cases.

Its glitter attracted most of the profitable obstetrical work away from two nearby hospitals-with the result that the better of them, giving good medical care to difficult and needy cases, faces a grave financial crisis, and may have to close. In southern Michigan, two general hospitals are 2 miles apart, choked with a redundancy of equipment-and fighting a growing annual deficit.

An aura of the miraculous surrounds open-heart surgery; but every community does not require daily medical miracles, alluring as their description may make them seem. "Now we can thread catheters into the heart, and know things we've never known before," say Dr. Martin Cherkasky, director of New York's Montefiore Hospital. "We can get chemical information-like how much oxygen is in the blood-by taking samples from different heart areas. That tells us where the leak is. Then we need pictures, but to take them you have to inject radio-opaque substances into the heart. Since the heart pumps a fifth of a pint of blood through itself every second, any substance is going to be there only momentarily. So you need a complex device linking the heart, at the precise moment the substance is in it, to the machine that takes the picture. When the diagnosis is known, further complexities arise. To operate you need to stop the heart, but you cannot interrupt the flow of blood to the brain. So you have mechanical pumps-but very specially made and operated, because you can't bruise the red corpuscles. You need 10 people, who have worked for years as a team, operating first on animals, for such a cardiac procedure."

But Cherkasky is quick to add his belief, which jibes with the opinion of many another thoughtful doctor, that not every hospital can have all this. Even if smaller hospitals could afford to spend the money for the equipment, they could not find skilled teams to operate it. The death rate would be high, while the costly equipment would be used irregularly. People who need such operations should travel to the large general hospitals, where both skill and equipment are kept sharp by constant use.

THE UNMUSSED BED

After the war, great momentum went into a drive for the construction of new hospitals. But the drive was too successful: now we are living with, and paying for, more hospital space than we need. What we have is badly distributed. One out of four community-hospital beds in the United States was vacant on an average day last year. The cost of vacancy ran beyond loss of income, since hospitals must be geared both in numbers of employees and in space allocation to full occupancy. (One-third of the space in an average hospital goes for beds, two-thirds for the services the sick require.) Robert Sigmond, executive director of the Hospital Council of Western Pennsylvania, believes that hospital beds in the United States should be reduced until individual institutions run at around 85 to 90 percent of capacity, instead of the present 70 percent. Other experts have suggested that the 1,400 U.S. hospitals which have fewer than 100 beds be closed or converted into badly needed nursing homes. Remarks one consultant in the field: "When I go around to my community hospital with a donation, I stop in to chat with the administrator-and tell him he should close up shop." Studies and samplings of hospital practices-objectively examined only rarely 25 years ago, but subject to more frequent review and scrutiny today-often light up areas where utilization of hospital space can be improved. For example, Kings County Hospital in New York was recently forced because of overcrowding to discharge some mothers 2 days after delivery. A matched sample of cases stayed on for the standard 5 days. A study later revealed that those who were hospitalized for the shorter period of time fared just as well as those who stayed longer. Commenting on those findings in New York, one Pittsburgh expert said: "Once we are sure it is good medical practice, we could introduce the idea of a shorter stay into our hospitals. Then we wouldn't have to provide another maternity bed in Allegheny County for 30 years."

The cost in dollars of medical facilities that overlap and are badly utilized is hard to estimate. But unnecessary hospital construction can saddle a community with onerous obligations: for every $2 million it spends in building, a community must lay out an average of $700,000 to $1 million annually for support of the new facility. To the average U.S. citizen, medical care from 1958 to 1960 went up more than three times faster than any other kind of personal expense. Private expenditures for hospital services have tripled, from $1.9 billion in 1968 to $6 billion in 1960. In the New York area, hospital rates for a semiprivate room went from $11.30 a day in 1946 to $34 in 1960. The "hotel" costs of a hospital day-room, board, maid service-dropped from 55 percent of the total in 1946 to

29 percent last year, and now come to only $8.50—“and what hotel will give you a room and serve you meals in bed for that?" asks one lay administrator. But the cost of medical technology—an average of 23 tests per patient a day in teaching hospitals, the therapy, and so on-has gone up 400 percent for the same period.

Projections indicate that these costs will go on climbing. Technological progress, the goad that urges costs upward, will continue. The bedridden will continue to need lots of personal attention-and two-thirds of a large hospital's expenditures already go to meet its payroll. Wages for hospital employees, not protected by minimum-wage laws, are certain to go up over present salt-mine levels; and the number of people employed by a hospital is not likely to do anything but increase. The quality of the medical product is getting better and better; and this steady improvement, as it continues, will mean that medical care will in the future take a higher percentage of personal income.

