Category Archives: The Modern Hospital

Three classes of patients in Canada

Two years ago, a Commission of Inquiry in Alberta was called to explore improper preferential treatment in the healthcare system. It was a result of a public outcry after members of the Calgary Flames hockey team and their families were vaccinated for the H1N1 virus ahead of the general public during a declared pandemic. Other allegations of preferential treatment were made as well. The commission was formed with the mandate to consider, “whether improper preferential access to publicly funded health services [was] occurring; and if there [was] evidence of improper preferential access to publicly funded health services occurring, [it was to] make recommendations to prevent improper access in the future.”  Volume 1: Inquiry Report of the Health Services Preferential Access Inquiry was published in August 2013.

Alberta Health Minister Fred Horne in an interview with CBC regarding the inquiry’s findings.

The vaccination of the Calgary Flames team was investigated by the College of Physicians and Surgeons and Albert Health Services before the inquiry. The college found that the doctor in charge of the clinic that vaccinated the hockey players and their families, decision was “an error in judgement, not professional misconduct. As a result, the Investigation Chairman has directed that this complaint be closed. The public reaction to this incident, as well as the complaint, has served as very useful feedback to [the doctor involved] regarding the ethics of seeking preferred services for an elite group of individuals in a publicly funded health care system.”  On the other hand, Alberta Health Services fired the administrators involved in setting up this special clinic. The Commission of Inquiry found that this was indeed improper preferential access and a clear rule should be put in place to avoid such incidents because they undermine the public’s confidence in a publicly funded system.
The inquiry looked at several other cases where there might be a question of preferential access.  It found that where a physician deemed a case to be especially urgent and the patient was allowed to jump the queue once that diagnosis was made, then this could not be considered a case of improper preferential access. Even if the patient had special access to the doctor because of personal or professional relationships, once the urgency of the case was established, then there could be adequate medical justification for jumping the queue. The inquiry recognized that there was no way to stop the practice of “courtesy calls” where doctors see patients outside regular hours as a courtesy to their colleagues. As a result it looks like there is really no way of eliminating some level of preferential treatment of first class patients. But the inquiry concluded these patients should not be allowed to jump the queue without clear medical need.  It also found that this small group did not significantly affect the care of the rest of us.

The question of third class patients was not investigated by the inquiry. The commissioner declared that the inquiry was limited to looking at whether there were people who were “getting access that is superior to the norm.” It did not look at cases where people were getting access that is markedly inferior to the norm. However it did note that the groups listed below were receiving inferior access:

  • Rural populations;
  • Individuals without family doctors, particularly individuals with complex medical issues;
  • Individuals with addictions and/or mental health issues;
  • The poor;
  • The elderly;
  • Individuals whose first language is not English;
  • Those with hearing or vision loss or mobility issues; and
  • First Nations communities

These are the third class patients. So it looks like even today in Alberta, and probably across Canada, we have the same three classes of patients in our publicly funded system.  What do you think we should do about it? Are there others who should be added to the list of third class patients?

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Three classes of patients

This year’s blogs will explore the history of medicine from the patient perspective.  In The Modern Hospital there were three distinct and well defined classes of patients.

Third class patients were placed in the large free wards. In these wards patients did not pay, and were considered to be charity cases. They were seen on teaching rounds and their medical care was part of the obligation of physicians to teach and care for all who could not afford it. Ignaz Semmelweis, who I referenced in a previous blog, was mainly concerned with this class of patients.

Second class patients were placed in small private wards. The costs associated with their hospital stays were typically paid for by their employers directly or through insurance.

First class patients were placed in larger private rooms. The Modern Hospital notes that a modular small ward could also function as a large private room (see the image in my blog about the modern ward). These spaces were reserved for wealthy people who would often get private nursing care to supplement what was provided by the hospital. Additionally, first class patients typically received private visits from prominent doctors who could charge what the market would bear.

At the height of his power, William Osler would typically charge about $300 in today’s money for such a visit. According to his biography (William Osler: A Life in Medicine; Michael Bliss, University of Toronto Press. 1999.) his hourly rate was roughly $600. Osler recorded his work and believed that between 15 – 20% of his time was without remuneration, which would indicate that Osler saw first class and third class patients.

Despite the stated view on visiting that I noted in my last blog on the patient in the modern hospital, there were three different sets of rules for the three classes of patients in the children’s department, for example:

Visiting time in the Children’s Department shall be as follows

  • Large (free) wards: 2:00 – 4:00 pm Wednesday and Sunday
  • Small (private) wards: 1:00 – 8:00 pm daily
  • Private rooms: without limitations aside from the order of attending physicians (page 340, The Modern Hospital)

A question worth pursuing is how much do these distinctions continue today? And if so, how do they manifest themselves?  I will explore this further in my next blog.

