The Development of a University Medical and Health Center

Citation preview

M B BBVBlOlPlTOf Of A d fX V lltS J ff MEDICAL ABB IpA^/iWff CSBTSB

by diaries B. Burbridge

A disaertation submitted in partial fulfillment of the requirements for the degree of Boetor of Ifellosophy, in hospital Administration in the (graduate College of the State university of Xoua February 1950

|h t r University oi Iowa U B B A ttY

ProQuest Number: 10991953

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T yr^

'

o

«iop,2^ TAB1S OF CONTESTS Chapter

page

X Introduction . , .

........

*

X

Scope of thesis ......... 1 Historloal background of medical end health services * 3 Service and educational responsibilities of the university medical and health center 15 Current trends in the field of medical and health services • • » » « • • • • « • • • • • • * • # 26 Analysis of needs in respect to personnel and facilities .................... 33 IX Components of the university medical and health center • hb Organizational patterns * * * . * « • * . • • • ' • « hh Medical staff relations . * • » • , . . . * * « « • 5U Patient core facilities « « . • * • « • • • * • • * * 69 The distribution of beds by financial classification • * . ............ * ......... 72 The distribution of beds by clinical service • . . 73 Education of professional and technical personnel* • * 75 Medical education * 76 Nursing education * * » . « » • . » . « » . • • • * 83 Education of administrative personnel . . . . . . . 96 Education of other professional groups ........ 100 Public health integration . . . . . . . . . 100 Hole of the university medical and health center in the promotion of research in scientific medicine* * * 100 XXI Conclusion . . . . . . . . . . . . . . . . . . . . . . .

108

The need for closer community relationships........ 109 The problem of financing hospitals ........ • . * 112 The challenge of leadership to the university medical and health center . . . . . . . . . 316

^

Bibliography •

121

Appendix

12U

ii

table of r r n m m

Figure

page X

XX XXX X?

Illustration of Soalar Process and Span of Control..........

• • • .

Illustration ofLack of Span ofControl Dual System of Hospital

Control................

Organisation ofthe Medical Staff

ill

..............

1(8 50 53 57

TABLE 01* TABLES

Table

page

1 II III

Governmental and Non-Govemmental Hospital Service . • • . ........

35

Number of Hospitals According to S i z e ........

36

Rotation Schedule . , .

...........

8U

X?

How Indigent Care Deficits are Increasing* • * « . .

lib

V

Average Operating Cost per Patient Day in Voluntary Non-profit Hospitals • . • .

115

iv

i Chapter t INTRODUCTION

At no time In the history of our country* has it become more acutely necessary that the scope of and the responsibility for health services for the people at large be clearly defined*

Particularly

urgent is the definition of the extent and content of the University Medical Center’s participation in the total picture of patient care, professional and technical education, public health, and research in the United States*

This thesis proposes to deal with the major problem

mentioned above in the course of treating what would appear to be a secondary problem, but which is really the main theme of this dissertation - the development of the University Medical and Health Center* In the interest of the better organisation of a variety of material, the thesis is being divided into three chapters, with a different approach being employed in each of the three sections. Chapter One proposes to set the stage for the entire thesis, pointing up the environment out of which our hospitals have developed, the responsibilities, alleged or real, of the modern teaching hospital for service and education, and the increasing recognition of government of its moral and financial responsibilities for the health of the people; this recognition being sharpened by a low inventory of personnel and facilities for health and the increasing inability of

2 the average citisen to pay for those services that are available. Chapter Two, it is hoped, will provide a flexible blueprint of the components of the University Medical and Health Center* Without going into philosophies, an approach which Part One employs, to some extent, this section will develop the structures and functions of operating hospital programs in the areas of patient care, education and research, that may be carried on In the modem medical center.

In

addition, special attention will be given to the requirements for accreditations and approvals of teaching programs. Chapter Three is again a departure from the other two approaches, in that it does not propose to ruminate as to the "why11 of hospital development or to delineate as to the "how” of a program of patient care, education, research, and prevention, but rather to offer a pattern whereby the University Medical Center may logically fit into the total structure of society as one of its necessary basic institutions. It is believed to be necessary at the outset to define the term "University Medical and Health Center" as it shall be used in this dissertation.

A University Medical and Health Center is a hospital of

25>0 beds or more, located in a university setting, with a direct medical college affiliation and with responsibilities for four functions as followsI 1. 2*

Patient care. Teaching programs for a wide variety of professional and technical personnel. 3. Conducting programs of investigative studies and research in medicine. U* Coordination and integration of hospital programs with preventive medicine.

3 Historical Background of Medical and Health Servioes in the United States --------------One can scarcely give proper consideration to the signifi­ cance of the history of medical and health services in the United States without looking at them against a backdrop of related history from the beginning of recorded time*

Inasmuch as the medical and

health center or the hospital, as hereinafter it shall be called for convenience, Is the focus of interest, the historical background will be examined briefly with the hospital occupying the center of the stage. Hippocrates' famous words, in referring to medicine, "Where there is love for humanity, there is also love for the art*1, may be paraphrased and, in capsule, refer to the whole develop­ mental history of institutions of healings

“Where there is

civilisation, there will always be hospitals to care for those who need their services"• Actually, there can be no real distinction drawn between the development of the modem hospital on the one hand and clinical medicine and medical education on the other#

Clinical medicine,

represented by its teaching, practice, and research, found its inception and has made most of its advances in the hospital} each, clinical medicine and the hospital, growing more competent in fulfilling the needs of the other*

The art and science of medicine

has increasingly required finer equipment, more adjunct services and personnel} and the hospital, as a basic community institution, has made more and more demands upon medicine's knowledge and skills

4 to cope with tha treatment of siekneae and trauma and the prevention of disease* However, the most important stimulus in this parallel development has not been the cycle of interaction and response that has been operating between medicine and the institutional medium in which it grows, but a far more fundamental motivation - man’s ageless egoistic and altruistic drives to better the physical lot of himself and his fellow* Robinson orients the origin of medicine in the 2,000,000 years of the Earth’s existence probably as accurately as history will permit when he says the first cry of pain through the primitive jungle was the first call for a physician* Early man moistened his wounds with saliva, he extracted the thorns that lodged in his flesh, he used the pointed stick to dig sandfleas from his skin, he put leaves or mud or clay on his wounds, he tasted herbs and some he spat out and some he swallowed, he was rubbed or stroked when in pain, his broken bones were splinted with branches, and when bitten by a venomous animal he sucked the poison from his body or his fellow did it for him* Medicine is a natural art, conceived in sympathy and b o m of necessity; from these instinctive procedures developed the specialised science that is practiced today* Similarly, the hospital idea, the centralisation for the purpose of care of persons no longer functional in society by reason

1* Victor Robinson, The Story of Medicine* p. 1

5 of sickness or accident, was conceived in sympathy and b o m of necessity*

The ancient temples of health in India and Egypt were

ecclesiastical expressions of a feeling of religions obligation toward the sick and homeless, while the military hospitals of Rome were an expedient for the armies in the field* What and where was the first hospital of antiquity? As in the case of medicine, there is no accurate record upon which a factual statement can be made.

Several references can be found in the

literature of the medical and surgical procedures practiced in the ancient civilisation of Mesopotamia, which references may infer a period between 5,000 and 6,000 B.C.

Singer says*

"Moreover, there

was in Mesopotamia a standardisation of both medical and surgical procedures*.." ^ It might be conjectured that these procedures were practiced in an institution of healing.

Stubbs and Bligh make a

somewhat similar statement but add that details of medical practice could be found only of the time of Hammurabi (c.1950 B.C.). ^ However, in placing the origin of the hospital and of medicine, too, for that matter, we are on sounder ground if we select Egypt, the

2. Charles 4* Singer, A Short History of Medicine, p. 7 3. S. G. Blaxland Stubbs and E. W. Bligh, Sixty Centuries of Health and Phystck. p. 12

6 medical history of which does offer as record the three medical papyri: the Papyrus Ebera (1550 B.C.), the Papyrus Harris, and the Berlin Papyrus.

In commenting on early medical history In Egypt, on© source

says s The Egyptians made great advances in Medicine. Their priests who acted as interpreters between the gods and men, approved of the opening of dead bodies to ascertain the cause of death and this also had the sanction of their kings. The germ of a hospital system may be found here also as there were in the eleventh century B.C. official houses to which the poor went at certain times, apparently corresponding to our Out-Patient Departments. There was also a college of surgeons, supported by the state which regulated the nature and extent of the practice of medicine. The college belonged to the sacerdotal cast. Women were allowed to practice medicine. According to Pliny, as these physicians were paid by the state they were required to treat the poor gratuitously. This they did in official house® ”or hospitals” rather than in the homes of the poor or in the physician*s consulting room.^ This would certainly indicate the early relationship between the medical school and the hospital.

However, because of the magical

and mystical flavor of Egyptian medicine, these practices and institutions could hardly be considered the beginnings of rational medicine and the modern teaching hospital.

Traumatic surgery may

have found its inception here through the repair of wounds and fractures but other illnesses were treated by incantations' and spells.

Arthur C. Bachmeyer and Gerhard Hartman, The Hospital in Modem Society, p. 5

The temples were not as much treatment centers as they were havens of rest*

For this reason, m m y writers assert that rational medicine

began in Greece with Hippocrates and Galen and the hospital system with the Romans * It has been said that the three major factors contribut­ ing to the development of hospitals have been war, religion, and advance in scientific medicine*

History gives ample support of this

truism* War, without doubt, has exerted a profound influence* soldiers in early campaigns were sent home for treatment*

Roman

As the Roman

frontiers spread even wider this became impossible and hospitals were founded at important strategic points.

The sites of several such

military hospitals have been excavated*

The best explored is at

Dusseldorf and was founded about 100 A.D.^

In organisation and

construction, the iatreia (surgeries) and valetudinaria (infirmaries) of that period are a tribute to the genius of the Romans.

Incongruous

as it may seem, down through the ages each war, with its deadly purpose of decimating men, has in large degree contributed to the development of the institution which has as its purpose the saving of life*

£* Charles J* Singer, A Short History of Medicine, p. £0

8 Religion* s contribution is measured in human values.

As

Nathaniel W. Faxon puts it, "Christianity produced a new spirit of compassion toward the sick".

Or, as Fielding H, Garrison says,

While the germ of the hospital idea may have existed in the ancient Babylonian custom of bringing the sick into the market place for consultation and while the aesculapia and latrela of the Greeks and Homans may have served this purpose to some extent, the spirit of antiquity toward sickness and misfortune was not one of compassion and the credit for ministering to human • suffering on an extended scale belongs to Christianity. * Thus we have war providing the seed of organization and Structure of the hospital and religion the spiritual undergirding so necessary to the humane care of the sick.

What of medical science?

