Pie-in-the-Sky Conundrum Facing Dr. Williams
Basically, there were only two logical sources of money to fund this important nationwide system of general-purpose hospitals. One was the profit from thousands private hospitals (best est. 8,000 hospitals in US at that time) existing at that time, and the other was public funding provided by the federal government. In theory, these two resources could have negotiated a public-private partnership to the benefits of all.
However, neither of these sources was an option. Here’s why they wouldn’t work and why Dr. Williams had to come up with a creative ‘workaround‘.
Why private hospitals profits were not the answer
Historically, hospitals were not a for-profit business but were charitable providers of last resort for the desperately ill and injured (also homeless pregnant women and founding babies) who, in almost all cases were NOT able to pay for their care. As a result, hospitals were mainly charity institutions financed by the Catholic Church and run by religious orders of monks and nuns, or financed by the State who employed local staff to run them.
At the time Dr. Williams wrote his 1914 book, there were a couple dozen big charity or state-funded hospitals in large American cities, but the business model for thousands of hospitals the United States was still as a very small doctor-owned business that provided services only to paying customers.
This arrangement was obviously convenient and profitable for the two doctor who went into business together to own and run the town’s 2-to-10 bed non-acute-hospital. Instead of these doctors spending day driving all over the county to make house calls, they could concentrate the majority of their sickest patients in one place and employ shifts of nurses to watch them day and night.
Of course, this profit-making business model couldn’t, and didn’t, address the needs of the many ill and injured who were in immediate and desperate need of the kind of medical services we now call “intensive care”.
There is a historical truism here that dare NOT be ignored by those who contemplate owning or running a general hospital. Plainly put:
Depending on sick people as paying customers is now, and has always been, a failed business model!
The ill, injured, elderly and infants are a demographic category that, with the rarest of exceptions, is NOT able to pay for expensive and often lengthy medical care. That is why the history of hospitals starts out with charity institutions run by the Church or State, and a few very posh private hospitals owned by wealthy doctors and financed by the fees of their even wealthier patients and patrons.
This idea is not rocket science — orphans don’t financially support orphanages, school children do not pay the salaries of their teachers, jail inmates don’t hire their prison guards and soldiers don’t fund the military. Even public libraries are financed by someone other than the kids who check out books.
Unfortunately, there just aren’t enough really wealthy sick people to support general hospitals as profit-making business ventures. Period.
Dr. Williams was no fool; he knew only too well that the money he needed would not be found in the pockets of most hospital patients.
Public Funding or (yikes!) “Socialized Medicine“
This was a total non-starter for American doctors. Organized medicine was dead-set against ANY type of ‘national’ system of hospitals or the provision of medical services the mirrored the model of public funding used in Western Europe.
Organized medicine has always interpreted the idea of America as the “land of the free” to mean “land of free enterprise”. After all, our European ancestors didn’t risk their lives for nothing, suffered months of hardship as they crossed the Atlantic ocean in a crowded, storm-tossed and often leaky wooden boat while being actively pursued by pirates.
America was suppose to be as big as everyone’s biggest dream; as a class, doctors were dreaming big about making their mark in a country defined by an unlimited entrepreneurial spirit and the freest form of free enterprise.
All this was in sharp contrast to what AMA members saw as their not-to-bright European counterparts. In their opinion, the ‘professional’ status of a doctor was always demeaned by becoming mere an employee of someone else, especially a state-run hospital system.
As if that was not bad enough, doctors working in nationalized systems had to deal with the politics of a State bureaucracy. Far too often, the King would appoint his wife’s brother’s once-removed nephew as a hospital’s chief of staff. That he wasn’t a doctor and didn’t know jack-shit about the job of running a hospital was irrelevant.
As a physician-employee, the politics of big bureaucracies meant that who you knew mattered far more than most what you knew, or how good or hard working you were. Instead of being lauded for their innovative ideas, these doctors were dismissed out-of-hand or even criticized and demoted. At the same time, their lackluster, gold-bricking, brown-nosed counterparts were sky-rocketing up the bureaucratic latter, with fat raises and guaranteed job security!
