HSA 4421 Florida International University Legal Aspects of Healthcare Essay

Each group spokesperson shall post the group’s narrative response addressing all of the issues in the case of Kirk v. Mercy Hosp. Tri-County, 851 S.W.2d 617 (Mo. Ct. App. 1993). Found in Ch 20 (pg 553-554). Making sure to comply with the requirements set forth in the syllabus guidelines and grading rubric.

Legal Aspects of Health Care Administration THIRTEENTH EDITION George D. Pozgar, MBA, CHE, D.Litt. Author, Speaker, Consultant Gp Health Care Annapolis, Maryland Legal Review Nina M. Santucci, MSCJ, JD JONES & BARTLETT LEARNING 2 World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]. 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If legal advice or other expert assistance is required, the service of a competent professional person should be sought. 23986-7 Production Credits VP, Product Management: David D. Cella Director of Product Management: Michael Brown Product Specialist: Danielle Bessette Production Manager: Carolyn Rogers Pershouse Production Assistant: Brooke Haley Senior Marketing Manager: Sophie Fleck Teague Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: codeMantra U.S. LLC Cover Design: Kristin E. Parker Director of Rights & Media: Joanna Gallant Rights & Media Specialist: Merideth Tumasz Media Development Editor: Shannon Sheehan Cover Image: © Marilyn Nieves/Getty Images Printing and Binding: Edwards Brothers Malloy Cover Printing: Edwards Brothers Malloy Library of Congress Cataloging-in-Publication Data Names: Pozgar, George D., author. Title: Legal aspects of health care administration / George D. Pozgar, MBA, CHE, D.Litt. Description: Thirteenth edition. | Burlington, MA: Jones & Bartlett Learning, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018002863 | ISBN 9781284127171 (casebound) Subjects: LCSH: Health services administration—Law and legislation—United States. | Medical laws and legislation—United States. | Medical personnel— Malpractice—United States. | BISAC: BUSINESS & ECONOMICS / Information Management. 4 Classification: LCC KF3821 .P69 2018 | DDC 344.7304/1—dc23 LC record available at https://lccn.loc.gov/2018002863 6048 Printed in the United States of America 22 21 20 19 18 10 9 8 7 6 5 4 3 2 1 5 I dedicate this book to Denise Mirafuentes. Your life was an inspiration. Your love for family, friends, caregivers, and the many lives you have touched never failed. Your unwavering faith in God and the challenges you faced have forever changed the lives of so many. Your life is a testimony to goodness, kindness, and compassion. Though the thoughts I wish to impart continue to swirl in my mind, words alone will never suffice. So I leave you with this my dear friend, Your signature phrase to “Live, Laugh, and Love” describes you well. “The best and most beautiful things in the world cannot be seen or even touched, they best be felt with the heart.” Helen Keller ALOHA & MAHALO Until We All Meet Again 6 7 Contents Epigraph Preface About the Book Acknowledgments Chapter 1 Hospitals Through the Ages Learning Objectives Early Hindu and Egyptian Hospitals Greek and Roman Hospitals Hospitals of the Early Christian Era Islamic Hospitals Early Military Hospitals Medieval Hospitals The “Dark Age” of Hospitals Hospitals of the Renaissance Hospitals of the 18th Century Early Hospitals in the United States Late 19th Century Renaissance 20th-Century Progress Health Care and Hospitals in the 21st Century History Challenges Us to Do Better Chapter Review Review Questions Notes Chapter 2 Government, Law, and Ethics Learning Objectives Development of Law Sources of Law Government Organization Department of Health and Human Services Government Ethics Political Malpractice Chapter Review Review Questions Notes Chapter 3 Tort Law—Negligence Learning Objectives Objectives of Tort Law Negligence Forms of Negligence 8 Degrees of Negligence Elements of Negligence Summary Case Chapter Review Review Questions Notes Chapter 4 Intentional Torts Learning Objectives Assault and Battery False Imprisonment Defamation of Character Fraud Invasion of Privacy Infliction of Mental Distress Products Liability Chapter Review Review Questions Notes Chapter 5 Tort Reform and Risk Reduction Learning Objectives Mediation and Arbitration Statute of Limitations Structured Awards Medical Malpractice Screening Panels Collateral Source Rule Contingency Fee Limitations Countersuits: Frivolous Claims Joint and Several Liability Malpractice Caps No-Fault System Regulation of Insurance Practices