Medical science and the hospital are indivisibles they are interdependent*

Stern has the following to say concerning the

contribution of one to the other* The high standards attained by the medical professions would have been impossible without the development of the modem hospital which gave the physician practical experience to enrich his theoretical training. The value of hospitals in the development of medical skill has only recently been understood# The growth of the

6. Arthur C. Bachmeyer and Gerhard Hartman, The Hospital in Modem Society, p. U 7. Ibid., p. 7

hospital is as dependent upon medical progress as medical progress is upon the hospital. Ability to control puerperal, typhus and other fevers was necessary before hospitals could begin to lose their reputations of being vestibules of death. The discovery of anesthesia increased the use of hospitals. Yet only when asepsis was introduced did hospitals cease to provoke terror in prospective patients and become gradually the central and Strategic factor in medical care and medical education.g Thus far, an attempt has been made to place the origin of the hospital and to establish the major factors influencing and stimulating its devabpment.

Fx*qsi tihi»8 point* in

^ 1/ho hospit&l. h&s inflix*cln©dL @jctb.

in arm with civilisation from Horae to England, France, Germany, Spain, Italy, Arabia, to America.^

It cannot be said that this sojourn was

always characterized by a constant improvement and that each era brought forth hospitals superior to their predecessors.

In fact, there

were times in the evolution of the hospital when progress seemed to stop and the movement to have even regressed.

The dark age of the

human race in Europe was the dark age of the hospital*

Medicine was,

for the most part, witchcraft and the institutions of health were far below the standards of earlier hospitals. creature of the environment.

The hospital is truly a

Even as Europe and many of its

hospitals groped in darkness, the great Ai Mansur Hospital at Cairo reflected the sanity of Egyptian culture of the 13th century.

8. Bernard J. Stem, Society and Medical Progress, p. xiv* Malcolm T* MacEachem, Hospital Organization and Management, p* 2f>

10 Several great hospitals sufih os St. Bartholomew* a and St. Mary1a in England were founded during and survived this period in Europe and were ready to serve as the foundation upon which to build again at the advent of the Renaissance.

About this time the health movement was

beginning to stir in America* In shifting the scene from Europe to the Western Hemisphere, we see the Pennsylvania Hospital (1751) as the earliest hospital to be established in the United States; the first hospital in the Americas being an institution founded by Cortes in Mexico City in 152U to care for his soldiers.

During the almost 150 years

between the landing of the Pilgrims and the founding of the Pennsyl­ vania Hospital, there were practically no facilities and personnel for health in this country#

In writing of these times, Packard says,

"None of the physicians stayed long in the colony, for in 1609 Captain Smith was injured and was obliged to return to England for surgical treatment*

For there was neither chirurgeon nor chirurgery

at the fort (Jamestown, Virginia)."^

However, after the establish­

ment of the Pennsylvania Hospital and subsequently hospitals in other cities, medical education began to emerge and in the late 18th century and the early 19th century we find physicians being produced by this

10. Francis R. Packard, M.D., American Medicine, Vol. I, p. 9*

11 country.

Formerly, members of the medical profession were entirely

of European origin either by birth or medical training or both.

As

Packard said, "The source® of the strength of American medicine are to be found in the studies pursued abroad in Great Britain, France, Holland, and later in Germany, by the young men who subsequently occupied teaching or laboratory positions in our young medical colleges, Although it is undeniably true that American medicine came from Europe and the new hospitals in this country were strongly influenced by ones abroad, particularly in England, the health move* ment in this country, when it finally gained momentum in the latter part of the 19th century, was primarily an indigenous phenomenon* The University Medical and Health Center, as the focus of service and education, found its inception in the early hospitals that were part of or served university medical education programs*

Probably the

best means of tracing their evolution is to follow the development of the American medical colleges* Pennsylvania, which gave us the first hospital, also

12 produced the first medical faculty in the United States at the TP College of Philadelphia in 1765* This was later to become the University of Pennsylvania*

King *s College of New York, in 1768*

added a medical department which, though broken up during the war with England, was revived in 181U and merged with the College of Physicians and Surgeons and eventually was absorbed by Columbia University*

Other medical colleges soon appeared} Harvard in 1783}

Dartmouth in 1798} and Yale in 1810*

These first schools were of

high calibre but unfortunately stimulated the growth of a number of inferior institutions*

It has been estimated that in the one hundred

years between 1810 and 1910 no less than U00 medical schools were opened} many of them going out of existence even before graduating a class* tion*

At the turn of the century, there were 155 schools in opera­ In leas than fifty years, the number has been decreased by

more than half, to seventy-one, and the quality of teaching increased a hundred fold* Many factors have contributed to this refining process, chief among which were, state licensure of practitioners beginning in New Jersey in 1772; the American Medical Association, organised in 1817} and the Abraham Flexner report on medical education in 1910*

12* Henry E, Sigerist, American Medicine, p. 131*

13 Although the trend toward state licensure of physicians began early, it was not until 1895 that practically every state had a board of medical examiners*

State examinations raised the standards of

medical colleges by requiring of their graduates not only an extensive knowledge of the main fields of medicine but also of the basic sciences such as anatomy, pathology, physiology, and pharmacology* Although an exceptional student from a poor school might be well tutored and manage to pass the state examination, by and large, a medical college had to offer an adequate educational program in order to maintain a high percentage of graduates receiving licenses, a desirable condition upon which depended its continued existence* Several years passed after the founding of the American Medical Association in 181*7 before It became the potent influence in the medical field that it is today*

Its first emphasis was upon

medical education reforms and the improvement of professional stand­ ards*

However, as the American College of Surgeons was to discover

later, the American Medical Association soon came to learn that little could be done in promoting the improvement of professional standards and medical education without establishing the hospital as a frame of reference*

Out of this realization has grown the hospital registration

and accreditation programs* State licensure and the American Medical Association brought About gradual, permanent reforms but the Flexner report, sponsored by the Carnegie Foundation, when published in 1910, had almost immediate

14 results in needing out many of the inferior colleges#

Its merciless

criticisms of the abuses of many of the medical schools of that time were only slightly softened by the constructive suggestions offered for reform# The impact of the report can be easily discerned in the decrease in the number of schools from 1U8 in 1910 to 107 in 191U* Many of the early schools had neither hospital nor university connections and were merely diploma mills created solely to capitalise on the popular upsurge in medical education#

However, the better schools

that have survived to this day soon realised the indispensability of a hospital affiliation and took steps to avail themselves of such facilities*

Thus we see three professors of King's College in New fork

in 1776 founding a hospital to enhance the medical education program* For the same purpose, the Harvard Medical School moved from Cambridge to Boston in 1807 in order to be near a hospital#^

It is axiomatic

today that the medical college should be located in a university setting and have one or more hospitals at its disposal to implement the clinical teaching of medical students*

Therefore, there has evolved the

University Medical and Health Center fusing its dual purpose of education and caring for the sick into the single objective of improving the health of all people and in the course of Implementing this objective emerging in the dominant role of leadership in the health field#

is Service Educational Responsibilities of the University Medical ~an l) Eh P? (d r-t

>»O

Illustration of Scalar Process and Span of Control

SUPERINTENDED

48

49 refers to the obvious fact that there are limits to human capacity, and that when attention is spread too thinly over too many circumstances, unsatisfactory results occur* . 36 This principle, which is particularly applicable to hospitals possibly has been more ignored than any others.

Thus we find in many

hospitals from ten to fifteen department heads reporting directly to the top executive, as in Figure II. The advantages of an organisation following the principle of span of control are at once obvious from even a casual examination of Figure I.

No single department head has more than five different

activities to supervise, permitting more time and incentive for planning. Coordination is simplified, channels of authority and responsibility are more clear-cut, and the work of the organization more evenly distributed. There are disadvantages to this type of organization that are as obvious as its advantages*

The chief executive is isolated from a

large portion of his organization; communication® are not as direct as in other types of organization; and several weak department heads In strategic positions may disrupt the workings of the entire institution. In spite of these rather real disadvantages, this type of organization offers a functional arrangement capable of attaining a high degree of

36. Leonard D. White, Introduction to the ^tudy of Public Adiainistra* tion, p. U7

50 3

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2* lii>. Essentials of Approved Residencies and Fellowships, American Medical Association, pp. 1-32.

81 internship aaA Residency Trainlag Program Internship Xa the interest of p m l i i a g a broad training program for physicians who pim

to go late general practice, a two-year internship

i« suggested, the ar»t poor of which shall bo comparable to a one-year rotating internship and the second poor of which shall giro additional training in medicine, pediatrics, and obstetrics, the divisions of nodi* cal practice in which the physician will do moot of bio work after loafing the hospital,

fb» first poor of the two-year internship should meet all

of the requirements of a one-year internship as tboro will be, in all probability, thooo pbyoiolans that plan entering specialty training after the first year or who, due to other circumstances, oannot spend two years in the hospital,

Such an arrangement will in offset provide

both an acceptable analyser Internship for those physicians who can only spend one year for one reason or another and also a two-year internship for those physicians planning to go into general practice. Registration with the American Hsdieal Association Is the first step the hospital vast take toward becoming eligible to apply for ap­ provals for conducting various training programs.

As a matter of con-

venienee in referenee, the eenplete statement of the Essentials of a Registered Hospital as prepared by the Council on Medical Education and Hospitals of the American tfsdieal Association, revised to December, 19fe8, is being incorporated in the Appendix.

82 Kafcodied in ti» l.wntial. of to Approved Xtrtornaltlp, rovlaed in Kovesfeer, 19^5,

the Counc13. on Medical Iducatlon ot the American

Medical Association, era the present requirement* fox* internship approval. la summary, the requirements are as follows8 1. the hospital must be registered, have a capacity of 100 beds or o w , and maintain an average daily census of at least 85 pa­ tient* and an annual admission rata of sot less than 2,300. 2. ®ie hospital must maintain a necropsy rata of at least 20#. 3. fhe Intamship must he mall organized with emphasis upon the educational aspaota of the program. b.

She Council believes that the rotating internship it likely

to provide the heat hasie training for either the future general prac­ titioner or the specialist.

A rotating internship is defined as one which

provides supervised experience in internal medicine, surgery, pediatrics, obstetrics and their related subspecialties, together with experience in laboratory and radiologic diagnosis.

