years. Dr. Oliver Cope, the hospital's chief endocrine surgeon, is the kind of doctor who make Massachusetts General great: a specialist who knows the limits of his specialty, a humanitarian who spends hours with patients discussing problems remote from endocrinology-but perhaps closer to the patient's true problem. Says Cope crisply: "Thyroid disease and endocrine disease are not the entity. The individual is the entity. Studying only the disease is like trying to understand how a grape got that way without studying the bunch, the vineyard, the soil, the climate. We have to understand disease as a cropping out as a result of circumstance *** susceptibility is a complicated concept. But surgery is riddled through with susceptibility, even in straightforward appendectomies. It's just harder to see than in the common cold. The egg-laying pattern of hens, for example, is related to the increment and decrement of light. They lay most in January and February. Thyroid disease and chronic mastitis follow that same pattern; my office is packed in those months. It is essential to recognize that emotional, cultural, and sociological factors are immense in glandular disease. The importance lies in the fact that unless you recognize the fundamental cause you can only prevent or cure the specific disease but the disorder will break out again in another form. Only this year did I come to realize and to teach that." Since men like Cope and his fellow physicians not only practice at Massachusetts General but are also professors at Harvard Medical School, they impart a fine academic character to their institution, which outside doctors sometimes call "Mecca." So intimate is the relationship between Massachusetts General and Harvard that doctors become teachers simply by going downstairs to conduct students on ward rounds, or going upstairs to the Bulfinch Building's ether dome-where ether had its first successful public demonstration "to a dumbfounded audience" in 1846-to give a medical lecture. At Bulfinch are held clinical-pathological conferences, in which a doctor is given a complicated case history, and students and professor alike give their diagnosis after examining all the facts that were available to the doctor treating the case at the time. When all the diagnoses are in, the conference pathologist-the only man in the room who has known the answer from the beginning-gives the correct solution; even the professor may turn out to have erred. "In Europe," says one doctor in admiration of this free academic spirit, "no professor could ever admit he was wrong." At one recent conference in the ether dome, where cardiac cases are discussed by doctors in the presence of students, a group of visiting Russian professors heard the elucidation of the complex surgical processes necessary to implant a transistorized battery in a man's chest to keep his heart beating rhythmicallyand then they saw the man wheeled in. Dr. Paul Dudley White introduced Dr. Edward Churchill, chief of the hospital's surgical services, to the Russians as “a pioneer in chest surgery." Unawed by the Russians' serious mien, Churchill began his talk by describing the pioneer as "someone who is lost." TOWN AND GOWN Doctors are paid in a wide variety of ways at Massachusetts General, but the important point, one doctor says, is that "if you are a member of this hospital, you have no trouble making a living." Staff members who practice at Massachusetts General and teach at Harvard Medical School are paid part of their salaries by one institution and part by the other. Those doctors adhere to a "gentlemen's agreement" not to earn more from private patients than the sum of their salaries, so that they will not become distracted from their teaching duties. A Massachusetts General doctor who cares for patients in the hospital's Baker Memorial wing (limited to patients who can pay, but whose income is under $12,000 a year) charges in accordance with a fee schedule set up by the hospital, based on the type of treatment and the patient's income. The hospital sends the patient one bill for both doctor and hospital charges; it collects, and pays the doctor from the proceeds each month. When he works at Phillips House, whose patients have incomes over $12,000 a year, the doctor may send his own bill uncontrolled by any fee schedule-but a copy of the bill goes to the hospital administration to check any abuses. Some 20 general surgeons at the hospital formed in January a group practice that will pool and then divide surgical fees in accordance with a plan whose details are still being worked out. Says Dr. Churchill: "The method of remuneration is a detail." All the doctors at Massachusetts General contribute something to the institution at large, as well as to the medical school with which they are so closely affiliated. About half the staff doctors at the hospital make their living entirely from private