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New topic 691 2020-09-08 21:49:55 TITLE Pennsylvania Hospital, Nation's First :
It was sixty years before Philadelphia had a second hospital, so the way things were done at the Pennsylvania Hospital tended to set patterns. The central pattern was: charity for poor folks, during a period when prosperous people were treated in their homes. Since Franklin was the secretary of the Board of Managers, it is in his own handwriting that we see "Founded for the sick poor and, if there is room, for those who can pay." In 1900, two-thirds of all hospital beds in Philadelphia were still ward beds for the poor. In 1948 when I was a two-year unpaid intern there, a posted sign said the accident room charge was fifty cents, but in fact, it was only collected if the patient happened to have insurance. The student nurses ran the place unpaid, and the main exceptions were the two paid administrators, the Steward, and his secretary. Philadelphia was settled for religious freedom, enjoyed many new religions, and consequently had a long era of Methodist, Episcopal, Presbyterian, two Jewish hospitals and the hospitals belonging to three Catholic Orders.
With the advent of the Civil War, PGH (Philadelphia General) grew to seven thousand beds, all of them free, when it was discovered more soldiers were dying from diseases than from wounds. Surgeons and obstetricians built specialty hospitals for their patients, mostly small ones, like Babies Hospital, Preston Retreat, Contagious Disease (mostly polio), Casualty, and a host of tuberculosis and psychiatry hospitals, Eye Hospitals, HEENT Hospitals, Children's Hosptial, and a number of small paying hospitals. The Civil War and the invention of anesthesia created a need for small hospitals for people who could pay, like Skin and Cancer.often in the shadow of larger charity hospitals for those who couldn't' pay. The first question any audience asks with bewilderment is about the cause of so many current hospital mergers. Part of the answer is we once had too many hospitals, and the rest of the answer was that the Flexner Report created a surplus of government money, intended to support research, and similarly stimulated by the creation of Blue Cross in the 1920s. Flexner favored research money, and the Universities grabbed it. The insurance mechanism was the best available means to save money when you were well, in order to spend it later when you were sick, but insurance muffed the chance. They chose one-year term insurance, mostly because short-term business was paying the bill. When money was no object, money was wasted.
The quickest example of honey attracting flies was observed shortly after 1965, when Philadelphia teaching hospitals (there were 104 of them at the time) went to Mayor Rizzo, suggesting PGH should be closed, ostensibly in order to facilitate the flow of federal funds to private hospitals. Thus they would help teaching hospitals absorb the abundant flow of government charity while eliminating the $11 annual cost of PGH to the City. That transformation from mostly charitable to largely private hospital care took from 1977 to 2010, to the private amusement of those who had been present at the meeting. At the end of this transformation, their positions had reversed; the teaching hospitals now bemoaned the shocking disappearance of the city's medical charity through PGH, casting such people back onto the teaching hospitals. Vannevar Bush probably had a hand in this, as the pretext was that only teaching hospitals did research. Meanwhile, they lobbied strenuously to retain monopoly control of federal research money, at the expense of charity beds within the teaching hospitals. In other words, we had a reasonably satisfactory system of charity care until charity patients demanded equal facilities from public money. Lyndon Johnson gloried in his achievements, but the fact is they opened the door to the unsupportable expense. The nursing profession was utterly flummoxed to be given degrees in return for the disappearance of their profession. If the combatants had stopped long enough to ask, there simply was not enough money to do what politics was demanding. The nursing school was always the heart of the hospital; the doctors were too busy tending to patients. And charts which they mostly falsified to save wasted time. Adding to the confusion was the effect of shifting nurse training costs, from the hospitals (diploma) to university responsibility (bachelorette degrees) and the adverse effect on nurse quality was noticeable. Doctors no longer married nurses, for example, they married lawyers and similar pre-professionals. The greatest effect, aside from higher cost, was to remove the loudest objectors from the scene, at just about the wrong time. The universities were clamoring to transform the nursing profession into administrators, in order to satisfy a seemingly insatiable demand stirred up by muddling the medical record-keeping system with the task of creating huge records which no one has time to read. The public regards medical matters as too obscure to understand and so does not appreciate how much cost has been created by switching everything non-essential around. It seemed obvious to them that non-essentials were poorly done. But not being medically trained, they weren't able to tell what was non-essential. Improving legibility and interphysician communication was nice, but it wasn't the main business of a hospital. Physicians learned to practice good medicine in tents and scarcely saw any difference.
Lawyers have learned something, too. They learned that antitrust violation is not signaled by per se violations or even vertical integration. It is signaled by mergers. Senator Specter may have kept Robert Bork from the Supreme Court. But the Law is slowly catching up with mergers, and Bork's books are still in print.
The future of hospitals does not lie in buildings. Doctors' practices are easily moved to retirement villages where the old folks are. Patients are there a long time, and equipment is easily moved there to be with them. It would save a lot of money because diseases are disappearing. Something like five diseases now represents something like 80% of the cost, but all that money spent on hospital buildings has already been spent, so it will take too long to get there peacefully. For all I know, five new diseases will replace five old ones, but the trend is downward. Costs keep going up. Doesn't that tell you something? What's going to happen to all that real estate after we cure cancer?
During the number of years I was in business as a stationer, printer, and postmaster, a great many small sums became due for books, advertisements, postage of letters, and other matters, which were not collected when, in 1757, I was sent by the Assembly to England as their agent, and by subsequent appointments continued there till 1775, when on my return, I was immediately engaged in the affairs of Congress and sent to France in 1776, where I remained nine years, not returning till 1785, and the said debts, not being demanded in such a length of time, are become in a manner obsolete, yet are nevertheless justly due. These, as they are stated in my great folio ledger E, I bequeath to the contributors to the Pennsylvania Hospital, hoping that those debtors, and the descendants of such as are deceased, who now, as I find, make some difficulty of satisfying such antiquated demands as just debts, may, however, be induced to pay or give them as charity to that excellent institution. I am sensible that much must inevitably be lost, but I hope something considerable may be recovered. It is possible, too, that some of the parties charged may have existing old, unsettled accounts against me; in which case the managers of the said hospital will allow and deduct the amount, or pay the balance if they find it against me.
|A Medical History of Benjamin Fanklin: Troubled Water: Benjamin Samuel Abeshouse ASIN: B0069X8GFS||Amazon|
|Benjamin Franklin: An American Life Walter Isaacson ISBN-10: 0684807610||Amazon|
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In 1747, Benjamin Franklin had a life-transforming experience, acting quite unlike his character before, or later. At that time, Old Europe was engaged in some distant tribal skirmishing which has come to be known as King George's War. King George II, that is, under whose rule Franklin in 1751 inscribed on the cornerstone of the Pennsylvania Hospital that Pennsylvania was flourishing, "for he sought the happiness of his people."
The cornerstone of the|
Pennsylvania Hospital inscribed by Franklin.
Those distant commotions suddenly developed a harsh reality for the little pacifist sanctuaries on the Delaware River, when French and Spanish privateers suddenly raided and destroyed settlements on Delaware Bay. The Quaker Assemblies and their absentee Proprietor merely dithered and huddled in the face of what impended as a totally unexpected threat of annihilation of the pacifist colonies. It probably only seemed natural for the owner of the largest newspaper in the colony to publish a pamphlet called "Plain Truth," urging the inhabitants to rally to their own defense, and pressure their government to lead them. The Quaker leaders were in fact unable to readjust a lifetime of pacifist belief in a few days of an emergency, and the English Proprietor, then Thomas Penn, was far too remote to take active charge of matters. So, Franklin gave speeches, also an unfamiliar role for him, and finally brought out a detailed proposal for the creation of a Pennsylvania Militia. Ten thousand volunteers promptly signed up, elected Franklin as their Colonel; but he declined, and served as a common soldier.
|Benjamin Franklin in 1767.|
Against naval attack, the Militia needed cannon, which did not exist in the colony. So Franklin organized a lottery, raised three thousand pounds, and tried to buy cannon from Governor Clinton of New York. New York declined to sell, and so Franklin led a delegation to New York to negotiate. The negotiations largely consisted of getting Governor Clinton drunk and convivial, but they were successful, the artillery was shipped off to Philadelphia. Although they were undoubtedly grateful to Franklin for saving the day, this entirely extra-legal recruitment of an army badly rattled the Quakers and their Proprietor, since it demonstrated the ineffectiveness of their governance at a time of obvious crisis, and might ultimately have led to their overthrow. Franklin's heroic behavior seemed so threatening to Thomas Penn that he described him as "a dangerous man," acting like "the Tribune of the People."
When the underlying commotion in Old Europe subsided, the threat to the colonies disappeared, so the Militia disbanded in a year. Franklin seemed to be just as uncomfortable with his unaccustomed role as the governing leaders were, and he hardly ever mentioned it again. However, this is the sort of reflex leadership that makes political careers, and it surely influenced his decision to retire from business in 1748, run for election to the Assembly, and live like a gentleman. Seven years later, during the French and Indian War, he had become the chosen leader of the Pennsylvania Assembly, had much longer to think through what he was doing, and had learned how to organize a war. By that time, as the saying goes, he knew who he was. He was a man whose silent memories could flashback to that time when a bald fat printer stepped out of the crowd, saying "Follow me," and ten thousand men with muskets did so.Franklin was a hero to every man in Philadelphia, except one. That was Thomas Penn, who thought to himself, "That man is dangerous."
As commonly stated in medical history circles, the history of the Pennsylvania Hospital is the history of American medicine. The beautiful old original building, with additions attached, still stands where it did in 1755, a great credit to Samuel Rhoads the builder and designer of it. The colonial building on Pine Street stopped housing 150 patients around 1980, supposedly at the demand of the Fire Marshall, although its perpetual fire insurance policy still owes the hospital several thousand dollars a year as an unspent premium dividend. There may have been one small fire during two centuries of use, but its true fire hazard would be difficult to assert. It was just out of date. The original patient areas consisted of long open wards, with forty or so beds lined up behind fluted columns, in four sections on two floors. The pharmacy was on the first floor, the lunatics in the basement, and the operating rooms on the third floor under a domed skylight. It was entirely serviceable in 1948 when I arrived as an intern doctor. Individual privacy was limited to what a curtain between the beds would provide, but on the other hand, it was possible for one nurse to stand at the end of the award and recognize any distress among forty patients immediately. In this trade-off between delicacy and utility, the utility was certain to be preferred by the Quaker founders. Visitors were essentially excluded, and if a patient recovered enough to be unnaturally curious about neighboring patients, well, he had probably recovered enough to go home.
Located between two large rivers, South Philadelphia up to ten blocks away was essentially a swamp until the Civil War. So, there were seasonal epidemics of malaria, yellow fever, typhoid, and poliomyelitis at the hospital until the early twentieth century. Philadelphia was a port city, so sailors brought in cases of venereal disease, scurvy, even an occasional case of anthrax or leprosy. During the Industrial Revolution of the nineteenth century, tuberculosis, rheumatic fever, and diphtheria were part of clinical practice. But underlying the ebb and flow of environmental effects, there was a steady population of illness which did not change a great deal from 1776 to 1948. These patients were all poor, because the rules in Benjamin Franklin's handwriting restricted service to the "sick poor, and only if there is room, for those who can pay." In 1948 there was a poor box for those who might feel grateful, but no credit manager or official payment office. The matter had been considered, but the cost of collection was considered greater than the likely revenue. When Mr. Daniel Gill was offered the position as the hospital's first credit manager, it was suggested that he be given a tenth of what he collected. To his lifelong regret, Dan Gill regretted that he refused an offer that he had felt he could not afford to accept.
So, the wards were filled with victims of the diseases of poverty, punctuated by occasional epidemics of whatever was prevalent. And a second constant feature of the patients was their medical condition forced them to be housed in bed. For centuries, physicians dreaded the news that a new patient was being admitted with "dead legs".
CONVENE BLUE RIBBON COMMISSION TO REPAIR PSYCHIATRIC INPATIENT CARE. The 1983 BRA switched hospital inpatient reimbursement to payment by diagnosis (DRG). Abuse of the psychiatric exclusion then led to "corrective" legislation which has essentially reduced American's psychiatric inpatient care to an underfunded national disappointment. The problem is not an easy one, so a commission should devise a workable methodology for psychiatric hospitals, relying neither on present approaches nor on DRG. But overpayment is a better outcome than no care at all. Homeless people sleeping in cardboard boxes on downtown steam grates are the consequence any visitor to the area can observe at night after the commuters go home. Psychiatric social workers readily recognize their daytime patients in the boxes.
* * * * *
|Daniel Blain, M.D.|
Daniel Blain, M.D. (1898-1981) was just about the most important psychiatrist in America. He was the Physician in Chief of the Institute of the Pennsylvania Hospital at 49th and Market, the first and in many ways the most prestigious psychiatric hospital before it was closed. Before that, he was the first Medical Director of the American Psychiatric Association, itself the first (1844) medical society in America. His fame rested on organizing the disorganized psychiatry of the Veteran's Administration into a chain of advanced "Dean's Hospitals", a huge and very important achievement. Before that, he had achieved considerable fame as the man who took the dilapidated State Psychiatric Hospitals with a reputation as "snake pits" and made them a respectable part of the medical community. And before that, he had been born in China as the son of missionaries. As a matter of fact, even before that, he was a descendant of General Mercer of Revolutionary War fame.
Dan was an outstanding example of the peculiar fact that Psychiatry was dominated by social upper crust psychiatrists in Philadelphia for a very long time. In fact, Benjamin Rush of the 8th Street branch of the Pennsylvania Hospital is known in some circles as the "Father of Psychiatry", while in other circles he is known for signing the Declaration of Independence. That isn't true in other cities, and it definitely isn't true in New York City, where the psychoanalytic school of Sigmund Freud took that city by storm, and essentially drove every other school of psychiatric thought out of town, out of medical schools, out of psychiatric hospitals. The famous sixteen-year psychoanalysis of Woody Allen is an example of the extremes of that fad. Every profession has petty civil wars of that sort, best left undiscussed in public. But in the case of psychiatry, it was indirectly a material contributor to the present disappearance of inpatient psychiatry, and the related appearance of lots of homeless people on steam grates. Let me give a biased view of what is a massive human tragedy, which someone else can "rectify" if he chooses.
It starts with a Budget Reconciliation Act of the 1980s, which brought us the DRG (Diagnosis-related) system of paying for hospitalized patients. The idea was that appendicitis resulted in essentially 7 days in the hospital, give or take a couple of days, and the bills for admission for appendectomy were for more or less the same amount. If you had fifty or a hundred cases a year in your hospital, the high bills balanced the low bills, and the overall hospital reimbursement was essentially the same without itemizing the bandages and whatnot. Congress bought this package, and after it got going, just about all hospital bills were reimbursed at one of three hundred prices, the cost to the government was the same, and there was a whole lot less bookkeeping and accounting cost. It was a success, except for a few cases where the costs did not closely line up with the diagnosis, and psychiatric hospitals were where they concentrated. So, psychiatric hospitals were excluded, and psychiatric bills skyrocketed. This experience has been carelessly cited as an example of the evils of payment by service ("fee for service"), when in fact the duration of psychiatric hospitalization is related to features of the condition, like danger of suicide, rather than the diagnosis itself. Psychiatric leadership at the time contained many in a subset of physicians who did not think much of inpatient psychiatry in the first place and even less of lobbying, and they underestimated the severity of the assault on the specialty. Apparently, no workable formula for pricing inpatient psychiatry has since been brought forward to be approved by a Congress which is more accustomed to getting its lobbying in the form of one-liners. And would you believe it, psychiatric inpatient care soon disappeared.
That's right, if someone in your family needs psychiatric hospitalization, I wouldn't know where to tell them to get it -- at any price. From considerably overpaying for psychiatry inpatients to paying scarcely anything for them, this little change of the regulations caused every psychiatric hospital I know of by name, to close. It helped balance some state budgets, but it also was a considerable factor in filling the steam grates of American cities with people who sleep on cardboard boxes. And what it illustrates is that this is what political society always seemed to do, before Dan Blain and a small group of upper-crust psychiatrists were temporarily able to shame them into something better. In fact, if there is any tattered remnant of good inpatient psychiatric care left in America today, it is in the Veterans Hospitals that Dan was able to straighten out.
Dan Blain will probably eventually be bypassed as a curiosity, like his wife. She was a Wister Logan Blain, descended from families who ruled Philadelphia a hundred years before even General Mercer came along. So the Blain couple lived on an enormous farm plot, centered at 20th and Olney right next to LaSalle University, which is built on their property. It also contains the Peale House, where Charles Willson Peale lived as the elected president of the rebel faction of the American Revolution. Peale didn't know what he was supposed to do, so he resigned and painted portraits of people. The Blains enjoyed keeping a cow on their land, the last cow in Philadelphia, and the LaSalle students enjoyed stealing the cow and leaving it on the top floor of a dormitory, for laughs. Meanwhile, the Blain couple had cocktail parties on their front porch for visiting dignitaries. They usually wore blue jeans, and Mrs. Blain, the absolute Queen of Philadelphia society, was occasionally observed to pour vodka into her glass of beer. That sort of background may well have been useful when psychiatry needed to be built up and humanized, but it became a liability when the rest of inpatient psychiatry failed to appreciate what was knocking on its door.
At the same time, the horse and buggy era has been left behind, causing new separations along class lines, the flight to the suburbs, and the migration of philanthropy toward the exurban sprawl, as well as into urban centers. In all this commotion it was overlooked for a long time that medical care was not merely following the patients to new locations, it was becoming more of an outpatient occupation. Inpatient care was shrinking, and somehow expensive hospitals were swallowing their smaller (and less expensive) competitors. It wasn't a necessary development; Switzerland still favors small luxury "clinics" of ten or twenty beds, usually containing wealthy patients of a celebrity doctor. Local customs like this will change slowly. What America appears to need is more hospital competition and more ambulance competition; the two may actually be somewhat connected issues. For amusement, I once studied the patients in the Pennsylvania Hospital on July 4, 1776, when historical notables were congregating three blocks away. The diseases were remarkably similar to what is seen in hospitals today; problems with the legs, mental incapacity, major injuries, and terminal care. People are treated in hospitals because they can't care for themselves at home.
A BLUE-RIBBON COMMITTEE NEEDS TO STUDY INSTITUTIONAL COMPETITION IN HEALTHCARE. This is a complicated issue and may take several years, or even several studies to sort out. What is useful for urban settings may be inappropriate in exurban ones; local preferences must be separated from special pleading, and that is not always easy. However, the continuing care center seems to be a permanent direction which is growing in popularity, as is also true of rehabilitation centers and retirement communities. Many of these institutions might incorporate doctors offices for their surrounding community, using the same parking facilities and many of the same medical specialties for both the neighborhood and the core facility. There seems no reason to oppose either rentals or private condominium-style ownership nor any reason to resist group clinics. Exclusive arrangements, however, are more questionable. All of these arrangements should be studied, and unexpected problems flushed out. No doubt the preliminary studies would lead to pilot and demonstration programs. And some practices which initially seem harmless, should in fact be prohibited. We have a lot to learn before we start overturning the existing order. But nevertheless, some arrangements will prove to be superior to others, almost all of them are regulated in some fashion, and the regulations should be examined, too. It should accelerate needed changes to know in advance which ones are ready to be tested, and tested before they are demanded.
Everyone knows Americans are living thirty years longer because of improvements in health care, and some grumpy people are waiting with glee to see if Obamacare will put a stop to that sort of thing. It must be left to actuaries to tell us whether the nation saves money or not by delaying the inevitable costs of a terminal illness. But one consequence has already made its appearance: people are entering retirement villages in their eighties rather than their seventies. Presumably, people in their seventies are feeling too well to consider a CCRC, although other explanations are possible.
Accordingly, a great many CCRCs are seen to be building new wings dedicated to "assisted living". A cynic might surmise there must be some hidden insurance reimbursement advantages to doing so, but the CCRCs are surely responding to some kind of increased demand when they make multi-million dollar capital expenditures. Assisted living is a polite term for people with strokes or Alzheimers Disease, or some other condition making it hard to walk, or, as the grisly saying goes, perform the activities of daily living. One really elegant place in Delaware has suites with servants quarters, but for most people, the only affordable option is to be in a room designed around the idea of assisting an invalid. It's generally smaller and more austere but fitted out with railings and bars and special knobs. Meals generally have to be supplied by room service.
