medical hotels that provided labor-intensive “hospitality” services” to the ill and injured. This is where the word “hospital” comes from – a place of caring that provides shelter, a dry bed, clean sheets, and marginally-skilled workers who change the linens, served meals, help patients to the bathroom, give back-rubs and empty bedpans.
Then suddenly, in the space of 10 or 20 years, “modern medicine” came on the scene and turned everything upside down. What had been essentially “hospice” care for the hopelessly ill was (gratefully!) replaced by modern medical science, which has able to actually cure many diseases and successfully treat many injuries that would otherwise have been fatal or left patients permanently crippled.
And yes, this came with a ‘down-side’ – actually a double down-side. First, the kind of hospital that was equipped and staffed to provide these new scientific cures and treatments was obviously a large and very capital-intensive enterprise and such places were exceeding rare in America at the beginning of the 20th century.
The entire country only had a few dozen fully-equipped and staffed general hospitals able to provide “comprehensive” care – an emergency department and in-patient medical, surgical, obstetrics and pediatric services. The vast majority of these general hospitals were in NYC and the upper East Coast, Chicago, New Orleans, Denver and larger metropolitan areas on the West Coast.
In stark contrast, historians estimate that in the early 20th century the US had about 8,000 tiny, doctor-owned, two-to-ten bed facilities, most of which were housed in aging 19th century mansions or old hotels. Their most modern technologies usually consisted of electric lights, a telephone, a microscope and perhaps a used x-ray machine. But the era of hospitals as places that proved “hospitality” services was on its very last legs and would soon fade away altogether.
The Double Whammy of Medical Science
For the very first time ever, revolutionary and life-saving medical breakthroughs – that mystical quality called “medical cures” – now existed. However, “modern medicine” did not come cheap! Hospitals were required to make big cash outlays – i.e. “capital investments”—in order to upgrade or remodel their facility and purchase the expensive medical equipment necessary for the scientific version of “state of the art” care. This made running a modern hospital orders of magnitude more expensive than the 19th century “hospitality-hospice” care provided by the typical 2-to-10 bed doctor-owned hospital as a for-profit business.
To provide the full ranges of medical services, a hospital had to have a clinical laboratory, an operating room, and a central supply department. To house these new services and specialty areas, many hospitals either had to remodel or add new building. Better equipment and new medical technologies became available every year, creating a miniature Tsunami of things that hospitals would need to purchase such as an x-ray machines, x-ray film, developer solution, surgical instruments, and autoclaves to sterilize supplies and equipment.
As noted above, the miracles of modern medicine were expensive, and these hospitals were depending on sick people as “paying customers” cover the cost of their care and provide a reasonable profit for the proprietary owners.
It’s not hard to see the problem this represented – while 20th century science provided the knowledge-based, medical and technological equipment and professional skills that effectively prevented needless suffering and deaths, this ability had not yet become a practical reality.
A primer in Hospital Economics
As privately-owned for-profit business, hospitals depended on their patients being personally able to pay their hospital bills. But hospital bills are not the same straight-forward financial transaction as the purchase of most other services. By definition, hospitalized people (i.e. patients) are sick, injured, disabled, crazy or infected with communicable diseases. As a demographic, hospitalized patients are not able to generate income. If they are really ill or injured, they will require a lot of intensive and expensive medical and nursing care. Even worse, a significant number of hospital patients die without having first paid their hospital bill.
Sick people are the very worst demographic to depend on as paying customers. As an economic adventure, it became increasingly clear that technically enriched 20th century hospitals could not depend on 100% of the seriously ill or injured to pay 100% of the cost of their care. The conclusion was inescapable — there were not enough sick people (as paying customers) to support the 20th century practice of medicine as a technologically-enhanced medical science. As a result, many small and medium-sized hospitals were just barely squeaking by.
MOVE back up to same topic and use second computer to help reconcile the two versions!
Another big issue ~ Most Americans have no access to emergency services and comprehensive medical care at a large regional general hospital
Unfortunately, economics was not the only “hospital-related” problem on Dr. JWW’s mind. The other big problem was a near total lack of access to general hospitals for the vast majority of the American population, which didn’t happen live in one of the populations centers where most of these big well-equipped hospitals were located. In that regard, the US was very different from industrialized countries on the European continent.
