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.