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care of the head of that department or of his responsible representatives and never remain a patient of a nursing, social service, or therapeutic department. That is, that each nurse or social worker should be directly responsible to the professional head of the department for each patient directly or indirectly receiving any aid from that hospital, and that in each case the professional department involved should be the one which would assume full responsibility for the life or sanity of the patient were his condition to become serious. This, we hold, is a great weakness of the modern American hospital. Our love of organization in business has spread to hospitals and has developed a fallacious idea of hospital or departmental responsibility. There is no such responsibility. Some fully responsible person should direct. Such duties he cannot delegate honorably to others.
In order to illustrate the strategic importance of a large general hospital as the best health center the advantages and disadvantages of other medical agencies which now also serve as centers may be reviewed. One of these is the dispensary. By this we do not mean an out-patient department of a hospital, but an ambulatory clinic not organically connected with any hospital. While these, especially if connected with teaching institutions, may give splendid service in the care of patients not requiring hospitalization, since their responsibilities for the patients are so seldom brought to the testing point and they have such difficulty in following and controlling their patients, yet their staffs seldom develop the professional quality of hospitals or of hospital out-patient departments, and tend to superficial routine work. A good illustration of this danger would be a contrast between the work of one of the so-called "child guidance clinics" and the average dispensary nervous and mental clinic. Neither of these is a hospital department, but the child guidance clinic is a professional unit in itself. The dispensary clinic is usually conducted by a psychiatrist and one social worker who acts also as secretary and stenographer, usually sees four or five new cases in one afternoon, and is happy in its work. A properly organized child guidance clinic, on the other hand, consists of a psychiatrist, a psychologist, three social workers, a secretary and a stenographer-seven persons—all on full-time service, all working at least six hours a day and five days a week, and yet unable properly to care for more than six new cases each week. Yet the influence of such work spreads much farther than their consultation rooms and the homes of these six children.
Another group of health centers which have increased so rapidly during the past two decades are the local branches of those national organizations, with a membership drawn chiefly from the laity, which interest themselves in special health problems such as mental hygiene, the control of cancer, child welfare, the antituberculosis movement, etc. These are one of the most astonishing developments of modern medicine and promise miracles for the health of our future people. Their development, as rapid but as normal as possible, should receive our earliest cooperation. As matters stand today, however, one result of
their mushroom growth is considerable lack of coordination with other medical movements and especially with the most important of all, the modern general hospital. The greatest value of these organizations is their potential power to bring to an end the problems which they attack. Provide abundant relief for the tuberculous, for those with cancer, for the incipient mental, etc., and theoretically you will not at all have solved the problem of cancer, of tuberculosis, of insanity, etc. But collect, concentrate, and direct into one channel by means of a lay organization much of that interest in, and fear concerning, these diseases which exist in the minds of the laity, but now in scattered ineffectual form, and you will have organized a tremendous power for education, and therefore for future reform. Such organizations, however, should keep professionally sound, that is, keep close to the well-organized general hospitals, and not branch off on their own responsibility publishing the special propaganda of a separate medicine. These organizations tend to establish a dogma of belief and a routine for practice which, although correct at the hour of its adoption, soon is no longer safe. For illustration, the influence of hospitals and sanitaria for tuberculosis patients has led to an undue emphasis on the importance in the diagnosis of active tuberculosis of the examination of sputum and of the Roentgenological examination of the chest. These tests are important when skilfully used. Again, the present almost reverence for the Wassermann test in the diagnosis of syphilis is due in great degree to lay influence, yet is quite without justification. The Wassermann test is useful when wisely applied. A still better illustration is the emphasis placed by the laity on the so-called Binet-Simon psychometric tests for the detection of feeblemindedness and, as a result, the fear of the so-called moron group as the chief disturbers of the social peace. These tests are very valuable in the hands of the man who can use them as tools wisely, but that is all. In the hands of amateurs they have done far more harm than good. The influence of lay organizations has spread a tremendous amount of faddism concerning infant feeding; it was laymen who proposed that man has a right to expect to live to be 150 years old, while as a matter of fact even with preventive medicine man seems to have difficulty in maintaining his present latter limit. All of this represents medicine (at basis perfectly good medicine), but when isolated from the current of medical thought it soon becomes a danger. Such ideas become more and more exaggerated, more and more bizarre, and in the end tend to discredit medicine.
Next we have those social organizations which are not primarily medical but which nevertheless provide medical relief-the charity organization societies for the improvement of the condition of the poor, various homes for unfortunates, etc. These have an apparently irresistible tendency to organize their own medical centers, centers which are, as a rule, poorly manned and cheaply supported. Laymen decide how much they should cost, which doctors should be employed, what these doctors should do and what they should not do. Such work becoming more and more of a cheap showy routine and yet one which
often is very pleasing to its sponsers. Medical men working under such difficulties can scarcely avoid finding in medical practice exactly that which each social movement would seem to call for. At least they can make no pretense at conducting impersonal, unbiased, accurate examinations and treatments. When we remember how difficult it is, even in well-arranged hospitals, to keep on steady keel, we must not expect too much of those less fortunate. Our own records of short-circuiting bowel operations, suspensions, subtotal thyroidectomies, vaccine treatments, etc., should keep us humble.
Then finally should be mentioned various religious organizations which usually have a peculiar urge to enter the medical field. The medical activities of organizations have been generally unsuccessful and have reflected considerable loss of reputation, not to themselves, but to medicine. We should, however, study this problem carefully, since the logical evolution of modern medicine leads us, if we wish to live up to the best there is in medicine, definitely to the point of controlling the religious life of our patients, whether we enjoy that prospect or not. As it is now the medicine adapted to religious causes is "made to order" to suit the philosophy behind the religious movement to which it is made subordinate, and while it may "look good," yet it seldom is accurate or even honest.