Not everyone is destined to have a protracted period of decline, but it's fairly frequent and universally feared, so it's a comfort to know your present residence is attached to a wing which provides for it. The question is how to pay for it. There are two main approaches currently in use, adapted to the limited financial resources of the aged and the particularities of CCRC arrangements.
In the first arrangement, there is no increased charge for moving to assisted living, which helps overcome resistance to going there. However, the monthly maintenance charge for others who remain behind in "ambulatory living" is increased, usually about 20%, to provide funding for those who eventually need special assistance. That's a financial pooling arrangement, sort of an insurance plan, and like all insurance, it has a tendency to increase usage unnecessarily. It also increases the cost to those who enter the CCRC at an earlier age, because they make more monthly payments before they use them. Although the monthly premium probably goes up as the costs rise with inflation, there may be some savings hidden in applying an earlier payment stream at a lower rate. That's called "present value" accounting, but like just about all accounting, its unspoken advantages and disadvantages contain a gamble on unknown future inflation.
In the other common financial arrangement, you pay as you go, when and only if you actually use the assisted living quarters. Because of the likely limit to resources, there is usually an attached agreement to garnishee the initial entrance deposit if available funds prove insufficient. The one thing which won't happen is being thrown out in the snow for non-payment; there's a law prohibiting that. Bigger apartments with large initial returnable deposits are of course better off paying list prices. Those with smaller apartments may have smaller deposits, and favor payment by a percent withdrawal. Some places haven't thought this through and offer no choice. In that case, more attention should be paid to those list prices and the percentage markup from audited cost. Better still is to have a free choice of both options, with cost transparency.
The remaining choice is between two CCRCs with differing options, made at the time you enter. The Obamacare fuss has made a lot of people acquainted with "adverse risk selection", which is largely based on the idea that an individual has a better idea of his health future than an institution does since that includes family history as well as earlier health experiences. But in general, a young healthy person is going to live longer without needing assisted living than an old geezer who going to need it pretty soon. A hidden adverse incentive is created for younger healthier people to set the choice aside, and come back in ten years, providing they remain alert to the underlying reason the monthly fee is then somewhat higher than in some competitive CCRC. At the far end of the age spectrum, an incentive is created to go into assisted living quarters a little earlier in life, generally regarded as an undesirable choice.
All this financial balancing act can seem pretty overwhelming to an elderly person who isn't entirely comfortable with the CCRC idea in the first place. Rest assured that everything has to be paid for somehow, and after you die you won't care what choice has been made. If you trust the institution to have your best interests in mind, the only consideration of real importance is whether your money will last you out. The institution cares about that even more than you do, so while they aren't likely to offer unrealistically bargain choices, they may offer a few which are too costly.
America has had a ninety-year romance with insurance because it is so comforting to be secure and oblivious to finances. This is just another example of the struggle between the search for a security, and the struggle to devise ways to pay for it. While no one can be positive about it, we're all in this together.
The American Medical Association feels unappreciated and misunderstood, and that is indeed a pretty accurate appraisal of things. In 1976, when I was offered an opportunity to be nominated to the AMA House of Delegates, I naturally was flattered to represent a thousand physicians. But I must admit that an extra incentive was the opportunity to learn what the AMA was all about. Since that is not exactly a superior qualification for election. I kept it quiet until now, but I can tell you that it is a very common feeling among new delegates. Even up to the time of being invited to give this lecture, my thoughts were formless or subliminal, and it is actually a welcome opportunity for me finally to coagulate my thoughts in order to say something useful to you tonight. Some would say, it is about time I made up my mind.
It seems helpful to begin with a broad historical perspective. Most of you know that the AMA was founded in Philadelphia in 1847 and that this Philadelphia County Medical Society is older than the AMA, and older than the Pennsylvania Medical Society. That was entirely natural, since Abraham Lincoln was then a small child in a log cabin in the forests of Illinois, whereas Spruce Street was lined with mansions, and the Pennsylvania Hospital was one of less than a dozen hospitals in the whole country. Things changed dramatically during the Nineteenth Century, but it would be important for you to recognize that by the year 1900, only seven percent of American physicians were members of the AMA. The AMA was founded as an elite brotherhood, adhering to a Hippocratic Code of Ethics, protected by stringent entrance restrictions, and internally disciplined by active boards of censors. If you were a member of the AMA and had not yet been thrown out, the public could be assured that you pledged active allegiance to Code of Ethics.
Well, as you know, the news media now jeer, and the AMA now despairs, that membership has declined to slightly less than half of all practicing physicians, a fact which is probably correctly attributed mostly to the rather high dues. Again, you should know that at the peak of membership in the 1930s, when it is fair to say that almost every physician was a member, the dues were free.
What happened to the ama was the Flexner Report in 1914. At that point, the AMA enlarged its traditional posture of self-discipline in a naughty world to active involvement in the processes by which medical excellence is produced. The Flexner report was devoted to examining the scientific content of the medical educational process and membership in the AMA came to stand for scientific as well as ethical excellence. Without intending for it to happen, the AMA had stumbled on the real secret of medical prestige, and after that, the AMA had no problems with attracting membership.
Throughout the Nineteenth Century, the major accomplishment of the AMA had been to establish the state licensing process. As a result of its formative activity in lobbying legislatures to create state boards of medical licensure, and it's later spectacular success in specifying the best medical educational process, the AMA has long played an influential, indeed dominant role in both areas. The Joint Commission on Accreditation of Hospitals was another AMA project, and so was Blue Shield. None of these secondary power centers (now dominant in licensing, education, hospital regulation, and health insurance) was established as an AMA vassal,but their formats were established from the beginning using the AMA model, their early leaders were all AMA leaders, and to this day, the AMA is certainly where to be if you want to learn the ropes. It must surely be frustrating to the enemies of the AMA to see how fruitless it has been to resist the power of the AMA in these areas, because so much intangible power rests in the experience, savvy, and contacts of the AMA in these areas, because so much intangible power rests in the experience, savvy, and contacts of the AMA leadership. They know where the bodies are buried, and they know all about the personalities and politics of the process. You could spend three lifetimes as an outsider just trying to learn what is going on. By the time you learned, the situation would have shifted just enough so the information wouldn't do you any good.
So, you can see that in some ways the AMA is an object lesson in the way that society often gives power to idealistic leaders, and then Idealism struggles to check the corrupting pressures of Power. The ancient Greeks thought it was a good idea to have philosopher kings, but history teaches us that even they acted more like kings than philosophers. Since this seems to be the universal nature of human behavior, it is vital that we search for self-regulating mechanisms in our institutions. The one I suggest for the AMA is the very unpopular suggestion that we be careful how we lower the dues, and we must never achieve automatic membership of the entire physician community. We must be cautious of defining success in the Morris Fishbein sense of getting rid of all dues because then the staff and leadership won't need to solicit membership. When we stop scratching and scrabbling for members, the members lose their ultimate power to impose their wishes on the organization. No one now needs to sign a petition or make a speech, and it is definitely counterproductive to threaten the leadership that you are going to resign. Rather, the invisible hand of the perceived wishes of the membership is raised in every vote at every Trustee meeting we must care of this or that, we must be careful of our image, else the membership might not like it. The paradox is that the AMA is now much more representative of members than it ever was in its heyday. When Morris Fishbein was coining a fortune in cigarettes advertising in the JAMA, the wishes of the membership be damned.
The thought I would next pursue is that the bumper stickers, paraphrased as "If you don't like the AMA just try to practice medicine without it." The . AMA is the largest medical publisher in the world, and while New England Journal has more prestige at the moment, it wouldn't take a charismatic editor more than five years to put the JAMA back on top of the prestige heap. The AMA News is by far the best medical newspaper in the world, and it supplies an absolutely unique information role.The AMA has a program in the health care within our prisons which has almost no visibility, but which I can assure you is something you can be very proud of as a humanitarian effort conducted for its own sake. The AMA is extremely active in such abstruse but vital projects as creating medical nomenclature coding, uniform insurance billing forms, medical manpower surveys, health economics monitoring, and clearinghouses for personal exchanges. Whenever we have had a war or physicians draft, the AMA has been the only organization capable of coordinating the civilian and Military medical needs of the country. The AMA seems to be the only organizations which give a hoot about the Veterans Administration or military medicine. There is a very large building in Chicago filled with a thousand salaried people doing many other very necessary things, and doing them quite creditably, without getting very much public credit for it.
The United States of America is a republic, not a democracy as we sometimes tend to say. The American Medical Association is a much purer form of a republic, and its retention of some republican forms which the National government has lost has been a very useful political education for me. I take my seat in the House of Delegates by presenting a little yellow card, signed by the current president of the Pennsylvania Medical Society. If I have the card, I am seated; no card, no card. The cards are given to the State societies in the proportion of one card for every thousand AMA members. The AMA sees to it that the State Society Presidents are in person at the meeting to adjudicate credentials disputes. States may elect their delegates in any way they like and there are several methods. In Pennsylvania, the election is made by the Pennsylvania Medical Society House of Delegates, where membership is roughly one for every hundred members, sitting by countries. Philadelphia County has 30 delegates, and three AMA delegates, although there is nothing official about that.
The AMA House of Delegates meets twice a year for a week. Since you cannot retain your seat without tending to the political fences, a delegate must also attend the state and local meetings. A delegate must thus expect to devote four full weeks a year to the experience, and he need not expect to be influential at the AMA until he has been there at least five years. The AMA delegates feel very strongly about personal commitment; you can be tolerated if you are pretty eccentric, but if you don't come to a meeting, you are instantly ostracised, and probably will be quickly replaced.
The delegates have two main duties. They are an electoral college and they are a legislative body. The House of Delegates elects the President of the AMA and the Trustees, who run the organization between meetings of the House. The House also elects the members of four Councils, who are the specialists in matters of science, legislation, medical practice, and governance. The 70 officers, trustees, and councilors are the leadership, the Curia so to speak, and House of Delegates meetings are highly charged with the politics of these elections as well as the shadow of elections coming in future years. I am inclined to think the candidates take the elections too seriously and the delegates do not take them seriously enough, but it is a matter about which you cannot be entirely certain. There is absolutely no doubt that every delegate has ample opportunity to know every candidate very well, and it is likely that the House makes relatively few mistakes in its choices.
Acting in its legislative role, the House of Delegates usually receives a very thick handbook of agenda, two weeks before every meeting. Most newcomers are overwhelmed by the unexpected volume of detail and are quite unprepared for the ensuing experience of holding up their hands and voting on two or three hundred issues in the course of a week. There is a knack to mastering the process, of course, but mostly the knack comes from making the awful acknowledgment that you really must spend all evening studying the handbook, every evening for the two weeks before each meeting. You don't have to do it, of course, and some members are obviously bluffing. But if you expect to be effective you must do it, and if you want to get effective you must do it, and if you want to get effective you must do it, and if you want to get promoted you have to be seen to be effective. Business starts at 7 AM sharp, often in a city where you must cope with three hours of jet lag, and it goes straight through to midnight. The fact that you are eating breakfast o at a reception does not change the business nature of the day. Only a profession of workaholics could produce three hundred delegates and three hundred alternates, the majority of whom will put up with this grind for ten or fifteen years. Some of our decisions may be wrong, but we sure try hard to make them right.
In closing, I think I should say something about the AMA lobbyists. The AMA is rightly known as having the most effective lobby in Washington, but you ought to know what that means. Since we are a national organization, and every congressman has a doctor, and every congressman lives where there is a county medical society, it is possible to create an organization which can influence the entire Congress, but only with a massive organizational effort. Congressmen too are overload with work and live in a constantly confusing environment. Just to be able to get them to listen to your story is an achievement, and it is necessary to work very hard at repairing this network of contracts. AMPAC raises campaign contributions, and this is one way of reaching some congressmen. Knowing who is on what committee, how he leans, who can influence him, and when the timing is right is an enormous organizational job. Sometimes extraordinary measures are needed, was true in April 1984 when mandatory assignment of Medicare benefits looked as though it might pass. The AMA flew in 125 state medical society presidents and other key contracts and led each one up to the appropriate doors at the critical moment. As you know, the effort was successful.
Most lobbying, however, is far less dramatic. The Federal Register is published weekly and averages seventy thousand pages a year. Perhaps a twentieth of that fine print pertains to medicine in some way, and it must be culled out, studied, decided about, and lobbied with the staff assistants and bureaucrats who are producing it. here are no major victories in this sort of work and you lose a lot of arguments. But there is little doubt that the steady pressure, the constant alertness, and the presentation of superior information have the effect of pushing this avalanche of legislation in directions which are much more favorable to medicine than if the effort were not undertaken.
And fellows, it all takes money. We can raise money by forming captive malpractice insurance companies, or getting advertising in our journals, or charging for computer networks, or speculating in real estate. But who pays the piper calls the tune. In the long run, the member will only control their society if the society remains heavily dependent on their dues. You really must choose between three alternatives. You can have no one represent the profession in an era when everyone else is represented. You can be represented by a bureaucracy which constantly reflects your wishes because it constantly hungers for your dues. The decision is yours and you can expect, in the long run, to get what you pay for.
|No Ambulance, But Faster|
On a pleasant Spring Sunday some time ago, I was at home, doing nothing in particular, when I suddenly experienced severe, crushing pain deep inside my chest. No doubt in my mind what that meant, so I quickly took an aspirin and looked at the clock: 6:50 PM, daylight time. Out the window to my right, my neighbors were having a yard party, so I walked thirty feet over to them. Side-stepping the big Hollywood hello, I told my neighbor I was having a heart attack and would please like a fast trip to the hospital. There was some talk of calling an ambulance, but that was brushed aside. No time.
|E-Z Pass Speeds the Trip|
Neighbor Charlie took the wheel, a friend got in the back seat, and off we went, fast. About that time, I started to sweat, just like they say in books, but to my surprise only after two or three minutes of the pain. The pain continued unchanged. Luckily, on Sunday evening, traffic was light. Down the main road to Benjamin Franklin Bridge, through the gate with E-Z Pass, over the bridge, turn left. I asked the man in the back to call the Emergency Room on his cell phone to tell them I was coming in, please get the cardiac intervention team to come to meet me at the hospital in a few minutes. We made one wrong turn on a one-way street, adding three blocks to the ride. I knew better but didn't feel equal to protesting. We were soon at the right door, and then into the reception area of the Emergency Department. This area is almost brand new; the first time I had been there. But I had been all over that hospital every day for years at a time, and for two years had been the Physician in charge of the Emergency Room, myself.
I didn't recognize the nice lady at the desk, who wanted to know my next of kin, Medicare number, other insurance coverage, the color of my eyes, the name of my dog. My companions are very large fellows, and I was about to tell them to be polite, but if necessary knock her down, when actually I said the magic words,"Severe chest pain". That was part of her standard protocol, apparently, since I was immediately ushered onto a stretcher through a side door, had an electrocardiogram, watched the resident pick up the phone to call the cardiac team. Then I waved off somebody's informed consent speech to the effect that I didn't just consent to, but in fact, demanded an angioplasty. My clothes were taken away, intravenous lines were placed, ice-cold antiseptics were swabbed around. I was shaved in a business-like way in what the lady cutely called a Mohawk. The surgeon appeared, started his own informed consent speech which was waved off. The locks on the wheels were kicked loose, the stretcher started for the elevator, surrounded by scrambling attendants holding bottles. When we came to rest under a big light in some ceiling, I looked at the large wall clock. It was 7:20 PM. That was exactly thirty minutes after the pain began.
I was more or less awake during the whole procedure, getting to watch the dark black line of the catheter moving around on the scope beside me. I didn't know this particular surgeon, but it was obvious he was good. Usually, you can watch the catheter tip advance, then pull back, try again, pull back, try again and hit an obstacle. This evening I had the joy of watching a virtuoso performance, with the catheter smoothly advancing to its destination, twist and come to rest. Black dye squirted out, outlining the artery and its branches. The electrocardiogram correctly predicted the obstruction in the right anterior descending artery, and to general relief, the other atrerieswere "clean".
Probably because I got there so fast, plus swallowing an aspirin at home and chewing several in the Emergency Room, no clot had formed around the obstruction, which apparently was caused by a plaque of cholesterol with a split in it occluding the wall of the artery by bulging into the lumen. There seemed to be no clot behind the plaque or in front of it. The catheter had a stent over the balloon tip, which is to say it contained what amounted to braided chicken wire. The whole contraption gets opened up by inflating the balloon, then deflating and withdrawing it, which allows the artery to be held open by the unfolded chicken wire which remains in place. With the early versions of stents, fibrous scar tissue would grow over the chicken wire and block up the artery a few weeks later. Hence, the stent was coated with a chemical which prevents fibrosis. Unfortunately, this chemical also retards the growth of cells which line an artery on the inside, so coated chicken wire provokes clots. While I was still in the operating room, the solemn incantation was begun: I must take an anti-clotting drug every single day for a whole year, and if I missed a single pill, I could immediately die. I was to hear this incantation twenty times, so I guess they really mean it.
|On a scale from 1-10, how bad is it?|
Well, I was asked to call out a number from one to ten, indicating severity of chest pain. It had been "three" when I got to the operating room, even though it had begun as a "seven", and rose to "seven" several times during the procedure. Seven was my own invention; if I had to ask for pain-killer it was going to be an eight and would get to nine if I had to cry out. It never got worse than seven. When they pulled the catheter out of my groin, it was zero. It has stayed zero ever since.
It was a cause of some interest that my enzymes never rose. When heart muscle is injured, characteristic enzymes leak out and appear in blood tests; you can more or less measure the extent of the damage by the level it reaches. I had reached the emergency room so quickly the enzymes had not had a chance to rise. And the artery was re-opened so soon, they never did rise. For the first time in my life, my blood pressure was 250, so I guess I wasn't as calm as I let on. Somewhere during the procedure, the sweating stopped.
|Severe chest pain|
So, off to the cardiac care ward, where the custom is for each attendant to write his or her name on a whiteboard, while the date and time are prominently displayed for continuing orientation. They give you a phone so you can call your nurse, but my suggestion is to offer earplugs to drown out the continuous chatter at the desk. A patient of mine once called it the Racket Club. The food is, well, hospital food. Protocol says it should have no salt. I discovered that breakfast arrives on the dot at 9 AM, supper on the dot at 5 PM, lunch somewhere in between. I believe I understand the reasoning. Two days of this, and I'm discharged. Nothing to it, if you get there fast. Let me repeat, if you get there fast.
Since this light-hearted day trip is in sharp contrast with the six weeks of strict bed rest so routine in the days of my internship, not to mention the considerable mortality and disability that prevailed until quite recently, it justifies some reflection. As a medical student, I knew Andre Cournand and Dickenson Richards, who perfected the cardiac catheter. They were awarded Nobel Prizes, as was Michael Brown, who invented the statin drugs to lower cholesterol. Affable and modest men, they have saved millions of lives, now including mine. Or at least they did so, with the assistance of thousands of other doctors who perfected one by one the details of the little minute we danced in the operating room, each adding some little refinement, or eliminating some little hindrance to success. But, doggone it, you have got to get to the hospital fast.
To do that, you have to give it some thought in advance; some community organization would also be useful. In my case, waiting for an ambulance would have slowed me down. Not everybody can live within a few minutes fast drive of a hospital, and not all hospitals are equipped to handle such cases. The range of effective rescue could be extended with helicopters, but you have to give some thought to where you would have to drive to find a place for a helicopter to land. Philadelphia is almost unique in having the largest evacuation company in the world, headquartered in Trevose, but it would take a lot of negotiation to arrange a system for the whole Philadelphia area. It just happens my oldest son was helicoptered off a mountain in Nepal this year (by an affiliate of this company), but his helicopter almost ran out of gas. These things can be done, and yearly evacuation insurance is about $200 a year, anywhere in the world. But it would take an awful lot of community planning and argue -- and maybe suing -- to make it happen. Is it worth it? Sure, but a little hard thought in advance might offer better solutions for most people.
Harry Heston, CFO and great curmudgeon of the Pennsylvania Hospital, was having lunch with me and Joe Nicholson one day. It wasn't exactly a happenstance, because Joe had expressed interest in seeing what a business doctor could diagnose in the financial pathology of hospitals. So, when Joe and I were having lunch in the hospital cafeteria, I spied Harry sitting alone (of course) at a table and asked him if he would like us to sit with him. He could scarcely refuse, and I set the conversation going on accounting issues. We chatted about fund accounting, and Harry allowed as how the Pennsylvania Hospital didn't use it. His system was to throw all money into a common pot and use it as best he could.
