The Public vs. "Closed Hospitals"

The rise of hospitals to their present state of physical development has served to improve the care of the ill. Under modern living conditions, such as the small and crowded apartments of our cities, hospitals are essential for the care of the seriously ill. Many cases of illness can be cared for efficiently only in a hospital; for the hospital makes available many of the more complicated and cumbersome devices used in modern medical practice.

The very dependence of the public on its hospitals that compels it to accept what is given, makes the abuses which have grown up in them just so much more critical and less excusable. Nevertheless, it has become the custom of the public to veer away awesomely and foolishly from the dread topic of hospital abuses. The traditional attitude is:

"We must have the hospitals in spite of their abuses. Since we do not know what to do to remedy the situation and no one who does know is willing to tell us, we may as well accept it and make the best of it."

This attitude of condoning the abuses merely serves to aggravate the situation. Therefore, I shall not discuss merely the dangers of hospital abuses, but also the remedies.

The nature of the work done by hospitals and the high physical state which some of them have attained has served to hide from public gaze some of the serious defects and abuses which have crept into hospital organization and management. But the discriminating patient can quickly discern that much is wrong in hospital and clinic organization. He feels that he is regarded merely as a cog necessary for the operation of the hospital machinery. If he has spirit and demands needed attention, he ranks as a nuisance. He feels that he is recipient of as much individual attention and interest as a bolt emitted from an automatic lathe. He is right in this feeling. In addition to the reasons which have been related, there are others that are rooted in the nature of the hospital rackets that account for it.

The hospital has become a business device for "mass-production," advertising and selling medical and surgical wares. Human values consequently may assume curiously distorted proportions in hospitals. Neither patient, physician, nurse or personnel count for much in the views of the present-day "closed" hospital administration. Its motto is: "Folks come and go, but the hospital goes on forever."

It is only when hospitals seek to lure funds from the public that there is any pretense of catering to it. The hospital is represented to the public as belonging to it. "Contribute to build your hospital" was the typical slogan coined by the clever publicity men that raised the funds for the Columbia-Presbyterian Medical Center. The patient who has contributed to the hospital in response to the fraudulent plea that the hospital belongs to him and to the community, may well wonder on receiving his bill whether he is not being called upon once again to buy the hospital.

This phase of the hospital situation is thrown into sharp relief by a very pathetic case that has recently come to light. A wealthy contributor who had liberally endowed a prominent hospital lost his fortune during the depression. He was refused admission by the very hospital that he had endowed because he could not pay its minimal charges. The high cost of clinic and hospital care gravely concerns many folks.

THE MONETARY COST OF CLINIC CARE

The monetary cost to the public of clinic care, in contrast to hospital charges, is often quite nominal. In municipal clinics no charge is made. In the voluntary hospital or pay clinics, the charges may range from pennies to dollars. In some of the Medical Center pay clinics charges are sometimes higher than in private practice. But the actual total cost in loss of working time and wages may run very high.

An illustration of this cost is case 58 of the One Hundred Neediest Cases reported by the New York Times in December 1927. The father of a family of three was required to attend a clinic each morning. As a consequence, he lost his pay for half days; and by exactly that sum he was pauperized. Public charity was called upon to donate that sum. The man might have had treatment at the hand of a physician privately at a time which would not have interfered with his work, and avoided pauperization. Eventually his clinic medical care made him a public charge.

A similar case is that of Leonard P. who suffered from a trivial disorder of the nose which he was told by the clinic physician required treatment twice a week. He was employed as a cook and earned a fairly good salary, but wished to save the relatively trifling cost of private medical care. To attend the free Bellevue Clinic he was compelled to drop work at midday and take off the balance of the day. As a consequence, he regularly lost his job and was more often unemployed than employed. In the end he became a public charge.

Many needless visits are required of clinic patients for mercenary and other reasons. It is established practice for cities to pay clinics for the care of charity and relief cases, a small sum for each visit. Most voluntary clinics extend little charity. Inasmuch as the physician is not usually paid for his services, these sums represent profit to the clinics and hospitals. Consequently, it is demanded of the doctor that he compel the patient to return often, however unnecessary that may be, in order that the sums collected by the institution may be larger. In addition, the larger the number of patients lured into the clinic, the greater will be the business lured into the hospital. Even in municipal clinics, the management and the social workers like to show ever increasing attendance to justify increasingly larger appropriations.

