III. HEALTH

THE HOSPITAL AS A HEALTH CENTER

Charles P. Emerson, M.D., Indianapolis

The modern hospital is by no means the least interesting of the marvelous institutions of modern times. Originally merely a house of refuge for the destitute, and especially when sick, a hospital now not only offers to rich as well as to poor the best there is in medicine and surgery, but also serves as a great health center for the community at large. This is rather a surprise to the physicians of the past generation, but the modern hospital, like all other successful institutions, soon outgrew its original form and found itself confronted by unescapable and unexpected duties and responsibilities which might seem foreign to, or even irreconcilable with, the former idea of a hospital.

Not more than twenty-five years ago a hospital's doors stood open to anyone who needed medical care. The professional staffs considered themselves responsible for the patient only while he was their guest; whence he came and whither he went was, they felt, no concern of theirs. It was even their boast that patients returned for treatment for the same condition six, ten, and—as in the case of one poor woman with mitral stenosis-even twenty-six times. Then, in 1901, came the development of environmental medicine. That is, we began to teach the students to ascertain and evaluate as many as possible of the factors which aided in the production of each patient's condition, in order better to understand the problems which his case presented. Four years later came the splendid development of hospital social service, a movement which frankly recognized our responsibility that our professional service for the patient be not easily lost. After that hospital staffs ceased to boast that women with mitral stenosis returned even twenty-six times for treatment; they realized that such a record was in itself evidence of their failure to help that woman. Now, with the aid of a social service department, such cases probably would come to the ward but once or twice, since social workers would follow her to her home, would effect some reorganization of her life, would arrange treatment in an out-patient department, and, as a result, would aid her to live a much longer and more useful life. The man with aortic insufficiency is no longer forced by the circumstances of his life to return to the forge; and for the man with chronic lead poisoning now is found a less dangerous occupation. We remember so well that little foreign baby brought to the ward with gastro-intestinal troubles and sent home well; brought back again in a few weeks with the same trouble, and again relieved;

and brought back after a few weeks for the third time in a similar condition. It was then that the trustees of that hospital, business men and lawyers, none of them doctors, took a firm stand against such charity, stating that they did not feel morally justified in spending the trust funds under their care for expensive professional service which, even before it had been begun, we knew would quite certainly be wasted. If, said they, the food bought for the patients were wasted, if carelessness were proved in their salary roll, their critics would be unsparing. What, after all, was the essential difference between such waste and the waste of professional service? The result was that a nurse followed that baby to his home and taught the mother how to keep him well. Then it was that that hospital became a health center. The superintendent of a hospital for the insane in New York State found that his budget was too small with which to care for his ever increasing number of patients, and so, since he could not obtain a larger appropriation, he trained two nurses to follow to their homes the patients discharged well after an attack of manic depressive insanity in order to advise them, to organize their lives more carefully, and so to prevent a recurrence of their trouble. In this way, that is, by making that hospital a health center, he reduced the population of the hospital.

The next step in the evolution of the modern hospital is logically unescapable. That is, since a hospital thus well organized can serve the community as health center, since it is, in fact, the only institution which can serve the public helpfully in this capacity, then it is the hospital's duty to render this service whether its staff desires to or not. One of the first of these new activities was the examination of the other members of a patient's family in order to prevent the development of other similar cases. Another activity was the formation, in connection with the hospital, of classes of patients with very slight grades of one disease, as tuberculosis, "nervousness," etc., or with no definite troubles at all, in order that they might receive definite instruction in the methods of preventing a further development of their conditions and also of increasing the quality of their health in general. Then followed better out-patient departments, the organization of district nurses, of school nurses, dispensaries in community centers, campaigns of education, the development of summer camps, etc. Today the treatment of a patient in a hospital ward has far greater significance than the treatment of that patient, fine though that may be. In that ward the doctors, nurses, dietitians, and social workers of the future receive their training, and while the future career of each will be directed to the care of the sick, yet the greatest contribution of each will be the education of the community in matters of disease prevention and especially in methods of increasing physical efficiency; and all will be powerful forces in shaping public opinion in the interest of health. In short, the care of each patient is the least of the hospital's service, for treat one patient well, and you have treated one patient well, but show a doctor, a nurse, or a social worker how to treat that patient well, and you shall have helped all the future patients that student shall treat, and you shall have

strengthened his future influence in the cause of health in the community in which he later practices.

First, we feel that all nurses and medical social workers while engaged in any practical medical work should be more closely related to a responsible hospital staff organization. In reply to the question which doubtless now is on the lips of many: whether, granting such desired relationship is not possible, the nurse or social worker should stop her work, we would express the opinion that she should so proceed, but that the technical medical aspects of the work be greatly curtailed. There will be plenty of splendid social work to keep her more than busy. Unfortunately, one of the great temptations of each of us is to essay professional work a little beyond our depth. This is a dangerous sport. As we shall endeavor to show later, the great danger of American medicine today is the practical application of so much popular medicine by those who, whether doctors, nurses, or neither, are eager to do good, yet have not the training to attempt their problems without supervision.

Among the activities as health center which each modern hospital now accepts as unescapable moral obligations is the prenatal clinic, a most profitable health venture which prepares the mother to withstand her approaching ordeal with as much safety as possible, and gives the expected infant a better chance for a normal birth and for a healthy life; classes where mothers receive instruction and advice; child welfare clinics; classes for nervous patients, where the neurasthenic and psychasthenic may receive encouragement, and the incipient insane may be helped to recover without danger of commitment, etc. Thus it is that the modern hospital has indeed become a health center.

Thus far we all may agree. Concerning the details of the program we may not all agree. For illustration, we draw a sharp distinction between social workers assigned to medical cases, and medical social workers. The former group is composed of women more or less well trained in social work who are assigned duties in connection with medical cases, but who, in general, are more responsible to the head of the department of social service, and through her to the administration of the hospital, than to any physician. The medical social worker, on the other hand, is first of all well trained in social work, but one who belongs to a professional team and who is responsible to the professional head of the hospital staff. On this professional team she has her part to play just as have the bacteriologist, the Roentgenologist, the serologist, the physical therapist, and others. Like them, she has her professional rank and title. Her part in diagnosis and therapy is carefully mapped out for her, and her reports are not a unit, but a definite part of one case report. Such a medical social worker must, of course, depend on the department of social service for much of her assistance, but it is for her to dictate very definitely just what help she needs.

Second, we would urge that each patient, whatever his illness and whether real or incipient, should be actually registered in one of the major departments of a general hospital and, personally known, should be under the responsible

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