Fund accounting has the underlying concept that the trustees have to respect the varying wishes of the donors of various money, so they kept them from being commingled. My daughter had said that the underlying flaw in the system was that there was a need to have the books balance, so things were shifted around between funds in a way that no one could follow. In the process, management lost all of the information value of the accounting system, since things which always come out even don't tell you very much.
We touched on other matters, and then it came out. "George, you always have poked your nose into other people's business." Here emerged the real theme song of administration-medical staff relationships, as sung by administrators. The finances of the hospital are none of the doctors' business. If one of them occasionally makes the effort to understand matters, administration wishes he would shove off. It isn't that administration thinks it needs to hide something shameful from the doctors, it is that doctors should remain in their primary role, which is to fill the beds with paying customers, just as administrators should never, never comment on medical management. That's fair enough, isn't it?
Well, as a matter of fact, no. The implication that the medical staff and the bookkeepers are equals, forced to work together and therefore forced to be tactful about each other's undisputed area of dominance, is utterly impertinent. Someone once compared hospital administration with the deck officers of an aircraft carrier, and the doctors with the fighter pilots. A retort was made that a better analogy would be with the steersman of the landing craft and the soldiers in the hold. Both ideas miss the mark, but the concept of interservice friction is a good one to ponder. The history of all major wars is filled with tragic stories of the Air Force bombing its own artillery, or the artillery bombarding its own forward infantry, or the Navy sending the fighters off the carrier without enough fuel to return, or the Secret Service agent abandoned by the promised rescue boat. Interservice rivalry, interservice friction. Mind your own business, flyboy, this is our aircraft carrier.
Girard was born in Bordeaux, France and never went to school. By the age of 23, he had become a sea captain, like his father and grandfather. By the age of 27, he owned his own ship and was thus launched on a successful career in a very dangerous occupation. Depending on the destination and weather during that era, up to forty percent of sailors were lost at sea on long voyages. From the point of view of the passengers and shippers, when you were selecting a captain you wanted one who had returned unharmed from many voyages. It was irrelevant whether he had been lucky, or diligent, or had learned a lot from his relatives in the trade.
Stephen Girard did start with a handicap, being born blind in one eye. It may have been a personality disorder which drove him to precise, minute instructions to his subordinates in excruciating detail; he might now be called a "control freak" and be disliked for it. For example, he kept a handwritten copy of all letters he wrote, and at his death, there were 14,000 of them, sorted and filed. His wife went insane, and after spending years at the Pennsylvania Hospital, was buried on the grounds. If this is the price of being rich, some might consider remaining poor. During his working years in Philadelphia, he would normally get to the counting-house at 5 AM, go to his bank at noon, and go to work on his 600-acre farm in South Philadelphia after 5 PM. He said he liked farm work the best. The image left behind by this role model, then, was workaholic. Nevertheless, if you wanted to become the richest man in America, here was the pattern to follow.
Girard probably came as close as any rich man in history, to "taking it with him" when he died. His innately compulsive personality, combined with the sure knowledge that his relatives and others would probably try to break his will for their own benefit, led to the construction of a last will and testament that withstood a century of court challenges. It launched remarkable philanthropy for thousands of orphans and organized the whole Delaware Valley into an industrial machine unlike anything else in the country. Although he left the largest estate in the nation's history, that estate continued to accumulate money from his minute instructions to executors, eventually enlarging his vast fortune fifty-fold, a century after his death. In retrospect, Philadelphia might well have slowly declined into obscurity after the nation's capital moved to Washington in 1800. Instead, the coal, canal, railroad and industrial empire of the Philadelphia region became the "arsenal of the North" during the Civil War, and the main wealth generator of the Gilded Age which followed.
Girard's business career can be somewhat oversimplified as consisting of shipping at the base of his early good fortune, followed by banking during the era when banking was poorly understood and usually ineptly managed. He ended his career with an eager and successful embrace of the emerging Industrial Revolution. Throughout all of this, he characteristically took great risks for great profits, through recognizing what others were too timid to accept fully. On many occasions, his risky ventures resulted in very large losses, made acceptable by other risky ventures proving unexpectedly successful. An example would be Girard's Bank. When the Federal Government first started and then abandoned the First National Bank Girard bought up the remnants and made a great private success of banking, where he had little previous experience. He saw the potential of the canals, and later the railroads when others were content to be farmers or country gentlemen. When he was 79 years old, he purchased vast tracts of wilderness containing some outcroppings of coal, because he could foresee a great industrial future for the region. No pain, no gain.
Another way of looking at Girard was as the most prominent French-American citizen of his time. He arrived in Philadelphia at about the same time Benjamin Franklin stepped off another boat, returning from abusive treatment by British officials which finally flipped him for American independence. Franklin recognized that independence from England meant an alliance with France, or else it meant defeat. It is possible to view the American Revolution as an episode of France searching for an American foothold after its expulsion fifteen years earlier in the French and Indian War; trouble between Britain and its colonies might re-open opportunities for France. Girard was extremely friendly with Thomas Jefferson, the most Francophile of founders and early American presidents. When the War of 1812 with Great Britain threatened disaster for the new American state, Girard staked $8 million dollars, his whole fortune, on financing that war. During the entire period from 1776 to the Louisiana Purchase, America was wavering between its gratitude to France and underlying loyalty to the English-speaking community. During that long formative period, Girard the very rich Frenchman was hovering in the background, probably influencing American foreign policy more than is known, even today. But the France that Girard stood for was neither aristocratic of the LaFayette variety nor intellectual of the Robespierre sort. It was France of the French peasant, crabbed, acquisitive, and morose, forever responding to a "hidden hand" of his own self-interest in a way that paradoxically benefited his whole community, and thus would have hugely amused the Scotsman Adam Smith.
|Regina E. Herzlinger|
Local attitudes always somewhat persist among migrants from home. What's distinctive about the Philadelphia diaspora is how unconscious most of them are about still carrying the hometown mark. Philadelphia leaves a prominent birthmark, but it's sort of back between your shoulder blades and you forget it's there. What occasions this observation is a Christmas call from a prominent California surgeon who was once my roommate, back in the days when residents were actually resident in the hospital. More than fifty years ago Bill Doane also served as best man at my wedding. Our conversation turned to clots in the lung, and he related a story. He had once fixed a hernia for a 22-year old girl in the days when it was customary to keep hernia cases in bed for a while. Getting out of bed for the first time, she coughed and turned blue, suddenly on the edge of death. Taken back to the operating room, her chest was opened, and Bill removed a clot which was essentially a cast of the blood vessels of one entire lung. As surgeons like to say, she then did very well.
One doctor can tell such a story to another doctor in four sentences, while lay people who overhear it miss the whole point. The fact is, not one surgeon in ten thousand today could carry this off. Nowadays we train thoracic surgeons to open the lungs; they never repair hernias. Conversely, we train hernia surgeons to fix a dozen hernias daily through a little telescope; they never open a patient's chest. So it is hard to imagine many contemporary surgeons who could recognize this disastrous complication of hernia repair, then fix it themselves in time to rescue the patient. Although this disheartening decline into repetitive super specialties has been forty years in the making, it has been recently popularized with the general public by Regina E. Herzlinger, a Harvard business professor. Writing books and speaking to businessmen groups, she has popularized the proposal to outsource the general hospital into what she calls "focused factories." She rightly characterizes the medical profession as reluctant. She's a nice person, and undoubtedly sincerely believes focused factories will save money, improve quality. But we must not let this idea take hold.
Specialty hospitals have actually been given more than a fair trial. About a hundred years ago, the landscape was peppered with casualty hospitals, receiving hospitals, stomach hospitals, skin and cancer hospitals, lying-in hospitals, contagious disease hospitals, and a dozen other medical specialty boutiques. With a few notable exceptions, they all failed for the same reason. Sooner or later they found they could not adequately service their specialty without the backup of a full hospital service. Children's hospitals do thrive, but they have patients who are generally of the wrong physical size to fit adult hospital facilities and equipment. There are plenty of things to regret about general hospitals' design, but the inescapable fact is they all must have a very wide range of services to perform any mission, no matter how discrete. It would be still better if the doctors had an equally wide range of skills in their own heads, but the avalanche of innovation and lawsuits has forced sub-specialization, compartmentalizing, and narrowness of viewpoint. Circumstances have forced the profession to hunker down, but that trend must be resisted, not celebrated.
The instant and successful repair of pulmonary embolism make a dramatic illustration, but the reasons for broad medical training are more extensive than that. In the first place, it is much cheaper to use the generalist office than to bounce people to a gastroenterologist for heartburn, a psychiatrist for anxiety, and a dermatologist for pimples. The American employer community is desperate for a way to reduce its burden of employee health costs, and flocks back to their nurturing business schools for advice. They would do better to seek repeal of the tax dodges which tempted them into their present muddle, of course. But in any event, they must be persuaded to recall the disaster of managed care and at least, avoid meddling in hospital design.
That's the cost issue, where specialization surely raises costs. Constant repetition of the same procedure seems superior to first-time fumbling, although it is questionable how long it takes a well-trained surgeon to pick up a new procedure and do it well. But for this system to work, the referring physicians need to be more skillful, not less, in choosing a good one to refer to. There's just nothing like the experience of working for a few weeks in the specialty as a rotating intern, to tell you what to look for and what to avoid. If every doctor in a hospital is making a dozen internal referrals a day, the cumulative effect on the quality of the whole institution is dramatic -- when they have had sufficient past involvement in the specialties to which they now only refer patients. Some specialists will become popular and rich; others will sulk around unnoticed for a while, then go elsewhere. This process, of course, occurs everywhere; what's institutionally distinct is the culture underlying the standards for preferences.
We'll talk later about the Doane brothers of Bucks County, who were judged to be too handsome to hang. Right now, the point of this story can be summarized by the old Pennsylvania Hospital adage, that you must first be a good doctor before you can be a good specialist. Not only was the Pennsylvania Hospital the first in the nation. For sixty years it was the only hospital in the nation, and for decades after that, it was the only hospital in Pennsylvania. In medical history circles, it is said that the history of American medicine, is the history of the Pennsylvania Hospital.
|Outdoor Ice Skating|
There was a time when ice skaters and rowing enthusiasts were having a little war on the Schuylkill, and the rowers won. We are indebted to our dear friend the late Elmer Hendricks Funk MD, a past president of the Philadelphia Skating and Humane Society, for some of the history.
Ice skating is both dangerous and seasonal. In the Eighteenth Century, ice skating was concentrated near the center of population on the Delaware River, and that's where you found the Skaters Club. You also found the Humane Society, whose main function was to pull drowning skaters out of the water. The Humane Society got to be quite rich because people were inclined to be sympathetic to lifesavers. In time, however, people moved away from Delaware and the two clubs, Skating and Humane, merged. No doubt the skaters thought they would be acquiring the substantial endowment of the life-saving club, but in fact, the Pennsylvania Hospital got most of the money in one of those genteel struggles that volunteer organizations sometimes get into. Skating moved from Delaware to the Schuylkill, and the club built a little house on what is now boathouse row, right next to the lighthouse.
The lighthouses at Turtle Rock was useful for the southern terminus of the canal just across the river on the West Bank, and for many years there was a little canal house on the Westside, making it easier to see what this was all about. The lighthouse became incorporated into a boathouse for the first women's rowing club, but the club died out and this combined, Sedgley, is now a women's luncheon club. Next door was the Skaters and Humane, fighting to survive among all the rowers. Since rowing has a much longer season than skating, the skaters feared they would be overwhelmed. They passed a club by-law that no officer of the club could be a rower.
However, the skaters had another enemy in the ice companies, who tended to chop up the first and best ice to form in the area. And the final blow came when the Arena was built at 45th and Market Street with artificial indoor ice. So, the boathouse became the home, in 1938, of the Philadelphia Girls Rowing Club, and the skaters and lifesavers moved first to the Arena, and then to Ardmore. Haverford College was glad to sell them a swamp they owned there since it wasn't much good for a college but the local springs provided needed water for the skating rink. With a rink, skating became year-round, and there was a roof to protect against snow and rain. You can't fall through the ice in a rink.
The club had a number of lucky breaks by being first, constructing its building cheaply in the depression, being able to use ammonia as a refrigerant, and getting cheap land. There are other skating clubs, but few of them own their own rinks, and no other skating club has the national prestige of the Philadelphia Skating and Humane Society. It is the oldest, the first, the best, and the most famous. If you are anybody in skating, this is where you want to skate.
There are plenty of problems with American health financing, but three features are the basis for optimism and the subject of this book. The first is the possibility that research can get us out of the jam we are in. The National Institutes of Health has started to prioritize its research, sensibly focusing on the most expensive diseases first. Opportunities will always dictate the attractiveness of a particular line of research to the investigator, but to the extent, a funder can influence choices, the N.I.H. has started to put a priority on the cost of diseases that cost the most to treat. It is their estimate that eighty percent of healthcare expenditures can be roughly assigned to only six diseases (Cancer, Diabetes, Parkinsonism, Arteriosclerosis, self-inflicted Conditions, and Psychosis.) If somebody gets us an inexpensive cure for only one of them, it would have a big impact on costs. At the moment, the best estimate of lifetime health costs is roughly three-hundred fifty thousand dollars per person, in the year 2000 dollars. By spending the present annual 33 billion dollars on research, it seems reasonable to look for a decline in health costs in the next decade, after which even research costs should decline. Expense is most heavily influenced by the need to institutionalize certain situations. I once wrote a paper on the patients in the Pennsylvania Hospital on July 4, 1776, and the diagnoses were remarkably similar to the present time, concentrating on disorders of the legs and brain, where you have to be put into bed to be cared for.
One thing we can, of course, be very sure of: everyone will eventually die, and thus will have one terminal illness. We can eliminate any or all five-- and you can be sure that something fatal will take their places, although you can't be sure it will be cheaper to treat. Nevertheless, longevity will lengthen, making healthcare cheaper, per unit of longevity. Perhaps the way to put this is to aim for only one fatal condition per lifetime and to re-design our insurance to anticipate this direction of things. As a side consequence, the longer you delay the grim reaper, the more income will be generated within Health Savings Accounts, more patents and copyrights will expire, more drug competition will lower costs. Unfortunately, the longer you live, the more it will also cost to extend that retirement. The resulting certainty is for greater consumption pushed into old age, and the likelihood is, more money will be spent on living expenses and less on sickness expenses. Any way you turn it, Social Security or it's equivalent will need more money, and Medicare or its equivalent will probably need less.
In later sections of this book, we discuss the creation of last-year-of-life insurance, as a re-insurance step to make this transition more automatic and less a debate about fairness. It takes decades to grow this fund to the point where it can accomplish its intended goal, so if we procrastinate, the problem will someday be upon us, leaving too little time to get it started. In the meantime, it's entirely possible to spend the premium money on short-term expenses, leaving it to our children and grandchildren to worry about. Since it's absurd to suppose toddlers and grammar-school children can be persuaded to fund their retirement by agreeing to consume fewer lollipops, it seems likely the first-movers will be well-to-do-parents, seeing an opportunity to escape taxes or refund future expenses of their own, like college tuition. And then, we might play the counter-cyclic game with the economy. Ingenuity might be applied to linking immigration quotas to domestic unemployment, or top-heavy stock markets. The worse our unemployment pool becomes, the less we need immigrants, and the more we need surplus cash for retirement endowment. If we are destined to have a fairness argument about prefunding retirement, let it be based on considerations like this. At least it has the potential to set ground-rules far in advance and can demonstrate what is politically feasible. For many decades it will be impossible to guess what future costs will look like. but meanwhile, actuaries and statisticians will be encouraged to speculate on how well we are doing, and how much individuals will have to supplement from their own resources. Newsmedia will have room to find examples of people who gambled and lost, or gambled and won, or what is likely to happen to everybody who ignores the problem.
The second optimistic direction to take has been known since Aristotle. Compound interest thrives on increased longevity. Ever since the pirate ships of the sixteenth century, our country has resisted the simple teachings of this mathematical assertion. In the past thirty years, we have crossed over the bend in the curve where it really is possible to derive astonishing multiplications of assets, simply by living as long as most people now survive. Never mind the trivial or even negative interest rates imposed by the Federal Reserve. The Fed has the mandate to maintain stable prices, and it will return to it, after a brief interval of praising inflation as a useful tool to manage a recession. The sixteenth-century pirates liked shares better than gold because they never could tell in advance when a sail they were pursuing into harm's way was a rich prize or a molasses barge. If we had to, we could base our currency on common stock index funds just as well as on debt or credit, and after a brief turmoil, things would be much the same.
And finally, we are edging toward a recognition that healthcare ought to enjoy a common tax exemption. We aren't there yet, but the tax exemption of Health Savings Accounts could close most of the gap for all Americans, and it has already made considerable progress. You could close the gap entirely by the passage of a one-line amendment, but you could also essentially close it by extending Health Savings Account deposit accounts to the point where differences were no longer worth fighting over. Once again, we have crossed an invisible line. When the public sector grows to be more than a quarter of the Gross Domestic Product, tax preferences become dominant and are no longer tolerable. We aren't going to shrink the public sector appreciably, we can't grow the GDP even up to a 2% growth target. So increasing the tax exemption is about all that is left.
We might, if you like, add a fourth direction to take. At 18% of the GDP, healthcare is too large to be distorted by a linkage to employment. Everybody naturally is reluctant to threaten a gift of 20% of his income; indeed, it would seem monster ingratitude to do so. Even though we know it is unfair (after all, life is unfair), and it makes the whole structure unsound to balance the health cost of the whole nation on the one-third of the population which is working -- and on less than half of that third -- who mostly aren't particularly sick. This can't last, folks, and you can say you read it here, first.
Between the Civil and First World Wars, we had a flirtation with specialty hospitals. Usually small, they were often owned by physicians with a large specialty practice. As a preamble to the Flexner Report and development of medical centers, they often clustered around a larger general hospital. Thus, the Pennsylvania Hospital was surrounded by several small special hospitals, in an era generally ending with their absorption into some larger general hospital with a wider range of services. So I taught podiatrists for a while and went crosstown to teach future veterinarians. I wasn't paid, I received no title; I just taught because some staff member asked me to, as a small extension of the "rotating" internship concept. That veterinary hospital is still the only private veterinary school in the nation, all others are state schools. To complete the background, the School of Podiatry was in the building of the Skin and Cancer Hospital, a block away from the Babies Hospital. Of these, only podiatry expanded and was moved a few blocks away, under the supervision of Temple University. Others just withered away. The University of Pennsylvania absorbed the veterinary school, found a few wealthy families to pay for it, and moved closer to the farms which survived the shrinkage of agricultural workers to 2% of the workforce.
I have to suppose podiatry flourished while the others withered because podiatry patients have since grown abundant, insurable and smelly--you could make a living without as much competition. Like funeral parlors, I see them scattered around the city, often taking up abandoned mansions in formerly prosperous suburbs. The tools of this trade are the heavy clippers for fungus-thickened toenails, and the occupation was once satirized by Tom Stoppard in the preamble to"Rosenkrantz and Guildenstern are Dead". Stoppard himself missed the point of Rosenkrantz's monologue, which was that older people mostly went to a podiatrist because their backs were so stiff they couldn't reach their toenails themselves.
|Dr. Charles Czeisler|
The Institute for Experimental Psychiatry Research Foundation meets alternatively in Boston and Philadelphia, in recognition of its rather complicated historical relationship with Harvard and Penn. The Spring 2005 trustees meeting was held in Boston, with Dr. Charles Czeisler of the Brigham and Women's Hospital making a presentation of his work with sleepy resident physicians. Sleep is now a central focus of the work of the Institute, particularly the effect of lack of sleep on performance. Resident physicians are a group with lots of experience with sleep loss, so much that such experiences as residents are central imprinting in the lifelong brotherhood of the profession. The public tends to regard the torment of protracted craving for sleep as some kind of dangerous hazing inflicted on professional newcomers by sophomoric seniors. Every once in a while, someone gets hurt by these games. That seems to be a general public reaction. For the most part, by contrast, members of the profession who have themselves undergone the experience turn away silently from such unfeeling remarks. As the old contraceptive joke about the Pope has it, if you don't play the game, don't make the rules.