The public would never have been able to meet the rising medical costs of the postwar period if health insurance had not become generally available. Seventy percent of U.S. families now subscribe to one form or another of medical or hospital insurance. Blue Cross alone covers 54 million people in a complicated setup with 79 different contracts. But insurance, useful as it is, fails to give many subscribers the protection they need. Some surgical bills are not fully covered, few plans cover long illnesses, and persons over 65 find it difficult to get the kind of coverage they need. Notes one insurance consultant: "Curing the physical man is no great thing if it leaves him crippled with debt and worry."

A BALLOON TO PRICK

In short, insurance is no answer to the problem of ballooning medical costs. To hold down such costs, U.S. communities need to develop an interrelated hospital system that can make efficient use of expensive medical equipment and other resources, at the same time providing a higher, more economical occupancy rate. Samples of this new system are surfacing in Pittsburgh and Columbus, Ohio.

In western Pennsylvania, two organizations-the Hospital Council of Western Pennsylvania and the Hospital Planning Association-have worked hand-inglove to coordinate hospital services and facilities in Allegheny County (population: 1,500,000). The first organization collects basic data from its 28 member hospitals: the second, making use of that data, gives counsel to hospitals contemplating additions, and to groups planning new hospitals in the county. The merits of the joint function were demonstrated recently when the planning association, headed by an oldtime professional in the field, Rufus Brown, reviewed some hospital council data and found that separate projects for hospital expansion totaled $90 million. By informing one hospital of the other's plans and giving advice based on understanding of the overall pattern, Rorem persuaded the hospitals to revise their total estimates downward: one hospital dropped its requirements from $11 million to $2 million. Given the fact that the area's largest corporations and wealthiest families (United States Steel, A. J. Heinz, Gulf Oil, etc.) are represented on Rorem's board, withholding of its blessing is usually enough to scotch an undesirable project. But even Rorem doesn't win them all: against his board's advice Passavant Hospital, at last report, was attempting to raise $3,700,000 for a 200-bed project in northern Pittsburgh suburb, adjacent to a number of hospitals that are already operating below capacity.

DISCOVERY IN COLUMBUS

Integration and coordination of hospitals and their services have gone further in Columbus, Ohio, where the Columbus Hospital Federation is headed by an extraordinarily able administrator, Delbert Pugh. His federation staff assembles the essential hospital data, and works with the hospitals to detail their respective needs; then a committee of some of Columbus' leading citizens passes on the project. Pugh's board includes a majority of business leaders, because Pugh finds that "if businessmen are in on the planning from the beginning, it's much better all around when the money has to be raised. It is much more effective than going to them with a plan and saying, "This is a fine idea and we want your endorsement." "

Pugh proved that theory when he interested a prominent Columbus businessman, the late Edgar Wolfe, in joining his board of directors. Wolfe went to work on a public bond issue to meet the needs of growing Columbus' nonprofit but nongovernment hospitals-first persuading the legislature to pass legisla

tion making such a procedure consistent with the State constitution. Under Wolfe's formula, hospital deeds were transferred to a county commission before any construction was begun; after the new facilities were built, the commission leased the facilities back to the hospitals' management for $1 a year. Both the device and Wolfe's money-raising campaign worked beautifully; the first part of a bond issue, totaling $15 million, was approved by 76 percent of Columbus' voters. The money was not earmarked for any one project, giving administrators the latitude they need for efficient use of the funds.

WHY BUILD YOUR OWN?

After successes like that, Pugh found it easy to persuade some large Columbus corporations, like the Jeffrey Manufacturing Co., to join with his association to expand community medical facilities. Now all the big businesses in the area, including General Motors, Timken Roller Bearing, and North American Aviation, join in Pugh's federation, and through it make substantial contribu tions to the community's hospital needs-secure in the knowledge that the needs are genuine. (Pugh took a persuasive line with a receptive management at North American Aviation when he pointed out that on an average day about 90 North American Aviation employees or members of their families are in Columbus hospitals.) Since it began in 1948, the Columbus Hospital Federation has allocated funds or planned facilities totaling $73 million; of that, only $600,000 has come from the Federal Government's Hill-Burton program of hospital construction. Remarks Pugh: "By the time Hill-Burton started, we were already on our way."

Columbus' 9 general hospitals, which in 1959 admitted 104,000 patients and spent $26,700,000 in operating expenses, now are neatly related to each other. Children's Hospital is expanding into the area center for obstetrical and pediatric care; other institutions have been discouraged from developing such services. The newest addition to the Columbus complex, the $13-million Riverside Methodist Hospital, has a psychiatric wing with an electro-encephalograph unit in full-time operation; another hospital was dissuaded from purchasing such a unit because it would have cost $4,500-and the machine and its "human investment" would have been used only 2 days a week.