She Council recommends that at least

three months he devoted to both surgery and internal medicine, an assign­ ment of less than two months being considered unsatisfactory. 5.

the bed capacity of the hospital is used as a basis for

determining the number of interns, with a range of 15 to 25 beds per intern recommended. 6.

the "Essential*" suggests that an orientation period be ar­

ranged at the beginning of the intern's service during which the staff should aeguaint him with the administrative and professional organisation

83 of the hospital and introduce M m to the ancillary servicea which are to asaiat him in the oaro and treatment of the patient. $h keeping with the requirements for approval and hearing in wind the need for flexibility, the internship might w U be rotating with provisions for a aeeond year for those physicians planning to enter gen* oral practice, as suggested earlier. the first year of the internship Should provide training in internal nedleine, surgery, obstetrics and gynecology, pediatrics, labors* tory, and radiologic diagnosis,

dotation could be effected through eight

services, male medicine, female medicine, obstetrics and gynecology, labo­ ratories, radiology, male surgery, and female surgery,

the second year

of the internship, which Is designed primarily as preparation for general practice, should give additional training in medicine, obstetrics, and pediatrics. A sample schedule is provided in fable 111 with the qualifies* tioa that it Is only intended to serve as a guide*line to the preparation of an outline of training for interne considered to be most suitable with* in the framework of accreditation requirements.

84 sable t n notation Schedule first Tear

III

mo.* lj mo.

1 mo.

1 mo.

A

X

2

3

b

S

2

3

b

c

3

b

3

b

X mo.

1 mo.

l£ mo . X| mo.

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7

8

5

6

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1

5

6

7

8

1

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Key:

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5 - laboratories

2 - Female Medicine

6 - Radiology

3 - Obstetrics

7 - Male Surgery

b - Gynecology

8 - Female Surgery Second Tear

Division

Period

Medicine

6 months

Obstetrics

3 months

PediatrloB

3 months

* Short period sufficient for orientation to be included at the beginning of the year.

85 Besldsncy training of physicians for specialties is one of the major contributions to medical education that the university hospital can mafce* Among the general requirements for certification of residency training program are reglatration with the American Medical Association! adequate clinical material! sufficient equipment and apparatus! and an organised medical staff. By an organised medical staff is meant division lute the specific clinical departments in which specialty training is to he offered! including departments of radiology and pathology, all of which should he headed hy qualified men*

It la required that there he an ae~

eeptahle percentage of necropsies and that the staff hold cllnlcal-patho* logle conferences at least once a month.

It is also necessary that the

hospital maintain complete medical records and have an adequate medical library. the Council on Medical Education and Hospitals of the American Medical Association believes that the educational effectiveness of a residency program depends largely on the quality of supervision and or­ ganisation.

it is important therefore that methods of instruction he

employed which are host suited to the special fields.

Emphasis should he

placed on bedside instruction, clinical experience, related laboratory studies, teaching rounds, departmental meetings or seminars, clinicalpathologic conferences, demonstrations, and lectures,

familiarity with,

and critical analysis of pertinent medical literature is an important feature of residency training.

86 tense in any of the various specialties in clinical nodi* oino require* i knowledge of the basic medical sciences employed in the specialty.

therefore, residency and fellowship programs acceptable to

the Council mad the American Boards must provide for training in the ap* plied basic medical sciences. Snob training does not necessitate formal course mark, specific assigned laboratory exercises, or affiliation of the residency hospital with a nodical school.

It should be distinctly

of an applied nature closely integrated with the clinical experience of the resident.

Any resident seeking competence or certification in a

specialty suet be able to apply at least the following basic sciences to his special field of medicine*

anatomy, bacteriology, biochemistry,

pathology, pharmacology and physiology. Residents should be assigned teaching responsibilities and, if possible, be encouraged to engage in research* Special Requirements - ffeie regulations pertaining to individual specialties describe the special training, in addition to the foregoing required for competence in the practice of the various specialties of medicine and for the admission to the examinations of the American Boards in those specialties.

Special requirements for certification In the

individual specialties of internal medicine, general surgery, pediatrics, and obstetrics and gynecology are set forth in the Appendix.

87 Medical gducation As once observed by Br. William H* Welch of Johns Hopkins Hospital, the studies of a medical student* once begun, go through all lid the remainder of his life* It is axiomatic that the university medical and health ©enter presents opportunities for postgraduate train * ing in the nature of refresher courses, demonstration clinics* institutes* and consultative services that would seek to stimulate interest in continued study on the part of the practicing physician. The continuation center* mentioned earlier in this disserta­ tion* has the Specific function of providing facilities in which such programs can efficiently be carried on* An indication of the extent to which such programs are utilised is reported by the national Health Assen&ly* which states that the 1*500 refresher courses given in 19h7 had an attendance of more than hi d0,000 physicians* or about one-third of the total in the United States* The fact that this phase of medical education has not been given the emphasis that the more formalized programs have* should by no means be interpreted to mean that the continuing education of the practicing physician is not of foremost importance.

In the present

state of rapid flux in which medicine finds itself* due to many advances

k6. Journal of the American Association of Medical Colleges, Nov. X9k9» Vol. 2b* H o ~ * p. 372* 2*7* The National Health Assembly* America* s Health, p. lU.

88

in medical science growing out of fundamental research, the practicing physician, if he is to keep apace, must make an effort to keep in touch with recent developments*

the university hospital is an excellent

medium through which he might achieve this objective Nursing Education Nursing is an old and honorable art which, contrary to common belief, did not begin with Florence Nightingale who, however, made the significant contribution of organising, in 1860, at St. Thomas Hospital in England, probably the first school of nursing approaching modem concepts of nursing education*

Prior to that time, nursing was

conducted by either members of religious orders, who dedicated their lives to the care of the sick, or by persons employed without attention to their selection, and who were often of the criminal class, had no V religious spirit of self-sacrifice, and exploited and abused the patients*^® the first schools of nursing in the United States were established in 1873, at which time there was one practicing trained nurse*

There a m now over 300,000 nurses, a fact which certainty

indicates the rapid growth of nursing education*

In spite of the large

production of graduate nurses, there is a pressing need for more of these vital personnel*

Further, there is a need for a definition as to

i*3* Malcolm f* MacEaehera, Hospital Organisation and Management, p. 16.

89

what f o n basic programs for the education of this group should take, and the enigma of discovering a modus operandi for increasing quality without doing violence to the quantity,

thus, we find nursing at the

threshold of a national system of accreditation designed to bring Standardisation to all educational programs of nursing. Unlike medical education, with its precise categories of training programs, those of a formal nature having carefully prescrib­ ed standards upon which accreditation can be granted, nursing educa­ tion is in a state of uncertainty with apparently only one common point of agreement running through all viewpoints - a conviction that there is a need for larger numbers of better trained nurses. The controversial Brown report of 19U8 on nursing education, with objectives in relation to nursing schools somewhat skin to those of the 1910 Flexner report toward medical colleges, stimulated a move­ ment within the nursing field to establish a National Nursing Accredit­ ing Service.

Growing out of this program sponsored by six national

nursing organisations, was the publishing of an interim classification list of schools of nursing with basic programs, in the November, 19U9 American Journal of Nursing. The interim classification was derived from 1,195 responses from 1,215 circularised schools, the programs of which were evaluated by consultants from hospitals, nursing and education.

Participating

schools were divided into quarters - highest quarter, second and third

90

quarter®, and low®at quarter.

The Hat was published, including only

885 schools of the 1, 195 reporting.

Of the 885 schools listed, 300 were

classified in the top quarter, 576 in the second and third quarters, with nine left unclassified but included.

Therefore, out of the total 1,195

reporting, 310 were left unclassified, a fact with slightly more than apparent implications. Or. Charles T. Dolesal, assistant director of the American Hospital Association, and Secretary of its Council on Professional Practices, gives the following brief summary of the Brown reports 1. Nursing groups, hospitals and health agencies have failed to provide the public with adequate and competent care. 2. Conditions in the 1,250 schools of nursing are unsatis~ factory# with analysis showing that 88 per cent of student nurses fail to progress beyond the high school level of education. 3. Enrollment in schools of nursing ranges from 5 to kh2$ with a median of 73, and 300 schools have fewer than 50 students. it. The average school, with only three full time staff teachers, cannot offer adequate instruction and experience and since adequate standards of education would be too costly for such schools, affiliations are necessary. 5. Thousands of graduate nurses have relatively little education, and from an educational viewpoint the majority of existing schools cannot be classified as truly professional. 6* Only those nurses who (a) are graduates of accredited educational schools, (b) have been qualified by examine-* tlon, and (c) have been qualified by examination in a special capacity can be regarded as professional. 7. Adequate care of patients calls for two grades of nurses, graduates of degree courses in basic nursing, and practical

91 nurses with X2 Month# of classroom and practical training in an educational inatitution and another year of super** wised practice before licensure. 8* Hospital schools of nursing may be classified as distinguished* relatively good* and socially undesirable. Distinguished schools are few, and almost 30 per cent fall below the grade of relatively good. Rated as poor are 256 schools and as very poor are 76. 9. Present graduates of hospital schools should be rated as semi-professional and thereafter be classified as bedside nurses.^ An editorial in "Hospitals", the official journal of the American Hospital Association, gives probably the best and most concise analysis of the current situation regarding accreditation of schools of nursing that the writer has seen in the literature! The complete story of current efforts to accredit schools of nursing is so long and intricate that it seems doomed to come out piecemeal. At the moment, these efforts at accreditation are some­ what less than universally popular* This is odd, since nearly everyone is agreed! THAT the standards of nursing service should be raised, THAT this calls for raising the standards of nursing education, THAT accreditation of schools is a suitable method, and THAT chief responsibility for any accreditation program belongs to the nursing profession. The present program has failed to win maximum support, even among nurses, simply because of some errors and omissions that can be rectified. Most of the opposition is based on suspicion toward the interim classification of schools, which has never been given a forthright explanation.

1*9. Charles T* Dolesal, Hospitals. January 1950, Vol. 2U, No. 1, p. 1|6.

92 Whatever Its ultimate good purpose* this interim classification has the appearance of a device for arbitrarily closing 25 per cent of the schools* If it is ever to dispel such suspicion* the accreditation program must offer some definite assurance that this will not happenj that scores of existing schools will not be closed until there are other facilities for supplying the nurses needed to keep hospitals open. A great deal of support could be enlisted by making three changes in the interim classification procedure. First* instead of appearing to abandon the least acceptable schools* a way should be found for helping them work for acceptance. Second* the classification list should be revised at regular intervals* perhaps annually* to encourage and facilitate rapid self improvement. third* a different and more stable basis of classifying schools should be developed* so that 25 per cent of them are not perennially and automatically barred from recognition. the national nursing organisations could decimate another form of opposition without much trouble! By making it clear that accreditation will not become entangled with the governments power to withhold federal aid-to-edueation funds; and they will have this opportunity soon when the subject is reopened in Congress.^ A brief background and a contemporary view of nursing educa­ tion have been given in order that the problem facing the university hospital In designing training programs for nurses can be fully appreciated.