practice, but they all must give some time to care for ward patients. Many also do some research or free teaching for the 200 Harvard students who study at Massachusetts General. The hospital itself pays the entire cost for its interns and residents, even though some of them do part-time teaching for which, strictly speaking, the hospital should be reimbursed. But typically, neither Massachusetts General nor Harvard has any interest in a fastidious breakdown of teaching and practicing costs-between what Dr. Alfred Kranes, assistant chief of the medical services, calls "the town and the gown." Although he is a careful man, watching over the hospital's dollars, Clark believes that "it is not too useful to make these cost distinctions. We don't want to divide a man up and say he is so much researcher, so much teacher, so much clinician. The only useful thing is to keep the patients from paying for anything that is not patient care-and this we do." Indeed, since Massachusetts General has always adhered to its philosophy of the hospital as a receptacle for patients ("We really do take anyone, unlike some hospitals that just say they do," says Clark), most of its patients usually get a bit more care than they pay for. Income never quite matches expenditure at Massachusetts General. Last year, when the hospital spent $17,100,000 for patient care, its total income from patient payments, insurance for patient care, and public assistance for needy cases came to $15,300,000. Endowment, the United Fund of Boston, and assorted gifts contributed $1,300,000; the hospital's reserves had to be drawn upon for the $500,000 balance. Costs averaged out to about $40 per patient per day-higher than most nonteaching hospitals because Massachusetts General gets more difficult cases. While prices went as high as $45 a day for plush private rooms in Phillips House, the hospital average was $32 a day. Prices went from $28 down to zero for ward patients. NO PRAISE FOR WIZARDRY This gap between income and expenditure is always likely to be there, since the hospital always meets medical emergencies first, and worries about financial problems later. Cases in point range from the costly attention of specialists recently given to a stroke case in an emergency ward, to a polio epidemic a few years ago, when all hospitals in Boston were asked how many patients they could handle. After every other hospital named its quota Massachusetts General announced it would take everyone left over-500 patients. No one knows— or cares-exactly what that siege cost the hospital. Explains Dr. Ellsworth Neumann, the hospital's administrator: "We know no one is ever going to praise our administration for financial wizardry. The best we can do is organize the financial situation so that it does not hinder professional standards. If you want innovation and improving standards, you can't have a peaceful institution. This place is not peaceful. It's costly-emotionally, and monetarily." The problem of money, however, takes on a curious twist when Massachusetts General and Harvard jointly come to a vital point in the discharge of their teaching functions. Unlike research, where means must be constantly sought to keep the focus on the patient, in teaching the growing need is to find the patient to focus on. Traditionally the patients used for teaching, both in wards and outpatient (i.e., for the nonhospitalized sick) clinics were what medicine called the sick poor-people who could pay little or nothing for the care they needed. This tradition continues today, so that only patients who cannot pay professional fees are used for teaching-in spite of latter-day opinions by many good doctors that a patient gets the best care when he is a teaching subject, and "eager young men take a continual, inquiring interest in him." But now, medical insurance, despite its inadequacies, has made it possible for a much higher proportion of the sick to pay something-thus diminishing the numbers of the sick poor, and confronting the medical profession with a dwindling of its essential material for training young doctors. Says Dr. John Stoeckle, chief of the medical clinic: "For reasons that are as much internal as external, we need a new clinic." TO SERVE ALL SEGMENTS To meet that need, Massachusetts General is now considering establishment in one building of an outpatient department that would be available to all sick people, not just to the medically indigent. If such a clinic is established, the present hospital system of referring paying patients from the outpatient department to a hospital doctor for treament would be changed; any patient could walk in, be treated on the spot by the outpatient clinic. A clash of views over the advisability of such a move, and not the $9 million it would require ("We don't have the dollars yet, but a campaign will raise them," says Clark), is delaying a decision. There is, as Clark