Every town has its army of clinic-bred paupers of the type above described, They do not stop to realize that in seeking cheap or "free" care, they are losing their jobs and livelihoods. Hospital social service workers do not disillusion them, for they know that clinic attendance butters their bread. They feel that reference of these sick folks to physicians privately would be suicidal. Private practice furnishes no social service jobs; and it is therefore the avowed goal of social service to destroy private medical practice, no matter what the cost to the community. How little charity is extended in the clinics of the voluntary hospitals is indicated by the 1932 annual report of the Manhattan Eye and Ear Hospital. It shows that the hospital made a profit of almost forty thousand dollars on eyeglasses that it furnished its "charity" clinic patients.

HIGH FEES IN "CLOSED" HOSPITALS

It is tragic irony that "charitable" hospitals often mean financial ruin for the very individuals who have generously contributed to their building and support, when they require the services of the hospital. Instances of this can be found in almost any large city. In New York City, for instance, no one factor has contributed more to the impoverishment of Jewish families in normal times than the excessive charges for medical care in the very institutions which they build and support.

Most notorious is the case of Mt. Sinai Hospital. By adroit publicity and politics, it has built up for itself a reputation for quality of service and excellence of medical personnel that it has not earned or deserved for many years. When lured thereby to seek the services of the hospital and its staff, the subscribers who seek private care are often excessively charged; and cast out or thrown into the wards when their funds are exhausted. It might be said, with considerable justice, that the most serious disease affecting the Jewish folk of New York is "Mt. Sinaisitis."

The irony of the situation is intensified when such social service organizations as the Federation for the Support of Jewish Philanthropic Societies aid and abet the establishment of rapacious "closed" hospital monopolies. Its complexion is not improved by the fact that physicians do not remain on the staffs of institutions that it supports, if they fail to contribute to the "charity" sums of money deemed adequate.

"CLOSED" HOSPITALS MAINTAIN HIGH COST OF SURGICAL CARE

"Closed" hospital monopolies, fostered by organized medicine, the A.C.S., and organized social service raise the cost of medical and surgical care to the public. They are not designed to foster either honesty or fairness nor do they protect the health and life of the patient. For they compel the family physician to surrender the care of his patient who enters a "closed" hospital and turn it over to the hospital staff and deny the patient the benefit of truly responsible and personalized care.

The surgeon's responsibility to the patient however is slight and his dealings sporadic and occasional. A surgeon's reputation is little affected by individual mishaps or deaths. Patients are forced into his hands by the "closed" hospital monopoly and must accept his services. He is protected by the code of secrecy to which members of the staffs of "closed" hospitals are pledged. There is no better way of covering up needless criminal or careless surgery than to perform it in a "closed" hospital.

"Closed" hospital staff members generally charge patients highly for their monopolistic services. They also do their best to wean them away from outside family physician who loses caste by being excluded from the hospital and the care of his patient. If and when the patient is returned to the family physician he is often so stripped of funds that he cannot pay for further services required.

The interest of fairness to the patient and his family would be served if they were given an all-inclusive fee for operative services which they might prepare and budget. That fee should include the charges for the very real services rendered by the family physician to both the surgeon and the patient, such as making the initial observations and diagnosis, inducing the patient to seek the surgeon's services, arranging the fee, attending the operation, watching over the aftercare and following up the results. This should be done openly and with the cognizance of the patient.

Such a plan implies the continued care of the patient by his family physician in the hospital. This means elimination of the "closed" hospital monopolies. There would result protection of the health and life of the patient and a material reduction in surgical costs.

The relatively high cost of surgery to the American people is amply attested by the report of Lee K. Frankel to the Committee on the Cost of Medical Care. This report indicated that the average cost of medical care among 2,678 families was $37 for a half year. The average cost of surgical care in 212 families was $74 exclusive of hospital expenses for the same period. In other words, the average cost of surgical care was found to be twice that of medical care.

The monopoly of surgery established through such agencies as the "closed" hospitals and the American College of Surgeons contributes largely to the high cost of surgical care. But it is by no means solely responsible.

THE VENERATION OF THE AMERICAN PUBLIC FOR THE SURGEON AND FOR SURGICAL PROCEDURE AND THEIR WILLINGNESS TO PAY HIGHER FEES FOR SURGERY, ARE FUNDAMENTAL REASONS FOR MUCH NEEDLESS SURGERY AND FOR THE HIGH COST OF OPERATIONS IN MONEY AND LIFE.