One example of how crazy this could get is the story surrounding the invention of the stethoscope in 1816 by a Parisian doctor (Rene Theophile Hyacinthe Laënnec). Many doctors were excited by this new cutting-edge ‘technology’ and eager to use it themselves. But the head of the medical staff at the big general hospital in Vienna didn’t understand how it worked and thought it looked silly and unprofessional, so he forbid his staff doctors to use it for several years.
In sharp contrast to these European customs, the practice of medicine in the US meant privately-owned clinics and hospitals, in which doctors saw themselves as patriotic entrepreneurs. As self-employed professionals, doctors were their own “boss”, beholding to none, which is to say they were not hamstrung by the policies and protocol associated with institutional systems and free from the political limitation that inevitably accompany bureaucracies!
So Dr. Williams, the hero of our story, knew he had to look elsewhere if he ever wanted to see a nationwide system of general hospitals become a reality in the US.
What to do? Stay tuned for a really big surprise . . . .
The Invention of “Elective Hospitalization” for healthy paying customers
Dr. JWW knew that depending on hospitalized sick people for a profitable revenue stream had long ago been demonstrated to be a failed strategy. So he boldly turned his attention in a novel direction and invented the idea of “elective” hospitalization of healthy paying customers.
In the far future, the categories of ‘electively-hospitalized healthy patient’ would expand to include cosmetic surgery patients, those undergoing bariatric (weight-loss) surgery and those hospitalized for diagnostic work-ups. But in 1914, the only demographic of healthy people that were obvious to Dr. Williams — who was himself an obstetrician, chief of Obstetrics at Johns Hopkins Universtiy Hospital, appointed Dean of the University’s School of Medicine in 1911, was healthy childbearing women.
Lying-in Wards & the new demographic of electively hospitalized patients
Adding ‘Lying-in’ wards to the basic services provided by hospital for the ill and injured was to become the core of a new business model that would catapult small hospitals with marginal profits into privately owned or not-for-profit general hospitals, remodeled and retrofitted with state-of-the-art equipment and one or more modern operating room.
The math was simple: when the new mother’s 14-day postpartum stay was added to the14-day stay of her baby in the hospital nursery, it produced an annual census of 9,800 patient days. Maternity patients paid only a few dollars a day for their hospital room, but combined with small additional fees for use of the L&D facilities, other supplies and newborn nursery charges, each new lying-in ward would generate tens of thousands of dollars in additional revenue annually. This steady revenue stream would handsomely underwrite the expanded services of a community hospital and the purchase microscopes, operating tables and x-ray equipment.
Dr. William’s plan replaced the idea of “build it and they will come” with a new paradigm: “if you can get them to come, you’ll have enough money to build it”.
Dr. Williams’ Dream-Solution to the funding problem
The plan was simple: every small and medium hospital in the US should add a ‘lying-in’ ward (or ‘re-purpose’ an unused or unprofitable part of the building). At that time, the vast majority of hospitals in the US were proprietary facilities with less than 25 beds owned and run by physicians and only able to provide very limited services. Dr. Williams’ plan would allow them to extend their basic services to include physician-attended childbirth services and a 14-day postpartum stay for the mother and 14 days of nursery care for her healthy newborn.
In the early 1900s, the average married woman had 6 children, so repeat business was a given for a large (and healthy) segment of the population who were happy to pay a modest (but still very profitable) fee for this ‘elective’ service. Most notable of all – Dr. Williams’ his plan economically revolutionizes the business end of hospitals without involving the federal government (the dreaded idea of ‘socialized’ medicine) or any other centralized bureaucracy that might limit the many entrepreneurial opportunities available to the medical profession.
It is no surprise that Dr. Williams’ plan to electively hospitalize healthy maternity patients was eagerly embraced by the medical profession and organized medicine. While they greatly appreciated his plan’s ability to generate additional revenue, they also saw hospitalized maternity patients as an invaluable asset in two other important areas.