IT WORKS FOR THE PUBLIC

Thanks in part to his "community-oriented" board of directors, Pugh has done and exemplary job of gearing hospital construction to Columbus' other public works. Near one of his hospitals today there is a large playground and recreation building where yesterday there were slums; Pugh managed to bring the slum-clearance program into relation with his own. The hospitals are so located in relation to the belt of superhighways now being built around Columbus that patients and doctors will be able to move from one hospial to another some miles way without the delay of a single traffic light-and such ready access, in turn, made it more practical for the hospitals to have complementary facilities. When Pugh had to bow to public sentiment to enlarge a big downtown hospital that he thought Columbus didn't really need, he recouped nicely by encouraging it to prepare especially for emergency cases, most likely to occur in a densely populated area. Another hospital in the system is expert in the care of chronic diseases—and it is located hard by Columbus' senior citizens' housing center.

COMMUNITY HEALTH CENTER

This kind of relationship between hospital and community is speeding the emergence of the medical institution as "a center for community health." As a herald of the change, many hospitals since the war have expanded their emergency facilities into what has become in effect a general clinic for the walking sick-a dispensary for outpatient care. Only the minority of patients now seen in the emergency wards of big hospitals are genuine medical emer gencies; many go there for treatment of complaints ranging from colds and

headaches to arthritis and anemia.

Where once only the indigent received outpatient care in a hospital, now some medical centers offer such treatment to all members of the community. The Hunterdon Medical Center, serving Hunterdon County in New Jersey, is truly a creature of the community, built to its specifications after a study of community needs and desires. Its internal organization is patterned after the incidence of diseases most common to the rural area it serves. The center offers a wide range of care, from specialized attention for rheumatic heart

disease to a public-health dental clinic. Before the medical center was established, the rural county's 53,000 people had not one specialist in their midst. Now the center's 13 services (urology, psychiatry, gynecology, etc.) have a staff of 22 specialists. The doctors in the area refer patients to Hunterdon's diagnostic wing, located close to radiology rooms and laboratories. Since the diagnostic wing will take any patient, utilization of services is high (22,000 visits last year) and rates are reasonable.

At Montefiore Hospital in New York, the concept of the hospital as a community health center has been carried a long and difficult step further with the attempt to establish a home-care program for chronic diseases in the Bronx. Now that diseases are being transmogrified from the infectious (with a dramatic onslaught running swiftly to a denouement: cured or dead) to the chronic (with an insidious onset whose denouement may be postponed for years), Montefiore treats patients with a continuity of care. "The hospital is no longer a place where you simply do something to a patient, and then eject him back into the world," says a Montefiore doctor. Care continues after hospitalization in the form of diagnostic reviews, repeated laboratory examination, and supervised home therapy. Montefiore's home-care program brings the hospital into the homes of some 100 chronically ill patients by equipping their rooms with medical devices and having them regularly visited by a team of doctors, nurses, physical therapists, and social workers. Cases are discussed by Montefiore teams at group meetings ("What is the attitude of the son-in-law to the situation? Can the patient's daughter put her own little girl in a nursery school?") in the kind of detail that the family doctor was supposed to know about, but probably didn't. The program frees hospital beds for more pressing needs-and costs less than $5 a day per patient.

THE MERCY OF QUALITY

Just as the intelligent organization of relationships between hospitals and communities is an antidote to the poison of high costs, so another kind of organization-in the internal structure of the hospital-can offer the patient another great mercy: the mercy of quality. Once doctors practiced medicine in hospitals as though the hospital were a hotel that the patient was visiting, largely for purposes of convenience. The hotel was managed by a nurse, who saw that the bed sheets were changed regularly. If a patient went swiftly from bed sheet to winding sheet, that was no concern of the hospital's management. But the intricate mechanism of a hospital today (1,000 beds, 475 doctors, 3,100 employees, 2,200 ambulatory patients a day at Ford Hospital in Detroit, supported by a labyrinth of laboratories and a maze of diagnostic and therapeutic I facilities) makes a broader responsibility for hospital management inevitable. A doctor could no more practice medicine as a private entrepreneur in a great medical institution like Ford Hospital than a bank teller could conduct his own personal business through the windows of the Morgan Guaranty Trust Co. In fine hospitals, the doctors work as an integral part of the hospital itself, merging hospital services with their collective learning, rubbing minds with each other, discussing patients and getting what Dr. Alan Gregg called "the stimulus of competent critics." Hospital care and medical care in a hospital have become one product.