notes, "a growing sentiment that we should have a clinic to serve all segments of the population"; but there is also an opposition, led by the Massachusetts Medical Society and supported by some of the hospital's doctors, that is fearful of the competition the new clinic would offer to private practitioners. Himself a member of the local society, Dr. Clark says, "We are trying to persuade the association that a teaching hospital is not just competition-it is an additional resource for all the doctors in the area." Giving another reason for broadening the base of the new clinic, Dr. Stoeckle contends that it would "expose students to all kinds of patients while their basic attitudes are still being shaped," and would further Massachusetts General's role as a community health center. The fact is that while the new clinic would widen the area of contact, Massachusetts General is already in touch with much of its community through its present outpatient department. A total of 225,000 visits were made to that department last year, by patients only 30 percent of whom had any earned income and half of whom were foreign born. Almost half of the foreign born came from Italy. Doctors had to meet the expectations of that cultural group: the Italian patient did not want to hear talk of complicated problems and inconclusive symptoms; he wanted a quick diagnosis and a prescription, and did better if he got them. Another social manifestation was met by Massachusetts General when, after noting that more than half the clinic's patients were over 50 years old, it developed outpatient techniques to meet the emergencies of old age, such as heart failures and strokes. "The change, involving extraordinary expense to keep people alive but not always functioning, has introduced some major social questions into patient care," says Dr. Kranes. In another community relationship, Massachusetts General, following a plane crash at Logan Airport, plans to install a small outpatient clinic there, and has worked out with Boston a plan whereby highways can be quickly closed, supplies rushed to the field, and patients brought back to the hospital by ambulance in case of another disaster. Such community consciousness has won the hospital local respect matching its national prestige. The CHAIRMAN. The committee will adjourn until 10 a.m. in the morning. (Whereupon, at 6:50 p.m., the committee adjourned, to reconvene at 10 a.m., Friday, August 4, 1961.) О COMMITTEE ON WAYS AND MEANS EIGHTY-SEVENTH CONGRESS FIRST SESSION ON H.R. 4222 A BILL TO PROVIDE FOR PAYMENT FOR HOSPITAL SERVICES, AND ON SIMILAR PROPOSALS Volume 4 JULY 24, 26, 27, 28, AND 31, AND AUGUST 1, 2, 3, AND 4, 1961 Printed for the use of the Committee on Ways and Means UNIVERSITY OF MICHICAN. IRRADICa Wisconsin, State Medical Society of, Dr. Robin N. Allin, chairman, com- Page 1171 751 Young Women's Christian Association of the U.S.A.: Persinger, Mrs. Richard B., chairman, national public affairs com- 1202 Wickenden, Elizabeth, technical consultant, national board and 1202 OTHER MATERIAL SUPPLIED FOR THE RECORD Abrams, Robert E., American College of Apothecaries, article_from_the St. Louis Post-Dispatch, July 9, 1961, entitled "Health Care Program". 1161 Alabama League of Aging Citizens, Inc., Rubin M. Hanan, president, Adams, Albert C., chairman, Committee on Social Security, National Association of Life Underwriters, letter dated August 4, 1961, to Congressman Mills... 1826 2036 2065 1976 Alabama State Nurses' Association, Lillian Smith, R.N., letter dated July 14, 1961, to Congressman Mills.. 717 Alger, Hon. Bruce, a Representative in Congress from the State of Texas: Article entitled "Indigent Medical Care Needs of Texas Public 241 1533 Allegheny County (Pa.) Medical Society, Dr. William A. Barrett, president, statement... 2196 Allman, Dr. J. F., Jr., secretary, Piatt County (Ill.) Medical Society, letter dated July 25, 1961. 2176 Alper, Dr. Irwin, Oneida, Herkimer, and Madison Counties (N.Y.) Medical 2191 Amalgamated Meatcutters & Butcher Workmen of North America: Gorman, Patrick E., secretary-treasurer, letter dated August 17, 1961 to Congressman Mills. 1978 Lloyd, Thomas J., president, letter dated August 17, 1961, to Congressman Mills... 1978 American Association for Social Psychiatry, Dr. Edward C. Mazique, president, statement.__. 2224 American Association of Doctors' Nurses, Madeline K. Vitale, statement. 2265 2228 2245 American Bar Association, Earl F. Morris, chairman, standing committee on unemployment and social security, letter dated June 30, 1961, to Congressman Mills.. 2243 American College of Apothecaries, Robert E. Abrams, article from the St. 1161 2222 Garland, Dr. L. Henry, president, letter dated July 27, 1961, to Wachowski, Dr. T. J., chairman, board of chancellors: Letter dated August 7, 1961, to Congressman Mills. Reuther, Walter P., president, United Auto Workers and Industrial 346 347 348 412 |