Fortuitous Side-effects of Dr. Williman’s Invention of ‘Elective Hospitalization of Healthy Patients
First was the expanded opportunity for clinical training of medical students. The medical profession had quite a list of reasons for objecting to midwife-attended births, but very high on this list was the food fight over ‘teaching cases’, or as described by obstetricians “obstetrical ‘material‘”.
Every time a midwife attended a normal birth, the obstetrical profession claimed they had ‘wasted’ a perfectly good opportunity for a medical student to expand his clinical knowledge and sharpen his skills. In the opinion of the medical profession, the training of future doctors was ever so much more important than the “dubious” contribution of midwives.
“It is generally recognized that obstetrical training in this country is woefully deficient. There has been a dearth of great obstetrical teachers with proper ideals and motives, but the deficiency in obstetrical institutions and in obstetrical material for teaching purposes has been even greater. It is today absolutely impossible to provide {teaching} material.” [1912-B, p. 226
When we recall that abroad the midwives are required to deliver in a hospital at least 20 cases under the most careful supervision and instruction before being allowed to practice, it is evident that the training of medical students in obstetrics in this country is a farce and a disgrace.
It is then perfectly plain that the midwife cases, in large part at least, are necessary for the proper training of medical students. If for no other reason, this one alone is sufficient to justify the elimination of a large number of midwives, since the standard of obstetrical teaching and practice can never be raised without giving better training to physicians.” [1912-B, p.226] {emphasis added}”
In addition to the steady revenue created by electively hospitalizing maternity patients, there was a second bonus — an expanded market for the services of graduate physicians. Since only medical doctors were allowed to practice in hospitals (practice privileges extended by MDs to MDs), this instantly eliminated the economic competition of midwives.
While increased income was the primary goal, the dramatically improved job opportunities and working condition for doctors were greatly appreciated. Physicians who normally attended births in the homes of their patients were quick to grasp the time and labor-saving elements of Dr. Williams’ plan to cluster their labor patients together in one place – the convenient local hospital.
For doctors, this was a huge improvement in working condition compared to the typical experience of a general practitioner who routinely provided care in the cramped, inconvenient, poorly lit and often unheated home of a farm family having its 10th child on a cold and stormy mid-winter night. Even if everything went perfectly and quickly, it was still an uncomfortable and inconvenient experience for the doctor.
If any kind of medical or surgical intervention was required, having instant access to a well-equipped hospital and well-trained staff was obviously a vast improvement. Hospitals conveniently provided a clean, spacious, warm and well-lit facility, plenty of nurses and other staff, access to special equipment, and (thankfully!) a central supply department that did all the cleaning and sterilizing of instruments.
Last but not least the hospital maternity ward provided an on-going opportunity for social and professional interaction between the community’s physicians, thus creating a camaraderie that helped elevate the status of the medical profession in its own eyes.
None of these physical, technological or social advantages could have been duplicated in the old, time-consuming system of house calls that dispersed doctors to the far reaches of their geographical district, isolating them from the daily contact of their peers and technologically-centric improvements of ‘modern’ medical science.
Standard Hospital Birth In America ~ 1910 to 1960 ~Physician-attended childbirth in an American hospital during the early decades of the 20th was starkly different from the historical experience of midwives and MD birth-attendants during all preceding centuries. In fact, it was the most profound change in normal childbirth practices in the history of the human species. As a result, healthy childbearing women became the patients of a surgical specialty and normal childbirth was turned into a surgical procedure to be ‘performed’ by a medical doctor.
Nonetheless, the medical profession enthusiastically embraced this drastic change in how childbirth services were provided to healthy childbearing women without too much concern for how this affected these women and their families. Hospitals, as the central location for all the childbirth services provided by doctors, made as dramatic a change in the working lives of doctors as it did in the experience of the childbearing families.