In the first place, it is wrong to suggest that resident physicians are somehow helpless victims of authority, abused slaves of somebody's profit motive, or warped masochists enduring the process in order to inflict it on someone else. Perhaps the example of my classmate Seibert is useful. As a freshman medical student, Seibert was so overwhelmed by the volume of facts he was expected to learn, that he decided to give up sleep entirely. Seibert, by the way, was no moron; he was an honors graduate of a very selective Ivy League university. And he actually did stop sleeping for more than two weeks until he collapsed and had to be stopped. This was his own choice, gamely adopted in spite of general ridicule. And to show that overachieving is not limited to physicians, there was my oriental patient, the daughter of the President of her country. She related that as a graduate student she did not go to bed for three years; during all that time, she sat at her desk, slapping her face to keep awake. What we are talking about here is a self-selected group of committed and dedicated people, perhaps overly shamed by the specter of failure.
The work of our Institute has helped document and understand the injurious effect of sleep loss on performance; no one can go very long without sleep before responses and vigilance begin to deteriorate. A great many vehicle accidents are caused by drowsy drivers; it is a concern that pilots of airplanes on long-distance flights are to some provable degree less competent to land the plane. Therefore, it is not completely surprising to find that interns on protracted duty do make 20% more errors in medication orders, and nearly 50% more diagnostic errors. It is jarring to discover a measurable increase in the number of intern auto accidents, particularly when driving home from work. Maybe we ought to pass a law about it.
Commiseration is one thing; proposals to interfere are quite another. For one thing, the time-honored protection against the harm of this problem is redundancy. The complex, fast-paced and dangerous environment of a hospital, like that of an airline cockpit, has very little tolerance for lack of vigilance. Our solution has been to do everything three times, with overlapping responsibilities and repeated opportunity for catching errors before they get through to the patient. Although the malpractice lawyer seeks to pin the whole blame on some person, particularly one who is covered by insurance, the reaction of doctors to adverse events is to presume that at least three people must have cooperated in letting it slip through. At night and on weekends, the reduced staff tends to weaken the defensive network. But by every assessment, the greatest threat to our protective screen of redundancy is cost control. Any manager of managed care can find duplication and overlap in ten minutes of searching for it in a hospital; redundancy is a big factor in the high cost of running a hospital. The law of decreasing returns will dictate that it becomes very expensive to eliminate the last one percent of errors. To state it in reverse: it is very tempting to save a bundle of money in a competitive world, by accepting only a small increase in the errors. Since it is a matter of opinion, physicians are grimly determined that it shall be physicians who strike that balance. Those who press for more punitive treatment of physicians in the matter of errors should reflect that it surely will convince physicians to flee the risk of responsibility for the decision of where to strike the balance.
If you bend metal repeatedly it will crack; if you stretch a rope too hard it will snap. These unfortunate events are not called errors, and it is improper to search for blame in them. The medical profession is aghast that the public does not seem to appreciate that average life expectancy has increased by thirty years in the past century. That's not ancient history; life expectancy has increased by three years in the past ten. A system that produces a result like that is entitled to a certain amount of tolerance for its errors if we must call them errors. In other environments, that's known as pushing the envelope. Anyone who thinks it's fun to stand on your feet for thirty-six consecutive hours -- hasn't tried it.
Surgeons are perhaps somewhat more conscious of the need to train young professionals to drive themselves beyond ordinary endurance. After all, if an operation is unexpectedly prolonged, the surgeon can't just quit, he must finish. Neurosurgeons, with their fourteen-hour procedures, are particularly vehement on the topic. But it is true of every physician, too. When the telephone rings in the middle of the night, will this young fellow haul himself out of bed, or will he tell the patient to take an aspirin and call again in the morning? Increasingly, we hear complaints from patients that other doctors didn't even take the trouble to examine them; the implication that we are somehow not like that is very flattering. Part of the training is forbearance, too. At three in the morning, it is very easy to feel sorry for yourself and to reflect that an administrator with four times your income is home in his nice warm bed. The fact is, that if the person who is up and on his feet doesn't do the job, no one will.
Some incomprehension from bystanders must simply be endured with patience. Beyond that, it could be futile to seek a complete understanding. Quite recently, I was explaining to a young lady in a tailored suit who Thomas Cadwalader was. His portrait, beneath which we were standing, hangs in the great hall of the Pennsylvania Hospital. Although he died in 1789, Dr. Cadwalader is still famous for his remarkable, unfailing courtesy. A sailor in a tavern on Eighth Street once waved a gun and announced to the crowd he was going out the swinging doors to shoot the first man he met. The first man happened to be Dr. Cadwalader, who tipped his hat and said, "Good morning, sir." So, the sailor shot the second man he met.
The young lady in the tailored suit brightened up. "The moral of that story, " she said, "Is always wear a hat."
This little story of discarded pink slips, even after fifty years have elapsed, is on the short list of things I am proud of. I probably remember it so well because it was the forerunner of several other seemingly unrelated matters.
In 1956, I was the Chief Resident Physician of the Pennsylvania Hospital. That position doesn't exist anymore, but most hospitals at the time had a Chief Resident, who was in charge of the house officers, the interns, and residents. The Chief Resident was usually a doctor who had just finished his formal specialty training and was thinking about starting a private practice. He was the father figure to the doctors still in their post-graduate training years, all of them overworked and tense, concentrating on avoiding dangerous mistakes while learning to assume new and difficult responsibilities. He was old enough to carry the weight of authority but young enough so the residents could talk to him frankly, and still call him by his first name. The Chief Resident had his office and secretary near the accident or receiving ward, next to the resident's lounge, which contained mailboxes and coat hangers. The lounge was pretty shabby, as bachelor lounges tend to be, but it was all doctors, all the time, coming and going. If you wanted to know what was going on, this was the place to learn it.
Tom Paton, the credit manager, had his office further down the hall. In spite of his occupation, he was a jovial, convivial fellow, a former rugby player and soccer referee who fit right in with the lounge crowd. One day, I noticed he was throwing away a large stack of pink slips. He seemed surprisingly eager to tell me all about it. These slips represent the lifeblood of the hospital, sez he, without the flow of cash we would have to close the doors of the institution. Well yes, Tom, but taking care of the sick folk is sort of important, too. After a little explaining, I had to agree that he was talking about an interesting subject.
One of the everlasting problems in any hospital is to have the bill ready at the time the patient goes home. Nowadays, hospitals all have databases and many gigabytes of computing power, but the patient's bill is never ready when the patient is discharged and may take weeks to be sent to them. Hospitals put on a good face, don't you worry about the bill, madam, we trust you and we'll send it to you when you are feeling better. And all that, but the truth is they haven't a clue what your bill is.
All of that drove Tom Paton nearly crazy. The time to collect a bill is when the tears are still hot. Every day you delay the bill costs you a provable fraction of it, and so on. So, the system was devised that the tabulating machines of the hospital would routinely work all night to produce a bill for everybody, every day. If they went home today, they were handed a bill. If they didn't go home, the bills were thrown away. For accounting purposes, a carbon copy of each bill was kept on pink paper. It was an amazingly simple idea, far less expensive than the random-access real-time whatchmacallits that nowadays do a far less effective job, and are out of commission much of the time. Let the record show that in 1956, every single patient at Nation's First Hospital got his bill as he was leaving, any time night or day. IBM charged us eleven hundred dollars a month to rent the machines, which also did the payroll and inventory systems.
An idea occurred to me. If you are only going to throw them away, could I please have the pink-slip copies of the bills of the patients who did not go home? Those patients are still in the hospital, and these slips show how much cost each patient is in the process of running up. So a system was established that my secretary got these pink slips every day, and put them in the mailbox of the doctor taking care of the patients. It was a simple thing to do, but the reaction it got was explosive.
At first, the interns thought I was warning them, or criticizing them, but they soon got over that. We were all appalled at the costs which were being generated and particularly appalled when a patient stayed a little longer than necessary. In those days before Medicare, any unpaid costs had to be made up by contributions and private endowment. The house officers and the student nurses who did most of the work received no salary. The sense of guilt that arose from looking at those bills was very strong, and it was obvious that every one of them went back to the wards to try to speed things up. Since they all left their training to practice in various communities for fifty years, I like to believe that the multiplier effect was significant.
In those days, we had a two-year rotating internship. Every month before rotating to a new service, each intern would summarize the remaining patients on his ward for the benefit of his successor. In doing so, they were able to reflect in retrospect how each case could have been speeded up a little, and therefore wouldn't still be here to require a summary. There is an invisible counter-pressure at work. From a doctor's point of view, most of the heavy work of each admission to the hospital is concentrated in the first couple of days. You get things into motion, and then sort of watch it rolls out. But if your ward is full, you can't get any new admissions, so your day suddenly gets a lot easier. Just let one of them go home, and bingo you have a new one. This little human frailty affects every one of them to some degree, and each one thinks he may have discovered this hidden incentive to slow discharges, except on the last day of the month. It was my job as Chief Resident to keep the system from sludging up. As much as for any other reason, an increased turnover meant more cases per intern, and therefore more training and experience. That's what most of them thought I was up to when I started handing out the pink bill copies. It really wasn't purposeful at all, it was just sort of an accidental discovery of something useful.
From that, I developed an interest in efficient use of hospitals, a subject we called utilization review. Through the County Medical Society, I formed a club of other doctors at other hospitals who had the same interest. When Senator Bennett of Utah got a law enacted, this organization turned into the Philadelphia Professional Standards Review Organization, which became part of the Pennsylvania PSRO, and eventually a national one whose name has changed several times. We had some interesting battles at the AMA House of Delegates, which dissolved into insignificance when the national business organizations took matters into their own hands and used their control of employer health insurance to push HMOs, Health Maintenance Organizations, onto the hapless public. Public outrage about HMOs put egg permanently on the face of national business, but the matter is now worse, not better.
What I got out of all this was an enduring interest in computers, which has served me well for half a century. And a sense of outrage bordering on apoplexy whenever some well-meaning activist declares that the doctors are responsible for pushing up hospital prices to enrich themselves in some way.
|General Giuseppe Garibaldi|
General Giuseppe Garibaldi unified Italy, but a great many Italians either didn't want to be unified, or emigrated to America after 1860 to escape the turmoil. The far western tip of Sicily was the most remote place in Europe, protected by mountains and volcanoes, speaking its own language, and loyal to no government except its own informal one. Over a period of centuries, secret traditions of feudalism and invisible governance had protected Sicily from invaders of various sorts. Although religion was a powerful force, theirs had traces of the Greek Orthodox Church; allegiance to the Vatican faded out as the local priesthood got closer to it. These people mostly wanted to be left alone, and dealt with outside authority in various devious ways, not stopping with murder if necessary. Informal taxes were collected as "paid protection" since a secret army costs money if only to support funerals and soldiers' widows. Rank within the underground army was identified by various degrees of "honor", which could sound vague but were in fact quite unambiguous. Central to the code of the Sicilian underground government, like all guerilla movements was a strict rule of silence, "omerta". As an intern in a hospital accident room, I have seen members of this organization actually go to their deaths, grimly repeating the mantra, "I don't know nuthin."
Italy may have been unified by Garibaldi in the sense of being freed of French, Austrian and Papal domination, but unification was far from peaceful and contented, with losers often choosing emigration. A second wave of emigration was provoked by the harsh rule of the dictator Benito Mussolini, who determined to squelch underground resistance once and for all.
Western Sicilians originally chose New Orleans as their new home, which unfortunately for them already had its own secret society, the Ku Klux Klan. A prompt reaction to the "Italians" with ten or twelve lynchings soon convinced the Sicilians to resettle elsewhere. It seems possible that some of the later techniques of the Mafia were learned from the Klan. In any event, the Sicilians split into two main groups, one going to New York and the other to Philadelphia. Offshoots of the New York group moved to the mining areas of Luzerne County in central Pennsylvania (Hazelton), while another early group migrated to Norristown. There were, of course, links of intermarriage among these groups, but in the early years they drifted apart as separate colonies.
Italian immigrants were no exception to the common tendency of new immigrant groups to gravitate into crime. Records of the Pennsylvania police and jail systems for three centuries show successive waves of inmates with surnames identifying Scottish, then German, then Irish, and eventually Italians. At present, seventy percent of prison inmates are black. Almost without exception, the main victims of immigrant predation have been members of their own immigrant group. Immigrants are easily victimized, somewhat defenseless, and uncertain of the assistance of local law enforcement. Among the most famous of the lawless predator groups among the Italians was the Black Hand, whose specialty was extortion with notes signed with a black hand symbol, enforced by putting bombs under porches. Locals will show you a place on Ninth Street a couple of blocks from the Pennsylvania Hospital where the Black Hand blew things up. The Black Hand, however, was not the Mafia; it exemplified what the Mafia was formed to control.
The Italian community for fifty years was centered on Christian Street, mostly between Eighth and Ninth, gradually migrating westward toward Eleventh Street. Christian Street had been named by the Swedish Philadelphia colony after their monarchs, but the original Swedes tended to remain in Queen (Christina) Village, along Delaware, while the newer migrants drifted to newer areas. During the Civil War, northern railroads heading south ended in Camden. In time, the main Civil War traffic ferried across the Delaware River to wharves at the foot of Washington Avenue. South Street was the honky-tonk area, with a black community growing along with it. After the War, an immigration station was constructed in the Washington Avenue wharf, and the new Italians tended to settle nearby. As the streets were extended westward, the street names were also extended, but the region of Eighth and Christian was largely open fields when the Italians moved into the area, and never had been Swedish. Although there were forty or more murders in the block of Christian from Eighth to Ninth in ten years after the first World War ("Murderers Row"), in modern times the neighboring region is prized by Italian residents as an extremely safe place to live, because the Don likes it nice and quiet.
While it is probably true this safety net quality might not be so evident to blacks and Vietnamese, the safe streets for Italians feature are universally attributed to the Mafia. The Sicilian group quickly reestablished the secret army of "soldiers" and "dons" (usually one don overseeing ten soldiers), started collecting taxes in the form of protection money from the local residents, and putting one "capo" in overall command. You had to be a Sicilian, and a Western Sicilian at that, to be eligible for membership in this secret army. The hierarchy was secret but could be surmised by the elaborate "respect" paid by one to another.
My office partner, Dr. Robert Gill, tells a story illustrating the paying of respect. He was called in consultation to an Italian home by Dr. Baglivo, a highly respected general practitioner in the Italian community. The two of them walked down Eighth Street, and as they passed a barber shop, Dr. Baglivo suggested they both go in for a haircut. Evidently, the patient to be visited was a very important person, and as they went in the shop, Dr. Baglivo introduced Dr. Gill to the group of assembled loiterers as the big doctor from the Pennsylvania Hospital, come to visit you-know-who with the last name ending in a vowel. The group jumped to their feet, in respect, and the barber turned to the lathered-up, half-shaved man in the barber chair. "You!", he cried out, "Get out of that chair! Let the Doctor have a haircut.!" The man dutifully scrambled out of the chair with shaving cream dripping, and humbly sat in a waiting chair, while the big doctor got his haircut. As they left the shop, payment for the haircut was elaborately refused. The point, of course, is not so much one of respect for the medical profession, as respect for someone who had been chosen to attend a capo.
The Mafia was thought to do a fair amount of slashing and breaking of kneecaps, but killing was not permitted except at the order of the boss, or capo. The police could be fairly tolerant of informal methods of law enforcement, but dead bodies brought newspaper attention where even paid-off politicians might not be able to shield the Organization from "heat". For the first forty years, members of the Mafia were sort of volunteer firemen, earning their living as tradesmen and laborers; Mafiosi were paid protection money but were not generally wealthy. The identity of the capo was for forty years a complete mystery to the non-Sicilian community.
But then, along came Prohibition.
Prohibition created big money fairly safely, so bootleggers proliferated widely. It was soon no longer possible for one tightly-knit fraternal organization to intimidate a whole host of petty criminals acting alone or in small groups, so the Mafia was forced to control the bootlegging industry through dominating its sources of supply. As a general rule, "rum-running" involved bringing in conventional brand liquor from Canada. That route made Chicago, Boston and New York the major entry and distribution points for "good stuff". From Philadelphia south, most illegal liquor was "moonshine" or other illegally distilled products. Some liquor was distilled in abandoned buildings and garages, but a substantial amount was distilled in the Pine Barrens of nearby New Jersey. The colorful history of the Teamsters Union can be traced in part to the transportation network established for conveying one form of bootleg or another to its retail destinations. Trucks were often hijacked, so paid protection took a new motorized form. The manpower required soon exceeded the number of Sicilian neighbors related by intermarriage. Local groups had to be coordinated with national groups, requiring the establishment of syndicates and governing councils. Even then, one group of recognized Mafia might collide with another; the resulting murders had to be negotiated through a quasi-judicial appellate system.
Philadelphia appears to have had a share of gangland warfare, but mainly that was based in Chicago and New York. In one year, Chicago experienced four hundred gangland murders, Philadelphia only forty. Al Capone came to visit Philadelphia, for reasons unknown, was assured he was most unwelcome and got himself put in jail, for his own protection. Eastern Penitentiary likes to show off his well-decorated cell, to which meals were apparently catered. What was really going on remains a mystery. A group of ten Philadelphia Mafiosi is now known to have gone to New York to participate in the "Castellammerese Wars", where two large New York Mafia groups engaged in a fierce battle for supremacy in what was now a source of vast riches. Occasional lurid episodes like this surfaced in Philadelphia, but the Mob was determined to remain as obscure as possible, and many details are missing or deliberately misrepresented. The essence of it all was that Prohibition had transformed the Mafia from a little vigilante group who imposed law and order on a lawless immigrant community, into a tightly organized army of killers, who mostly devoted their war efforts to exterminating rival tribes, while their daily activities consisted of running marginally tolerable criminal activities like gambling and loan sharking.sting book by Celeste A. Morello called Before Bruno. In 1927, the Mafia decided they could no longer tolerate the Zanghi gang of four or five or a somewhat larger gang of Lanzetti brothers. On Memorial Day, 1927, several Zanghi members were standing on the corner of Eighth and Christian, when they were approached by several men in black overcoats. Down the street came a car with several others carrying shotguns. After the smoke cleared, three Zanghi (one of them the uncle of Mario Lanza the singer) were lying in a pool of blood, and the car went careening down Christian Street with four Mafiosi, including Salvatore Sabella, crouched on the running boards. "Musky" Zanghi, who was intended as another victim, emerged from the neighboring building and acted like a crazy man. "Sabella," he cried, "Sabella did it!". And he continued to squeal, right into the police station and newspapers. The unthinkable had happened; someone ratted. As it turned out, Sabella was revealed as the Capo himself, and general consternation ensued. Just how this information got circulated is unknown, but a story has it that $50,000 was paid to Musky to shut his mouth, Musky failed to appear in court as a witness, the court system was persuaded to blame the whole thing on an unknown underlying named Quattrana (who went to jail for eight years), everybody else was not guilty, Sabella retired as capo at the remarkably young age of 40 and lived for years in Norristown. In fact, because of the 1929 crash, Sabella the capo had to work as a butcher in Norristown, receiving small gifts as a pension. And, as these undocumented stories would have it, it took fifteen years but eventually someone, surely a friend of Sabella, "got" Musky Zanghi, who was hiding out in New York.
And the Lanzetti brothers? Well, they got eliminated, reputedly by Sabella's successors in the organization, but the violence triggered extensive Grand Jury investigations led by Judge Edwin O. Lewis, later the father of Independence Mall. Thereafter, mob rubouts became considerably less frequent. Although newspaper and FBI activity had been extensive, and apparently effective, a more detached view makes it more likely that repeal of the Volstead Act was the major factor causing mob activity to subside.
|Blood and Honor: Inside the Scarfo Mob, the Mafia's Most Violent Family George Anastasia ISBN-13: 978-0940159860||Amazon|
|Before Bruno: The History of the Philadelphia Mafia Book 2 C. A. Morello ISBN: 978-0967733425||Amazon|
|The Last Gangster George Anastasia ISBN-13: 978-0060544232||Amazon|
|The Last Mouthpiece: The Man Who Dared to Defend the MobRobert F. Simone ISBN-13: 978-09401596932||Amazon|
|The Pine Barrens: John McPhee: ISBN-13: 978-0374514426||Amazon|
Many of the a older houses in Philadelphia still have Plaques to the front wall, usually between two windows on the second story. These are the symbols of colonial fire companies, signifying that this particular house had paid its dues to a particular company and was entitled to its services if it ever had a fire. There are two exceptions to this rule, one showing four hands gripping wrists (the fireman's "carry" technique), which was the symbol of Franklin's fire insurance company, otherwise known as the "Contributionship". The other shows a Green Tree, the symbol of a competitor fire insurance company which found a business opportunity in ensuring houses with a tree on the property, something the Contributionship declined to cover. These fire insurance companies are the only survivors of a type called "perpetual" fire insurance. Since the Contributionship is the oldest fire company in America, while the Green Tree company was fairly recently involved a controversy with its directors some of the most prominent people in the City they generate highly interesting histories, as organizations.