As previously stated* the teaching hospital has a

responsibility for providing* to the limit of its facilities* quantities of health personnel* including nurses* in the interest of

50. Hospitals* January, 1950* Vol. 2kg Ho. 1* p. 57

alleviating current shortages • However* there is a parallel obligation to insure the quality and subsequent functional ability of these personnel*

Therefore* the question arises as to what programs of ears

should be provided by the university hospital*

The fact that the

nursing profession itself has not adequately answered this question* makes a solution that much more difficult in that the hospital must direct its programs for special groups in conformity with what is considered by those groups to be their professional objectives. It is believed* however* that compatible with: one* the nursing profession's general objective* two, the need for additional nurses of all types; and three* what can be effectively accomplished* the teaching hospital may well conduct or participate in* four different programs of education designed to implement various demands for personnel in the ranks of nursing education and nursing service* These programs might bes 1.

The basic three year course* organisationally lodged in

the university hospital.

This course would be designed to meet present

day requirements for general duty nurses and to serve as an undergirding for advanced training.

The basic nursing course is the ration­

al between two extreme trends now taking place simultaneously in the nursing profession - the trend toward the "not-too-we11-trained" nurse* the practical nurse, and the "too-well-trained" nurse, the five year course nurse.

It should immediately be said that the use of these

descriptive titles are applicable only when the popular version of the

94 traditionally trained general duty nurse is used as the frame of reference*

Trainees of both of the categories represented by the two

trends are vitally needed for the special jobs for which their training specifically fits them* but the focus of need in the field is, to this writer*s way of thinking* for the traditional product of the basic nursing course* the individual that has earned for the profession the honorable name it now enjoys* 2* Graduate training in one of the nursing specialties such as surgical nursing* pediatric nursing* etc.

The university hospital with

its wide degree of departmentalisation and highly trained staffs* is in excellent position to conduct such programs.

The courses should be

under direct supervision of the university hospital* 3* Collegiate Course: The collegiate course should be set up with well defined objectives in term© of the type of service for which they are educating student®.

In other words* there may well be four

degree programs that might be conducted at the university level for those students who have already completed basic nursing courses.

These

programs might be designed to produce the following types of personnels Public Health Nurses Administrative Nurses Supervisory Nurses Nursing Instructors* iu Training for practical nurses#

In the past few years* the

we11-trained practical nurse has earned for herself a place in the whole Structure of nursing personnel and is contributing largely to the

95 increased efficiency of nursing service* By "well-trained practical nurse1* is meant those personnel completing courses approved by the national Association of Practical Horse Education, local board of education, and hospital and health officials of the community concerned*

These courses, which average a

year in duration, are usually conducted by vocational schools in cooperation with health authorities, using one or more affiliating hospitals for clinical teaching* Training programs for practical nurses could well be Integra­ ted into the total program of nursing education in the university hospital*

There is no good reason why certain courses given for nurses

in the three year programs could not be given at the same time to the practical nurse trainee*

Xt has been standard practice for some time

that introductory courses in the school of dentistry are given to both dental and dental hygiene students, which fact in no way leads the graduate dental hygienist to believe that she should enjoy equal professional status with the graduate dentist*

This same practice

extends to other fields and is not only thoroughly satisfactory from the standpoint of economy but establishes a rapport between two different types of personnel at the student level which may well be extended into the working area* Xt Is therefore believed that programs for practical nurses might well be conducted in the university hospital nursing school under the supervision of nursing education which could then have under Its

control the educational proceeaea of all the personnel that uniat render nursing service to patients. Education of Administrative Personnel Brief mention will be made here of one of the newest of the university hospital educational programs, the education of administrative personnel*

These programs have been interchangeably called administra­

tive apprenticeships, internships, or residencies.

The currently

acceptable term is administrative residency, which may consist of a period of one to two years spent in a hospital subsequent to the comple­ tion of the academic phase of a program of formal training in hospital administration.

Each of the thirteen formal courses being conducted

in the United States requires from eighteen months to tiro years for completion, usually the latter half comprising the residency, during which time, although the course school retains contact, the student is under the supervision of the hospital in which he is doing his residency. A number of hospitals are at present conducting administrative residencies which, though basically similar, differ in emphasis. Program at State University of Iowa Hospitals at Iowa City, and Freedman's Hospital in Washington, D* C. are illustrative of two different types* State University of Iowa Hospitals The State University of Iowa Hospitals which, in cooperation with the Graduate College of the University, conducts formal programs leading

97 to higher degrees in hospital administration, also offers a unique administrative residency for students having completed formal course work.

The residency program is essentially a supervised program of iiw

service training*

The course is Intended to prepare the graduate

student for employment in hospital administration by intensive inservice training, immediately prior to accepting employment# Students enrolled in the program in hospital administration will be required to complete two full academic years of study and administrative service, and will develop from an administrative interne ship through an administrative residency, and in certain cases, to an administrative ass1stantship*

In addition to training at the State

University of Iowa Hospitals, a number of rural and urban community hospitals will participate and offer their staff and facilities for teaching purposes* The program at Iowa slants its emphasis to the post-didactic phase of training for administrative personnel*

This is accomplished

by providing for those students who qualify for admission an environ­ ment in which they may find practical application of the principles of hospital administration that they have studied in the formalised class­ room work*

The program extends over a sufficiently long enough time to

provide ample periods of orientation and administrative practice* Freedman's Hospital, Washington, D, C, The program at Freedmen's Hospital, in keeping with the best thinking at the Minneapolis Conference on Administrative Internships,

sponsored by the Joint Commission on Education of the American Hospital Association and the American College of Hospital Administrators, is designed to carry the student through the following three major phasest (1) orientationj (2) departmental study* (3) general administrative practice* Orientation! The orientation period may be designed to cover three months but if this period is too short, should be extended as this is probably the most important phase of the program as the success of the other two phases depends upon its adequacy* Airing orientation, the residents should be directly attached to the administrator's office*

At the very beginning of the program,

the residents should be inducted into the organisation at the same meeting at which house officers are introduced to officials and given instructions as to the hospital's rules and policies*

Subsequently,

the students are introduced to the department heads at regular staff meetings.

When such meetings do not interfere with assignments, they

are permitted to sit in on union negotiations and intra- and inter­ departmental conferences which are held to resolve probfems and work out better relationships* In addition to day-by*day contact with the preceptor and reading of material pertaining to the hospital, the residents engage in the following activities during the orientation period*

1* Administrative rounds and inspections which have familiaris­ ed tfesm with the physical plant and permitted contact with department heads at the operating level* 2. Field trips* a* Hospitals b* Organisations concerned with health 3* Attendance at the American. Hospital Association meetings, both national and regional* b. Assignments running concurrently with the orientation period* a* Preparation of annual report b* Assistance in preparation of hospital budget* c* Preparation of newspaper release articles on service departments of the hospital d* Acting as guide for visitors who are shown the hospital, e* Beginning the revision of the hospital's regulations* Departmental Study* The second phase of the residency is expected to provide a rotation of each resident through all hospital departments.

The

residents determine the sequence of their individual rotations and the time that they would like to spend in each department.

Naturally, the

schedules are different* Prior to the resident's going into a department, a conference

100 is held by the preceptor with the department head and the resident-

An

attempt is made to explain the purpose and the philosophy of the residen­ cy, and the responsibility, in this cooperative adventure, of the super­ visor and the resident*

Interspersed with the rotation are conferences

with the preceptor* Administrative Practices the third and final phase of the residency will be a period during which selected administrative responsibilities will be placed upon the resident* Education of Other Health Personnel the following is a check list of some of the other important educational programs for health personnel that may be conducted in the university medical and health centers Dental Education Education of Pharmacists Education of Dietetic Interns Education of Medical Technologists Education of X-Ray Technicians Education of Occupational Therapists Education of Physical Therapists Education of Medical and Psychiatric Social Workers Education of Medical Records Librarians Education of Nurse Anesthetists Education of Oxygen Therapists Education of Electrocardiography Technicians Public Health Integration In the area of preventive medicine, the hospital performs on© of its most important services*

It is through this phase of the program

101 that the hospital coordinates and integrates its efforts with those of governmental and voluntary health agencies on both the local and national levels la the interest of better public health services,

Through its

out-patient cllales and other facilities, onset of serious nodical eon* ditions nay be prevented, health education nay be disseminated, and the ecniblaed skills of all health workers focused upon those diseases and conditions that are not only the concern of the individual but also of the community. The university nodical and health center is the ideal medium in which the public health function any find full expression,

there is

a definite tread in recent years, not only to coordinate the efforts and integrate the functions of hospitals and health departments but, in nany instances, to so arrange the physical facilities in order to house both units, as was suggested earlier in this dissertation.

The need for

this has become increasingly evident as knowledge concerning the pre­ vention of disease has advanced and as the appreciation of close co­ operation between the fields of public health and curative nedlcine has grown. She university nodical health center is able to provide the coordination and integration so necessary, along nany avenues which would be of value to the community and the nation.

Some of these areas

are as follows: 1

.

Preventive Programs*

integration of Hospital Clinics with CoaBiunity

1 0 2

The teaching hospital will have many clinics which are im­ portant in the prevention and control of certain major public health diseases and conditions.

These would include the following clinics:

venereal disease, tuberculosis, prenatal, infant hygiene, adult hygiene, cancer detection and rheumatic heart disease. 2.

Communicable Disease Control:

Early hospitalisation is often important in controlling the course of epidemics In the community#

The medical center, by providing

facilities for communicable disease aids the community in the aore effective control of these diseases. 3-

Health Educations

Health education Is an integral part of a community health program, yet at the present time, few hospitals are taking advantage of the opportunity to provide health education for the many patients who come through their doors, either for olinie or in-patient ears#

In an

integrated center, facilities and personnel can be provided whereby educational programs can be carried on in cUnies and in wards through motion pictures, lectures, literature, and exhibits.

This type of

program has been well worked out at Johns Hopkins University Hospital. b.

Out-Patient Departments

The out-patient department offers many opportunities for Integration with the activities of the health department.

Through the

facilities of the university hospital, all phases of public health service for aafbulant patients may be strengthened and provide the common

103

ground upon Which the activities of the medical profession, hospitals, end public and private health agencies Can he integrated and cooperative­ ly developed in the interest of a more effective health service for the community. 5- Visiting JVurse Services Too often there la little cooperative work between local health departments and the follows of patients after they have been discharged from the hospital#

Thus, much of the effort put forth in the medical

care of the hospital patient is vitiated by the negligence and indiffer­ ence shown at home.

The university medical center offers the logical

agency to develop a program whereby public health nurses, using the hos­ pital as an operating base, could follow selected cases when discharged from the hospital. 6

. Cooperation with Federal and national Voluntary Health Agencies s

The intense national interest in matters concerning health has stimulated the Federal Government, through its official health agencies to offer many grant programs designed to improve the health of the people.

These moneys are administered at the local level and translated

into significant contributions to coswunity health by the hospitals. Some of these projects have to do with venereal disease control, teach­ ing and diagnostic tumor clinics, infantile paralysis and streptomycin research and many others. 7.