The patient in the modern hospital

This blog series has been leading up to the role of patients in the modern hospital. And the role is pretty clear. When reading books of the time, we see that patients hardly play a role in healthcare, except to bring his or her body along for treatment.

The medical superintendent, the matron, and all the other doctors and nurses made the decisions. The times were rather hierarchical and the doctor would decide most things and rarely consult patients. When patients entered the modern scientific hospital, they basically gave themselves over to its care.

Under the section ‘Hospital Visitors’ in The Modern Hospital, the author declares his position very clearly:

We may begin with the flat argument that it would be best for all sick people if all visiting could be prohibited and it is a recognizable situation in nearly every hospital that has visiting days that the temperatures are higher at night on the visiting days than at other times, all else being equal, and this is due to the excitement caused by visitors, not alone one’s own visitors but those who come to see other people…

In considering the visiting question, therefore, we have two or three fundamental ideas in the foreground; one of them is that we ought to restrict visiting as much as possible and we ought in any event to limit visits to the one patient whom visitors come to see. And visits should be as short as possible and whenever it can be done each patient should be restricted to one or two or at least a minimum number of visitors.

This is based on a seemingly scientific fact that the excitement of visitors causes the patient’s temperature to rise, hence it is for the patient’s own good that visitors are restricted. However, on reading further, one begins to think that the inclusion of visitors disrupts the orderliness of the hospital. It is best to allow as few as possible outsiders into its inner sanctum. Care for the patients is best done by those who are trained to provide it professionally, scientifically. The human body is the object of medical intervention and is best treated in isolation from all other influences that might disturb it further.

Photo from 'Yes Minister'These views are no longer current, but they do form a kind of baseline for change, as slow as it may be. In 1981 an episode of the British comedy Yes Minister comments on the issue by bringing the Minister of Health to present an award of excellence to St. Edwards – a hospital that is entirely without patients: “no patients” might improve quality even more than “no visitors”. The staff will be able to perform their duties without the distraction of real sick people. Perhaps this hospital with all its busy doctors and nurses cares for human bodies without feelings of illness, worries about their present condition or future state, and certainly without visitors who might disrupt the orderliness of the institution.

One of the questions for our time is how much of that old culture remains? And where does it pop up? Do you ever feel that you are intruding on the order of the hospital? That medical staff would be able to do their jobs more easily without your input? Or that their job is to fix your body or that of your family member and it would be better if you would simply let them get on with it? If so, you have found a remnant of The Modern Hospital of 1914. From the stories that come to us, some of it is still there, and we are hard at work to make it disappear.

Nurses in the modern hospital

The modern nurse emerged from the church and the military. Religious sisters served in almshouses, caring for the poor and sick as part of their religious service. Military nurses came from two classes, patriotic women who wanted to serve their country, and servants and camp followers who knew how to provide hands on care. Florence Nightingale was very clear about the two classes of nurses. The patriotic women were the managers and Florence required them to have little direct contact with patients; their job was to direct the work of the floor nurses. The direct care nurses came from the large service class who understood how to be of service in any way necessary.
Florence Nightingale
In the modern hospital, the head nurse or matron had similar authority over nurses as the medical superintendent had over the entire hospital. She was in charge of training and supervising a nursing staff that was made up largely of trainees who usually lived in the nursing school and served for long hours in the hospital. The nurses were being trained in the ways of the modern hospital and their schools were modelled after the medical schools in many ways. As trainees, student nurses were given many of the more menial tasks in the teaching environment that had been the responsibility of apprentice doctors before medical schools became professionalized. The political friction that characterizes the relationship between doctors and nurses was present as far back as 1914.

In The Modern Hospital, we read:

There seems to be something radically wrong with the trained nurse of today – the medical profession says there is something wrong; the thinking women at the head of training-schools say there is something wrong; and the lay public finds something radically wrong. Not all these elements agree as to just what the trouble is, in fact, they all seem to differ. The doctors say the nurses who are being graduated from the training-schools are not efficient, and a great many thinking members of the medical profession say that the nurses are being trained to too fine a point, but not in the right direction . The heads of training-schools think the nurses are not being sufficiently trained. The public does not seem to care to analyze the situation, but merely finds fault with the nurse as an individual (pg. 34).

