THE MODERN HOSPITAL.

Otago Daily Times, Issue 19528, 10 July 1925, Page 4

THE MODERN HOSPITAL.

ORGANISATION AND ADMINISTRATION. MEDICAL SUPERINTENDENT’S VIEWS. ADDITIONAL REPORT. The following additional report by Dr Falconer, Medical Superintendent of the Dunedin Hospital, on the principle or organisation and administration of the modern hospital, will be considered 'at the next meeting Of the Standing Committee of tht Otago Hospital Board; — RESIDENT MEDICAL STAFF. “Without a resident appointment in a modern hospital a medical student’s training is incomplete. Herein lies an essential difference between American and English methods. After passing the final examination, an English student does not obtain his degree until he has spent a further year in residence in a hospital as an intern, where ho is given a course of advanced clinical instruction and learns to apply the knowledge he has previously obtained in the clinical years of his medical course. Any errors he may make in diagnosis or in suggested treatment are corrected, and actually aid in his training. Following such a training he enters practice after his skill in diagnosis and treatment has been demonstrated —a matter of obvious importance to the public. To my mind no greater present advance could he made m medical training in New Zealand than by carrying out Sir Lindo Ferguson’s idea of instituting a ‘hostel’ for final-year students adjacent, to the Dunedin Hospital, so that our medical students would receive to some extent the great advantage insisted on in the American curriculum. Hero is an opportunity for the wealthier of our citizens who are keenly alive to the necessity of medical efficiency. The resident medical staff are answerable to the visiting medical staff in professional matters, and to the superintendent as regards the general welfare and all administrative matters in connection with the patient. The superintendent is, of course, finally responsible to his . board to see that its patients are given a high order of professional as well as general care. In Great Britain the house staff are mostly junior, the theory. being that a member of the visiting’ medical staff becomes immediately responsible for the diagnosis and treatment of the patient as soon as his name is Inscribed on the patient s chart and posted in the ward. Acting for that member of the visiting staff the house surgeon orders the routine treatment' he knows his chief desires, and he himself is considered capable of appreciating the symptoms which would demand the advice or the attendance of the staff member. In an epoch-making book on Medical Education, by Abraham Flexner (published last year and reviewed in the last number of the British Medical Journal) a gentleman who made a comparative study of medical education In certain European countries and America on behalf of the Carnegie Foundation for the Advancement of Teaching, a criticism is made of the British system in the following terms: — (a) “the excessive responsibility laid upon the juniors,” and (b) “the junior assistants are not equal to the load laid upon them.’ At present in Dunedin we have three grades of the resident medical staff—junior house surgeon (first year), senior house surgeon (second year), and assistant medical officer (third year). In America in any of the medical, surgical, or other services there Is invariably a resident of at least three (sometimes six) years’ standing, otherwise the service would be considered incomplete. Such a grade of officers ensures a higher order of expert assistance to the visiting staff. According to American standards in Dunedin we should have three residents —a resident physician attached to the medical service, a resident surgeon attached to the surgical service, and a resident special surgeon attached to the gynecological and eye, ear, throat, and nose services. Each resident under the authority of the medical superintendent should act as registrar and admitting and discharging officer in his own service, and also assists in the training of the’house surgeons and final-year students: the resident physician should, In Dunedin, act as first assistant medical superintendent, the resident surgeon as emergency radiologist and orthopaedic assistant, and the resident special surgeon might also act as director of the outpatient clinic and as emergency anaesthetist. American authorities would consider that we were quite understaffed In these respects. “Such senior resident positions would he equally beneficial to the hospital and to the medical school, and should be combined appointments by the hospital board and the university, the latter also sharing in part of the expense, as each resident in addition to the teaching of final-year students should have oversight of all the medical students attached to his own service. RELATION OF THE. HOSPITAL TO THE MEDICAL SCHOOL. “We now come naturally to the relation of the Hospital to the Medical School. Hornby says: ‘The relationship between affiliated hospitals and medical schools has been very far from satisfactory in the past, largely duo to the difference in viewpoint between hospital administrators and the faculties and trustees of medical schools. Faculty members in medical schools have ‘ been, and still are, very prone to feel that the teaching end of the combination is about the onlv part really worth while, and that the hospital is an after consideration, and should be merely an adjunct and consequently under the absolute direction of the school' authorities. , , “The viewpoint of the college professor is that hospitals as a class do not spend sufficient money to bring the hospital up-to-date from a scientific and teaching point of view. On the other hand the man in the street demands good care for the patient first and the abstract benefit to science as an after consideration. And so the ‘classical controversy of medical school versus hospital’ goes on. It should bo the ambition of the hospital governing body to have . their patients given the best possible scientific attention. No one visiting America can fail to be struck with the immense advantage there is to the patients of the hospital in a medical school connection. I did not see a municipal hospital in America of any particular value which did not have such Even in New Zealand there is no gainsaying the fact that the standard of treatment in the medical wards of the Dunedin Hospital is on a higher plane than in the other three centres. The jioint mainly in dispute is the financial one. Theoretically "the hospital should furnish everything required for a high order pi scientific care for the patients, as it would do if there were no school, and the school pav for what is required in the actual teaching of the students and which is of no particular value to the treatment of the patients. But the adjustment is not so easy as this statement would seem to warrant In fact, it is os often as not incapable of adjustment. Hence a special grant should be made by the Government to the Dunedin Hospital. QUESTION OF CONTROL. “The question often raised is which body should control the hospital. In America in a number of places, I found a very satisfactory adjustment as between the medical school and the hospital governing board—og. Lakeside Hospital of Coveland with tho’ Western Reserve University (where 1 represented the OUgo University last October at tho inauguration of the new president of the university, and the openinn- of the new medical school); also the Barnes Hospital with the Washington University at St. Louis; the M'Gill University with the Royal Victoria Hospital, Montreal; tho Toronto General Hospital with the Toronto University; and the University of Manitoba with tho Winnipeg General Hospital. Toronto is an example of the feasibility of a smooth-working connection between a university medical school and a hospital which in a sense may be called a ‘municipal’ hospital, in so far that it is largely subsidised both by the municipality and the Government, both. of whom, I was told, consider that their representation on the incorporated governing hotly gave thorn all the control of tho hospital they desired. At Toronto there is a ‘Joint Hospital Relatiqns Committee of University and Hospital,” consisting of four members of the University Board of Governors and four hqspital trustees. Only two or three meetings axe required each year to do the z business required. Recommendations for appointment on the hospital staff come from the various departmental heads of medical services who are required to give the record of the men whom it is proposed either to appoint or to drop. The professor, say, of surgery or medicine, might bo asked to attend a meeting in addition to giving his own report. No medical man is'allowed in the university section of the committee, and tho hospital by-laws preclude any member of the staff likewise haing a member of this committee.