THE HIGH COST OF HOSPITAL CARE

Needless hospitalization costs the public heavily. The physicians and surgeons who are given monopolies of facilities by "closed" hospitals are expected to boost its business and keep its beds filled. Since it is a convenience to busy practitioners to have their patients concentrated in hospitals, instead of having to visit them in their scattered homes, they are not at all loath to impose this item of unnecessary cost on their patients while boosting the patronage of their hospitals.

In the great majority of "voluntary" hospitals interns and nurses-in-training receive little or no pay. Pay, and working and living conditions of the other workers are so unbelievably poor that even their unionization has not succeeded in New York in bringing the average wage level up to fifteen dollars per week. The hospitals which continually appeal to the charity of the community and play on its gullibility, show little or no charity in these dealings. The social service workers and superintendents, alone among the workers in the hospitals, are amply or munificently paid.

Barred by law from showing a profit, these hospitals generally manage to show a deficit on their books. They are built and exist on the charity and philanthropy of the community, continually begging funds. Though they often extend little or no charity to the public, they are exempted from taxation and are subsidized by the taxpayers as "charitable institutions."

PRIVATE HOSPITALS OFTEN SUPERIOR AND SHOW PROFITS

The exorbitance of the "closed" hospital charges becomes more apparent from a comparison with those of the commercial, proprietary, or private hospitals. These hospitals are privately financed and built, and are operated for the frank purpose of netting their owners a profit. The contrast is sharp.

The modern private hospital is a high class hotel for the sick. It receives no endowments or contributions from the public. It is erected on valuable ground which is purchased for the purpose. The construction is generally luxurious, fire-proof and ultra-modern. It is expensively and comfortably furnished, and its appointments are the best. The equipment is complete and the last word in modernity. No expense is spared to insure the safety, comfort and well-being of the patients. They generally pay their help better wages than do the voluntary hospitals, and hire help of higher caliber. Unlike the voluntary "closed" hospitals, they pay taxes. Nevertheless, private hospitals generally charge the patient less for the same caliber of service and accommodation. And when properly managed, they generally show excellent profits.

The public has discovered that the cost of the superior accommodations of the private hospitals is less than in the supposedly "charitable," voluntary hospitals, and the treatment better. The patient in the private hospital is not called on to surrender his rights as a man and as a citizen. He is allowed to freely choose the physician to whom he will entrust his care. The patient is not denied the trusted, competent, and reasonably priced services of a physician of his choice as is the case in the voluntary hospital merely because that physician is not a member of a monopolizing clique.

In many communities the voluntary, "closed" hospitals have been able to hold their own against the competition of the private hospital only with the aid of the corrupt powers of the A.C.S., A.M.A. and social service allies.

It is not surprising that the private hospitals show good profits when properly managed and times are propitious. They are merely hotels for the ill. Though the menage of good hotels is even more luxurious and expensive than that of a hospital, they generally manage to show good profits when well patronized. Not even the plea of expense of special hospital equipment can be interposed as an item that imposes higher costs on the hospital; for many modern hotels have completely equipped hospitals on their premises for the use of their guests and for the help. It had become the custom of many physicians in cities such as New York to refer their operative patients to hotels for superior hospital service at lesser costs. But the hospital lobby stopped this devastating competition by prevailing on the licensing authorities to deny licenses to hospitals maintained in hotel premises.

DEFICITS OF VOLUNTARY HOSPITALS NOT DUE TO CHARITY

The surprising feature of the situation is that the voluntary hospitals can manage to show such large deficits in spite of their exorbitant charges.

When questioned on the matter, hospital authorities point to their "charity work" as a justification for the losses. But the voluntary hospitals generally extend little charity to the community which it does not pay for. The ward cases either pay an average of three and a half dollars a day for their hospitalization, or the community pays it for them. When no payment is available, the voluntary hospitals transfer the cases to public hospitals, often at grave risk to health and life. The relatively small amount of occasional charity extended by institutions is outbalanced by the charitable contributions obtained from the community by appeals and "drives."

Charges made by the voluntary hospitals for services in their wards should not involve any loss to the institutions if they were efficiently and honestly managed. This is made apparent by a comparison with the charges made in the second rate and the workmen's hotels. In hotels of the latter class, a modestly furnished room and three meals a day which are adequate for a healthy man, may be had at one and a half to two dollars a day. For a bed to sleep in, three simple, meagre meals a day, medicine costing a few cents, and the moiety of service which costs them little or nothing, the hospitals of New York and of other cities charge the ward patient from four to six dollars a day; and they cry that "charity" is exhausting their funds.