Dr JWW happened to be familiar and extremely interested in this issue of regional general hospitals. when he graduated from medical school in 1889, the US had only a handful. Shortly after that, he enrolled in a two-year clinical training program in some of Western Europe’s the most famous hospitals and was thunderstruck to discover that most European countries had regional systems of well-equipped and well-staff general hospitals. These large facilities were able to provide comprehensive health care to people of both genders and all ages, which included emergency care and in-patient medical, surgical, pediatric, and obstetrical services.
Compared to other developed countries, America was still a backward and undeveloped country in in the early 20th century when it came to “state of the art” hospital services. Unlike the regional hospital systems in Western Europe, the US had no reliably effective system for providing emergent or comprehensive medical and surgical services. As Dean of the Johns Hopkins School of Medicine, Dr. JWW understood the magnitude of these medical problems at a practical level, whether it was an absolute lack of emergency medical services or great delay in accessing appropriate care.
It was crystal clear to Dr. Williams that Americans desperately needed a nation-wide system of general hospitals able to serve patients where they lived, rather than attempting to transfer the critically ill and injured to a general hospital a 100 miles or a day’s travel away.
This was the fate of all desperately ill or injured patients, such as a farmer with a badly mangled arm, a pregnant woman who was hemorrhaging, a child in critical condition with 3rd degree burns, or an entire family badly injured in an automobile accident. While they lay in the back seat or an open flat-bed truck, each one of them had to be transported over long distances while the frantic driver dealt with rain and snowstorms, poor roads, flat tires, and no gas stations.
Obviously, this was a really serious problem that called for a coordinated national response and serious efforts to close the gap between where people lived and where major hospitals were located. But in addition to the functional lack of regional hospitals, small and medium-sized hospitals needed to purchase modern medical equipment so they could provide new technologically-enhances services. This left all but a lucky few hospitals bleeding red ink in their effort to “keep up with the Jones”.
This always brings us back to the issue of hospital economics in America, and its “Mission Impossible” — the crazy idea that depending on sick people as paying customers was a viable “economic” model. Historically, this model has been proven wrong over and over again. Since St Laundy established the first public hospital in Paris in 600 CE, all the large hospitals in Europe were charity institutions run by Catholic Church or the State government. The reason was simple: sick people are a poor (pardon the pun) demographic to depend on as paying customers. As the centuries passed, it become increasingly clear that hospitals could no more depend on the seriously ill or injured to pay for hospital care than orphanages can expect orphans to pay room and board, or prisons can expect inmates to reimburse the costs of their incarceration.
The 19th century business model for those 8,000 small doctor-owned private hospitals was profitable only because the cost of running a small medical hotel was so very low. These establishments were staffed by 27-7 by one or two nurses and a bevy of unskilled “helpers” who cooked and cleaned and helped patient to the bathroom. Nobody was hooking patients up to a cardiac monitor, giving blood transfusions or starting IVs to administer chemotheory drugs. But in the technology-intensive 20th century, those same small hospitals suddenly found the deck stacked against them, as they worked harder and harder to keep up with improvements in the practice of medicine as a constant advancing science.
That brings us back Dr. JWW and his multi-part, multi-generational plan for privately underwriting the modernization of smaller hospitals and helping to develop a country-wide general hospital system in ways that would not provoke the ire of organized medicine.
As noted earlier, Dr. Williams’ dream was finding a way to help small and medium-sized hospitals upgrade their facilities and medical equipment and ultimately to finance a nation-wide system of general hospitals in the United States like the ones on the Europe Continent. However, as judged by American doctors, who generally were self-employed entrepreneurs, the European system was fatally flawed in two aspects. First was the previously mentioned “meddling” associated with government funding. This inevitably paved the way for large insular bureaucracies that rewarded stogy cronyism and punished ingenuity. But the real deal-breaker was that the medical doctors on staff at all these European regional hospitals were government employees.
That was the exact opposite of the practice of medicine in the United States, where the idea of a doctor being a mere employee who worked for someone else was insulting. Why spend years in medical school only to become someone else’s lackie? In America, medical doctors are not hospital employees, but independent practitioners that apply for “admitting” and “practice” privileges at area hospitals.
American doctors, born and raised in the land of the free, home of the brave, saw the practice of medicine as an “entrepreneurial opportunity”. They dreamed of coming up with an ingenious discovery or important new treatment that would advance the practice of medicine and ultimately make them rich and famous. The word “bureaucracy” had long ago been stricken from their own vocabulary and that of the American Medical Association!
Ch 4 — The specifics of Dr JWW’s audacious plan to fund modernization of small private hospitals by encouraging them to add “”lying-in services” electively hospitalize healthy women as paying customers for childbirth the following 14-day “lying-in” period