The Hospital's Public Health Besponsibllity to Its Own Organisations

104

tn concluding this section, on important point, which is so often overlooked, should he mentioned in relation to the hospital's public health responsibility -to its own organisation.

Ideally, there

should be centered la one physician those functions that will insure the maintenance of an acceptable standard of hygiene in the institu­ tion,

Xa seme of the governmental hospitals this Individual is called

the sanitary officer.

Although the same title may not be given in a

voluntary hospital, the same duties and responsibilities may be centered in one member of the medical staff specifically trained in epidemiology Who will answer directly to the head of the institution and have rather sweeping authority in relation to internal public health policy*

The

duties of such a medical officer are as follows: # To be officer in charge - responsible for mapping a course of action in case of epidemics or other serious health hazards to patients and employees.

1

2.

Supervision of the health and safety program for employees.

3. Supervision and inspection of sanitary standards in kitchens, wards, rest rooms, etc. Dr. M. X, Dames, Dead of the Department of Hygiene and preventive Medicine, State university of Iowa College of Medicine, adequately subs up the hospital's responsibility in this respect. Health hazards originate in patients, visitors, the hos­ pital personnel or In the physical setup of a hospital. Because of their sporadic occurrence, attention usually is not directed to the avenues idiereby Infections are transferred. Thus these transmission paths remain unde­ tected even though open. In a general hospital of moder­ ate size the problems encountered justify placing the responsibility for current epidemiologic service on some

105 definite staff member for the bettor protection of tlie pa* tients, of the hospital personnel and of the community, Bole o£ Jgw *mivarsity Medical and health Center in tto> Promotion of Besearch One of the four broad functions assigned to all hospitals la the cam of research.

However, research, in the true scientific meaning

of the tens, cannot he significantly conducted to any degree except in these hospitals in which the basic sciences are fully represented, these hospitals are the teaching hospitals, shore the cork of the pro* clinical scientist and the cHniciaas may be effectively integrated into the development of projects of fundamental research and the application of their verified results to clinical care. there are two types of research that the university medical and health center might conduct,

first, clinical studies can be made,

which involves little more than the gathering, classifying, and interpreting of data taken from the thousands of medical charts that accumulate in the large hospital,

this type of research is valuable and

is expenelve only in time and the cost of personal services of a few medical statisticians. She second type of research, however, is not only costly in tine, and highly skilled personnel, but requires the acquisition of expensive laboratory equipment and other facilities,

therefore, advanced

91. VUiford K. Barnes, Journal of the American Medical Association. Tol. 1191 fovesflber i 23,' ^>9^®, p. l^gg. 1 '

106 planning is J&i&ly necessary to insure the adequacy of space to house clinical laboratories, animal quarters, statistical quarters, and the like.

Ibis type of research, according to present day thinking, is the

kind for ghlch the large medical centers are being held increasingly responsible. the conservative Hoover Beport gives research the highest priority in importance along with preventive medicine, public health, and education. The necessity for medical care, which requires heavy expend!* turea and much personnel, must not be permitted to result in minimising the even greater importance of controlling dis­ ease. Research must be stimulated, and supported to the extent which may prove necessary, to 'Mae maximum potential of the skilled manpower available to conduct it. Since the federal Government now gives varying degrees of medical care to one-sixth of the ilatlon and since it may very well face expansion in veteran's hospitalisation as veterans grow older and as their numbers increase, the Government can protect Its financial position best by using every means to prevent disease rather than to treat it by unlimited hospitalisation, this will also promote both the national welfare in peace and a stronger manpower to preserve our security in war. the highest priority In federal medical expenditures should, therefore, go to the research and public health fields. WO must, and to a large degree we can, if we will, control disease.^ The federal Government has certainly not been delinquent in providing funds for research, having long since established the public

92

. iihe Commission on Organisation of the Executive Branch of the Government, Medical Activities, pp. 39, 30.

107 polity of financing project* designed to contribute to Improvement of health and to a sound industrial and agricultural economy. Wem Steelmam Report (prepared by Jobn B. Steeiman for the President in August of 19^7) etated tbat $1 ,1 6 0 ,0 0 0 , 0 0 0 was spent in tbe national research budget in

19^7

by government, industry, tbe

universities, and miaoellaneous sources,

tbe government spent

$685,000,000 (exclusive of atomic energy), Industry $^5 0 ,0 0 0 ,0 0 0 , and tbe univerelties $b5 »0 0 0 ,0 0 0 . 5 3 It can be seen tbat industry and voluntary agencies aHfee also contribute beavlly to tbe financing of fundamental researeb. However, tbe cost of tbese projects sometimes goes beyond tbe capacity or willingness of private organisations to carry tbe full financial responsibility• Xt would, therefore, appear to be proper tbat tax money be used for this purpose which is concerned with tbe provisions of benefits for everyone.

5 3

. Journal of the American Medical Association, May 1, 19b8, Vol. 137 BO. 1 , p* 1 0 .

Chapter XXX

COBGLbSIGMf the dissertation thus far baa carried the reader through the historical background of the hospital with special reference to the uni­ versity medical and health center} has sought to define within broad limits its responsibilities for service and education} and has described current trends in the field with acme attest being made to analyse the existing need for both facilities and personnel.

Moving on from this phase, which

was intended to establish the general milieu out of which the hospital has evolved, the components of the university medical and health center were examined, keeping in the foreground the responsibilities for service and education already described.

Shis entailed a statement of organization

first in the generic sense and second in those respects in which it applies to hospitals and their medical staffs, discussing briefly medical staff relations.

Saving developed the principles of organisation, the hospital's

four functions * service, education, public health integration, and re­ search - were shown as they might appear within organisational framework, the extent and arrangement of patient care facilities were suggested, the major educational programs discussed, and the role of the university hos­ pital in preventive medicine and research given consideration. the concluding pages of the dissertation will be concerned with the hospital as a basic community institution which, in order to attain full expression of its capabilities for service, must be Integrated into the social fabric to the same extent as have the schools and churches,

fhe

109 university hospital with its obligation for leadership in the health field should therefore continually strive to strengthen eemnunity relationships, with the full realisation that it is only through the cooperative co­ ordinated use of all health agencies that the total armamentaria known to medical science can be brought to bear on the ills of man. She Heed for Closer Community Belatlonshipa The single hospital can no longer exist in a vacuum, performing a ruggedly individual function with no particular reference to other health objectives of the local or national community.

This is a truism

which points up the inescapable need that the university medical and health center align its objectives with total community goals and coordinate its activities with all other activities of a health nature that go on about it. The coordinate planning, the pooling of facilities and personnel, the interchange of ideas, and the actual integration of services, when carried on by a number of agencies and institutions in a given community, has been referred to by the U.S. Public health Service as Coordinated Health Services, by the Rational Health Assembly as State and Community Planning for Health, and by the Commission on Hospital Care as integration of Sci^ital services.

These several names, and there are other similsr

ones, all have reference to the same concept - one of cooperatively meshing Ideas, personnel, and facilities with the design that no area of need will go unsatisfied and duplication and overlapping of services be eliminated.

no There ere a number of programs sow Is operation and several others proposed which are designed to produce an Integrated hospital system. To name a few, there are the following; 1. Hospital Connells at local, state, or regional levels i&ldh, thron^i the cooperative action of their membership, seek to re­ solve eanmoa problems, eondnet certain centralised bnslnees aotlvltles in the interest of economy, and conduct Joint educational meetings.

This

type of council is important but not geared to long range planning. S.

Foundation Programs are conducted by the Duke Foundation,

Commonwealth Fund, and the W. K. Kellogg Foundation for the purpose of assisting in the organisation and financing of hospital services.

The

Ccamisslon on Hospital Care sums up their contribution when it says, "Although they result in institutional stability, and each has been of great value to the institutions and communities participating, they are not applicable throughout the country*.^* 3.

Voluntary Flans may operate Informally as in the ease of

two or three cooperating hospitals or formally as in the ease of the Bingham Associates Fund of Maine which links together 22 small rural end large urban institutions.

Highly trained personnel of the large hospitals

provide adjunct diagnostic and therapeutic services for the smaller institutions.

The larger institutions also accept difficult eases on

5b. Commission on Hospital Care, Hospital Care in the Halted States, p. 353*

transfer.

The educational function ie implemented through the coopera­

tion of the Tafts College Medical School. b,

Only two governmental plans for integrated service will be

mentioned beret

gas, the official state planning agencies growing cut

of the requirement of the Hospital Survey and Construction Act and two, the M.S. Public Health Service's Regional Plan. The State Advisory Councils set up in keeping with Public haw 725 are concerned only with construction and ore not of sufficient scope in either program or authority to Integrate hospital activities to the ex­ tent desirable.

However, it is believed that the H.8 . Public Health

Service's Regional Plan provides a proposal whereby public and voluntary hospitals may cooperate with other agencies in a broad program of integra­ tion and through which the university hospital may find optimum expression for its special talents. In this plan the region, which has been developed by the state in connection with the Hospital Survey end Construction Act, may be defined as the sum of two or more normal general hospital service eemsunitie*. Bach of the regions will have three areas;

The base area, contalnlfkg a

medical college and Its affiliating hospital and having a population of at least 2 5 ,0 0 0

1 0 0 ,0 0 0

} the intermediate area, having a population of at least

and at least one general hospital of a hundred beds or more} and

the rural area, with no stipulation as to population or facilities.

112 Tli* plan recommends the formation of a Regional Council, with representation from the participating hospitals, the State Health Bepartnent, the State Hospital Agency and the public, Which will be responsible for coordination among hospitals and planning for future development of the region.

The proponents of the plan propose coopera­

tive action in coamunity* planning, the promotion of demonstrations, the provision of administrative services, consultation, and education ser­ vices. The Regional Plan may not be the complete answer but it does combine the better features of the other plans and significantly po­ sitions the university hospital as the focal factor in the entire pro­ gram.

It therefore merits serious consideration as a means whereby com­

munity planning for health Can be made more effective. The problems og Financing Hospitals problems of financing hospital operations were touched upon somewhat earlier in the thesis When discussing current trends in the health field.

Xt Is believed to be important to give more consideration

to this subject Which has implications in practically every aspect of the hospital's activities.

Without money none of the programs necessary

to the ear* of the sick and the education of health personnel can be carried on. Oovemmental hospitals derive their income from legislative appropriation of tax funds, from reimbursements from other governmental agencies, and from receipts from paying patients.

113 Voluntary hospitals have four sources*

receipts from paying

patients* endowment income* community funds such a® gifts, toquests, eoaauaity chests, and other types of local contribution* and tax funds from federal, state, or local governmental aouraas in reimbursement for the oaro of indigent patiante or other public beneficiaries.33 the major aoare* of income for voluntary hospitals is from patients who pay between 60

to T % of all operating costs either directly or through prepaid

Insurance plans.