“In Toronto they tried for five "years an arrangement whereby the Dean of the Medical School and the medical superintendent of the hospital were combined m the one appointment. But this arrangement did not work, and the occupant of the office was pensioned at 5000 dollars a year for five years. I was told the experience was not likely to bo repeated, and it has not been tried anywhere else. The reason is obvious: no man can serve two masters, and good administration cannot be founded on what is obviously usound organisation. Of course, in the case of a State (e.g., Califoria) or a municipality (e.g., Cincinnati) owning both the university and the hospital, it is a very satisfactory method to have the one head. “In tho arrangement quoted as regards Toronto between the University Medical School and the ‘municipal’ hospital, technically, neither set of trustees can renounce control; they must ratify appointments; but that act can either be reduced to a fo'rmality or expanded into ■ meddlesome supervision, as the trustees choose. In this instance (Toronto) it has a mere form; and two objects, both precious, are most effectively promoted in consequence. On the strength of these instances it is perhaps, worth while to make one more plea for an understanding between existing hospitals and deserving medical schools. Cannot an arrangement be consummated bv which the administration and financing of a private or a municipal hospital shall be left to the 'trustees -and their appointed agents, while eoually, even though' not technically, complete and separate responsibility for the medical conduct of the hospital and for teaching within the wards is left to the medical faculty? As these functions are absolutely distinct from each other, there is no reason wbv two bodies of intelligent men. desirous of doing right in their respective spheres, should not thus co-operate (report to the Carnegie Foundation for the Advancement of Teaching). CENTRAL MANAGEMENT. “Another quotation from the same authority is apropos: The management of the British hospital is highly centralised. lt« business affairs are entrusted to a single officer —secretary or superintendent-—desig-nated bv the governors, and acting under their instructions r the_ mangement would seem to he highly efficient. At the London, St. Thomas’s. Middlesex, this official is a layman: at Guy’s, the Western Glasgow, etc., a medical man. The relations between the executive officer and the hospital staff are now, as a rule, excellent. For their respective spheres are, as in Germany, sharply delimited. How effectually clean-cut demarcation of executive _ from medical responsibility eleminates friction is strikingly illustrated at Guy’s, where Sir Cooper Perry (now Mr Herbert Eason) is not only superintendent, but visiting physician. Ho holds and exercises _ his several functions rigidly apart. As visiting physician ho virtually ceases to be hospital superintendent. As hospital superintendent ho lays aside the character of medical mam His medical knowledge and experience may affect his courwe. but qua superintendent, ho docs not deliberately rely on it. The same may be said of Dr Donald Mackintosh, superintendent of the Western Infirmary at Glasgow. The title of “medical superintendent” is a misnomer _ in Great Britain as in Germany if it is interpreted as in anv wise qualifying tho_ supremacy of the physcians and surgeons in their respective wards. TTiore is no interference with them from any source whatsoever. Trouble has indeed arisen at times, when too busy consultants have slighted their hospital engagements. But friction duetto meddling would be one thing as friction due to neglect is quite another. Tho former is for all practical purposes _ unknown. In general, then. Great Britain bears out the experience of the Continent, ■that sharp differentiation of function as between administration and medical oversight is conducive to efficiency and carries with it no countervailing peril, provided onlv the staff members hold definitely to their obligations.”