Medical History Fails to Indicate the Best Health Care

Medical History Fails to Indicate the Best Health Care

William C. Kashatus
Philadelphia Daily News
October 12, 1999

One year ago, the Allegheny Health, Education and Research Foundation placed the future of eight Philadelphia hospitals in jeopardy. Saddled with a $1.3 billion debt and with most of its operations, employees and patients in a crowded Philadelphia market, the Pittsburgh-based hospital network sought Chapter 11 bankruptcy protection for its Philadelphia hospitals and Allegheny University of the Health Sciences.

Not only did the crisis provoke charges of financial mismanagement and threaten research grants critical to the operation of a teaching institution, but it seemed to confirm the public’s worst fears that the city’s hospitals were too willing to put profits before patients.

At a time when health care in general is under attack, the Allegheny crisis served as a wake-up call for greater accountability. For all the improvements in technology, research and medical training, it was difficult to ignore the widespread suspicion that Philadelphia’s hospitals were failing in their most basic responsibility: to meet the health-care needs of the patient.

Nor did the problem appear overnight. It was an evolutionary process.

During the 18th century, health care in the city was the domain of religious philanthropy. The Quaker Alms House and the Presbyterian St. Andrew’s Society both provided for the indigent, while Pennsylvania Hospital, founded in 1752 by the Society of Friends, served the more affluent.

Most of the city’s physicians offered their services without pay. Some had studied abroad in the medical schools of Europe, but most doctors acquired their training through apprenticeship. With no state or national organization to supervise medical practice, many physicians employed crude therapies of bloodletting, purges, enemas and blistering. But during the early 19th century, medical theorist Benjamin Rush, surgeon Philip Syng Physick, anatomist Caspar Wistar and obstetrician William P. Dewees set high standards for the profession, making Philadelphia the center of medical education in the United States. By mid-century, approximately 1,000 medical students came to the city each year, attending such prestigious institutions as the University of Pennsylvania, Jefferson Medical College, Hahnemann Medical College, Women’s Medical College and the Philadelphia College of Medicine. With the American Medical Association, founded in 1847, these institutions struggled to improve the quality of patient care, establish a code of ethics and promote public health.

But the distinction of the city’s hospitals and doctors lay more in their educational role than in medical discovery or research. A new, more unified approach to healing was slow to evolve because of their differing philosophies and methods as well as competition for more affluent students who could afford to pay tuition. Public health care was still inadequate.

Not until the early 20th century was there significant improvement, when increasing immigration, urbanization and industrialization contributed to a rising mortality rate. The widespread demand for better public health care resulted in the investigation of the “negligent and deplorable conditions” that existed in the hospitals. There were few public health services in the city and those that did exist – the mental hospital at Byberry, Wills Eye Hospital and Philadelphia General Hospital – were the most underfunded of any leading American city’s.

Specialization became more common with the voluminous growth of information as well as new, more complicated techniques. Research grants for education increased, allowing for a more effective collaboration between the city’s medical schools and hospitals. The construction of health centers progressed slowly as funds became available. And physicians were accorded a more professional status.

From 1946 to 1970, Philadelphians enjoyed a quality of health care unparalleled in the city’s history, largely due to government intervention. Personal health insurance became available. Significant increases in federal funding for medical research and education placed the city’s medical schools on the cutting edge of new technology. And advancing techniques of diagnosis and therapy resulted in a longer life span for the elderly. But these improvements came at a cost.

Over the last three decades, Philadelphia, like every other major city, witnessed the commercialization of health care. Higher physician fees, increased patient loads and the necessity of keeping abreast of new technology have resulted in loosely monitored inpatient care. Increased government influence has led to greater regulation of services as well as a significant decrease in research funding. Private insurance companies require greater justification for the use of medical services, complicating reimbursement procedures.

Privatization has also led to the creation of HMOs as well as medical consortiums under the control of Jefferson and the University of Pennsylvania. Efficiency has been compromised by a bureaucracy of administrators and managers. A loosely organized system of hospitals once operating on the principal of empathy has been replaced by a tightly controlled industry driven by economics.