Tuesday, August 14, 2007

Service Wards

Being new to hospitals -- and being pretty oblivious to what they were like 10 years ago, much less 30 -- I recently learned something amazing. This will not be new to many readers who are above a certain age and spent time in hospitals, but for me it was a stunning revelation.

As late as the 1970's, the Boston hospitals -- including BIDMC -- had service wards. These were full floors of beds dedicated to those members of the public from lower income groups without insurance. Then, there might be different parts of the hospital with two or three patients to a room for the slightly better off. Finally, there would be private rooms for the well-heeled.

Corresponding to the bed layout, the service wards were staffed entirely by residents. Attendings, i.e., full-fledged doctors, would only serve the well-to-do patients. (By the way, emergency rooms were also totally under the authority of residents.) Nursing ratios, too, varied by income level. Our current Board Chair, Lois Silverman, told me of being a young nurse with total responsibility for 30 patients on a service ward!

Here is a marvelous description of this at Massachusetts General Hospital, written by Dr. Jerry Groopman, who was an intern there in 1976. (I include this as representative of the general situation because it is so nicely written, and not at all to reflect solely on MGH.)

There were three clinical services, Bulfinch, Baker, and Phillips, and over the ensuing twelve months we would rotate through all of them. Each clinical service was located in a separate building, and together the three buildings mirrored the class structure of America. The open wards in Bulfinch served people who had no private physician, mainly indigent Italians from the North End and Irish from Charlestown and Chelsea. Interns and residents took a fierce pride in caring for those on the Bulfinch wards, who were "their own" patients. The Baker Building housed the "semi-private" patients, two or three to a room, working- and middle-class people with insurance. The "private" service was in the Phillips House, a handsome edifice rising some eleven stories with views of the Charles River; each room was either a single or a suite, and the suites were rumored to have accommodated valets and maids in times past. The very wealthy were admitted to the Phillips House by a select group of personal physicians, many of whom had offices at the foot of Beacon Hill and were themselves Boston Brahmins.

Who would have thought that, only 30 years ago, equal access meant separate and not at all equal? Today, we when talk about equal access to health care, we actually mean equal. At BIDMC, care is truly delivered without regard to income. A Stoneman or Feldberg descendant from Back Bay or the western suburbs might be in single or double room in the Stoneman or Feldberg building named after their parents or grandparents -- but so might a Smith or Jones from Dorchester, Mattapan, or Roxbury. The staffing ratios -- residents and attendings and highly trained nurses -- are the same, the housekeeping is the same, the food is the same (room service!), and all the televisions show the Red Sox on channel 26, and have those cumbersome TV remote controls.

Full disclosure: The only physical amenity that is left to those who choose to pay extra is to acquire a single room when there is not the medical necessity for a single room. This is only permitted when such rooms are available. Otherwise, they are allocated first to those cases requiring isolation, and then generally assigned to other patients.

9 comments:

Anonymous said...

Any idea how long the hospital stays were in the service ward? Was there isolation for infectious disease? Curious.

Paul Levy said...

Dunno, will let others answer while I try to get answers myself.

Zagreus Ammon said...

Where I trained, there was an entire Pavilion of private rooms, fully about a quarter of the entire campus bed capacity.

Truth be told, it took a lot of time for the crash team (made up entirely of house staff and students toiling in the main med-surg areas) to get to the private Pavilion, so we called it the "Death Pavilion."

Anonymous said...

The remnants of such a situation were also in place when I was in medical school at the University of Va. in the mid seventies. Inter
eresting, because I thought it was because it was a southern school, although I have long heard of the "Boston Brahmins".....

Anonymous said...

Over the last ten years, I have visited patients in pavillions of two major NYC hospitals that were especially set up for the benefactors of the hospitals and their staffs and friends. The rooms were furnished like hotel rooms including carpeting, there were bellmen to take your luggage, at one of the hospitals, afternoon tea with piano music was served. All signs of hospital service (laundry carts, etc.) were discreetly hidden.

Paul Levy said...

Not available at our place . . .

Anonymous said...

we also have "VIP pavilion" at our hospital, which also suffers from the distance factor from the main inpt medicine units. while code coverage isn't so much a problem with the surgical icu team housed two floors below, the problem is that the pavilion is a full two buildings away from where the house staff is usu working. that means as house staff we barely make one/two trips to the pavilion/day - it's simply impossible time-wise, and i can help but feel that my patient's care could be better. unlike my other my other pts, i don't pop my head in as freq during the day to see how a pt is doing, i don't follow-up attending notes as promptly, i don't see the families when they come to visit b/c i round either early in the morning/late at night. ultimately, we are always watching and will follow-up on the critical medical issues, but the little things that i think give patients and their families a greater peace of mind are lost. it's not that the humanism of our medical student years are lost - the systems barriers just make it that much harder to execute every detail. you pick your battles...

the other issue with the pavilion is the disjointedness of multiple team coverage. the family who's paying the big $$ wants the chief of surgery to cover, but of course once surgery is done with the immediate operation they turf to medicine. that brings in the hospitalist who basically says - 'follow all consult recs.' so surgery floats in, randomly pulls a tube with no documentation as to planned dispo date. pharmacy's dropping notes re: antibiotic dosing, ID's dropping notes re: antibiotic coverage. during the pt's 10d stay on my coverage, i may have met the consult services a total of 4 times in person. i think we gave the family, nursing, and the discharge planner all of 18h to plan his discharge.

had the pt just been a normal pt on a nl floor without all these special consults, s/he would have had a well-greased system that would have been much more integrated and provided smoother/satisfactory care.

seems a bit ironic you should pay extra for what you could argue is worse care...

(ps. hope i was sufficiently vague with hospital course not to violate hipaa, kindly delete any inappropriate segments)

Alexandra said...

Your post reminds of the story of my sister's birth. Thirty-six years ago she was born in the back of my family's Land Rover. My mother, then 41, was supposed to have a C-section. When she went into labor unexpectedly, my father drove her to the BI (where I was also born, a few years earlier).

It was a cold January night. They pulled up to the entrance and were told to go to a different entrance, which turned out to be locked. After my father banged on the door, someone showed up and told them to go to the emergency entrance, where they were again redirected. Luckily, a nurse went along for the ride because my sister was born on the way.

Since she had been born in the car, my mother was put in one of the indigent rooms and the baby stayed with her instead of going to the nursery. However, the doctors and nurses addressed her by her last name while calling her roommate and the other women on the ward by their first names.

I recently heard this story again and was amazed that this happened such a relatively short time ago. Your post was right on point.

Anonymous said...

I, too, was a house officer there at that time. You might be interested to know that there were three separate OR suites – one in the White building serving the indigent patients, one in the Baker and a third in the Phillips House. Each morning the OR list for the day was printed (mimeographed) and available at the front desk. For the White and Baker ORs, the patient names and numbers were printed in full. In contrast, Phillips House patients were listed only by their room number. I suppose that the rich had HIPPA before the rest of us.