HOSPITAL SERVICE PLANS NOT ADEQUATE SOLUTION

"Hospital funds," which offer group hospital care for fixed annual charges in many cities, have partly solved for some of the public one aspect of the problem of hospitalization cost. But none of these plans provides for the largest item in the cost of illness—private nursing care. Partial breakdown of the hospital plan in New York City, which has resulted in cancellation of many contracts in 1939 and modification of others, indicates that more fundamental remedies are necessary. The situation is further aggravated by the custom of hospitals of imposing excessive charges for "extras" on the "hospital service" cases. The hospital funds also exclude from participation persons over the age of sixty-five years, leaving the hospital problem completely unsolved for this growing group.

"Hospital fund" plans, however, do aggravate the problem of the cost of medical and surgical care. For they have enabled the tottering "closed" hospital system to survive, and have saddled on the public the high costs of medical and surgical care which its monopolies foster. This will become even more intensified if the American College of Surgeons, the A.M.A and their social service allies, who are powerful influences in these plans, succeed in their efforts to restrict the benefits solely to "approved" hospitals. The solution of the problem of hospital costs rests primarily in the elimination of dishonesty, corruption, and rackets—in honest administration.

CLINIC TOLL OF HEALTH AND LIFE

As a result of concentration of the ill, and the crowding together of the non-infectious and undiagnosed infectious and contagious ailments, the clinic often serves as a focus of spread of infectious and contagious disease. A child taken to a clinic with a minor ailment may readily return home with the beginnings of scarlet fever or measles.

Even thoughtful laymen can appreciate this potential menace to public health. The Grand Jury of the Bronx, on the 28th day of November, 1937 handed up to Supreme Court Justice Tierney a presentment charging that the clinics of the Bronx were a focus of spread of contagious diseases.

Tragic delay in diagnosis and treatment of ailments often result from clinic organization. An instance is cited in records published by the New York City Health Department in 1928, in a survey of deaths due to diphtheria that were observed in the contagious disease hospitals of the city. The case reads as follows:

Diagnosis was not made on a child suffering from very early stages of diphtheria in the clinic of a hospital. When the child was returned on the following clinic day, two days later, advanced toxic diphtheria was obvious. The child died shortly after admission to the hospital.

A physician in his private practice would have continuously and repeatedly observed the child. Clinic organization made this impossible and was responsible for the death.

The barrier offered to follow-up of patients by clinic organization, the resultant irresponsibility of care, and its menace to health and life are freely acknowledged by even the staunchest advocates of the clinic system. The United Hospital Fund of New York stated in its 1927 report that the care given the public in clinics is not thorough. This is a mild statement of the situation, as will be discerned from the following case:

A.G., a man about 24 years of age; occupation, bricklayer; earnings ten dollars per day plus overtime. Admitted to clinic with infection of a finger. After the finger was dressed, the surgeon hesitantly told him to return on the following clinic day. The surgeon hesitated because he faced a dilemma. He realized that though the infection was slight, there was a possibility that it might spread rapidly. Though under the rules of hospital admission there was no justification for immediate admission, the hand should be watched twice a day. The surgeon would have been glad to refer the patient to his office for observation without charge; but by the rules of the clinic he was barred from so doing.

When the patient returned to the clinic on the second day following, he presented an angry infection of the hand and forearm which necessitated immediate amputation of the hand. This amputation might have been avoided if the victim had had adequate attention during the first two days of illness.

This case is one of many which may be found daily in the clinics of any large city. It constitutes criminal neglect and gross malpractice; but under the law of most states both doctor and clinic are immune from prosecution. The tragedy to the individual and his family is an outcome of neglect forced by the very nature of the clinic and of its rules and regulations. Such cases impress forcibly the fact that the most valuable item which the patient may require and secure from his physician is his personal care and the solicitude which accompanies the sense of individual responsibility. This is barred by clinic and institutionalized practice of medicine.

Nothing is more false than the idea that clinics offer a physician experience superior to that of private practice. The reverse is the truth. Clinics generally breed in their physicians habits of haste, inaccuracy and negligence. For the clinic doctor is a cog in the machine of medical "mass production." He is not paid for his services, is denied any voice in the management of the clinic, and must submit to the indignity of punching a time clock. His clinic hours are determined by those of the paid porter.