The author goes on to present the medical side of the argument –  doctors, now scientifically trained, have begun to assume the clinical authority that nurses used to have, and nurses have been left behind and resent their supportive role. One can see that the hospital has already become the battleground between doctors and nurses over the division of clinical labour. Today, nurses continue to struggle to work to “their full scope of practice.” Since early on nurse have been trained to assume far more clinical responsibility than they are actually given. For many years they were considered to be the aides and supporting staff for doctors: their role was to carry out orders of the doctors with no independent practice. From the beginning of nursing some nurses went on to become doctors in order to expand their role and authority. Some have accepted that their role is a ‘pink collar’ occupation, and see themselves as the health care equivalent of police and firemen. And yet others have taken on the political burden of making nursing a health profession fully on a par with medicine and with its own knowledge and philosophy of practice.

An excellent history of the development of nursing and its politics is presented in An introduction to the Social History of Nursing by Robert Dingwall, Anne Marie Rafferty, and Charles Webster. There are many good biographies of Florence Nightingale.

The role of medical superintendent

The modern hospital was very hierarchical, like many institutions of the day. The medical superintendent had absolute authority over every aspect of the hospital; the matron was his subordinate helpmate, and the administrator, if there was one, worked as his aide.

There were no strong internal boundaries between the various people who worked in the hospital; the boundaries were to the outside. Upon entering the hospital, every patient came under the authority of the medical superintendent, much as pupils were under the authority of the principal of the school of that time. The values of the organization were clear to everyone and not questioned – they derived from the central overarching authority of the medical superintendent.

Some of his authority came from the knowledge and wisdom attributed to him, and his knowledge was based on extended and intelligent clinical experience. Medical education came from a lengthy clinical apprenticeship. The medical superintendent embodied the sum of this kind of knowledge through experience. He kept up with the major advances of medical science and his authority reached all the operations of the hospital. He was not merely the final arbiter of decisions, he made them all. There was no long-term planning, nor any need for it: he just did whatever he felt was necessary. If there were any plans, they were in his head.

Because the hospital was usually built and funded by the community, it was a major social institution. Many communities identified themselves through the creation of their hospital. Its independence from external authority and its special place in the community allowed it to remain relatively stable for a long time. The importance of the hospital gave the medical superintendent status and prominence in the community which enlarged his authority even more. The board which appointed him would for the most part bend to his will.

The early modern hospital was in many ways related to the much earlier self contained church communities in which a chief cleric had absolute authority over all aspects of its activity. And many of these institutions functioned as villages or small towns. Early hospitals had not only wards, patients and operating rooms; they were full service organization with their own stables, farms, kitchens and laundries. When I worked at the Royal Victoria Hospital in Montreal in the 1980s, it retained some of these features. There were roofers who were constantly replacing fallen tiles from the huge slate roofs, an upholstery shop that made sure that the furniture in the head nurse’s public rooms were in tip top shape, and a full service laundry.

There was widespread agreement on the authority of the role of doctors and hospitals, and this occurred without a formal healthcare system. Everyone seemed to agree on the values associated with healthcare and healthcare professionals.

William Osler, Canadian born physicianA Canadian born doctor, William Osler, personified this kind of doctor. You might want to read about him and his struggles to understand the role of doctors in the modern healthcare system. Writer Michael Bliss recently published a biography of him, William Osler: A Life in Medicine.

More to follow on William Osler and his impact on modern healthcare.

The patron saint of hand washing

Ignaz Semmelweis was a young Hungarian obstetrician who began teaching in the Vienna Maternity Hospital in 1846. The hospital had been founded in the late 18th century, and it contained two free Maternity Clinics. Women received free medical and nursing care in the clinics in exchange for taking part in the training program for obstetricians and midwives. When Semmelweis arrived he found that the death rate for mothers was very high due to a disease called “childbed fever.” No one knew why the incidence of this disease was so high, but there were many speculations. Most believed that is was an epidemic disease caused by everything from the weather to problems with the birthing process. Semmelweis was concerned by the high death rate, and along with everyone else, had no idea about the cause. He did find one notable fact – the death rate in one of the two clinics was higher than in the other. He learned that after 1840, the First Clinic was accessible only to male medical students and the Second Clinic was visited only by young women studying to become midwives.  Table 1, taken from Semmelweis’ article, The Etiology, Concept and Prophylaxis of Childbed Fever, shows this difference over a period of five years.

Semmelweis data on death rates

His first conclusion was that the cause of the disease was not the result of an epidemic because epidemics would not occur in only one of the wards over such a prolonged period of time. He then tried changing various procedures in the First Clinic to make it more like the Second Clinic, and nothing worked. On March 2, 1847, he travelled to Venice with some friends, as he described, “I hoped that Venetian art treasures would revive my mind and spirits which had been so seriously affected by my experiences in the maternity hospital.”