One consequence of this blending is an expansion of the role of the hospital trustee. The days are past when, as one medical economist said, "the doctors ran the hospital, and the trustees ran the errands." Massachusetts General and other hospitals have a hard-working board of directors who share in the important decisions about the quality of hospital care and the hospital's future role in the community. Ultimately, the character and standards of a hospital will depend upon the policies of the trustees.

One way hospital management can uphold standards is to have a chief patheologist on a salary. His findings, reported to the all-important tissue committee, which inspects tissue removed after every surgical procedure, will sometimes disclose that unnecessary operations are being performed. If a gynecological surgeon, for instance, performed 30 hysterectomies in a month and the pathologist's reports showed that in 12 of the cases the tissue removed was normal, there would be good reason to warn the gynecologist that his diagnostic technique was faulty or biased. If the surgeon wanted to dispute this conclusion, data from other hospitals for similar surgical procedures could be adduced. The gynecologist could support his procedures in a closed court of his peers. When a pathologist depends on a surgeon for his livelihood, the pathological reports are less likely to be of a nature that stimulates hospital comment. Thus does the organization of the hospital hold the key to quality.

A CENTRIPETAL FORCE

The financial arrangements under which doctors work are variegated, and currently they have become the subject of a lively controversy. Many doctors believe that the profession will remain most responsive to the patient's needs if the doctor earns his fees directly from the patient-the traditional source of the doctor's income and contributes his services free to needy cases. The American Medical Association, while not of one mind on the matter, generally favors this fee-for-service system of payment of doctors, with the individual doctor varying his fees according to the patient's ability to pay.

But other professional opinion holds that the emergence of medical insurance and the complexity of modern economic life now makes it impossible for the busy doctor fairly to judge what the average patient can afford. This opinion favors placing the financial aspects of medicine in the hands of the institution: at Ford Hospital in Detroit, for example, the doctors work full time for a salary (said to run as high as $65,000 a year) and the hospital does all the billing and collecting in the doctor's name. At Montefiore Hospital the chiefs of the clinical departments are full-time salaried members of the hospital staff, while other doctors may be part time on salary, and also conduct a part-time private practice. Doctors, especially new ones, are becoming more inclined to accept salaries as they spend more time working within institutional walls; once on salary, they find that they are relieved of administrative details, better able to apportion their time among their patients without so much reference to the patient's individual ability to pay, and free to take regular vacations, keep more normal hours, and participate in retirement plans. As the centripetal force of the institution tugs doctors into salaried jobs, the doctor's loyalty is redirected to the hospital: "A private physician's first loyalty is to his profession-to the other solo practi tioners," remarks Dr. Henry Pratt, director of New York Hospital. "But a salaried doctor's first loyalty is to the quality of his institution."

There seems little question that it is the institution, able to organize to keep costs and prices down, able to impose standards to keep quality up, which holds the key to the future of modern medicine. On great medical islands, with their many bridges into community life, the new structure of medical care is being built. The thousand natural ills that flesh is heir to, as they change their appear ance and their character, must be combated by organized institutions-no bezoar stones. The slow evolution of the medical institution is what Herman Somers calls "the central plot of all social history-man's struggle to rearrange his social organization and institutions to keep pace with his accumulating knowledge, changing needs, and altered environment."

MASSACHUSETTS GENERAL HOSPITAL

To a greater degree than ever before, better medical care in the United States depends on hospitals, and among American hospitals Massachusetts General Hospital, in west Boston, is the acknowledged leader. In its concrete manifestation, Massachusetts General is a rag-bag collection of buildings that climb and ramble through 3 acres along the Charles River. The beauty of the hospital's original porticoed structure, built by Charles Bulfinch in 1821, has long since been hemmed in and obscured by a dozen ugly buildings that have sprung up around it, leapfrogging over one another to keep pace with a century and a half of growing fame. In a ceaseless striving to meet changing and expanding medical needs, floors have been tacked onto this old building, and wings have been fitted onto that new one. The effect is one of total architectural dishevelment. The tumultuous confusion within the hospital's walls matches their disordered exterior. Patients in slippers and bathrobes slap through crowded corridors; stretcher cases are wheeled into elevators already clogged with visitors and interns; doctors hold clinical conferences in halls or in the hospital's overhurried, overheated cafeteria. Entrances and hallways have an atmosphere about as quiet and as sacrosanct as the lobby of an overloaded second-class hotel.

Yet rarely has so mundane a web caught so divine an afflatus. Here the myriad elements of medicine are fused; here, by a process almost poetic, the precious amalgam of good care is scooped up and bestowed upon the sick. Doctors learn, and practice, and teach in a way that perpetually winnows out and mingles the experience of the past with the knowledge of the present. Here the headlong rush of a thousand technologies is arrested, and their ab