The clinic doctor, like the hospital attending, is the counterpart of the laborer on an assembly line. He is required to specialize and treat only a single organ or disease. In order to secure his appointment, he must be a man who is trained in the specialty. Since most clinics are woefully underequipped, he must furnish needed equipment at his own expense and risk.

Clinics generally require of their physicians that they see, and make at least a pretense of examining and treating all the "customers" before the clinic closes. Closing hours are determined by the hours of the paid personnel. Hurried and careless work is generally forced upon the physician. Often the pressure of work taxes the endurance and mental poise of the physician, which is so requisite for careful, thoughtful work. The very nature of clinic organization forces neglect and deception of the patient. Under these circumstances, the physician learns little more than careless, hurried methods of work which become fixed habits. It is idle to expect anything but negligence and malpractice of the clinic physician.

"CLOSED" HOSPITAL SACRIFICES

The most significant element in the cost of "closed" hospitals to the public is the sacrifice of human life. Though medical advances have improved the caliber of medical care and increased the expectancy of life, often patients fail to derive benefit from them in many "closed" hospitals. This results from the very faults that are inherent in the "closed" hospital systems.

The medical boss is expected to lure or drag his patients into his hospital, especially if they are wealthy or if the case involves much publicity. Not infrequently this is done at the expense of the patient's life. A notorious case of this character was that of a wealthy Long Island polo player who was thrown from his horse and suffered from a fracture skull and intra-cranial hemorrhage. He was taken to a local hospital. If he had been a poor man he would have been left there to rest and would have had an excellent chance to make an uneventful recovery. Instead a prominent professor of brain surgery from a nearby Medical Center was called in. He hastened to rush off his prize to his Medical Center. As might be expected, the jouncing sixty-five mile ride to the Center was too much for the patient. He died, a victim of the "superior" medical care which his wealth and prominence inflicted on him.

Authorities agree that in some types of cases hospitalization means an added risk of life to the patient. This is especially true in obstetrical cases, in which the risk of acquiring puerperal infections is intensified in hospitals.

Few "closed" hospitals have medical staffs large enough to care adequately for all of their patients, because of the desire of dominating cliques to restrict and monopolize the use of their facilities. Rather than dilute their monopoly by permitting competent outsiders to care for the patients in the hospital, the staffs turn them over to untrained, inexperienced and often unsupervised interns. The opinion of these self-same hospitals of the competence of the interns whom they entrust with the lives of patients is made clear by the fact that after they have graduated, they are denied for many years the privilege of performing in the hospital the operations which they performed as interns, on the ground of inexperience.

To the public, the "closed" hospital cliques pretend that their object in excluding the outside physician is the protection of health and life of the patient. The falseness of this claim is obvious. When no members of the staff are available, the patients of the "closed" hospitals are forced to accept the services of inexperienced interns even for dangerous operations rather than permit the outside physician, no matter how experienced he may be, to render competent services.

The lives of others have less value to merchants-in-medicine than their business monopolies.

This endangering of life for commercial advantage is an almost universal custom in the "closed" hospitals of the country. A prominent surgeon, Dr. A.J. Rongy F.A.C.S., has stated that over 50% of the cases on his service were operated by interns with or without adequate supervision. He stated that the inexpertness of the operations and the prolongation of the anesthesias spelled a grave risk to the health and life of the patients. This surgeon's accusation was amply confirmed in Commissioner Higgins' Kings County Hospital report which already has been mentioned.

The toll of death and disability due to the inexperience of the intern often is accentuated by the tremendous volume of work forced on the personnel. In many larger hospitals interns are compelled to work from twelve to eighteen hours a day; and in case of emergency they may be compelled to work a day, or more, without sleep. Nurses are also compelled to work sometimes for comparable periods. Fatigue of hospital workers contributes to the toll of human lives in hospitals.

DEATHS IN THE AMBULANCE SERVICE

Malpractice and error of diagnosis occur with especially high frequency in connection with ambulance services. Rarely do these cases attract any attention except when they form the basis of social service propaganda. They are so common-place that the newspapers do not favor them as news. In the early years of the depression, the social service forces conducted a publicity drive for the support of the ambulance services of the voluntary hospitals in New York City. As a result, some cases of negligence of ambulance surgeons were published in the press; they became "news" solely because of the activities of the social service publicity men.