IBndowmsnt income and community sources although stlU

available are so negligible that they are only mentioned In passing,

fhe

second large source of revenue is from the reimbursements by different levels of government for the eare of their beneficiaries. area that most of the hospital *s lucerne problems center.

It is in this As previously

noted, reimbursements are so deficient that more and more revenue is being sought from paying patients and other sources in order to balance income against arising expenses. fables IT and V indicate the progressive increase in local indigent eare deficits and the cost of patient care, both of which are operating to create a financial impasse for the hospital and the pa­ tient.

fhe hospitals are pricing themselves out of their market by

charging rates that are so hlgi that the average citizen can no longer purchase services, which would be too expensive even if sold at cost. Patients with elective medical conditions may forego hospitalisation

3 5

. fhe national Health Assembly, America*S Health, p. kj.

114 Table W Hoir Indigent Care Deficits Are Increasing

Regions

Hew England Middle Antiantic South Atlantic East Horth Cent* Bast South Cent. West North Gent. West South Cent. Mountain Pacific United States

Federal reimbursable cost rstes 191*8 191*9

iooal Indigent Can* retes 19l*8 1?1*9

$1 0 . 6 8 $13.1*3 $6 . 9 6 9.51* 11.57 6 . 8 6 9.35 11.33 7.59 18.07 9.65 7.39 7.73 8.51 6.85 8.13 8 .5 0 5.85 8.38 9.81 6.78 6 .1* 1* 9.05 11*.2*0 13.85 15.91 7.80 9.58

31.61

7 .0 0

$7.38 7.1*3 7.98 9.83

local indigent care deficiency 191*8 191*9

$3.78 8 .6 8

1.76 8 .8 6

6 .0 0

.8 8

7.55 6.2*3 7.87 10.70

8.28

8

.0 l*

1 .6 6 8 .6 1

6.05

$6.05 2*.l2t 3.35 8.82* 8.51 .95 3.38 6.53 5.81

8 .5 8

Sources Hospital Hat© Survey, 19k9* American Hospital Association*

3.57

115 TABUS V

AVERAGE OPERATING COST PER PATIENT DAT IN VOLUNTARY NON-PROFIT HOSPITALS

Tear

1939

191*0 19kl 191*2 191*3 19t*l* X9*«5 191)6 191*7 191*3 *

Patient Day Costa

* 6.1*8* 6.39* 6 .6 9 * 7.67* 8.50* 8.95** 1 0 .0 %** 11.78** Jl*.0 6 **

Hospital Management Reports from 20,000 hospital beds*

#• Americai Hospital Association Directory, 15>1*6, 191*7* 19U8 and 19k%

Sourest J. R. MeGibony aid Louis Block, "Better Patient Car© Through Considera­ tion", unpublished report, United States Public Health Service, I9h9*

lie and those t^at oust seek hospital eare nay veil become medically indigent by virtue of the inordinately big* coat of services.

This results in a

mounting load of relhburslble oaaoa for vhich the hospitals are paid ffen 75 to 30$ of aetual eoat. !tow are no patent aolutiona for

these problems tbat ara

subject to hundreds of variations in aa uajr ooamualties. partial ansvers bate already been suggested.

Hovever,

One la certainly a dynamic

program of cooperative community planning, anotber la a more extensive system of health inanranee tbat mill extend beyond tbe already reached by Blue Cross.

33

million mark

Still anotber la a frank governmental

subsidy, preferably at tbe etabe level but not to be refueed if stemming from oemtral government. fhe grant-in-aid devloe might veil be need to strengthen hos­ pitals that are legitimately in financial distress due to the lack of operating funds,

the principle of the use of tax funds for the construc­

tion of hospitals has more or leas been aeeepted.

Why it is acceptable

to build hospitals vith tax funds and not provide means from the same source for their efficient and effective operation Is a distinction that la difficult to make,

there are certainly no more important duties

for uhioh the public at large should accept a responsibility than the health of its ova mashership. Whs Challenge of Leadership to the university Medical and health Center By virtue of its unique position in tbe vhole structure of

117 health services, tint university medical sad health center haul I m s un­ questionably cast in * role of leadership.

Shroutfiout this disBertation,

a studied effort has been made to keep the teaching hospital in the center of the discussion, continually pointing oat its logical obligations to all phases of health service and health education.

ft is hoped by

hating so done it has been possible to establish several principles that peculiarly apply to teaching hospitals. t& this final section, these principles «111 he summarised as the major conclusions of the dissertation. 1.

Throughout history, the quality of hospital care has b w »

indicative of the degree of social sanity of the culture in which in* stitutlons of health hate either flourished, remained static, or re­ gressed.

the hospital has been the medium through which medical science

has made its most significant progress and In which education of health personnel mast of necessity he given fullest implementation.

In vies

of the medical center’s speeial place in the community and because of its capabilities, not duplicated in any other institution in the society, it has the following obligations. 1.

fhe university hospital as a part of the com­

munity hospital system, must gear its program to the needs of the community, reconciling the difficulties in so doing to the best of its ability*

In spite of the many complicating

factors in the picture, the medical center IS obligated to

118 ■use iti facilities to their fullest extent, tins only legit* lmate limitation being else. 2.

the university hospital must accept unequivoeably

the obligation for educating a* many classes of health person­ nel a* is possible sad to cooperate vltb ether hospitals la tfcetr teaching program, vith tao viev to not only Increasing the quality of

i tfl* vorhere but,also of eometlog current

shortages.. 3. Bollarwise, there is the implied Obligation that the university hospital conduct its operations in such a ana* nor as to produce maximum service at minimum cost.

Honoror,

the problem of financing an institution as socially signifi­ cant as the hospital does not rest entirely upon its shoulder but is rather a Joint coaauaity responsibility♦ II.

the university hospital because of its complexity should

apply the best principles in organisation in ordering its administrative structure thereby maiding possible the ultimate in efficiency of opera­ tion and utilisation of facilities,

hr effectuating a functional or*

ganization the teaching hospital is in better position to fuHy isaple* meat its four functions of patient eare, education of health personnel, public health integration, and research. 1,

the medical center should be large enough to

asst the demands of extensive d i m e d departmentalisation, sad to provide a bed complement adequate to meet the teaching

119 needs of medical students.

Patient facilities should be func­

tionally designed for comfort and clinical expedience and vltb tbe expressed objective of minimising differences restating from financial classification. 2.

tbe nedieal center, under optimum circumstances,

is capable of conducting at least fifteen major educational programs,

Numerically, physicians end nurses are tbe leading

groups of health personnel that the hospital is called upon to train,

xa addition to the residency programs and tradition­

al one-year rotating internship, a flexible tuo-year internship may be offered to meet the needs of the physician planning specialisation as veil as the one planning general practice, burse training should be focused upon the basic nursing courses in hospital schools, vhich courses may better fill one of the most pressing needs in the health field - the need for numbers of adequately trained general duty nurses. 3.

fhe hospital should give serious consideration to

Its public health function,

fhe device of integrating hospital

and public health activities functionally and physically vithin the framevork of the university medical and health center, makes possible a fuller realisation of the teaching hospital's obligation for integration of hospital services vith community preventive programs.

120 k. W m teaching hospital mast necessarily be a research center.

In no ether environment la the opportunity

better presented for the effective integration of the vork of the pre-elinieal scientist and the ellniclan in developing project# of fundamental research in medical seienee. III.

Responsibility la a bilateral phenomenon.

Not only does

the hospital have responsibilities to society but the society shich created it has certain obligations to its institution of health,

the

people, the society, the community or whatever terminology describee the eolleotlve man, vho responds to the culture and the needs of the culture, is obligated to give maitaam support morally and, more impor­ tant, financially to those institutions, vhlch dovn through the years have brought dignity to the nerd service.

Only through the cooperative

coordinate planning of all individuals and agencies concerned are the hospitals to reaeh their pinnacle of effectiveness.

1 2 1

BIBLIOGRAPHY

Books X* “America*a Health," A Report to the Ration by the Rational Health Assembly, Harpers an? Brothers, Wew lo'rk, N. 191*9. 2. Bachmeyer, Arthur C. and Hartman, Gerhard, The Hospital In Modern Society, The Commonwealth Fund, New York, M. T,, 19U3. 3* Gaus, John U«, White, Leonard B., and Qimock, Marshall E., The Frontiers of Public Administration, University of Chicago Press, 1936. ~~ k* “Hospital Care in the United States," Commission on Hospital Care, The Commonwealth Fund, Mew York, N. X*, 19U7. $• M acEachem , Malcolm T., Hospital Organisation and Management, Physicians* Record Company, Chicago, Illinois, 19L6. 6. Mooney, James B* and Reiley, Alan C., Onward Industry, Harper and Brothers, Mew Tork and London, 1931. 7. Packard, Francis R., History of Medicine in the United States, Vol. 1, Paul B« Hoeber, Mew Xork,m'M. XT, 1931, 8. Ponton, Thomas Ritchie, The Medical Staff in the Hospital, Physicians* Record Company, Chicago, 111,, 1939, 9. Robinson, Victor, The Story of Medicine, Albert and Charles Bord, Mew Tork, S. X., 1931. 10, Sigerist, Henry B.* American Medicine, W, W, Morton and Company, New Tork, N. X., 1933H 11* Singer, Charles J., A Short History of Medicine, Clarendon Press, Oxford, 1923. 12. Stem, Bernard J., Society and Medical Progress, Princeton University Press, Princeton, K 7 X 7 O T T "------------13. Stubbs, S. G. Blaxland and Bligh, E. W., Sixty Centuries of Health and Fhyslck, Marston and Company, London, Y93l.

122

lit# Thayer, Vivian T., American Education Under Fire, Harper and Brothers, Hew Tork and London, I#bb. 15. White, Leonard B., Introduction to the Study of Public Administra­ tion, MacMillan and Company, New^ork, if* I. ,” 1939* —

Serials and Pamphlets mss ssssssSsssssssssssss 16. "Accreditation Troubles," Hospitals, Vol. 2b, No. 1, January 1950, p. 57. 17. "A Study of the Financial Position of Hospitals in New Tork," Hospitals, Vol. 2k, No. 1, January 1950, p. 8918. Barnes, Milford E., "Applied Epidemiology in a General Hospital," Journal of the American Medical Association, Vol. 115, PP. 1757-

I76o,

19. Council on Medical Education and Hospitals of the American Medical Association, Essentials of Approved Residencies and Fellowships, American Medical AssociaTIon, Chicago, HI. 19b7* 20. Dolezal, Charles T., "Nurse Education and the Interim Classifica­ tion," Hospitals, Vol. 2k, No. 1, January 1950, pp. hb-b7* 21. "Higher Rates - But the Deficits Continue," Trustee, Vol. 2, No* 11, November 19b9, pp. 17-19* 22. "Hospital Service in the United States," Journal of the American Medical Association, Vol. lbO, No. 1, May 7, i9b9» pp. 23-36. 23. Houghton, Henry S., "Teaching Hospitals in Relation to the Public, to local Hospitals, and to the Medical Profession," Bulletin of the American Hospital Association, Vol. VIII, No. 1, January 193b, PPT19TC -------------2b* "Medical Education in the United States and Canada," Journal of the American Medical Association, Vol. Ibl, No. 1, September 3» 19b9» W r w - w .---------------25* "Our Need for Doctors," Journal of the American Association of Medical Colleges, Vol. 2b, No. b, July 1W9, PP* 2b8-£5o. 26. "Red Figures," Trustee, Vol. 1, No. 3, December 19b7, pp. 16-18.