But in many ways, the more interesting feature about them is their unique business plan, which contains some important lessons for the rest of the insurance industry, particularly health insurance. Since health insurance is now one of the great unsolved problems of national life, it is perhaps worth a little trouble to understand perpetual insurance as a concept. It isn't that hard, so stick with it.
A fire insurance company has to figure out each year's risk of fires and set a premium large enough to pay for that risk, but not so large as to drive away business. If there's some unspent money left over at the end of the year, that profit belongs to the company. When Ben Franklin was starting the first fire insurance, he had no way of guessing what the risk was going to be, so he guessed far on the high side. So as to keep from scaring away his customers, the agreement was that any surplus would be applied to the following years, invested in the meantime. After a while, the investment income was enough to pay for the fires, plus enough to pay a dividend and to return the whole investment if the home-owner wanted to move to another house. Here was perpetual fire insurance. A returnable, lump-sum investment paid for the fire insurance, paid a nice dividend, and you got your money back if you wanted it. Its most extreme example was the policy taken out by thePennsylvania Hospital during colonial times, which still pays about 15,000 annual dividend, plus they have had fire insurance for two centuries from an investment which seems trivial in retrospect. Why doesn't everyone have perpetual fire insurance? Why is it now a quaint little forgotten idea that almost no one knows about?
|the 1929 crash|
There are conspiracy theories, of course, that greedy insurance companies prefer to sell you a more expensive product that is more profitable for them; forget that line of argument. A more plausible criticism is that the managers of perpetual insurance have to take a long-term view of risk. The perpetual companies are reluctant to insure a house that has any significant chance of having a fire, ever. Philadelphia long ago prohibited wooden structures, however, and the building codes have become progressively more strict. Another source of customer reluctance grew out of the 1929 crash, which destroyed for generations the confidence of the public, and for that matter the board of directors, in the safety of long term investments. If the investments become too timid, they will generate a reduced return, and inflation of the cost of replacing a burned-down building may slowly pull ahead of the investment income which is supposed to cover it. The tax laws will inevitably change over a period of time which describes itself as perpetual, and somehow or other the investment safety may become impaired by politics.
A more subtle risk is inherent in the nature of building materials. If you have a stone house, you expect to have your fire insurance restore you to a stone house. But houses were built of the stone when a stone was locally abundant, and cheap. Nowadays, it gets harder and more expensive to find and transport suitable stone, and much harder to find a skilled stone mason. One of the reasons you hire an architect is to direct you to the newer, more modern materials and techniques, and away from obsolete, expensive materials of the past. In summary, therefore, the managers of the company must establish a set of predictions about the perpetual risk of your house burning down, and the perpetual cost of replacing it. If they guess too low, the money you invested will eventually run out, and you will be left with a perpetual promise, but no money in the treasury to pay for it. All of this woeful, fearful whimpering, however, must be set against a two hundred year history of a simply glorious investment opportunity. You have to trust your company to be smart and, to be honest. Who trusts anyone, any more?
Tax-hungry Pennsylvania government has voted to allow two gambling casinos to be built on the Delaware River, near the historic district. A lot of angry people declare that must never happen, and it surely will not happen much before 2012. For the time being, and we hope longer than that, the oldest and most historic part of Philadelphia will exist as a quiet little nook fifteen blocks from the business center, with quite a choice of very pleasant, moderately priced hotels and bed-and-breakfasts. In the midst of this, at 2nd and Walnut, is a very large parking facility, with even more parking space available within a couple of blocks. For reference, let's call the site of William Penn's own home the epicenter of all this. It's now called the Welcome Park at South 2nd Street. The ship which brought Governor Penn to his land holdings was called the Welcome. Anyone who can prove descent from those who were on the ship is eligible to be a member of the Welcome Society.
Welcome Park is across 2nd Street from a restoration of City Tavern, which only serves meals (in authentic period dress) but at one time was the place where the delegates to the Continental Congress and the Constitutional Convention stayed overnight. And of course, did lots of negotiation at night over a cold beer. It's also next to the famous Old Original Bookbinder's restaurant which unfortunately is out of business we hope temporarily because of ill-timed overexpansion by the former owner. It's a very large restaurant which used to be able to obtain four-pound lobsters and bake them for tourists. If legalized gambling does make an appearance, the winners are likely to frequent this spot, unless the new owner continues the former tradition of hiring the only truly surly waiters in our otherwise friendly town.
|Dr. Thomas Bond House|
A hundred feet away is a quiet upscale Sheraton, much favored by Society Hill residents. Over a footbridge is a Hyatt, next to the marina on the river, and favored as a hangout by the younger sports in the area. There are at least three charming bed-and-breakfasts along the block, of which the favorite is a 12-room hotel directly facing on Welcome Park. It is the former home of Dr. Thomas Bond, who founded the Pennsylvania Hospital with Ben Franklin's help. Not only did Dr. Bond found the Nation's first hospital, but he also started the tradition among American physicians of not charging for their services to the poor. Without that sort of leadership, the hospitals could never have survived their early years.
So, here is where to begin your tour if you are from out of town. A big garage to store your car, right next to several choices of quiet but moderately priced hotels, and a couple of dozen restaurants. This is a great place to branch out to the historic district, or Society Hill, or the seaport museums and marinas. And maybe some gambling casinos, although it is hard to imagine much tolerance between that group and the history lovers.
By the way, Philadelphia hotels are like hotels everywhere else in one respect. If you forget to make a reservation in advance, just breezing in looking for a room for tonight, you must expect to find the price is nearly doubled.
Charles Peterson developed the idea but was unsuccessful in popularizing it, that Spruce Street in central Philadelphia could be regarded as an architectural museum. It stretches from river to river but has no bridge or ferry landing at either end, so traffic is less. The earliest house still standing near the Delaware River was built in 1702, with successive houses just a little younger, or at least less old, as you progress toward Broad (14th) Street whose houses were built around 1880. And then onward into the early Twentieth Century, crossing Broad Street and going westward toward the Schuylkill. For a century or more West Spruce Street was where eminent specialists had offices, much like Harley Street in London, which it somewhat resembles. The medical flowering of this area was promoted by the surgical advancements of the nearby Civil War, as well as the contributions of Andrew Carnegie to moving the College of Physicians from 13th street to 21st Street, attracted toward the 7000-bed Civil War hospital which turned into Philadelphia General Hospital in West Philadelphia. A number of these houses are just plain too big to be manageable as single family houses today, and Spruce Street West has lagged Society Hill and other Easterly sections in restoring its buildings. Perhaps in a few decades, that will happen, and perhaps in the meantime, the present relics will be preserved enough to revive someday the idea of a house design museum. Meanwhile, West Philadelphia around Spruce Street has obstructed progression by plonking the University of Pennsylvania, Drexel University and the Science Center as obstacles to residential housing development.
So let's take a simpler idea. For roughly a century, the then-richest men in America lived in one of several houses located within seven blocks of each other, easy walking distance for a tour. The first to attract notice as a self-made rich man was Robert Morris. Morris made his money in shipping, maybe even a little privateering, and then went into banking to keep his money at work. It is said that his personal fortune, adjusted for changes in the currency and economy, was once considerably larger than Bill Gates' would be today, adjusted for inflation. As most people know, Morris financed the American Revolution personally, went broke, ending up in debtor's prison. The first real mansion he lived in was opposite Independence Hall on Market Street, now celebrated as George Washington's while he was the first president. It was earlier the place where British Admiral Gates lived while he was in charge of the 1788 British occupation, and although it was also where Washington lived during most of his presidency, the house burned down in 1832. This house is not to be confused with either the house built for Washington at 9th and Market but never occupied by him or Morris's later mansions which he also never occupied because of financial difficulties. One house in the midst of Jeweler's Row was so ornate some think it contributed heavily to his later bankruptcy. A second Morris house still stands on Eighth Street at St. James Street, but it belonged to the Quaker Morris family, no relation. Other owners named Morris bought and occupied this place for a number of years, so its history is a little mixed up, presently as a fancy restaurant. A DuPont heiress once bought and fixed it up, but her husband commented no one could sleep in that house because a subway built underneath it badly rattled its timbers. Next door to the Quaker Morris house rises a fifty story apartment house, whereas a precaution against rattles, the first nine stories contain nothing but parking spaces. Since the apartment building is owned by Arabs, it is likely they are pretty rich but not necessarily richer than Bill Gates. Aside from the Market Street partial restoration, the main Robert Morris remnant is on Lemon Hill, northwardly opposite the Art Museum, whereas the main Quaker Morris house is in the Morris Arboretum in Chestnut Hill. There are sixty or so Morris's listed in the Social Directory, so keeping the two families distinct remains a difficulty in some circles.
On the Northeast corner of Third and Spruce Street, once lived William Bingham, a former partner of Morris and later himself the richest man in America. Although sadly the house burned down, it is displayed in one of the famous prints by William Birch in his notable Eighteenth Century collection , widely available in bookstores. The striking thing about Bingham was that he was only twenty-eight years old when he achieved richest-man status and built the house, patterned after one owned by a British Duke. He made his pile three times over. First, running a privateer operation in the Caribbean for his partner Robert Morris. On returning home, he bought up any worthless Continental currency he could stuff into barrels, and then either persuaded his friend Alexander Hamilton to redeem the currency at par or heard his plan to do so. And then, as if he didn't have enough money already, he invested enough gold bars to finance the Louisiana Purchase for Jefferson, since Napoleon wanted gold, please, no paper money. Among the various things he bought as an investment was the area in upstate New York, now called Binghamton. He lost a pile of money buying the land we now call the State of Maine since post-revolutionary Westward migration turned toward Ohio rather than into his Maine holdings once the British prohibition on colonizing past the Allegheny mountains was lifted. Bingham's sister-in-law wanted to become engaged to the heir of the Crown of France, who was living in temporary exile around the corner on Walnut Street. In a famous, possibly fictional, response, the Dauphin was told, No. If you do not become the King of France, you will be no match for her "The Golden Voyage". Quite a good read, and of particular interest to Philadelphia lawyers who learn Bingham died in 1804, but his estate was not settled until 1960. The lawyer who closed the case reported his partners were less than pleased to see it go.
Stephen Girard built several houses a few steps west of Bingham on Spruce Street, identifiable by having marble facing on their lower few feet; Charles Peterson lived in one of them as the first pioneer resident of the Society Hill revival. Girard made his money in the China trade, as a ship's factor. Like Morris, he recognized America's crying need for banking in a story too complicated to repeat here and moved the Girard Bank into the First Bank of America, now a museum (Peale portraits, architectural fragments) of the Park Service on Third Street. His wife was insane, and spent most of her life at the Pennsylvania Hospital at Eight and Spruce, and was eventually buried there. Girard left thirty million dollars to found the Girard College for "poor, white, orphan boys". His 1830 will withstood all legal attacks until the mid-Twentieth Century but was eventually broken. The school now has many black girls, is bankrupt, and the definition of orphan has expanded to include any child whose parents are separated. The definition of "poor" is several times greater than the national definition of the poverty level. In his will, Girard specified that the estate should purchase what is now Schuylkill County and hold it for a century. Shortly thereafter (or just possibly very shortly before that), coal was discovered in the region and Girard College became far richer. His correspondence includes many letters to Lafitte the Pirate, so more may be heard of them.
Nicholas Biddle had "old money", which he made in the traditional way of buying real estate, particularly in Ohio. He thus made a better guess than Bingham about the likely path of westward migration. But like Morris and Girard, he needed a bank to finance the real estate. Biddle also acted as the reserve bank for the myriads of currencies then issued by individual rural banks and charged a transaction fee to translate Kentucky money into something useful in Philadelphia or abroad. Martin Van Buren, who was the political manipulator behind Andrew Jackson and who became Andrew Jackson's eventual successor, stirred up trouble about this reserve role, and Jackson "broke" Biddle's bank by withdrawing federal deposits. Jackson's complaint was that holding federal "paper" eventually resulted in a government guarantee the bank could never fail, in an echo of the present accusation of some banks being "too big to fail". Ultimately, investment banking began to take its modern formwhen in 1838, the richest man, Anthony J. Drexel, moved over the Schuylkill River on Walnut Street, amidst what is now the University of Pennsylvania, but not far from Drexel University. He walked to work each day, however, at 4th and Chestnut Streets. Drexel was the first big banker to make his fortune in banking, and when he died it was said Philadelphia banking died with him. The earlier big bankers started out with money they had made in shipping or land speculation, but Drexel somehow saw that banking was a different way to get rich, deftly filling in the gap created by Andrew Jackson shuttering Nicholas Biddle's Second Bank. Part of the idea in Van Buren's mind was to shift the focus of American banking from Philadelphia's Chestnut Street to New York's Wall Street, and he was quickly quite successful. J.P. Morgan was invited by Drexel to start a Wall Street partnership with him in correspondence with his father, Junius Morgan, who ran an international bank in London. In the era just after the Civil War, there was a great deal of money in Europe anxious to be invested in the railroads and other booming American industries. The Morgans provided a vehicle for transferring such investment capital between continents, but the Morgans were viewed as having excessively sharp practices. As it happened, Junius Morgan had been trained in this transoceanic concept by George Peabody, a former Baltimore resident who had moved to London, then, the banking capital of the world.
George Peabody earlier had also been involved with Anthony J. Drexel, and Drexel was the more successful of the two international bankers. The whole issue with European investors was whether you could trust those wild and wooly Americans, and Drexel consistently demonstrated he was entitled to be called a straight arrow. As related by a good book by Dan Rottenberg Drexel decided he needed the vigor of the Morgans and invited them to join him in a New York-Philadelphia partnership. From that point forward, JP Morgan was the shining star of honesty and straight dealing, a lesson he evidently learned from Drexel. Indeed, he and his biographers repeatedly stress this feature of him -- "I will never do business with a man I don't trust". He didn't mention women, but his behavior seems to show he probably didn't include them in the concept. Drexel, on the other hand, led a quiet sober life in West Philadelphia, reading books, starting his university, and helping his niece, who was later made a Saint in the Catholic Church, start numerous charities. Although the Drexel children more or less drifted out of sight, Drexel's business successor Stotesbury led a wild and extravagant lifestyle that is the subject of many songs and stories. His wife, for example, never washed the sheets; she always had brand new ones put on the bed. Morgan, of course, spent lots of money in a conspicuous way. The term Metropolitan identifies most of his projects, The Metropolitan Art Museum, The Metropolitan Opera, The Metropolitan Club on Fifth Avenue, with membership originally limited to his partners. The name Corsair also was a trademark, the name of his yachts, and a firm statement about his approach to things. Another difference between the Morgans and the Drexels was similarly in the New York-Philadelphia character. When Jack Morgan, the son of JP, died in the 1930's he left an estate of "only" three million dollars. It would be hard to say what the Drexel fortune was worth at that time, but it is safe to say it would dwarf that, considerably. Most of the Drexel family moved to London, but among other things, financed the restoration of the Benjamin Franklin House on Craven Street, a hundred feet from Trafalgar Square. When the House of Drexel was much blamed for the 1987 stock market crash, legions of Drexel defenders rose to protect the family name. Cabrini College, Eastern University, Valley Forge Military College, St. David's golf course and much of Radnor are only pieces of the Drexel holdings, today.
|Philadelphia Food Bank|
Philadelphia is full of people and institutions that have done wonderful things without a lot of fanfare and hype, butPhilabundance and its executive director, Bill Clark, surely set some sort of record. The organization has been in existence for twenty years and is generally known as a nice charity that gives surplus food to poor people. And how.
With a four-million dollar budget, they distribute food at a cost of about ten cents a meal. From that, you can easily calculate they are both efficient and big, very big. For a long time, they collected left-over food from restaurants and caterers and gave it to poor folks in shelters. But that was before someone had the brilliant idea to hire an executive director who had formerly been an executive in the supermarket business, rather than a dietician or a social worker or a retired lawyer. Nowadays, Philabundance still takes the calls from restaurants and caterers but refers them to some local food bank to do the pickup. And it doesn't distribute food to the poor itself, instead, it helps new churches get established in poverty regions, showing them how to organize and run food distribution agencies, or stores or kitchens.
Philabundance is going for big deliveries, and cutting the big costs in the food chain. Clark knew who was dumping the food, by the carload, and it wasn't restaurants. He organized a system of collecting bread from major bakeries, fruit from major importers, meat from the food distribution center -- in carload lots. Someone from inside the food distribution system knows how tightly organized the shelf life is, and if he can get bananas to his eaters in five days, he can have them free from people who absolutely must have eleven days to get them through a delivery chain of fussy people picking and choosing what is on display before they buy. In a market system where food is routinely discarded in order to maintain stable prices (ask any farmer), someone who knows what he is doing can really get some bargains for the poor. You have to know about taxes, too. Donations of food are not just deductible at cost, but at cost plus half of the normal mark-up. A great many of the cargo containers arrive at Philabundance warehouse, unopened because they arrived too late for the weekend buying rush, and would otherwise have to be sold at low Monday prices. There's a lot to learn about this business.
Food stamps might be a better way to distribute food to the poor, but big cities have an acute shortage of supermarkets, as you soon learn if you live there. New York has an extensive system of neighborhood mom and pop groceries, but Philadelphia doesn't. It's hard to know whether mom and pop stores can't survive in Philadelphia for some reason, or whether New York's notoriously political-legal system is slanted in favor of them, along with rent-controlled apartments on Park Avenue. Supermarkets in center city are hampered by the underlying supermarket the assumption that there will be ample place to park a car at both ends of the shopping trip. Since it is easy to pay $300 a month to park in center city, and even then you find the attendant may have parked someone else in the aisles, you can see that the supermarket idea, which largely developed in Philadelphia in the first place, is more popular in the suburbs.
So, anyway if you are going to throw food away you might as well give it to the poor and get a tax deduction. And if you are going to give food to the poor, you might as well be efficient about it. No doubt there will be some who raise the point that making things free for the poor will attract more of them into the region, raising Medicaid costs and so on. Maybe that's why Bill Clark draws so little attention to the splendid job he is doing, but if so, we really must betray him.
|South East Prospect of Pennsylvania Hospital|
There is a painting of the region around 8th and Spruce Streets in the 1750s, depicting a pasture, with cows, and three or four buildings between 8th and 13th Streets. When the Pennsylvania Hospital moved there in 1755 from its temporary location in a house located a block from Independence Hall, there were complaints that it was now located so far out in the woods that it was difficult and dangerous to go there. Still another description of the area is evoked by the provision which the Penn family placed in the deed of gift of the land, strictly forbidding the use of the land as a tannery. Tanneries have always been notorious for giving off noxious odors, so most people wanted them to be somewhere else, anywhere else. In any event, the main activity of Penn's "green country town" at that time was concentrated closer to the Delaware River, and the nation's first hospital was definitely placed in the outskirts. Two blocks further West the almshouse was already in place, but not much else. We are told that Benjamin Franklin had flown his Famous Kite at 9th and Chestnut, using a barn there to store his materials. It might be recalled that the population of Philadelphia, although the second largest English-speaking city in the world, was only about twenty-five thousand inhabitants at the time of the Revolution, and in 1751 was even smaller.
In any event, the first and oldest hospital in America was built on 8th Street between Spruce and Pine, and the Eighteenth Century buildings on Pine Street still present a breathtaking view at any season, but particularly in May when the azaleas are in bloom, and fragrance from the flowering magnolias fills the evening atmosphere for blocks around. Although some people today mistake the Pennsylvania Hospital for a state hospital, it was founded in the reign of George II, decades before there was such a thing as the State of Pennsylvania. The Cornerstone was laid by Benjamin Franklin, with full Masonic rites. Most doctors regard a hospital as a mere workshop, but the affection with which many Pennsylvania physicians regarded their special hospital is indicated by the number who have requested that their ashes be buried in the garden.