On December 8, 1931, the New York Journal reported that Clark Starbuck was treated at a hospital for a supposed laceration of the scalp and discharged. One hour later he collapsed and died at the Mt Sinai Hospital from what was later discovered to be a fracture of the skull.

On January 1, 1932, the New York Times reported that John Mul queen died in the East 126th Street Police Station, shortly after he had been refused as a patient by the Harlem Hospital ambulance surgeon.

On January 18, 1932, the New York Times reported that Robert Francis was discharged from the Fordham Hospital, with a diagnosis of mere lacerations after being struck down by a truck. Promptly after returning to his home, a summoned private physician diagnosed fractures of the skull, arm and leg.

The individuals described as the "ambulance surgeons" in these cases were, as usual, young, inexperienced and unpaid interns working under high pressure, for long hours, risking life and limb in the service. The failure of correct diagnosis was not their fault, but the fault of a system which forces inexperienced youngsters to do work which would often tax the skill of a veteran physician. Nevertheless, in all the publicized cases the young interns were made the scapegoats of the system and their records and reputations damaged.

It was not until September 1933 that interns at Bellevue Hospital summoned up sufficient courage to rebel against being made the scapegoats of the ambulance system. They protested against the suspension and reprimand of two of their number for fatal errors in diagnosis on ambulance calls.

One of the cases was Edward J. Sullivan, whose condition was diagnosed by the intern as "alcoholic gastritis." At death intestinal obstruction was found.

The other case, Norman Frankel, involved two interns who, on three successive ambulance calls over a period of twenty-four hours, persisted in diagnosing what proved to be a ruptured appendix as a mere stomach ache.

One can well understand the resentment of the interns on being made the scapegoat of the publicity attending these cases. In every large hospital with its mass production system, such cases are commonplace even at the hands of experienced staff physicians.

DEATH IN THE HOSPITAL

The attitude of the hospital authorities to the death-toll from negligence is one of supreme indifference, if it involves no publicity. They receive no publicity and are accepted as a part of the daily routine.

I recall an experience which illustrates this attitude. While in my third year at medical school, I was asked by a friend, a young intern at Bellevue Hospital, to substitute for him during his leave of absence. Though my knowledge of medicine was as scant as that of any third year medical student, I was entrusted with the care of a large ward of surgical patients.

One night I was called, after a long and hard day, to quiet a noisy, obstreperous and delirious drunk who had been admitted with a fracture of the thigh. I ordered the nurse to administer a fairly large dose of paraldehyde.

About two hours later, I was again awakened and told that the patient was once again disturbing the ward. I ordered another dose of paraldehyde.

About five o'clock in the morning, I was summoned to the bedside of the patient who was comatose and in collapse. The cumulative effect of the alcohol and the unwisely large doses of paraldehyde had been too much for him.

I promptly administered oxygen and artificial respiration and continued it over a period of four hours. At the end of that time, the patient was resuscitated and I was exhausted.

When I went down to breakfast, I was chagrined to find myself twitted and derided by superiors for having concerned myself about the possible death of an old drunkard. A death more or less in that mass of ailing humanity meant little provided it did not show in the operative mortality score.

Loss of life or impairment of health resulting from the high pressure of hospital and clinic work, accident, carelessness and negligence is quite commonplace in institutional medicine; the hospital code of secrecy hides them and rarely do they emerge into public notice. The attitude of hospital authorities toward deaths of this type is a pose of severity in the few chance cases which receive publicity. They stage a tremendous indignation which vents itself on intern, nurse or other subordinate, who is made the scapegoat; and a career is damaged or ruined. It is interesting to recall a few of the cases which have been given widespread publicity in the press of the nation because they served the purposes of the dominant cliques in medicine and social service.

NEW YORK HOSPITAL, CORNELL MEDICAL CENTER DEATHS

Three infants were put to death at the New York Hospital-Cornell Medical Center, in December 1932, by the injection of boric acid into their veins. An overworked nurse had injected the acid instead of salt solution ordered by the doctor.

Dr. Eleanor Conover, director of the Hospital Information and Service Bureau, a social service publicity bureau whose function it is to propagandize hospitals and clinics, told the press that accidents and errors are rare in hospitals. She said:

"The nurse who has made a serious mistake is no more granted another chance than the captain who has lost his ship. The patient who submits to treatment in any reputable New York hospital has the assurance that none of the nurses who will attend her have been found guilty of negligence to date."