When he returned to Vienna he learned that Jakob Kolletschka, the professor of Forensic Medicine, had become ill and died after pricking his finger with a knife while performing an autopsy. The results of the autopsy convinced Semmelweis that Kolletschka had died of the same disease as the women in the maternity ward. He remembered that infants who died along with their mothers had similar symptoms thus leading him to believe that they also died of the same disease. He concluded that “cadaverous particles” contaminated Kolletschka’s wound and that cadaverous particles on the hands of medical students were the cause of childbed fever.

He instituted the requirement that medical students wash their hands in a chlorine solution before visiting maternity patients and the result was a precipitous drop in mortality in the First Clinic. Once he instituted it in the Second Clinic, the mortality dropped there as well. He published a paper with his results and gained some followers across Europe.

But the medical establishment, led by people like Rudolph Virchow, did not support his views which were considered to be unscientific. They were taken to derive from Galen’s discredited humoral theory of medicine. At a medical conference in Speyer in 1861, Virchow – who was by then extraordinarily influential – attacked Semmelweis’ views. He said that local infection of the type Semmelweis described was only one type of childbed fever, and that it did not exclude the existence of the epidemic that most scientists believed existed. Virchow declared that the disease could be caused by atmospheric conditions, disturbances in milk secretion, excited state of the nervous system, and other possible causes. He also had some incentive to argue against the causal relationship between autopsies followed by obstetrical examinations and childbed fever. He was a pathologist deeply committed to the value of autopsies and the notion that one of the iatrogenic consequences of autopsies was the unnecessary death of thousands of women was unthinkable. Semmelweis published a book The Etiology, Concept and Prophylaxis of Childbed Fever soon after the congress in which he pointed out the fallacies in Virchow’s criticisms, but to no avail. There is no doubt that Virchow’s authority in medical circles prevented the recognition of the Semmelweis’ doctrine until Lister showed the importance of antisepsis, and until Pasteur and Koch established the germ theory.

Several years after that publication, Semmelweis became mentally ill and was confined to a Psychiatric Hospital where he died of gangrene after being beaten by a guard. Ignaz Semmelweis is the patron saint of hand washing and his story, like the account of the modern hospital, has relevance today.

The modern hospital and laboratory

I have been talking about critical changes that made the modern hospital central to health care in the early 20th century, such as the new operating rooms that enabled sterile pain-free surgery, and the nightingale wards that allowed modern nurses and hospitals to care for a broader population. Modern laboratory medicine is the next contributor to this change. According to the authors of The Modern Hospital, the modern laboratory has four functions: as an aid to diagnosis, as part of treatment, as an educational aid and as a contributor to scientific research. No longer is a hospital complete without laboratory capacity.

The modern physician is never content in this day to rest a diagnosis of even the simplest case upon his bedside observations, and requires the aid of the laboratory of pathology… In very modern, efficient institutions there is a routine laboratory practice that includes at least a complete examination of the urine, and a complete examination of the blood as a part of the routine of the admission of the patient, and in these institutions there is also a routine examination of the blood-pressure, the hemoglobin content, and a white and red and differential blood-count (The Modern Hospital, page 453).

These examinations were not by themselves new. Urine testing dates back to ancient times. The foul smell of the urine of a sick person has been an indication of illness as far back as we can look. Similarly, urine that is red with blood or dark brown with contaminants are obvious signs of illness. In the seventeenth century doctors who took urine samples were called “piss tasters” and could identify various conditions based on the smell and taste of urine. With the invention of the microscope, urine could be inspected more closely, and by the second half of the 19th century different types of kidney disease could be identified by the microscopic examination of urine.

Rudolph Virchow was a larger than life German doctor who made important advances in the microscopic examination of blood cells by showing that diseases like leukemia could be identified at the cellular level. He is celebrated as the founder of modern cellular pathology among many other accomplishments. He made a major contribution to the transformation of medicine from a home based service industry into a modern scientific profession. Rudolph Virchow Virchow was an accomplished microscopist. (The adept use of the microscope in his day could be compared to the skill of accomplished computer programmers today.) This helped him make major contributions to our understanding of cell division and modern pathology. He was also active in politics and was one of the founders of a liberal political party during the 1848 political turmoil.  (He was well-known enough to be challenged to a duel by Otto von Bismarck.) He was very active and competed vigorously in the scientific life of his day: he was accused of stealing some peoples’ ideas and of dismissing the important ideas of others. In retrospect, one of his most indefensible acts was his reaction to the work of Ignaz Semelweiss. But more of this in my next blog.