Before Dr. Williams’ plan for elective hospitalization was implemented, the family would call the doctor in the middle of the night and tell him “It’s time” (my wife’s in labor and she says its time for you to come”. The doctors had to get out of bed and drive to the often cramped and untidy quarters of a rural farmhouse on a dark and stormy night to provide his professional services.
After hospitalization became the norm in America, a doctor instructed his patients to go to the hospital when she was in labor. After being admitted to the Labor and Delivery ward, the doctor would be notified by phone and give instructions to the nurse to call him when the birth was imminent; then he went back to sleep.
This is another example of what I characterized earlier as “the most profound change in normal childbirth practices in the history of the human species“. In this case, the change is the doctor’s professional relationship with labor. Before Dr. Williams’ plan, part of the doctor’s role was to be present and attentive during the mother’s active labor as well as the birth of the baby.
But after physician-attended childbirth was moved out of the family’s residence to the hospital, doctors no longer had to do what was called “labor-sitting” — to sit in the room with a laboring patient. Nurses would call the doctor if a problem arose, but otherwise, he was not expected to provide hands-on care or be directly involved in the management of a patient’s normal labor.
Labor ~ the waiting period before the doctor is called
Instead, labor-related care became a function of the hospital’s nursing staff. This saved physicians from the tedium of a long labor. This perspective was aptly described in an obstetrical textbook of the era, which referred to labor as ‘the waiting period before the doctor was called’.
When the doctor was finally needed at the hospital, he was greeted by a clean, warm, well-lighted and well-staffed facility staffed by professionally-trained nurses eager and willing to do his bidding.
Between 1910 and as late as the 1980s, nursing care during this ‘waiting period’ started with regular injections of Twilight Sleep drugs (a mixture of the strong narcotic morphine and scopolamine, a hallucinogenic and amnesic drug), which were repeated every 2-3 hours around the clock. While the mother continued to labor in a semi-conscious state under the influence of these drugs, her doctor slept soundly at home or hospital’s OB call-room.
The next and biggest departure from traditional childbirth practice – normal birth as a surgical procedure performed on an anesthetized and unconscious mother
The doctor was not awakened or notified to come to the hospital until the heavily-medicated mother was completely dilated, actively pushing her baby into the birth canal and was already in the OR-style delivery room. This required the nurses to transfer each of these semi-conscious mothers from their bed to a stretcher and then wheeled into the delivery room and moved over to the delivery table.
Then her limp legs were strapped into obstetrical stirrups, her hands locked into leather wrist restraints (lest she rouses enough to touch something and contaminates a sterile instrument) and her entire body buried under sterile drapes. The nurse-anesthetist was called to give the mother general anesthesia.
After the mother was unconscious, the doctor came on the scene, already capped, masked, gowned and gloved. Over the next 30 to 45-minutes, the surgical procedure of forceps-assisted vaginal birth would be ‘performed’. This would include an episiotomy and low forceps delivery. This typically included instructions to the nurse to provide aggressive fundal pressure pushing down on the mother uterus from above as the doctor pulled on the handles of the forceps with each push from below.
After the baby was born, an L&D nurse would stimulate it to breathe as the OB doctor donned extra long sterile gloves so he could reach up into the mother’s uterus and manually disengaged the placenta from the interior wall of the uterus and bring it out. Then he would suture the episiotomy, to conclude the infamous “husband stitch”.
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Sorry but it’s unfinished — text below is to be used when i have time to finish this essay.
14-day stay of her baby in the hospital nursery, it produced an annual census of 9,800 patient days. Maternity patients paid only a few dollars a day for their hospital room, but combined with small additional fees for use of the L&D facilities, other supplies and newborn nursery charges, each new lying-in ward would generate tens of thousands of dollars in additional revenue annually. This steady revenue stream would handsomely underwrite the expanded services of a community hospital and the purchase microscopes, operating tables and x-ray equipment.
Dr. William’s plan replaced the idea of “build it and they will come” with a new paradigm: “if you can get them to come, you’ll have enough money to build it”.
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