For two hundred years, beginning with the first American resident physician Jacob Ehrenzeller, the interns and residents were paid no salary, so they had to live on the grounds. An Internet was just that, interned within the four walls for at least two years. Because the resident physicians had no money, they stayed in the hospital at night and on weekends, playing cards and swapping stories. The hospital was home for them, as it was for the student nurses, likewise unpaid but more strictly confined and supervised. This penury seemed acceptable because the patients were mostly charity ward patients, otherwise unable to pay for their own care. Ehrenzeller finished his medical apprenticeship and went to practice for many decades in the farm country of Chester County, but gradually upper-class Philadelphia moved from 4th Street westward to and beyond the hospital, and two of the richest men in American history, Morris and Biddle, had houses within a block of the hospital, although Morris never lived in his house, having more pressing matters in debtor's prison. Therefore, later resident physicians at the hospital had the potential of setting up a private practice in the area and becoming society doctors as well as academically prominent ones. Being a charity hospital in a rich neighborhood created the potential for volunteer work by the town aristocrats and large bequests for charity. The British housed their wounded in the hospital during the Revolutionary War and shot deserters against the red brick wall of the small cemetery to the north. A century later, there were a couple of dozen rooms for private patients in the hospital for the convenience of the doctors and the neighbors, but everyone else was a charity patient. And a century after that, the hospital still did not have an accounting department to collect bills and tended to regard people who asked for a bill as a nuisance. Benjamin Franklin is regarded as the Founder of the hospital, and his autobiography famously describes how he fast-talked the legislature into matching the donations of the public, not mentioning to them that he had already collected enough promises to see the project through. This seems in character; Franklin's biographer Edmond Morgan summed up that, "Franklin doesn't tell us everything, but what he does tell us, is straight." The idea for the hospital was that of Dr. Thomas Bond, whose house is now a bed and breakfast on Second Street, but it was characteristic of Franklin to be the secretary of the first board of managers of the hospital. In Quaker tradition, the clerk of a meeting is the person who really runs the show. It thus comes about that the minutes of the founding board were recorded in Franklin's own handwriting, among them the purpose of the institution, which is to care for the Sick Poor, and if there is room, for Those Who can pay. This tradition and this method of operation continued until the advent in 1965 of Medicare when charity care was displaced by concepts which the nation had decided were better. The Pennsylvania Hospital was not only the first hospital but for many decades it was the only hospital in America. Its traditions, sometimes quaint and sometimes glorious, cast a long shadow on American medicine.
|America's First Hospital: The Pennsylvania Hospital 1751-1841 William Henry Williams Ph.D. ISBN-10: 0910702020||Amazon|
In 1948 I was an intern at the old Pennsylvania Hospital, assigned for a while to the accident room. One of the accident-room duties of an intern is to sew up cuts and lacerations that arrive unexpectedly, but some lacerations can be out of your pay-grade and you have to call for help. On the evening in question, the victim had been so thoroughly slashed up that I had to call the chief surgical resident, Dr. Joseph Hoeffel. Hoeffel was big, tall, loud and self-assured, and swept majestically into the accident room with a little fellow trailing him. This follower seemed less than four feet tall but very quick and shifty. He didn't walk so much as he scuttled. Hoeffel bellowed, "Get out here!" and the gnome vanished.
While Joe was examining the laceration problem, the little fellow slipped through a different door to see what was going on. Most of us had the impression this guy might well be the one who inflicted the cuts, but in any event, he didn't belong where he was. "I told you to get out of here, and stay out," bellowed our surgeon. Again the scuttler scuttled away, while Hoeffel put on a sterile gown, sterile rubber gloves, mask, cap, and the whole ceremonial costume. He prepared to do his work, stamping out disease among the sick and injured, when a fist started at the floor. The little guy had slipped into the operating area once more, and soon the fist on the floor quickly flew in a wide arc, ending up on Hoeffel's jaw.
Hoeffel tumbled head over heels across the room, ending up in a corner. I don't think he was knocked out, but he was certainly dazed. The nurses called the police, who made a tumult of their own arriving to do battle. But the little fellow was gone, never to be seen again.
Hoeffel's son, the former congressman and current deputy member of the Pennsylvania Governor's cabinet, was the featured speaker. He looked remarkably like his father. I had to wonder if his father's lesson in diplomacy had made any notable effect on his progeny.
The following interview with George Ross Fisher, M.D., is presented to give specific answers to questions relating to the organization of the Foundation for Medical Care which is being developed by the Pennsylvania Medical Society. Dr. Fisher is a member of the Medical Care Appraisal Committee of the Pennsylvania Medical Society.
Q. Why are Foundations for Medical Care called Foundations?
A. Well, you will recall that Henry Kaiser started a closed-panel salaried group practice which he called the Kaiser Foundation. When the doctors in California, who felt threatened y Kaiser, started a rival organization, they wanted to use the word foundation, too. So the term has stuck to most similar organizations, even though it is a little confusing.
Q. Does the foundation offer a tax shelter?
A. Not at all, and you will see that the team is difficult to understand. Some foundations are chartered as non-profit corporations, and others as ordinary corporations. The ordinary corporations avoid taxes by avoiding profits, so there isn't much difference except in state regulation. The Pennsylvania Medical Care Foundation is a non-profit corporation.
Q. Now, slow down and be a little clearer. Suppose you give a one-sentence statement definition of what a foundation does.
A. It takes two sentences. A medical care foundation is a sort of insurance company. And it's also an organization for medical peer review. You might not think these two functions should be fused, but it really does make sense to do so.
Q. You have the microphone make sense out of it.
A. The foundation offers the patient unlimited medical care for a fixed insurance premium. It offers the doctor unlimited income on a fee-for-service basis. Obviously, there has to be peer review to prevent bankruptcy, just as there has to be an insurance pool in the middle. Of course, there must be a qualifying phrase when you talk about "unlimited" care and "Unlimited" physician income: It's unlimited if it's "necessary and reasonable." It's also limited if you run out of money.
Q. That seems to be pretty clear, but how does it get mixed up with the Bennett Amendment?
A. The Senate Finance Committee was very impressed with the Sacramento, Peer Review Plan, and the Bennett Amendment would make a similar nationwide plan. Senator Bennett noticed that, while you can't have prepayment without peer review, you can have peer review without pre-payment. So the paradox: there might be a great many foundations which limited themselves to peer review.
Q.What are the plans of the Pennsylvania Foundation?
A. The Pennsylvania Foundation has to go through some procedural steps before it can do anything, and it will not be ready to operate until the October 1972 meeting of the House of Delegates of the Pennsylvania State Society. At about that time, it ought to be ready to respond to whatever legislation is passed, whatever peer review contracts the hospitals sign with Blue Cross, and whatever spontaneous demand there is for peer review.
Q. What about the prepayment function of the Foundation?
A. It seems likely that this aspect will be slower to develop, although you can't be sure. This is an election year, and the Democratic State administration in Harrisburg gives signs of developing legislation affecting health delivery system. Since the history of foundations has been that they are a defense of the private practice, it seems likely that they will flourish to whatever degree that private practice feels threatened. There are a number of closed-panel pre-payment groups trying to start up in Pennsylvania. Probably the private practitioners in their neighborhoods will be the ones most interested in the foundation approach. The legal and administrative mechanism will be available if they are wanted.
Q. If the various government authorities don't raise problems, will that end the insurance matter?
A. Possibly, You have to ask yourself how much the public wants pre-paid medical care. The argument goes like this: The average citizen may want to budget his health expenses, having them deducted from his health expenses, having them deducted from his pay-check or however another manner. A pre-paid comprehensive health program allows the subscriber to spend his residual income without worrying about a rainy day. No doubt this argument has some attractiveness to some average citizens, but whether it has enough clout to overcome suspicions and conservatism is open to question.
A more serious stimulus might just come from industry, as surprising as that may sound. You will recall that may sound. You will recall that Blue Cross got its big push during the wage freeze of World War II. The industry was not allowed to raise wages, so it gave fringe benefits. This was the wage equivalent of a black market when labor was scarce. Well, we have another wage freeze today, as of course, you know.
Q. Would it be fair to call the foundation a contingency plan?
A. It might be accurate, but it wouldn't be fair. It takes an enormous amount of time and money to get a foundation organized. You don't make that sort of investment in a solution unless you think there is a reasonable danger that you will develop the problem it would solve. Rightly or wrongly the people active in it really think the foundation may have to be used.
Q. Well, our discussion has given me a fair idea of what the Pennsylvania Foundation for Medical Care is trying to do, but I now have lots more questions.
A. So do we.
How do you know it will succeed?
A. We were enormously impressed by a field trip to California Foundations. There are twenty-two of them, and the oldest has been running for 16 years. You never saw such enthusiastic cohesiveness among doctors as you find in the Stockton Medical Society for example.
Q. Maybe so, but how does the public react?
A. Public enthusiasm is what generates doctor enthusiasm out there, Over and over they proudly tell you of a recent subscription drive by Kaiser in the Foundation's area. Only 2% of the public signed up for Kaiser. The foundation approach is a way of presenting a legitimate alternative to closed panel threats to private practice, an alternative which the public usually prefers. The private practitioners have no need to form a union or to indulge in dubious competitive reactions.
Q. So, the foundation is a way of combating physician unions, too?
A. Let's get something straight. The foundation isn't against anybody. It merely seeks to provide an alternative for those who want an alternative. for those who want an alternative. Any doctor who wants to join the union is free to do so. We are talking about preserving legitimate options, with the faith that free competition will favor the best system. While we are on the subject of hostility, the foundation does not hamper group practice if the doctors want to practice that way within the foundation, nor does it hamper teaching hospital systems.
Q. It sounds that way to me.
A. Not at all. There is a portion of the public who wish to budget their health costs through payroll deductions or annual premiums. The Foundation sets up an insurance pool to make this possible. The foundation does not care whether the doctors are in group practices, medical schools, or solo private practice.
Q. If that's the case, what's all the fuss about?
A. There are probably only two principles on which the foundation must do or die. The first is that reimbursement is on the basis of fee-for-service at some point in the chain from subscribers to doctor. The Mayo Clinic, for example, collects fee-for-service from the patients and pays its doctors salaries. There is no objection to the doctors choosing to receive salaries as long as the payments mechanism has squeezed through the fee-for-service keyhole at some point. The second essential issue is physician domination of the foundation. We have no objection to competing with identical systems which are consumer domination, stockholder-dominated, or government-dominated. We merely wish to provide a physician-dominated alternative for those who wish to enjoy it. We have faith that a physician-dominated foundation will flourish in such open competition because we have faith that the premium will be wrong to offer the public a physician-dominated system without a free choice of systems with other types of domination. We are putting our faith in competition to achieve the greatest good for everyone, and since we are for competition, we have to have it.
Q. The foundation must have a competitor?
A. Certainly, and for a variety of reasons. First, to achieve the public image of being in favor of a free economy rather than, let us say, a non-free one. Secondly, the vulnerability of the premium. As everyone in Pennsylvania has come to realize, the insurance commissioner has to approve your premium or your request for premium increases. If you are running the most expensive system, you are apt to be badly squeezed. We are willing to risk the gamble that other plans will be more expensive. The exposure of being the only insurance scheme of this type is what is too dangerous to risk.
Q. All right, if you like the competitors so much, what's wrong with them?
A.Probably more through accident than design, the competitors have some features we would rather not embrace. Compulsory salaried practice, for example. As I mentioned, we have no objection to the group being paid fee-for-service and then paying salaries to their members. What seems objectionable to entrepreneur psychology is the use of compulsory salaries as a mechanism of cost control. Doctors on salary forgo the opportunity t work as hard as they please and thus, to make as much money as they can. Having less incentive to work, the salaried doctors have to be supervised, watched, suspected, threatened. Since most of the public receives salaries they see nothing abnormal about this, but most doctors selected medicine as a profession in order to escape it. So the entrepreneurial doctors have sort of a bargain with the public. They say they will work all kinds of ridiculous hours in return for being left alone. The converse of this is this is that universal doctor salaries lead to instant thirty-hour weeks. If you are already neglecting your family to work a sixty-hour week, you aren't very happy about the prospect of an instant doctor shortage.
Q. Why not build more medical schools?
A. Because the public won't adequately fund the schools we already have. And probably, it would be cheaper to have the doctors work longer hours than to build more schools. After all, a great deal of the overtime returns to the public as income taxes. But the foundation can't solve that issue, and we are talking about foundations.
Q. Sorry to digress. What's wrong with consumer-dominated plans?
A. From our point of view, there is nothing wrong, and I told you we need them as competitors. The flaw from the competitive point of view is that public-dominated plans are likely to be more expensive and to emphasize the wrong services. That is, they may well overspend on amenities and underspend on medical advances. It seems more likely that a doctor-dominated plan would recognize and drive toward new methods and new equipment, possibly sacrificing amenities to achieve it. It seems to me that this type of competitive tension is in the public interest.
Q. What's wrong with leaving things the way they are?
A. Not much, and it seems very likely the public will be very slow to enroll in any prepayment scheme. The public now has the choice of Blue Cross plus Blue Shield as a prepayment scheme, as well as self-insurance. By self-insurance is meant you save your money and pay your bills when they are due. A few people do what I do, which is to skip the Blues and buy a major medical plan with a low deductible.
Q. How does the foundation differ from the Blues?
A. In two ways. The first is to offer comprehensive ambulatory coverage, which includes everything done in a doctor's office, including routine check-ups. The second is to try to include the Blue Cross coverage under the umbrella of risk.
Q. Why include Blue Cross?
A. You have now touched on the most difficult issue of all. Everyone recognizes that public concern is aroused by the disproportionate rise in hospital costs. If we didn't have a cost-plus situation with Blue Cross and the Hospitals, we probably wouldn't be worried about delivery systems. By including the hospital cost in the package, we hope to provide an incentive for the doctors to reduce hospital utilization.
At the same time, it is important to recognize that the cost-plus feature of Blue Cross created some very important advantages. The first was that expensive medical advantages could be buried in the budget for later reimbursement by Blue Cross. You didn't have to fight with the insurance commissioner every time a new drug came along, or a new x-ray machine. Blue Cross completely ignored the hospital bill and paid actual costs. It was a free ticket for waste, but it was also a way of keeping up with progress.
Now, there was a second advantage to the system. It paid for expensive features which one hospital provided and another hospital didn't, but which the community in general needed. A good example would be nursing schools. If hospital A had a school and hospital B didn't, in effect hospital A was training nurses for both of them. And the cost was shared by all subscribers in their premiums, regardless of where they were hospitalized or even if they were never hospitalized or even if they were never hospitalized. You hear it said that it is unfair to make the sick patient pay for nursing education, but that isn't what happens. All subscribers pay for it in their premium, and Blue Cross distributes the money where it is spent.
Q. Yes, I just recently learned that Blue Cross does not pay hospital charges, but rather on some cost formula of its own. But why is this a problem for the foundation?
A. Because it leads to a vast difference in costs, they will very likely destroy the teaching hospitals and community hospitals. If you give the doctors an incentive to reduce hospital costs, they will very likely destroy the teaching hospitals by shifting their patients to cheaper institutions. The Pennsylvania Hospital has already announced the closing of its nursing school, and no doubt others will have to. In five years this sort of thing would totally disrupt medicine.
Q. Shouldn't the government pay for these things?
A. The nursing schools happen to be a discrete component of what we call quality medicine; no doubt you could isolate them and get federal funds even in an era of serious federal deficits. But how are we to pay for cardiac surgery? The prospect of total federal involvement in all expensive medical advances is too hideous to contemplate. There is an appalling serenity to the way a great many people are talking about this. For an era that has become alarmed about disturbing the forces of nature, this would be major pollution of medical ecology.
Q. What's to be done about it? No one wants to destroy teaching hospitals.
A. Unless you simply exclude hospital costs from the foundation package (as HIP in New York has done), two major strategies seem available. They are complicated to explain.
Q.OK, go ahead.
A. The first approach would be to recognize that a certain portion of the premium dollar isn't insurance at all, but a donation. That proportion could be put into an Education and Development Fund, which would be distributed for the purposes we mentioned, and which when exhausted could not invade the remainder of the pool for health care insurance. You still have the battle with the Insurance Commissioner when an unbudgeted medical advance appears, but at least everyone knows what is under discussion. And there is no scapegoat to hang it on.
Now, the second approach is experience rating. That's a fancy insurance term for saying that the premium will be less if all your subscribers, through experience, cost less than the standard plan. An underwriter is a person who pockets the profits in return for the risk that he will have to pay for deficits. Perhaps you begin to see that a consumer-dominated plan means that the consumer is the underwriter. And why, we believe, the physician-dominated plans will turn out to be cheaper. Because doctors are in a much better position to hold costs down.
Q. But if the doctors are the underwriters for the Blue Cross experience rating, don't they continue to have an incentive to shift their patients out of teaching hospital?
A. Yes, indeed. Although, if you isolate the education and development costs into a fund, it might not be entirely a bad thing to put pressure on the teaching hospitals to get their straight patient-care into line.
However, hospital cost accounting is so difficult that the teaching or metropolitan hospital is probably always going to cost more. A plausible solution would seem to be to divorce experience-rating from dollars and put it on a point-system of relative values. In the simplest possible terms, a ten percent reduction in patient days would result in a ten percent experience rating in dollars.
Q. How could the Blue Cross cope with a situation where there were more points than dollars? Where would the dollars come from?
A. You are assuming that the teaching hospitals are infinitely elastic and that every patient prefers them. On the contrary, the big move is from the city to the suburbs. Since the teaching beds are fixed, for every foundation patient into one of them there would have to be a non-foundation patient out of them. In the rather unlikely event that there was a net movement of all patients into teaching hospitals, only one solution is possible. The higher total cost of medical care to the community would have to be paid for by a Blue Cross premium increase. We've had them before. In this case, however, the public would be asked to pay for something it was asking for.
Q. Who asked for the recent 40% rise in Philadelphia Blue Cross premium?
A. I'm afraid we are wandering off the subject of foundations again, but let me make an example of that. Since 70% of hospital costs are personnel costs, we have to ask whether it is likely that either salary rates or the number of employees increased by 40% in two years. Since that obviously isn't the case, the Philadelphia Blue Cross situation has something special about it. That special thing was an extension of benefits to outpatients. The idea was that paying for x-rays and lab for outpatients would reduce the incentive to hospitalize. There was in fact no subsequent decrease in hospital admissions, and the out-patient benefits killed the Blue Cross finances. This experiment was mandated by the Insurance Commissioner of Pennsylvania two years earlier (Mr. Denenberg predecessor).
The whole thing illustrates the pollution-of-the-ecology theme. We are all in the medical space-capsule together, and we must all involve ourselves in disturbances of the environment by anybody. There is nothing for anybody to gain by slandering the closed-panel groups, the teaching hospitals, the full-time doctors, or the American Hospital Association. To the degree that we get polarized, we are going to lose the atmosphere of goodwill which is essential for everyone's survival.
Q. That sounds like a good curtain speech to me, but I have some more questions.
A. I can take it if you can.
Q. You haven't' talked much about peer review.
A. . Maybe not, but perhaps you can see why effective peer review is absolutely essential to the financial survival of the foundation, and the public will like that. Conversely, the risk feature of the insurance plan is a big help to peer review. One of the great surprises of the visit to California was to find how little friction the peer review system generated among the doctors subject to review. They had a very good reason to want effective peer review (on others, of course) and so they acquiesced to it for themselves. After all, the best way you have of knowing that the others are under control is to see how review touches your own practice.
Doctors commonly share the suspicion that, while their own practices are clean, there are a lot of other guys who may be abusing things. I happen to believe that there is a very minor degree of conscious abuse at the present time in Pennsylvania and that an effective peer review mechanism will prove it. If the reviewer isn't finding much abuse, he has to be quite an egomaniac to create much friction. We have a few doctors of that variety, of course, but we can cope with them. What we can't cope with is an enormous book of rules and regulations formulated by people remote from the problems. The methods and procedures of peer review can change with the times, but they need to meet only one standard: keep the premium cheaper than Kaiser. If the salaried systems, with their rulebooks and time clocks, can't keep their costs under control, you have demonstrated all that the public wants to know. Everybody in the foundation then gets a year-end bonus, and please keep out of our hair.
Q. Are the . unions going to let you get away with this?
A.You seem to need to learn what Mr. McGovern discovered: organized labor has become pretty conservative lately. Surprisingly, one needs to be a little concerned about big corporations. When a company gets bigger than a certain size it is run by managers, not entrepreneurs. Many of them had Mr. Kenneth Galbraith as a stimulating teacher. My hunch is that the fear of higher taxes is what will make friends of the corporation managers, not a commitment to free competition. The unions are beginning to see that closed panel groups have some of the features of a company store.