123 27# "The Medical Curriculum,” Journal of the American Association of Medical Colleges, Vol. 2b, No. 5, November 1 ^ , pV JW * Government Documents

28. "Medical Activities,” A Report to Congress» Committee on Organisa­ tion of the Executive Branch of the Government, Washington, Government Printing Office, 19b9. 29* "National Health Plan,” Hearings Before a Subcommittee of the Committee on Intorotate and Foreign Commerce Mouse ol Representa­ tives, Slatenentby division of ^ospiial Facilities, United States Public Health Service, Washington, Government Printing Office, 19b9* Unpublished Material 30. McGibony, J. R. and Block, Louis, "Better Patient Care Through Coordination.” Unpublished paper prepared in the Division of Medical and Hospital Resources, United States Public Health Service, Washington, D. C., 19b9. 31 pp. Class Lectures 31. Hartman, Gerhard, Seminar in Hospital Administration, State University of Iowa, November, 19b9. 32* Kelso, Hugh E*, Class in Public Administration, State University of Iowa, September,'' I9b9* 33. Vasey, Wayne, Class in Public Welfare Organization, State Univer­ sity of Iowa, November, l9b!9*

124

APFEHDEC

125 XMHKncus or a n e x s g u B aoansu.

Prepared by the Council on Radical Education and Hospitals oJP the American Medical Association

Oeneral Statement. — Hospitals should be organised and conducted primarily fear the purpose of presiding facilities share the slab and the injured of the eoMsuxilty any be given selentlfle and ethical nedieal sera. Registration is a basle distinction between all recognised hos­ pitals and those that are refused recognition.

Zt is a requisite to the

consideration of a hospital for approval for intern training or for reel* deneles in specialties. The registration of hospitals, the approval of hospitals for intern training, approval for residencies in specialties, and all other service of the Association regarding hospitals is carried on by the Connell on Radical Education and hospitals.

Separate essentials have been

adopted for each of these types of approval. Zt is the desire of the Council to cooperate in every way for the improvement of hospital service, whereby the sick and injured nay be pro­ vided with scientific and ethical nodical care. The Council does not have nor does it assume legal authority over any hospital.

It recognises clearly that the officers in charge of

such institutions have the unquestioned right to conduct the hospitals in any way they nay dean wise.

If a hospital desires to have its name

126 W w r on the American Medical Association Hospital Hegister and that have the recognition of that Association, It should ho silling to comply eith the principle vhich tha Council on Medical Education and Hospitals considers necessary. X.

Organisation 1.

fhe organisation should consist of a supreme governing

body qualified to administer a hospital,

this may he a hoard of trustees

or directors, a partnership or an Individual.

Such a hoard, partnership

or Individual must assume final authority and responsibility for the ad~ ministration. 2.

there must he a sell qualified executive officer vho may

he designated as administrator, superintendent or director or hy some other title,

this person should he responsible to the governing body

for carrying out Its policies,

fhe executive officer should he assisted

hy competent personnel adequate to the needs of the institution. XX.

Physical Plant 1.

fhe hospital plant should consist of modem, safe buildings

maintained in a sanitary condition, provided elth fire protection, profembly fireproofed, and adequately equipped and furnished for the comfort of patients.

Squlpnent for diagnosis and treatment should he reasonably

complete for all types of sork the staff purports to carry on in the hos~ pltal.

18? 8.

Institutions accepting surgical and obstetric patients

itowH provide a modernly equipped operating room, a delivery room and

a nursery, all suitably safeguarded. Hospitals that ore strictly limited in the service they offer are not expected to hare the complete ©rgaaizatioa aad equipment of a general hospital. III.

Medical Staff 1.

Since the nodical staff is the nest Important factor in

the delivery of medical service to patients, too great care cannot he exercised in the selection of staff aeafoors.

the staff should he limited

to physicians holding the degree of doctor of medicine from medical col­ leges acceptable to the Council on Medical Education and hospitals, having satisfactory Qualifications as to training, licensure and ethleal stand­ ing, and to dentists who are graduates of recognized dental colleges and those professional ability and standing ore known to the medical staff. 2.

Osteopaths, chiropractors and other cult practitioners out­

side the scope of regular medicine, or unethical physicians, may not he permitted to use the hospital's facilities,

they may not enter data on

the records, carry out diagnostic procedures or treatments, or in any way assist in doing this work. 3.

She form of organisation of the staff is determined hy the

size and the activity of the hospital in accordance with its needs. h.

In very small hospitals where there are few physicians and

where an elaborate organisation is not practicable, there should still he

128 seme authority competent to pane upon the qualifications of those who seek to use the hospital's facilities.

Particular care should he exer­

cised la the assignment of surgical privileges sines it Is essential for the safety of patients that both the surgeon and his assistants he prop­ erly qualified.

5* Where further organisation is needed it should consist of such officers as president, secretary end othersj and committees, such as executive, medical records sad credentials, elected or appointed ac­ cording to the constitution and by-laws. 6.

Staff sections such as medicine, obstetrics and surgery,

should he organised as may sews wise. T*

Staff meetings should he held for the review of the work of

the hospital, the discussion of results, the reports of autopsy and pathologic studies, the presentation of papers and such other matters as concern tbs professional work of the hospital. 8.

Minutes of all staff meetings and attendance records shall

he kept by the secretary. XT.

Pathology and laboratory Magnosls 1.

fhe laboratory facilities should provide as complete a ser­

vice as is practicable. 2.

the pathologist should preferably he a physician Who holds

the certificate of the American Board of Pathology.

Where it Is not pos­

sible to employ the services of a pathologist directly, arrangements

129 should ft. u l t for * eoasultltte s.rrle. for tissues, postmortem ex­ aminations and tbs interpretation of the mors difficult tests and ex­ amination* in clinical pathology.

All surgical tissues should he

examined, described and diagnosed hy a pathologist. 3«

the laboratory should he equipped for all routine pro­

cedures and for whatever additional tests and examinations are frequent­ ly called for hy the staff. A.

At least one well trained elinieal laboratory technician

should he employed. 3.

deports of all work done Should he kept on file.

6.

Autopsies.— Every effort should he made to secure consent

for the performance of autopsies,

they should he eomdueted hy a quali­

fied pathologist or under his supervision, and protocols, including clin­ ical smamerlea, should always he filed. T.

Badlology 1.

fhe responsibility for all radiologic examinations must

vest on the pkyeioiaa-roentgenologlst who is head of the department.

Bis

findings and conclusions for all examinations should he placed in the patient's chart,

nothing in this provision should preclude additional

study and interpretations by qualified attending physicians on the staff. 2.

fhe physlelaa-roentgenologiat should be preferably one

who Is a diplomats of the American Board of Badlology or a physician whose qualifications are acceptable to the Council on Medical Bducatlon

130 and Hospitals of Mho American Medical Association* 3*

It shall not be the policy of the hospital to make a profit

from tbs department of radiology* ft*

Anesthesia the anesthesia service should be under the direetloa of coupe*

tent medical personnel*

If a qualified specialist in anesthesiology is

not available, supervision may be assigned to some member of the staff who has had special training in this field or to a nurse anesthetist whose qualifications are acceptable* fll*

Versing Service 1*

A competent nursing service should be provided, adequate

for complete coverage for both day and night periods, and for surgical and obstetric supervision. tered graduates*

All nursing should be

supervised

by regis­

Hospitals that do general surgery should have a trained

operating room nurse* 2*

Hdetetios.— The services of one or more graduate dietitians,

as may be required, should be available for supervision of regular and special food services.

Where graduates cannot be employed, these func­

tions Should be assumed by seme competent person. ▼m.

Pharmacy the handling of drugs should be properly supervised and should

comply with all the legal regulations. tained.

Accurate records should be main­

A qualified person should be placed in charge, preferably a

graduate pharmacist* whatever arrangement la made, all prescriptions should be filled by a graduate pharmacist. XX.

Medical Beoords 1. m

adequate record system should be Maintained.

He cer­

tain forms eye recommended aiaee requirements wary greatly according to the else and type of hospital.

Samples of suitable forms for all de­

partments may be readily obtained from publishers of hospital records. 2.

Case histories end physical examinations should be re­

corded Immediately following the patient's admission.

In no ease should

it be longer than twenty-four hours after admission.

She history, phys­

ical examination, routine laboratory work and provisional diagnosis should be recorded before an operation except in emergencies,

The at­

tending physician is directly responsible for the accuracy and complete­ ness of case records, whether prepared by M m or by another. 3*

the usual case record consists of Identification data,

chief ccmplaint, past medical history, family history, history of pres­ ent illness, physical examination, provisional diagnosis; special reports such as consultations, clinical laboratory, pathology, x-ray and the like; medical or surgical treatment, progress notes, final diagnosis, condition on discharge and follow-up records; autopsy report when available. h.

Ho ease record should be filed until it is complete and then

only after it has been reviewed and signed by the attending physician. 3

. Monthly and annual analyses of services to patients should

132 be aade la order that the staff may be in a position to Improve its services. X.

Ethics In order that a hospital may be eligible for registration it

will, of coarse, be expected that the staff and management conform to the Principles of Medical XtM.es of the American Medleal Association with regard to advertising, eomnlssions, division of fees, secret reme­ dies, extravagant claims, wereomwreialization and in all ether re­ spects.

133 in I n n p t t r m

SSSESTIAI^I 0? fig ACCEFEABtB MEDICAL SetPaMhrt^Se SCHC)GL % the Connell on Medical Education and hospitals of the American Nodical Association. (Dealing vith qualifications for hos­ pitals affiliated vith a nodical school)

Section 5«

Clinical Facilitiest

eral hospital.

lie school nay ova or control a gen­

Wr control la noaat the unquestioned right to appoint

the attending ataff. fa this event the students cone into close and extended contact vith patients under adequate supervision.