The best reason why the well-equipped teaching hospitals only should serve as health centers can best be stated by saying that medical knowledge is a stream which, like a river, flows steadily on. It is not the same stream in any two successive years, since new truth is ever flowing up and each new truth shifts the relations between all the other elements of knowledge. It is difficult enough for the staff man of a teaching general hospital to keep his head above water in this rapidly flowing current; how very easy, therefore, must it be for medical men connected with various semimedical organizations to furnish medical service which is not up to date, which is lacking in proper balance, and which is faddy and generally ineffectual. We do not, by this figure of speech, suggest that medical knowledge is continuously proving itself wrong. Not at all. Nevertheless each truth is incomplete and the evaluation of each will depend on all the rest of knowledge. Like two automobile models which, if but one year different, seem similar, but if ten apart, quite different, and yet each was the best to date, so truth is in evolution. Each year the problems are those of emphasis and of selection between choices apparently desirable.
Second, our hospitals are best able to furnish efficient, well-balanced service, that is, to organize for the individual man efficient team play between specialists as well as between social organizations.
Medicine is still in the analytic stage; it has as yet developed more of these general philosophies which social and religious service demand and which they will create if we refuse them one. There is as yet little justification for standardized procedures or for routine practices, and social service centers will quickly formulate these if allowed. In medicine we are still dealing less with disease en
tities and more with individual cases, each a new research problem. No suit of clothes will fit two men equally well, and the better the tailor the more minute will the alterations be in order that the suit may be a perfect fit for one man. So it is in medicine: routine work is in itself a confession of inaccurate work. We must work out each problem as new, follow the evidence, and be willing to treat a headache by medicine, by glasses, by surgery, by physical therapy, by a new job, or by prayer if any one of these is what the accurate study of the case indicates. If therapy is so difficult, how much more difficult must be the application of medical science when applied to health?
If, therefore, medicine is to render to humanity its highest service, that is by furthering the good health of the community (and this is also its most difficult problem), its safest course is to apply to this cause its best forces, those of our general teaching hospitals. These best can serve as the controlling centers of all those medical activities which can convey to the public the best applications of scientific medicine.
PUBLIC HEALTH AND THE FEDERAL GOVERNMENT AN IDEAL ARRANGEMENT FOR FEDERAL
Lee K. Frankel, New York, and James A. Tobey, Washington
Public health, like any other social science, can attain its highest development only by means of unified leadership. Since public health is unquestionably a function of government, it seems logical that this leadership should be exercised by government and so utilized that the whole public health movement would be welded into a homogeneous whole, thereby promoting and enhancing the vitality of the nation.
Public health is today in a flourishing condition, but in spite of much talk and many efforts at coordination, nothing of epoch-making importance has as yet been accomplished. To be sure, there are many exceptionally able individual leaders in the field of public health, who are working in harmonious relations. In the voluntary field, the National Health Council, now over six years old, has had a beneficial effect in promoting teamwork and cooperation among its fourteen members, all agencies interested in various phases of the national health field. The Council has not, however, attempted to assume any real leadership, and its accomplishments have been in the way of creating better understanding and comradeship among its member agencies with prevention of duplication, perhaps, but no central direction of united efforts against universal disease enemies.
This matter of the national voluntary health agencies is mentioned in connection with the subject at hand because it is an integral part of the whole movement for the correlation of federal health activities. If there were today in existence a single powerful national public health association, with the combined
resources of the three largest existing independent national health societies, the influence which such a great organization could mobilize in support of a unified federal health service would do much to assure its success. Once such coordination was secured and a central leadership developed, there should be maintained the closest relationship between official and extra-governmental health agencies, the latter being the true supplements to the former, instead, as is now often the case, pointing the way and sometimes letting the government catch up as best it can.
In considering the actual methods requisite to achieve an ideal arrangement for the health activities of the national government, a basic proposition is that public health is a unit. It is, furthermore, generally a more important unit than any other single subject which may have health implications. Thus, the protection and promotion of the health of children, farmers, workers, mothers, city people, rural dwellers, immigrants, Indians, or any other class, group, or type of person is all part of the one big problem and cannot be separated entirely from it. Public health cannot be divided into age groups, or economic levels, or geographical or racial distinctions. It is the same problem in one of its ramifications, whether found in the home, school, factory, farm, or institution.
Starting with the proposition, then, that public health is a unit, it would logically seem to follow that all bureaus or activities of the national government which are carrying on health work should be brought together under central direction. As a matter of fact, more than one-third of the hundred or more major administrative units of the national government are concerned directly or indirectly with some phase of public health. There is no one bureau in the entire government which now deals solely with public health. Even that bureau which bears the name of Public Health Service devotes a large part of its energies to the administration of medical relief, which is curative and not preventive medicine or public health work in any sense of the word. Of all the bureaus and divisions concerned with public health there are, of course, only some eight which are concerned with the subject in a major way. With as many more the public health activity is important, but subordinate to the general scope of the bureau, as in the Bureau of Mines, where the promotion of the health and safety of miners is only one aspect of the entire mining problem with its many technical features.
Obviously, it would not be ideal to attempt to bring together thirty or forty bureaus or divisions merely because each had some sort of an interest in the public health. What can be done, however, is to assemble certain of the more important federal health agencies under the direction of a single executive, and from this central federal health agency detail experienced scientists to supervise or cooperate in the activities of other bureaus where it is essential that units other than public health services should take up health problems. This system is already provided for by law to a limited extent. For example, the chief surgeon of the United States Bureau of Mines of the Department of Commerce is