More truthfully, Dr. Charles Norris, then chief medical examiner for New York City, informed the public

"Something like this happens every two or three years."

He referred to the matter coming to public attention; not to the rate of incidence of such accidents. Anyone can realize that persons who are over-worked and tired are certain to make errors. There is an inevitable toll of mass production and fatigue in hospitals and clinics,

SOME OTHER HOSPITAL DEATHS

Four infants were asphyxiated by steam in the nursery of the Perth Amboy General Hospital, on October 23, 1939. According to the statement of the hospital, a steam valve with worn threads had been affixed to a radiator in the nursery with adhesive tape. Immunity of hospitals and clinics from liability for negligence contributes to the frequency of such incidents.

Some of the truth with regard to the conditions in "closed" hospitals began to leak out after the hospital personnel were afforded protection in tenure of position, in 1936, by organization into labor unions in the municipal hospitals of New York City. Thus Miss Marion Martin appeared for the hospital nurses before the Board of Estimate in October of that year. She revealed that in Harlem Hospital, during the month prior, nineteen babies died of infantile diarrhea while one nurse cared for fifty of them.

Occasionally, sensational cases leak into the press. Such a case was reported from Elizabethton, Tennessee, several years ago. Two surgeons who were intoxicated and in no condition to operate undertook to remove the appendix of a youth. After fumbling about, they closed up the abdomen, leaving the patient to die as a result of their malpractice. At autopsy, the coroner removed a perfectly normal appendix.

Though the above-cited case is extreme, operations by surgeons who are not in fit condition are almost regular occurrences under our present system of medical and hospital organization. The chief of service in the "closed" hospital is absolute monarch in his domain, and no subordinate who values his job or reputation dares question the sobriety or state of competence of the "Chief."

MASS PRODUCTION IN HOSPITALS MEANS DEATHS

Overwork of staff physicians and surgeons who seek to care for all the cases that their hospital monopoly brings them also accounts for much malpractice. For they are not robots. They have, like other human beings, their "below par" days. Seldom does it happen, however, that a surgeon refuses to operate, or turns his work over to a colleague, because he does not feel fit. This would be regarded as evidence of inefficiency in a Medical Center or "health factory." There have been surgeons who have jeopardized their own lives, and collapsed and died in the midst of an operation, rather than yield to another. Whipped on by the "mass production" machinery of the hospital, surgeons attempt to work on schedule as operative robots.

The organization of medical service for mass production—whether it be by the state or by social service agencies, whether in clinics, hospitals or medical centers—is inevitably signalized by a heightened disregard for the value of human life. In the mass production of objects, spoilage of a certain percentage of production is taken for granted. Accuracy is sacrificed to speed, The imperfect or damaged product is cast aside. But in the "mass production of health," spoilage means maiming or death of humans. "Mass production of health" readily translates itself into "mass production of disability and death."

The ultimate victims of the hospital rackets are the public, who pay the bill doubly in the "closed" hospitals. They often are compelled to surrender their rights as men and as citizens, and to permit themselves to be robbed and maimed, in order to enjoy the facilities of the very institutions which they support.

DOCTOR-PATIENT RELATIONS

Regard for human life should dictate painstaking and careful personal care of the ill. But the social service clique and merchants-in-medicine equally pooh-pooh the personal element in medicine. One can understand their attitude when one regards it in the light of self-preservation. An organization of the medical profession for careful and reasonably priced medical care provides no fat incomes for parasitic social service workers; and it also provides no immense and supremely lucrative incomes for individual physicians and surgeons.

In the private medical practice of the average physician a respect of human values, the health and life of the patient, is compelled by commercial considerations if it be not by humanitarian. If the physician be not excessively busy and hurried as are some "merchants-in-medicine," he treats the patient as an individual and not as a case; each individual patient assumes for him a human as well as financial significance. The law, financial interest and other considerations impose on the physician a high sense of personal responsibility. The disablement or death of a patient under circumstances which raise the slightest suspicion, however unjustified that suspicion may be, spells damage to reputation, loss of income and legal liability.

So heavily does this responsibility and its sense weigh upon the rank and file physician that there have been cases in which physicians have been impelled to commit suicide by the accidental death of a patient arising out of treatment. It is in part the anxiety which arises out of this, as well as the moral responsibility for the patient, that accounts for the high incidence among physicians of the dread and deadly heart disease, angina pectoris.

