Several years ago I took a one week course in Internal Medicine at UCSF. It turned out to be a very intensive review of what’s new in all the subspecialties of medicine. The ten 50-minute lectures a day for five days – sequentially nonstop from 8 a.m. to 12:10 p.m. and 1:00 p.m. until 5:10 p.m. were palatable only because of an unusually large syllabus with the fifty lecture outlines and literature reprints. When recently a course brochure arrived entitled, “History for Health Care Professionals,” with a subtitle “Perspectives, Research Approaches, and Writing Skills,” I thought it would be rewarding experience to help understand the present health care dilemma. I was not disappointed.
A prospectus for a research project had to be written and sent in two weeks before the course for faculty review. There were three daily lectures at 9 a.m., 12, and 1:30 p.m. followed by workshops each morning and afternoon on historical research and writing. We were on the university computer by the second day with access to a million and a half volumes. The library was opened until 11 p.m. for the more industrious. The basic research was done during these four days and an abstract to be sent within six weeks.
My topic “History of Health Insurance,” had tens of thousands of references in the literature. I narrowed the field to come up with a few hundred significant original articles. After this primary source search, I researched the secondary sources. These are books by authors who have researched the literature. I found six excellent books on the subject. Since four were two or more years old, and I had to deal with certainty, I simply xeroxed these and got the other two at the university bookstore.
Dr. Guenter Risse, an Internist, Professor and Chairman of the Department of History of Health Sciences, began the conference with a presentation on “Medicine and Society: The American Hospital Past & Present.” Hospitals initially had a shelter function (if you didn’t have a home), a caring function (if you didn’t have a mother), and a teaching function. They were religious institutions with monks developing surgical skills. Dealing with pain was an important function. They had water beds, basically baths, in which patients were suspended for wound healing. Patient stays were measured in terms of weeks and months.
The hospitals were laid out similarly to a church in the shape of a cross with all four corridors facing a worship center. Then a quadrangle was developed. Moffet Hospital at UCSF, built in the 1950s was designed in the late 30s. It was one of the first high rise hospitals. Stanford, however, continued the medieval quadrangle concept with wings extending laterally. This resulted in a lot of internal rooms without daylight which they have now solved with computer controlled electronic “windows” which change during the course of the day to follow your circadian rhythm.
In the late nineteenth century with the advent of anesthesia, laboratories, and drugs, hospitals became more important. John Hopkins developed private rooms which accommodated the entry of the middle and upper class into hospitals which provided services that could no longer be done at home. The revenue structure changed. Hospitals became dependent on paying patients. One of the first cost analyses by Uncle Sam revealed that hospitals spent $4.81 a day. The patient became important to the extent of his pocket book. Hospitals then had to find out who would be able to pay them. They developed a Santa Claus who worked 365 days a year, known as the social worker, who could tell them who would pay. Hospitals told the doctors they shouldn’t have to worry about the finances of patients, since these gatekeepers would keep them informed. Early technology, manifested in laboratories, along with surgery, became more important because it was the most direct way to diagnosis, cure and discharge. It also increased costs.
As costs increased, this country developed private health insurance, mostly through fraternal societies, which no country had ever done prior to government medicine. This insurance was paid for in large part by employers. This was one way employers could give employee benefits because of wage and price controls during the war. Hence, health insurance in this country was a historical accident.
But of even greater historical interest is that prior to health insurance, this country already had a health maintenance organization as early as the late eighteenth century. In Sacramento we have felt that HMOs are a phenomenon of insurance out of control. The historical pendulum swings again.
UCSF and John Hopkins are the oldest History of Medicine Departments having begun in 1929. Courses in the department are now totally elective. Historians cannot make pronouncements on the future just because they analyze and evaluate the past. They cannot predict. History, however, can be useful in understanding the present and for self awareness. Historical knowledge will have a relevance to present realities. Risse observed that transplant patients at UCSF are being discharged to motels after four days returning to the hospital daily for treatment. As hospitals are unable to care for post-transplant in-patients, maybe it is time for hospitals to return to a shelter and caring function.
Dr. Risse feels that years from now people will speak 1994 as one of the more important years in the history of medicine. A secretary of state remarked that in academia the battles are so great because the issues are so small. In government the battles are routine even though the issues are huge. Questions that will be asked will include the following: Where was organized medicine in this historical debate? Where is their historical perspective and why weren’t they relevant to the moment? Why were they edited out of the presidential policy planning table?
Since we had an historical accident which got us health insurance prior to government medicine, would it not be a stroke of genius if we could capitalize on the process and reform health insurance so that we could preserve the highest standard of medical practice ever envisioned?