In the

event that a nodical school depends for clinical teaching on an inde­ pendent hospital, it la essential that the elinieal teachers, either on nomination hy the school or hy agreement In conference between school and hospital, he appointed hy the hospital trustees to appropriate po­ sitions on the hospital staff. SuCh hospitals should he in close proatlalty to the school and have a daily average of not less than 200 pa­ tients sfc© can he utilised for clinical teaching, these patients to he of such character as to permit the students to see and study the conaon variety of surgical and nodical eases as sell as a fair? number in each of the so-called specialties,

m the use of this notarial, bedside and

ward clinics should he developed for sections of frcn five to ten stu­ dents, and patients in medicine, surgery and the specialties should he assigned to each student tinder a sell supervised elinieal clerk system.

134 treatment and care of these patients Should toe particularly observed and recorded toy the student under the strict supervision of the intern, the resident ar the attending staff of the hospital.

*he use of existing

municipal or state hospitals for teaching purposes Is also advised. the school stoould also ovn or oontrol emple hospital facilities for children's, contagious and nervous and nontax diseases,

She school

should ovn or control a sell ordered dispensary or outpatient department with a dally average attendance of at least 100 patients (visits).

Good

histories and records of the patients stoould toe kept and the material used in medical instruction,

The attending staff stoould toe draws largely

from the faculty, including those of highest rente. At least fifteen maternity eases should toe provided for each senior student, she should have actual charge of these cases under the supervision of the clinical instructor.

A carefully prepared report of

each case stoould toe handed in toy the student. faculties should toe provided for at least fifty necropsies during each school session which are attended and participated in toy students,

these should toe performed toy the professor of pathology or

a neatoer of his staff.

Use material thus secured should toe used in con­

nection with clinical pathologic conferences.

135

AIVH09X0 HB8IBBBR3IB8

ARB m XO W B HI F S Prepared By the Council on ifedteal Education and Hospitals of the American Medical Association Revised to June, 19^7

la t e s f t a s t e a i

Residencies and fellowships in Internal aedieine should be organised on a Brood Basis to furnish instruction In the various spa* claltles vhleh cenhlue to foam the foundation of practice in internal medicine.

Accordingly, the service should not Be limited entirely to

general modiolus and its subdivisions of allergy, oardiovasoular disease, gastroenterology, metaholie diseases, oontaglous diseases and pulmonary diseases But night sell include a reasonable amount of instruction in the divisions of psychiatry end neurology, dermatology and syphllelogy, sad pediatrics, non organised os independent specialties. Jn institutions offering residencies end fellowships in inter­ nal medicine, and in the special fields of allergy, cardiovascular disease, gastroenterology or pulmonary diseases, emphasis should Be placed on the educational features of the service and residents should receive regular instruction from members of the staff in methods of clinical study and diagnostic and therapeutic procedures.

Of particular

importance is the study of etiology, pathogenesis, symptomatology and course of the various diseases so that the residents may develop skill

136 sad accuracy In diagnosis as wall as a nature judgment sad resource­ fulness in therapy. Bader the supervision of qualified members of the staff the residents should assuue individual responsibility in actual case managegent,

They should also he required to correlate clinical studies with

postmortem pathology, review medical literature and take an active part in weekly teaching rounds, departmental seminars and clinical-pathologic conferences. See also the general Requirements for all residencies as given in Section t of these "Baseutlals". Quantitative Requirements,— for approval a residency in internal medicine should have at least BOO annual admissions. Applied Basle Science Instruction.— Anatomy, bacteriology, biochemistry, pathology, pharmacology and physiology are especially desirable and should be closely correlated with clinical experience. See Section 1-9 of these "Essentials” for a discussion of applied basic medical science instruction. Board Requirements.--The American Board of internal Medicine requires candidates for the certification examination to have an approval intern­ ship of at least twelve months, three years of special training and two additional years of practice in the field of internal medicine or its more restricted and specialised branches.

Rot more than one year of

instruction in the related medical specialties and basic sciences can be

137 applied to the three year period of special training,

general (or

"mixed*) residencies are ordinarily not regarded as satisfying any part of the required training.

Also, a second year of internship n i l

be recognised only if the second year is limited entirely to the nodi­ cal service in a hospital which is approved hy the Council on Medical Education and Hospital* for resident training in internal medicine. Physicians seeking certification in one of the special breaches of in­ ternal medicine (i.e., allergy, cardiovascular disease, gastroenterol­ ogy and pulmonary diseases) must first fulfill all the requirements far certification in internal medicine, including the examination.

138 rnmmm *$& mm& im Institutions offering residencies or fellowships in obstetrics and/or gynecology must provide gynecological mad/or obstetric facilities adequate for the clinical and teaching needs of the service,

They should

also furnish sufficient teaching material to afford residents a vide ex­ perience in elinieal diagnosis, treatment, and technical and operative procedures. Emphasis should be placed on clinical training in order that residents nay receive ample instruction in the various phases of obstetric and gynecologic service, such as antepartum cars, treatment of toxemias of pregnancy, management of normal and abnormal labor, technic of versions, breech extractions and instrumental delivery, diagnosis and treatment of the complications of labor, postpartum hemorrhage, puerperal infections, varieties of cesarean section and their indications, medical gynecology and its relation to endocrinology, minor procedures for ambulatory pa­ tients, and standard operations.

Bourses of instruction should include

assignments in pathology, demonstration on the manikin, departmental seminars, eHMeal-pathologle conferences and teaching rounds.

Training

la surgical technic should be sufficient to enable residents to undertake operative work on their ova responsibility especially toward the end of the residency program.

Prenatal and follow-np clinics are essential to

the program. gee also the general Requirements for all residencies as given in Section % of these "Essentials”.

139 Quantitative Requirements.— Ordinarily an admission rate of BOO patients a year is desirable in sash of the fields of obstetrics and gynecology whether these are separate or combined services. Applied jasiq Science Instruction.--Applied anatomy, bacteriology, bioChemistry, embryology, pathology and physiology are especially desirable and should be closely correlated with elinieal experience.

See Section 1-9

of these "Essentials” for a discussion of applied basic medical science Instruction. Board Requirements.— The American Board of Obstetrics and Gynecology requires candidates for the certification examination to have completed a year of internship and seven years of practice including at least three years of acceptable training in obstetrics and gynecology.

Although an

applicant may be practicing primarily in one of the branches (obstetrics or gynecology), a knowledge of the fundamentals of the other branch la required.

140 Pediatrics Clinical training should be Obtained in general medical pediatrics, nutritional disorders, ears of newborn infants, preventive pediatries sad outpatient elinies in the various departments of medical pediatrics.

Correlative studies ore recommended especially* In con­

tagious diseases, in clinics for veil babies, the mentally deficient and in those vith neurologic disorders or who present problems in behavior. In the wards and in the clinics the residents should be permitted to assume individual responsibility in diagnostic and therapeutic procedures and case management*

They should actively participate in teaching rounds,

clinical-pathologic conferences, departmental seminars and all other func­ tions designed to improve the quality of the clinical and educational ser­ vice.

Although the training need net be continuous or in the same insti­

tution, it is desirable that the educational program be systematised in the form of residencies of one to three years* duration. See also the general Requirements for all residencies as given in Section t of these "Essentials”. Quantitative Requirements.--fto supply an adequate amount and variety of teaching material a department should provide a minimum of approximately BOO annual admissions in general medical pediatrics. Applied Basic Science Instruction.— Sufficient time should be devoted to studies in applied basis sciences, especially in embryology, growth and development, nutrition, and other fields in physiology bearing upon

141 pediatries. Shis cork should be closely correlated vith elinieal ex­ perience.

Bee faction 1-9 of these "Essentials* far a discussion of

applied basic medical science irmtraction. Board Iteauirsacata.— the American Board of Pediatrics requires candidates for the certification examination to bare eottpleted fire pears of train* lug and practice after graduation from an approved medical school.

the

requirements include an apprered internship of one year, a carries of two years of acceptable training in pediatrics vhieh nay include a sin months residency in contagious diseases and tee additional years of specialised study or practice.

Physicians ifeo bare net the requirements

far certification in this field nay seek further certification by this board in the special field of allergy, or certification in cardiovascular disease by the American Board of internal Medicias.

142

Xtssideneies and fellowships in surgery may be from one to five years1 duration bat assd not necessarily be confined to one insti­ tution.

Individual residencies nay be conducted in general surgery,

neurological surgery, plastic surgery, thoracic surgery, proctology and other surgical divisions nos organised as independent specialties.

As

prelinittary training for residencies and fellowships in such specialties as neurological surgery, orthopedic surgery, plastic surgery, thoracic surgery and urology the Council recoasends at least one year of general surgery la addition to the internship. All surgical departments can readily subscribe to the seme general plan of training, although their scope of service nay shoe consid­ erable variation,

graining in oust of the surgical specialties is or­

dinarily limited to one division, but residencies in general surgery nay sell encompass the entire surgical field vith the possible exception of ophthalmology and otolaryngology. It is essential that adequate supervises be siaiatained by a competent department head responsible for the organization of the resi­ dency program*

Me should personally direct the plan of clinical and

operative training but may well rely on qualified assistants to super­ vise certain details of the educational service.

Beei&eneles and fellow­

ships should emphasise careful training in diagnosis, preoperative therapy and postoperative care,

ifels requires systematic bedside in­

struction, correlation of clinical and operative data, the study of gross and microscopic pathology and collateral reading.

Supplementary

143 instruction should be famished in the fora of departmental seminars, teaching rounds and clinical-pathologic conferences, usually on a weekly basis.

Surgical training should be obtained under the careful guidance

and supervision of competent specialists.

It Should be sufficient in

amount to insure a reasonable degree of technical proficiency and thus enable the residents to undertake operative work on their own responsi­ bility, espeeially toward the end of the residency program. Equipment and facilities for general and special surgery must be adequate to meet the needs of the service.

She clinical material

should likewise be sufficient to famish adequate experience and train­ ing in diagnosis, therapy and operative teehnle. gee also the general Requirements for all residencies as given la Seetion I of these "Essentials". Quantitative Requirements.— The general surgical service in an approved residency mould provide approximately 1*00 annual admissions per resident. A smaller number of admissions might suffice for such surgical work as might be done In a specialised field of surgery, but even la the most limited of these specialties there should be at least 150 patients treated annually. Applied Basic Science Instruction. — Experience in applied anatomy, bac­ teriology, biochemistry, pathology and physiology as pertains to surgery should be included in the residency program and should be closely corre­ lated with elinieal experience.

See Seetion 1-9 of these "Essentials* for

144 a discussion of applied basic medical science instruction* Board Requirements#— The American Board of Surgery requires candidates for the certification examination to have completed an approved intern­ ship and at least five additional years of special training in surgery* Two years of training credit may be allowed for work in an approved residency in one of the more specialized fields of surgery, such as neurological surgery, plastic surgery or thoracic surgery#

Hiysicians

who have fulfilled the requirements for certification in surgery, including the examination, may qualify for further certification in the field of proctology by the American Board of Surgery*