Q. What future would you personally like to see?
A. Like every other doctor, I wish the whole problem would go away and let me tend to my patients. Maybe the international money crisis will divert the government to other concerns. But very likely the pre-payment idea will slowly gather a small constituency, and I believe the public is entitled to choose pre-payment if it likes. I would hope that we could depolarize the consumer-dominated and doctor-dominated plans. Since you are entitled to dominate to the extent that you are at risk, I would hope that we can devise intermediate situations between all-or-none. (Again, allowing for the free option of all-or-none for those who want all, or none.)
|Apostle of Sight|
There have been at least twelve documented generations of the Rambo family in Philadelphia. Historical justification can be found for the idea that this was the first family to settle within what are now the city limits. Victor Clough Rambo MD was an unpaid intern at the Pennsylvania Hospital in 1927; you will find his nameplate on the wall.
Victor early made up his mind that he was going to go where he could do the most good. Considerable thought led him to learn how to extract cataracts, and go to India to extract as many as he could. from time to time, he would return to America to visit family, and to give some speeches to raise money for his project.
The builders of our enormously costly hospital castles might give some thought to the fact that Victor did most of his surgery in tents. His system was to send out teams to the next two villages, whenever he was, with the news, "Bring in your blind people, the eye doctor is coming." When he then arrived, he set about operating on cataracts from dawn to dusk, in a country where the supply of cataracts was essentially unlimited. There was no time to operate on the comparatively minor visual disturbances so commonly treated in America today; he had to concentrate on people who were really blind, and in both eyes.
He wrote a book about his experiences, and perhaps there you could find data to calculate the number of people who were restored to a useful existence by his efforts. Surely, it was thousands. He just kept going at it, and when he died he was a very old man.
For a long time, the Philadelphia General Hospital was the largest hospital in town, even growing briefly to seven thousand patients during the Civil War, but leveling off at about three thousand at the beginning of the Twentieth Century. At the end of World War II, it had shrunk to about 1500 beds, but it was Medicare and Medicaid in 1965 which finally did it in. By 1977 it was costing the City of Philadelphia about five million dollars a year beyond its revenues to run the place with only 300 patients, while the running expenses of the local private hospitals were actually less, per patient. Titles XVIII(Medicare) and XVIV(Medicaid) of the Social Security act constituted Lyndon Johnson's Great Society, and in effect they made every patient at PGH resemble a walking government check in the mind of hospital administrators. The local hospital association made the argument to the Mayor Rizzo that everybody would be better off if the hospital closed and those government checks were directed to the local voluntary institutions. After a few years, the federal government inevitably squeezed the generosity out of the bargain they would of course now like to abandon. But that's the way it goes. PGH is gone and it isn't coming back. The eighteen acres in Blockley Township, now West Philadelphia, were given to the University of Pennsylvania next door, and gigantic amounts of federal money were contributed to the building of skyscrapers replacements for the original PGH. Ironically, the two hundred children's beds now on the location are fewer in numbers than the three hundred adults once considered too uneconomically few to maintain, and the cost per day of hospitalization is roughly ten times the PGH cost which had been described as unsupportable. The rest of the real estate is built up with buildings involved in medical research, which is also an activity dedicated to working for its own extinction. Discovering a cheap cure for cancer would quickly create a need to fill the vacancies with something else. No one regrets this system of creative destruction, but everyone should regret the diminution of the spirit of local philanthropy which underlay it.
PGH was one of a dozen or so big-city charity hospitals, like Bellevue in New York, Charity in New Orleans, or Cook County Hospital in Chicago. Of these hospitals, PGH had surely been the best, and at the turn of the Twentieth Century a Mayor's commission issued a report about the place which began, "Philadelphia can surely be proud...." Having worked in Bellevue and having visited most of the rest, I can testify that was likely true. When PGH was finally torn down, the walls and floors had such substantial construction that changing the wiring and plumbing to some other purpose had become almost impossible. The PGH nurses were famous for running. Although the alcoholic and drug-addicted patients might be called the dregs of society, the alacrity of the student nurses in running them bedpans or answering other calls, was spectacular to watch. When a doctor came on the floor, they jumped to their feet and were usually ready with the patient's charts, unmasked. Unlike Bellevue, where the floors were creaky and wooden, the open wards at PGH were spacious, clean, well maintained and equipped. At Bellevue, the forty-bed wards were crowded with sixty or seventy patients, so close together you could almost roll from one end of the room to the other without touching the floor. I can remember seeing one seventeen-year-old Bellevue student nurse tending such award at night alone, the intern sharpening needles, and the medical resident developing electrocardiograms in the darkroom. None of this would have seemed acceptable at PGH.
|Dr. William Osler|
Old Blockley was the place where modern systems of medical education originated. Up until William Osler came to Philadelphia, medical education mostly consisted of attending eight hours of lectures a day. Osler had an electrifying personality and wandered among the sick at PGH with a train of students following him. He is much quoted, and once suggested his obituary ought to read, "Here lies the man who took the students into the wards." A somewhat more elegant statement of the value of the practical experience was included in his dedication speech at the Boston Library: "To treat patients without books is to sail an uncharted sea. To read books without seeing patients is never to go to sea at all. Osler was somewhat underappreciated during his time in Philadelphia and went on to found the medical school at Johns Hopkins in Baltimore. Nevertheless, the main reason he later left John Hopkins and went to Oxford was his dismay at the adoption of the "full-time" system, which is to say the faculty stopped having a private practice of their own to act as a gold standard for their research and teaching. When all is said and done, there are some areas of discomfort in the transition of students from observers to actors. The PGH system of learning surgery was commonly reduced to a slogan, "See one, do one, teach one,"; things have progressed to the point where it is probably right for the public to insist on greater supervision and control than the old almshouse provided.
The disappearance of old Blockley ended a controversy, or even something of a mystery, about which was the oldest hospital in America, PGH or the Pennsylvania Hospital at 8th and Spruce. There had been an infirmary in Old almshouse at Eleventh Street, and there is no doubt the almshouse was there first. PGH grew out of the almshouse. However, there were many comments at the time of the founding of the Pennsylvania Hospital that it was now the first; that's a strange thing to say when the almshouse was three blocks away. Social historians need to look into the mindset of colonial America, which seems to have included the distinction between the worthy poor and the unworthy poor. Somehow, the founding principal of the Pennsylvania Hospital was to get people back to work who were capable of productive work, possibly even paying for itself in that way. In their minds, apparently just giving solace and help to those who were down and out was not quite the same thing.
|Silas Weir Mitchell|
Silas Weir Mitchell lived to be an old man during the Nineteenth Century when it was unusual to get very old. He was an important part of both the Philadelphia medical scene and the literary one. He became known as the Father of American Neurology as a published studies of nerve injuries caused by the Civil War. He published about 150 scientific papers, including famous investigations of the neurological effects of rattlesnake venom. His most famous medical treatment was the "rest cure" for hysteria, while his most enduring scientific discovery was the phenomenon of causalgia. He despised Freud, and psychonanalysis. No doubt the feeling was mutual, but the passage of time has tended to favor Mitchell more than Freud. The central role of sex is the essence of Freud's viewpoint, while Mitchell is summarized in the remark that, "those who do not know sick women, do not know women."Struggling medical students can take heart from the well-documented fact that Mitchell applied to the Pennsylvania Hospital for an internship, and was rejected. Upset by the experience, he toured Europe for a year and applied again. He was again rejected. He later applied for the faculty at Jefferson and was rejected, but his reaction to that was one of rage and vengeance. Just what these two episodes out of Philadelphia medical politics really mean, remains to be clarified by Mitchell's biographers.
Mitchell's second career was literary, publishing 12 novels and 5 books of poetry. He is honored as the founder of the Franklin Inn Club, for century home to every important literary figure in Philadelphia. It is striking that he selected Benjamin Franklin as the guiding star of the Inn since Franklin similarly was eminent in both science and culture, and an ornament to conversation and society. In a pacifist Quaker City, both men approved of combat, and his novel about Hugh Wynne stresses that his hero was a "Free Quaker, meaning one who fought in the Revolution. Because of his strong Republican views, he was never made a professor at the local medical school.
|College of Physicians|
Mitchell's patient Andrew Carnegie donated the funds to build a new building for the College of Physicians when Mitchell was its President. When Mitchell was president of the Franklin Inn, Carnegie wrote him, asking for suggestions about donating a small sum, say five or ten million, and asking where it should go. That was the Inn's big chance, all right, but somehow it failed the test. Mitchell suggested that the money be given to raise the salaries of college professors, thus perhaps suggesting that this veteran of many academic revolts did eventually soften his views.
|Modern, High-Speed Elevator|
Elevators are a problem for any architect in any building, because they are expensive in a number of ways. If the building is no more than four stories high, it can manage to have hydraulic elevators, quite sturdy and comparatively inexpensive, but agonizingly slow. Taller buildings need high-speed electric versions, but the elevator itself is not the most expensive part. More important is that every elevator bores a hole in every floor, more elevators bore more holes, and the usable floor space on each floor is reduced. Further, the mechanical stress is mostly on the doors on each floor, which open and close hundreds of times each day, rather than the lifting engine of the cab. Elevators which seem to be breaking down continually, are mostly in need of new doors. In building a hospital, the architect confers closely with the administrator until the place is built and then the architect leaves. The administrator may leave soon afterward, too, because the hospital personnel who use the new building soon discover that when pennies were pinched, the result was fewer elevators. There's no right answer to this problem; nobody is ever satisfied.
|Waiting for the Elevator|
The surgeons long ago learned to cope with the problem by beginning their day before everyone else arrives. If the elevator comes immediately after being summoned and skips all intervening floors to the surgeon's destination, it can save at least a half hour of his time to make rounds at 5 AM. Multiply that imposed delay on hundreds or thousands of hospital employees, and it is possible to conjecture that hospital employees generally only work a 7-hour day, and spend the 8th hour waiting for the elevator. Whatever the actual calculation, it is a cost seldom actually calculated into the equation of constraining the installation of elevators because of cost considerations. Unwelcome crowding is a social cost, too. Bereaved relatives coming down in the elevator must meet students of various disciplines going up the elevator holding coffee cups and chattering. And all ranks and conditions must crowd into the unyielding back of the elevator when the door opens to confront a hospital bed with an afflicted patient aboard, surrounded by a team of attendants in pajamas, holding up bottles and tubes. Attempts are usually made to assign separate elevators for patients and/or equipment, but the attendants soon find out about elevators that save time, flocking to them in spite of signs, threats, administrative letters of admonishment, and dreary staff meetings. It is easy to identify new staff; they are the people who take elevators down. Everyone else learns to go to the top floor and walk down the stairwells. Outta my way!
So, hospital elevators evoke recollections. Mine include the many times I rode up beside a sullen teenager named Harry Gold, who was going to the chemistry department of the old Philadelphia General Hospital. If we ever exchanged a word I don't remember it, so I have to regret that I missed out on striking up an acquaintance with a real, convicted Soviet spy, the one who passed hydrogen bomb secrets to those Rosenbergs who went to the electric chair protesting their innocence. Something to tell my grandchildren I guess.
On another occasion, Dr. John Y. Templeton was standing impatiently for an elevator at Jefferson Hospital. John was a brilliant surgeon from Virginia, one of the inventors of the heart-lung machine, and also one of the quickest, most irreverent wits in Medicine. The door of the elevator opened, to reveal a completely crowded crowd of assorted folk, with a Doctor Zimskind standing in the front. Templeton's southern accent boomed out, "Going down?" "Going dow-un?" Lost in thought, Zimskind had trouble finding his voice and simply poked his index finger skyward two or three times. To which, Templeton shouted out, "The same to you, Dr. Zimskind. But are you going dow-un?"
And, much earlier when I was a resident wearing a long white coat, accompanied by a jolly sort named Carroll who wore the same, we got on an elevator which was empty except for a surgical resident wearing his particular uniform of a short white coat covering his green surgical pajamas. We had gossiped earlier about this surgeon, who had returned for training after some harrowing experiences in the Normandy beachhead. He was a mean, silent, sort, but Carroll was an irrepressible joker. "Well," sez Carroll, "I hear you carry a gun around with you. Do you carry it into the operating room?" To this, the surgical resident opened his jacket and, so help me, pulled out a pistol from his belt. "When I was in Germany," he murmured, "I killed lots of better men than you are." Under the circumstances, there was little more to be said, and we stopped breathing just to be sure. Those Jefferson elevators are awfully slow to reach the next floor.
And finally, there was Herman, who ran the hydraulic elevator in the original old building of the Pennsylvania Hospital. Herman the German we called him, although his accent was probably Central European. This elevator was an antique, with a big iron steering wheel that Herman turned to release the oil or water or whatever pumped the excruciatingly slow cage up two floors. There, for our contemplation, was America's first building of the first hospital, with the first operating room on the top floor. For more than a century, orderlies had to carry stretchers up and down the stairs with the apprehensive surgical patients, and then this marvel of a hydraulic thing was installed to great admiration. It has long been replaced with a fancy new self-service elevator. But so have the patients been replaced; one hundred sixty patient beds entirely replaced by administrators.
In 1948, one of the Internet physicians at Bellevue Hospital contracted tuberculosis. The senior medical students at Columbia were asked to volunteer to take his place, and for a month I did so. Since I knew I was soon going to Philadelphia to the Internet at the Pennsylvania Hospital, my interest was particularly taken by an old Bowery bum who was talking about untaxed liquor. In New York at that time, it was common for Skid Row denizens to drink the wood alcohol in Sterno, called "squeeze" because it could be extracted from the waxy contents of a Sterno can by wrapping it in cheesecloth or a handkerchief and squeezing out the juice. Another favorite was "Smoke", which was typically a mixture of automobile radiator fluid and other sundry handy ingredients. My new best friend at Bellevue was just recovering from the effects of such recreation, and was in a mood of "never again". He observed that "When I get out of the Bell View, I'm going to get on a bus and go down to Philly. They've got a drink there called Goat Head, and, man, is it ever smooth."
The Chief Resident of the Pennsylvania Hospital was happy to tell me what Goat Head was. It was bootleg liquor, made in the Pine Barrens of New Jersey. Bags of cane sugar were fermented and distilled through coils of copper tubing, obtained from old hot-water heaters. The smooth stuff that so intrigued the bums of Bellevue was what was otherwise known as "White Lightning". It was then sold in the alleys near South Street by "Goat Head Merchants", who carried a suitcase full of small bottles, sold for about 25 cents a bottle. They say that during the Depression, Goat Head was sold out of an open bucket, at 10 cents a dipperful. One of the Goat Head Merchants used the Accident Room of the hospital as his family doctor, let us call him Walter Apple.
One day, Walter had a heart attack and was brought in on a stretcher, in considerable pain. I had just completed an electrocardiogram on him, when the pain disappeared. A few weeks later, he had completely recovered and was going home. Every time I came anywhere near him, he announced to everyone in the vicinity that I was the best doctor in the world, having cured his heart attack by giving him the "wire treatment".
As he gathered up his belongings to go home, he apologized that he was not going to be able to pay his bill. He had once known Dillinger and all those other big shots wore a diamond stick-pin and drove a Duesenberg car. But now he was broke.
But grateful, too. So, if ever there came a time when I encountered someone unpleasant, who needed "pushing' around" -- just you call on Walter Apple, and Walter would be glad to pay off his debt.
|Dr. Thomas Cadwalader|
The early Quakers disapproved of having their pictures painted, even refused to have their names on their tombstones. Consequently, relatively few portraits of early Quakers can be found, and it might, therefore, seem surprising to see a picture of Dr. Thomas Cadwalader hanging on the wall at the Pennsylvania Hospital. A plaque relates that it was donated by a descendant in 1895. Another descendant recently explained that the branch of the family which continued to be Quaker spells the name, Cadwallader. Dr. Cadwalader of the painting, famous for presiding over Philadelphia's uproar about the Tea Act, was then selected to hear out the tea rioters because of his reputation for fairness and remains famous even today for his unvarying courtesy.
In one of the editions of Some Account of the Pennsylvania Hospital, I believe the one by Morton, there is a story about him. It seems there was a sailor in a bar on Eighth Street, who announced to the assemblage that he was going to go out the swinging doors of the taproom and shoot the first man he met. So out he went, and the first man he met was Dr. Cadwalader. The kindly old gentleman smiled, took off his hat, and said, "Good Morning, Sir". And so, as the story goes, the sailor proceeded to shoot the second man he met. A more precise rendition of this story comes down in the Cadwalader family that the event in the story really took place in Center Square, where City Hall now stands, but which in colonial times was a favored place for hunting. A man named Brulumann was walking in the park with a gun, which Dr. Cadwalader took as a sign of a hunter. In fact, Brulumann was despondent and had decided to kill himself, but lacking the courage to do so, had decided to kill the next man he met and then be hanged for murder. Dr. Cadwalader's courteous greeting, doffing his hat and all, befuddled Brulumann who went into Center House Tavern and killed someone else; he was indeed hanged for the deed.
I was standing at the foot of the staircase of the Pennsylvania Hospital, chatting to a young woman who from her tailored suit was obviously an administrator. I pointed out the Amity Button, and told her its story, along with the story of Jack Gallagher, whom I knew well, bouncing an empty beer keg all the way down to the Great Court from the top floor in the 1930s, which was then being used as housing for the resident physicians. Since the young woman administrator was obviously beginning to regard me like the Ancient Mariner, I thought one last story about courtesy was in order. So I told her about Dr. Cadwalader and the shooting.
"Well," she said, "The moral of that story obviously is that you should always wear a hat." There then is no point to further conversation, I left.
It probably took me twenty years to notice that, unlike most people, I had an incomplete separation of my second and third toes. I thought my toes were like everybody else's, but once you start peeking, you see that webbed toes are not normal, although they are not really rare, either. After another thirty years, it became apparent that most of my numerous descendants had the same kind of toe; it was obviously an inherited condition. When the family clan gathered at the beach, it was a source of mild amusement, possibly even a little pride. A few weeks ago, I happened to mention the matter at a party, whereupon another doctor promptly pulled off his shoes and socks, and revealed fused or webbed toes of a much more striking sort than mine; obviously, he was proud of it, too. He is of an old, old Philadelphia family that owns one of the oldest, if not the oldest, a house in Germantown. His family, too, is stigmatized in the same way only more so. In Philadelphia, when you are proud of your family, you are really, really, proud of it.
Which brings me back to my days as an intern in the accident room of the Pennsylvania Hospital. When there is a sudden crowd of emergencies in an emergency department, the nurses get all of them undressed, put in a hospital gown, and instructed to wait for the doctor behind a curtain that doesn't quite reach the floor. For some reason, as a medical student, I had been particularly struck by a photograph in a textbook of an inherited disorder said to have been first noted on a slave ship; the disease in the native language was named Ainhum. For reasons obscure, a tight little band appears at the base of the fifth, or little, too. It gets slowly tighter over a period of months, and eventually, the little toe falls off. That's all there is to Aihnum, and all that was known about it. So, imagine my surprise and delight to walk past a row of naked feet sticking out below curtains -- and there was my first and last case of Aihnum.
I summoned my colleagues, and the visiting medical students from both Jefferson and Penn who at that time shared training in our accident room. I raced off to my room to get a camera to record this momentous event. An elderly staff physician, either Tom McMillan or Charles Hatfield, wandered past and was invited to share the excitement. Well, he says, I saw one of those forty years ago, it looked just like that; old Doctor Norris showed it to me when I was an intern. Much murmuring ensued but abruptly stopped when the patient himself rose up and started putting on his clothes. He was going home, but why? "Well," he growled, "I came here because my back hurts, and all you people do is look at my toes!" He said he was going over to the Jefferson Hospital to get proper treatment, and I guess he did.
And finally, there is Morton's Toe. Or perhaps more properly, Mortons' Toes. There were in fact two Doctor Mortons, one of them at Columbia College of Physicians and Surgeons where I went to school, and the other at the Pennsylvania Hospital where I interned. In New York, Morton's Toe refers to a painful callous, or neuroma, that forms on the bottom of the victim's big toe. In Philadelphia, such an answer would get a failing grade, because the Philadelphia Morton had noticed that some people have a big toe that is shorter than the other toes, instead of being bigger as the term would suggest was proper. The tricky thing about this relatively harmless variant is that the big toe is actually not short at all. The foot bone, or metatarsal, is short, so the toe of normal length sits back farther on the foot and just looks shorter. The main significance is for shoe salesmen since the shoe needs to be long enough to avoid crushing the other toes.