The photograph below is from the archives of the Haslar Naval Hospital in the UK. Its first Medical Superintendent was James Lind (See my article on the history of scurvy and James Lind).Image is from the archives of the Haslar Naval Hospital in the UK. Its first Medical Superintendent was James Lind.

Developing the modern ward

The emergence of social institutions like churches and schools mark the coming of age of a community. Hospitals were no different at the turn of the century; they were social institutions as well as healthcare organizations. The 1914 textbook, The Modern Hospital, describes three kinds of community hospitals of the time: hospitals that catered only to charity cases on the model of the hospital-almshouses; mixed hospitals that were community-governed and provided charitable care as well as care that was paid for by patients or their employers; and private hospitals that did not provide charitable care, but catered only for patients who could pay themselves or through their employers.

Today in Ontario, one of the marks of small organized communities is their funding and support of Family Health Teams that provide primary care. Some of them are governed by community members who participate in setting policies and developing services of the Family Health Teams. The community usually collects funding for a facility that will house the Family Health Team and will often offer services that, according to the Association of Ontario Health Centres, have the capacity for “going outside the boundaries of primary clinical care” (reference).

A century ago, modern hospitals began to care for the sick in a hospital setting. If surgeons led the development of the operating room, nurses led the introduction of the modern ward. Open wards of the kind illustrated below were called Nightingale wards after the famous nurse, Florence Nightingale. Large windows could be opened for fresh, clean air. The book stresses that these wards can be built in multiples/modules, elongated and made for many more beds, and attached to a central core of any hospital building. The wards were open and patients would stay as long as they needed nursing. Needless to say, lengths of stay were far longer than they are today. At the Royal Victoria Hospital in Montreal, the Nightingale ward had radiators down the centre of the aisle and when patients became well enough to get out of bed and sit by the radiator in order to get warm, it was time for them to go home.Nurses Units Image

  1. The ward or private room
  2. Toiled room
  3. Nurses’ toilet room
  4. Serving room or diet kitchen
  5. A quiet room for one bed
  6. Bath room
  7. Utility or sink room
  8. Cabinet for linen
  9. Cabinet for medicine
  10. Station for nurses
  11. Solarium

Unlike the operating room, this design has no designated space for doctors who come to visit their patients; instead, it is dedicated to patients and their nurses. In the case of a rich patient, the entire ward can be transformed into private quarters. The quiet room for one bed (number 5) would probably be used as a mortuary of for a patient who is about to die because there is some distance from the nursing station. A nurse who had worked in a Nightingale ward told me that its great advantage was that you would know immediately whether or not a patient was in trouble – you could hear every patient when you were on the floor.

Developing the modern operating room

The modern hospital grew out of the almshouse – a place where impoverished sick people came to be fed and nursed. Anyone who could afford their own care was treated at home. The introduction of the modern sterile operating room was a critical factor in the growth of hospitals in the late 19th and early 20th Century. The first breakthrough was anesthesia. Before the introduction of anesthesia, and sterile conditions, major operations were largely unsuccessful. There was enormous pain and almost inevitable infection.  As seen in image below, the re-enactment of the first American surgery with anesthesia in 1846 shows little concern for a sterile environment.Blog 6 - 1Operations for people who were not destitute were often performed more successfully at home than in the almshouse hospitals. We now understand that this was because of a lower risk of infection, but the main reason at the time was that almshouses were places to avoid – it was significantly more comfortable for the patient to be at home. However when it became clear in the 1880’s that a sterile environment was critical to the success of surgery, the hospital became the location for specialized operating rooms, and thus began the relocation of safe acute medical care from the home to the hospital. The change was remarkably rapid.  In the 1870’s most community hospitals were largely for the poor and did not have operating rooms. Below is a photograph from 1876 of the operating area in the Rochester General Hospital: it was a table in the hospital library that was used by surgeons when the need arose.Blog 6 - 2By the 1890’s operating rooms were mandatory in general hospitals and the same hospital proudly photographed the operating room below. Surgeons now soaked their hands in carbolic acid before operating and used sterilized instruments.Blog 6 - 3A 1913 textbook called “The Modern Hospital” by John Hornsby, a doctor and Richard Schmidt, an architect, described every aspect of the hospital in great detail. The illustration below is of the sterile operating room of the period. The design shows an operating room with skylights, special spaces for local and visiting surgeons and many sinks and basins for assuring that everything is kept germ free. Today operating room are no longer described as germ free, instead the they admit more realistically to being “an almost sterile” environment.

Blog 6 - 4The operating room made it necessary for the general public to use and financially support the general hospital. Once the hospital began to be modernized it also became the place for other very sick patients to receive medical care. I’ll write more on this in the next blog.