The clinic and hospital, and often the private practices of medical "leaders," are organized for continuous working of the personnel under intense drive and pressure for "mass production." Not even the legal responsibility, that weighs down on the average physician in his practice, exists in these forms of practice.

Though the medical "leader" is theoretically as liable under the law as any other physician of the rank and file, his responsibility for the patient under the law is far less real. For under the interpretation of the law, a physician who treats his patient in accord with "accepted practice" is free of liability even though that "accepted practice" be a clearly demonstrable cause of disability and death. The "medical leader" is the arbiter of "accepted practice."

Legally, life loses value as soon as the patient passes into the portals of the hospital. Under many circumstances, virtual murder may be committed entirely within the law and with absolute impunity in the hospital and in other forms of institutional medical practice.

In the "closed" hospital all safeguards that serve to protect the health and life of the patient in private practice are wiped out. This is especially true in the case of the poor charity patients in the municipal and voluntary hospitals; their cases do not even present a commercial interest to the staff physicians.

The "closed" hospital with its "closed" staff, its bond of common interest and its stringent discipline, makes possible and enjoins secrecy in regard to mistreatment and malpractice. Falsification of hospital records to protect the hospital from even a suspicion of such abuses is not an unknown practice. The difficulty that interested parties have in gaining access even to the hospital records thus "doctored" is well known to any practicing attorney.

LAW AND THE HOSPITALS

To cap the climax, the law, in most states, absolves the hospital of any legal responsibility for malpractice perpetrated upon its patients. If it has exercised "reasonable care" in the selection of its personnel, which means if the doctors and nurses on its staff be graduates, no matter what injury may be done the patient as a result of defects of hospital management, the hospital is exempt from liability. "Charity" patients are also barred in many states from any claims against hospitals as a result of hospital and clinic negligence. It has become the custom, in those states, for voluntary hospitals and other institutions to parade as "charities" though they do little or no charity work, by meeting the scant requirements of the welfare or charity law, in order to avoid legal liability for negligence. There is an added inducement, in most communities, for this act in the provision of tax exemption, and sometimes public grants, for hospitals which register as charitable institutions. Even in cases in which there does exist legal liability for negligence of the hospital, awards are seldom granted the injured, so great is the aura of "charity" about the hospital.

The removal of legal check against negligence of hospitals is a menace to the health and life of the public. There is no justification for granting to any group in the community exemption from the laws safeguarding human life. Particularly should these safeguards be preserved in hospitals and clinics, where life so often hangs in the balance, and where even minor neglect of the patient can accomplish murder. A draught of air playing upon a patient rendered unconscious, by anesthesia or narcotic, may induce pneumonia and death. Error or over-dosage in medication may accomplish murder with little suspicion of foul-play. The possibilities of injury to health and loss of life by real or simulated negligence in the hospital are innumerable.

The law on negligence and malpractice and all other phases of the law leave absolutely no justification for the exemption of institutions from negligence liability. Liability for negligence by the hospital perpetrated through its nurses or its other agencies is placed squarely upon the shoulders of the physician in charge of the case even though he may be unpaid for his services and denied any voice in the appointment of the nursing or other personnel of the hospital.

Patients burned by excessively hot bottles of water applied by the hospital nurse have sued their doctors, who were in no wise directly responsible for the deed or the resultant injury. The physician, in such cases, found himself facing malpractice suit and damage to reputation and livelihood even though his own treatment of the patient was faultless and rendered absolutely free of charge.

The extent of the negligence and abuse suffered by patients in "closed" hospitals is unbelievable in some cases. A classical instance is that of the A.C.S. "approved" Kings County Hospital of Brooklyn. Brutal assaults upon helpless patients by orderlies and attendants brought to a head smoldering public resentment against the shameful and horrible conditions prevailing in the hospital.

DOCTORS VICTIMS OF "CLOSED" HOSPITALS

The public, in its resentment at the hospital rackets, has placed the blame for them on the medical profession as a whole. In this they have been entirely wrong. For the medical profession at large has been as much victimized by the dishonest "closed" hospital system as has the public.

The rank and file of the medical profession has suffered doubly. They suffer in the role of patients. For the hospital seldom extends to the doctors either grace or mercy in the matter of costs. They also suffer in the role of physicians. High hospital costs force the public to accept the "charity" of the hospital wards; and physicians generally receive no fees for the work done in the wards. The monopoly of the facilities of hospitals results in unfair competition by the merchants-in-medicine with the rank and file of the profession.