So now, you readers who were not lucky enough to go to medical school can get a feeling for what it seems like to be a doctor. The other significant shared bond within the fraternity is a sense of outrage at the way health insurance companies drag their feet paying doctors, but that's not limited to feet..
As told by one of his fellow interns who is now a very old man, Kitamura was one of the best interns the Pennsylvania Hospital ever had; diligent, dependable, intelligent and infinitely polite. He married one of the hospital's nurses, and they tended to keep to themselves, especially in 1941, as war clouds began to gather. About two months before Pearl Harbor, both of them mysteriously disappeared. Kimura's wife later wrote one of her friends that they were in Japan. After the war, it was learned that she had been placed in a concentration camp as an enemy alien, and when released, had divorced him.
Still later, it was learned that Kimura had a distinguished medical career in Japan. He kept up a minimal sort of correspondence with his old intern pals, inviting them to visit if they were ever in Japan.
In 1985 one of them did so, going to the largest hospital in Tokyo to inquire. Great silence ensued; unfortunately, the revered and distinguished physician had recently died. You knew, of course, that he was the Emperor's personal physician.
Because just about all medical internships still begin on July 1, I'm pretty sure I first met Bob Gill on July 1, 1948, which I remember was a very hot day in Philadelphia, especially in the old historical library of the Pennsylvania Hospital. That's the first hospital in America, and therefore the site of the first internship in America (Jacob Ehrenzeller). For alphabetic reasons we sat next to each other and were assigned as roommates on the third floor of the original old building. Since Bob's later life was distinguished by quite a bald head, this first meeting with Bob Gill was striking for remembering his original ("cute") widow's peak, which he soon lost forever. All eighteen of us two-year internet wore starchy white uniforms, probably the last time they were all so well ironed at the same time. The hospital laundry did wash them, but we bought our own, so uniforms were far from uniform. We shared the rigors of a two-year internship, without salary, rotating through all the services in preparation for general practice, but ultimately to measure up to the standard that you ought to become a doctor before you became a specialist. Today, an intern is paid about fifty-six thousand dollars a year. But there's a deceptive hook to that comparison.
The days of our 1948 internship followed the stock market crash of 1929 and the commodity crisis of 1930,s, -- years of depression, followed by wars and post wars, eventually finishing with two years of Korean War. We recognize now those were deflationary years, brought on by years of paying off the debts of World Wars I and II. In 1900 Philadelphia was thought to be the richest city in the world, eventually converting family-owned businesses into stockholder businesses, thus allowing industrial ownership to shift to Wall Street in New York. (There was also port-destruction by the maritime union, and wage-depressing migration from the South, suppressing wage levels, of course.) The consequence was protracted recovery from economic deflation, explained by conflicting theories of Maynard Keynes and Milton Friedman. Both were slow to perceive that medical revenues rose more slowly than economic circumstances justified for rapidly improving medical care; while the U.S. simultaneously struggled to pay off its war debts. Part of this was intended to hold down medical costs when corn flakes were substituted for beets and boiled potatoes for the resident medical staff.
Our grandchildren were to enjoy higher dollar income for doing easier work, yes. But grandchildren also accumulated a two hundred thousand dollar matching debt, mostly paid by the federal government, and often repaid later with federally-subsidized resident salaries. My grandson and I were to end up in substantially the same penniless condition, by different routes. Despite nine years after college without income, my generation never regarded itself as poor, because our future was bright. My grandson's generation, by contrast, enjoys a training period he seemingly hadn't earned. The big financial winners were the hospitals, insurance companies, and drug firms. The public may have added thirty years to its life expectancy, but could eventually foresee medical costs rising above what the public could afford. Although this complexity is considerably understated, essentially we had stretched ninety years of progress across forty years of revenue, It's almost too late to compensate the people who made the sacrifices, so we mostly compensate people who had other goals. Future sacrifices will be made by those who will almost surely outlive their retirement savings.
There's a trick to starting the internship on July 1. Without noticing it, the fourth of July quickly follows, and everyone else has arranged the schedule to have the newcomers suddenly in full charge of a hospital after three days of becoming a doctor. Let me tell you it is both a frightening experience and a totally unexpected one, with the fourth of July fireworks echoing three blocks away. Years later, I inventoried the records of the Pennsylvania Hospital for July 4, 1776. Not a great deal different from 1948.
Half a block away from the hospital was the mansion once occupied by Nicholas Biddle, comprising thirty or so rooms, reminding of the days when this was a rich neighborhood. One of Bob Gill's patients ran the Redevelopment Authority and offered the white elephant to Bob for the obvious bargain price of $25,000. It was no bargain because you could buy many similar neighborhood houses for $1500. The Biddle mansion had one condition; it had to be used as a single-family dwelling, so we had to split up our partnership since he had to run a medical office in it to afford it. Today, it posts a for sale sign for three million. Bob gradually filled the house with antiques and built up the Philadelphia equivalent of a Park Avenue practice in it, half a block from the increasingly posh hospital. Although Ben Franklin's own handwriting declares it is to be used for the sick poor, and if there is room, for those who can pay, the neighborhood circumstances gradually forced it into the mode of a fancy teaching hospital. It went from poor to land-poor, and eventually back to posh. In 1948 it was still a public charity, not finding it even worth-while to try to collect a 50-cent fee in the accident room.
Bob who died a few days ago at age 95, was one of three internets who were married, the rest of us stayed in the dormitory and played bridge on weekends. He was three years older than the rest of us because he started his educational career intending to become an engineer. Instead, he became a family doctor to the richest people in the city, as well as a member of the best clubs in town, and a famous historian of colonial Philadelphia. As a curiosity, he became increasingly British in his affections and interests, disappearing to London for long periods, and affiliated with many British organizations who for all I know regarded him as a British ex-patriot. He and I often enjoyed Thursday night roast beef at the Union League, single malt scotch at the St. Andrew Society, and his rehabilitated house gradually came to resemble a house on Wimpole Street. Nicholas Biddle once kept a baby elephant in the back yard, so it's not surprising to learn he had more outside yard space than I did in the suburbs, in retrospect a poor choice of real estate on my part.
This Indenture Witnesseth, That Jacob Ehrenzeller, son of Jacob Ehrenzeller of the City of Philadelphia hath put himself, and by these presents, with consent of his said father, doth voluntarily, and of his own free Will and Accord, put himself Apprentice to the Managers of the Pennsylvania Hospital to learn the Art, Trade and Mystery, and after the Manner of an Apprentice to serve the said managers from the Day of the Date hereof, for and during, to the full End and Term of five years and three months next ensuing. During all of that Term, the said Apprentice his said Master faithfully shall serve, his Secrets keep, his lawful Commands every where readily obey. He shall do no Damage to his said Master, nor see it to be done by others, without letting or giving Notice thereof to his said Master. He shall not waste his said Master's Goods, nor lend them unlawfully to any. He shall not commit Fornication, nor contract Matrimony within the said Term.
He shall not play at Cards, Dice or any other unlawful Game, whereby his said Master may have Damage. With his own Goods, nor the Goods of others, without license from his said Master, he shall neither buy nor sell. He shall not absent himself Day nor Night from his said Master's Service without his leave: nor haunt Ale-houses, Taverns or Playhouses; but in all Things behave himself as a faithful Apprentice ought to do, during the said Term. And the said Master shall use the utmost of his Endeavor to teach or cause to be taught or instructed the said Apprentice in the Trade or Mystery of an Apothecary. And procure and provide for him sufficient Meat, Drink, washing Cloths and Lodging fitting for an Apprentice, during the said Term of five years and three months.
And for the true Performance of all and singular the Covenants and Agreements aforesaid, the said Parties bind themselves each unto the other, firmly by these Presents. IN WITNESS whereof, the said Parties have interchangeably set their Hands and Seals hereunto. Dated the first Day of June in the thirteenth year of the Reign of our Sovereign Lord George the third, King of Great-Britain, etc, Annoque Domini, One Thousand Seven Hundred and Seventy Three.
Signed and Delivered in the Presence of Jacob Ehrenzeller, Jacob Ehrenzeller Sr, Sam V. Coates
* * * *
The Ex-residents Association of the Pennsylvania Hospital became active early in the Nineteenth century, and naturally concerned itself with just who was the first interne or resident of the hospital. It seemed probable that the first interne of the Pennsylvania Hospital would also be the first interne in America. When this indenture was discovered in the archives, Ehrenzeller became a likely candidate, although being apprenticed as an Apothecary did raise some questions. Nor did Ehrenzeller perform his indenture after the completion of medical school, as is now the custom; the first resident physician in that sense was Caspar Wister, in 1812. However, in colonial times most physicians did not go to medical school at all, qualifying as practitioners by working in the offices of practicing physicians, just as lawyers did for a much longer time. The argument is somewhat complicated by the existence of a medical school, the College of Philadelphia, created in 1765, and the fact that the upper crust of colonial medicine had gone to medical school in Edinburgh. That group of seven physicians with degrees gathered themselves together (in 1787) as the College of Physicians of Philadelphia, which still exists as the nation's oldest medical organization.
Dorothy I. Lansing MD, then the clerk of the Section on History of the College of Physicians of Philadelphia, interested herself in these issues, and privately published a pamphlet about it. The argument for regarding Ehrenzeller as an interned physician revolves around the fact that his father had gone to medical school in Europe, and was regarded as a physician even though he made his living by operating a tavern after he came to Philadelphia. Furthermore, the 16 year-old Ehrenzeller found his apprenticeship disrupted by the Revolutionary War, particularly the occupation of Philadelphia in 1777 by British troops who used the hospital for their wounded. Nevertheless, young Ehrenzeller served as a surgeon at the battle of Monmouth (June 28, 1778). Among the minute books of the Board of Managers of the Pennsylvania Hospital was discovered a minute of June 26, 1773 with the terms that Jacob Ehrenzeller, Jr. "shall have leave at his own or his Father's expense to attend the lectures of the Medical Professors out of the Hospital during the last two years of his apprenticeship; to attend the Surgical Operations and Lectures in the Hospital free of any expense; and that the Apothecary for the time being shall duly instruct him in Physic and Surgery." Dr. Lansing concluded that this was "a unique concurrent internship: apothecary apprentice cum medical student arrangement that no doubt suffered innumerable changes due to wartime problems; Jacob Ehrenzeller was awarded a certificate of medical competency. The College of Philadelphia medical school having ceased to exist because of the war, he obtained no degree in medicine."
Dr. Lansing found even stronger evidence of his physician rather than apothecary status in the fact that immediately after the war he established a practice in Goshen, Chester County. While it was customary for practicing physicians of the time to support themselves as schoolteachers, storekeepers or bankers, Ehrenzeller was able to live exclusively on his income as a physician. Indeed, after his death in July 18, 1838, his estate was one of wealth. It seems unlikely that an apothecary masquerading as a physician would have flourished in those competitive times, and on this basis it is concluded that he came as close as the times permitted to the description of an interned hospital physician. The Ex-residents Society of the Pennsylvania Hospital was satisfied enough to declare Ehrenzeller to have been its first interne. And invites the rest of the nation's medical community to examine whether anyone else might have been better qualified to have that title earlier.
|Carol and Bill Doane|
Bill Doane died in 2017, at the age of 95+, after a long career as Chief of Surgery in Santa Barbara, California. This letter was found among the relics of his former roommate at the Pennsylvania Hospital, the nation's first one, established in 1751 by Benjamin Franklin. With the aid of retrospect, we know he was to marry Carol Smith, who worked at the Philadelphia Evening Bulletin, and after some wanderings, settled in an upscale hospital in California, eventually dying at an advanced age in a Santa Barbara retirement village, where he was the daily tennis partner of Bill Scranton, the former Pennsylvania Governor. He did a lot of third-world traveling and surgical volunteering, out of which grew the founding of an international non-profit organization to distribute American hospital equipment to places like Afghanistan.
W.A. Doane USS Essex (CUA 9) F.P.O. --San Francisco Feb 20, 1954
Dear George, Stu, Georgie,Miriam (any others?)
I've enjoyed hearing from you immensely. Your Christmas Card was first and more recently. Carol forwarded a note from Stu. Needless to say, I gobbled the P.H. news voraciously. It really sounds like an old home week, with Twadddell, Deaver Alexander, Dinon, Cretzmeyer, J. Johnston, and Rakov holding the fort. The big news from the East China Sea is I'll be getting off this bucket in late March or early April and will be separated in early April. Our second offspring should be dropping in on us shortly thereafter and as soon as things get stabilized, I'll be in Philly to horse around and of course, come back to Pennsy for a look see. My plans for practice are still a trifle nebulous. I'd love to practice around Philly but I certainly hate the thought of hanging on for 2 years before I make a living. Keep your ear out to check the keyhole for me, Geo., and let me know of any golden or even castiron opportunities. Our year in San Diego was very pleasant, and if things don't seem very propitious about Philadelphia -- we might even settle in Southern California.
Our oldest (and only child at this writing) is really a delight to the old man. I just never realized that paternity could be so richly rewarding. I guess you never really look at kids until you have one yourself.
My travels in the Orient have been a bit restricted but I did get a few days in Hawaii and have had a quick tour of Yokosuka (?), Yokahanna and Tokyo. I find Japan quite fascinating. It's just not possible to tell anyone about it adequately ters the little toy people and their way of life are so different from ours. My overall impression is definitely favorable. They are exceedingly industrious, clean, pleasant and clever craftsmen. Also, they purvey very good beer in very large bottles for very small amounts of YEN, I can see how a guy could really go to pot out here. All drinks at the "O" Club at Yokosuka are 25 cents, and when you have been to sea for 3 weeks it's rather easy to accumulate a lot of quarters.
The money situation over here is a riot. When we neared Japanese waters, all hands were ordered to change their YONKEE DOLLAs for MPC-- military payment currency. The resemblance between this medium of exchange and Dick Tracy play money is striking. They make it in every amount from 5 cents up, and all are different sizes and shapes, and all are paper. So you go ashore on the naval base with pockets bulging with MPC. Before you can go out the gate into the town and buy anything-- you must exchange MPC for YEN--Jap currency. Again, you get a bale of flimsy colored paper in every conceivable shape.
$ 1.00 m PC = 360 YEN so you can see you have to have large pockets to carry it all. Every time you reach into your pocket for dough - a few stray scraps of YEN float away as you bring your hand out. The Japs are understandably anxious to relieve us of as much cabbage as possible and they have a large variety of ways of doing it. By far the largest business is, of course, the girl-sans. There's a pimp on every corner and every cabaret in town is loaded with Japanese dollies from age 15 to 25 -- all available for a price. Apparently, the price is always right because they do a booming business.I'm amazed our VD rate isn't 10 x as high.
Japanese hot baths (hotsy botsy as the Japs call them) are extremely popular with the troops. Sightseeing and shopping opportunities are endless. Cultured pearls, brass ware, silk, silver -- are all supposedly "best buys" over here. I'm just a typical tourist and am loading it up with all sorts of items. Cameras are dirt cheap here. If you know any of the fellows at the hospital that would like a camera, I might be able to bring one back. Don't noise this around too much, however. A Nikon f1.4 is about $120, and about $275-300 in the US. An Argus C-3 is $41 with case and flash, and $69 in the US. So it goes. (There will be a small carrying charge of course for all but G.R.F.)
I've rambled on at great length but it's time to hit the pad so must close.
Very best regards to you.
P.S. Give my regards to all the group.
|Henry Wadsworth Longfellow|
Since American relations with France are a little strained at the moment, it may not be completely welcome to hear it said that Philadelphia food is Creole. The reference is not to the several downtown French restaurants of outstanding quality, but to the two episodes when Philadelphia experienced waves of French immigration. The first of these was during the French and Indian War, when the Acadian French ("Cajun") were driven out of Nova Scotia, largely went to Louisiana and then were allowed to return. A lot of them stopped off in Philadelphia both going and coming. Henry Wadsworth Longfellow depicted, in his poem Evangeline, the tearful reunion of Evangeline and Gabriel in the hospital. And since for sixty years the Pennsylvania Hospital was the only hospital in the country, Longfellow had to put them here.
The second wave of French immigration was provoked by the guillotine in Paris, and the black revolution in French Haiti. Most people today are unaware that Talleyrand lived here, and LaRochefoucauld. The Duke of Orleans, future king of France, lived at 4th and Locust Streets, proposed to a (rich) Philadelphia lady, and was rejected by her father ("Sir, if you do not become king of France, you will be no match for her, and if you do become king, she will be no match for you.") Napoleon's brother Joseph lived at 9th and Spruce, and one of his marshals lived at 6th and Spruce. Really. Talleyrand had a deformed foot, and this somehow made him pals with Governor Morris who had a wooden leg. This friendship was part of the reason the Louisiana Purchase was possible, because they shared the favors of the same French lady, and had frequent occasion to meet. Both Franklin and Jefferson were ambassadors to France, it may be remembered, and for a while, Jefferson was quite a fan of the French Revolution, although the treatment of LaFayette by the French Revolutionaries did not exactly encourage that. The French treated Franklin like a God, but then so did Mozart and the King of England, and Franklin harbored many bitter memories of the French and Indian War all the while he was romancing the French into bankruptcy to pay for our revolution. The French refugees from Haiti brought Yellow Fever with them, and Dengue too, thus definitively terminating Philadelphia's hope of remaining the permanent capital of the nation.
It was during this Francophone period that Philadelphia cuisine acquired some characteristics which allow some food historians to call it Creole. Philadelphia Pepper Pot soup, for example, substituted tripe for terrapin. Those who know about these things say that many dishes now thought to be distinctly Philadelphian in fact had a French origin.
Charles Peterson, the famous architectural historian and preservationist, died just before his 98th birthday on August 19, 2004. It is to him we largely owe the redevelopment of Society Hill, and the design of the Independence National Park, as well as a host of restorations from the Adams Mansion of Quincy, Massachusetts, to the early French settlements along the Mississippi. He conceived of many national historic preservation projects, the most notable of which is the Historic American Buildings Survey (HASB) of the Department of the Interior.
|The Adams Mansion|
While he was most notable for large visions and huge projects, he also had a keen appreciation for fastidious accuracy in small matters, of which the Amity Button would be a vivid example. In the surviving Colonial buildings of Philadelphia, it is common to find a plain ivory coat button nailed to the top of the newel post of the main staircase. There's one in Independence Hall, another in the grand staircase of the Pennsylvania Hospital, and there is one in Charlie Peterson's own home, the one where he was the first Society Hill gentrification pioneer, a house originally built by Stephen Girard around 3rd and Spruce.
The Free Quaker
There is a strong tradition in Philadelphia that these strange buttons are Amity Buttons, nailed there by the Quaker builder at the moment when the new owner had fully settled his construction debt, symbolizing the amity between a willing buyer and a willing seller. Countless visitors to Society Hill have been shown these curious buttons, and it always seems to produce a warm glow of appreciation for the discovery. If you have one of these in your own house, you can be very proud.
Unfortunately, Charlie Peterson couldn't find any evidence for the truth of this fable, and you can be sure he subjected the matter to a totally dedicated search. You might think there would be some notations in the deeds, or in the correspondence of the day, or in the literature of the times. You would think that someone who repeats this tale would be able to relate where he got it, and that would lead to some letters in an attic, and that if you work hard enough, you will find it. But when the button matter came up, Mr. Peterson would suddenly become grim-lipped and sad, and repeat the mantra that there is no evidence to support the story. He even awarded prizes to architectural students for essays on newel posts, banisters, and stair rails, but no student essay ever turned up any authentication of the Amity Button story. Absence of evidence is of course not the same as evidence of absence, so it is remotely possible that the story will someday be vindicated.
Indeed, you have to believe there was something or other to start the story. Victor Failmetzger and his wife, who have a notable reputation for authenticating old house parts, relate that in Colonial Virginia it was common to have hollow newel posts on the stairway, and occasionally to find the deed to the house secreted in one of them. So the search goes on.
In fact, it always seemed likely that Charles Peterson very much wanted to believe the fable was true. But until some evidence turned up, he was going to go to his grave with the declaration that there existed no evidence for it.
|Benjamin Franklin 1767|
|Pennsylvania Hospital Asylum|