Reducing the Risks of Malpractice Collaboration in Tort Reform Chapter Review Review Questions Notes Chapter 6 Criminal Aspects of Health Care Learning Objectives Criminal Procedure Healthcare Fraud Kickbacks Tampering with Drugs 9 Internet Pharmacy and Sale of Drugs Falsification of Records Patient Abuse Criminal Negligence Homicide Manslaughter Rape and Sexual Assault Theft Chapter Review Review Questions Notes Chapter 7 Contracts and Antitrust Learning Objectives What Is a Contract? Types of Contracts Elements of a Contract Breach of Contract Corporate Contracts Partnership Agent Independent Contractor Conditions Performance Nonperformance Defenses Remedies Employment Contracts Medical Staff Bylaws: A Contract Exclusive Contracts Restraint of Trade Hospital Staff Privileges Transfer Agreements Insurance Contract Chapter Review Review Questions Notes Chapter 8 Civil Procedure and Trial Practice Learning Objectives Pleadings Discovery Motions Pretrial Conference Notice of Trial Memorandum of Law The Courtroom and the Judge 10 The Jury Subpoenas Burden of Proof Res Ipsa Loquitur Opening Statements Examination of Witnesses Judicial Notice Rule Evidence Defenses Against Plaintiff’s Allegations Closing Statements Judge’s Charge to the Jury Jury Deliberation and Determination Awarding Damages Joint and Several Liability Appeals Execution of Judgments Chapter Review Review Questions Notes Chapter 9 Corporate Structure and Legal Issues Learning Objectives Authority of Corporations Corporate Committee Structure Corporate Ethics Corporate Negligence Doctrine of Respondeat Superior Governing Body Responsibilities Corporate Reorganization and Mergers Chapter Review Review Questions Notes Chapter 10 Medical Staff Organization and Malpractice Learning Objectives Medical Staff Organization Medical Director Medical Staff Privileges Common Medical Errors Patient Assessments Diagnosis Treatment Discharge and Follow-Up Care Infections Psychiatry 11 Principles of Medical Ethics Physician–Patient Relationship Chapter Review Review Questions Notes Chapter 11 Nursing and the Law Learning Objectives Scope of Practice Nurse Licensure Nursing Careers Advanced Practice Nurses Legal Risks of Nurses Duty to Question Discharge Duty to Report Physician Negligence Chapter Review Review Questions Notes Chapter 12 Hospital Departments and Allied Professionals Learning Objectives Paramedics and First Responders Emergency Department Laboratory Medical Assistant Nutritional Services Pharmacy Physical Therapy Physician Assistant Radiology and Related Lawsuits Respiratory Therapist Chiropractor Dentistry Podiatrist Security Licensure and Certification of Healthcare Professionals Helpful Advice for Caregivers Chapter Review Review Questions Notes Chapter 13 Information Management and Patient Records Learning Objectives 12 Information Management Medical Record Contents Documentation of Care Privacy Act of 1974 Health Insurance Portability and Accountability Act Patient Objects to Record Entries Ownership and Release of Medical Records Use of Patient Data Collected Retention of Records Electronic Medical Records Legal Proceedings and the Medical Record Falsification of Records Illegible Handwriting Timely Completion of Medical Records Confidential and Privileged Communications Charting: Some Helpful Advice Chapter Review Review Questions Notes Chapter 14 Patient Consent, Rights, and Responsibilities Learning Objectives Patient Consent Patient Rights Patient Responsibilities Chapter Review Review Questions Notes Chapter 15 Healthcare Ethics Learning Objectives Ethics Morality Ethical Theories Principles of Healthcare Ethics Values Pillars of Moral Strength Religious Ethics and Spirituality Secular Ethics Professional Ethics Ethics Committee Reasoning and Decision Making Moral Compass Gone Astray Chapter Review Review Questions 13 Notes Chapter 16 Procreation and Ethical Dilemmas Learning Objectives Abortion Sterilization Artificial Insemination Surrogacy Chapter Review Review Questions Notes Chapter 17 End-of-Life Issues Learning Objectives Patient Autonomy Constitutional Right to Refuse Care Legislative Response Defining Death Futility of Treatment Do-Not-Resuscitate Orders Withholding and Withdrawal of Treatment Euthanasia Physician-Assisted Suicide Advance Directives Autopsy Organ Donations and Transplantation Research, Experimentation, and Clinical Trials Human Genetics Stem Cell Research Chapter Review Review Questions Notes Chapter 18 Legal Reporting Requirements Learning Objectives Abuse Child Abuse Senior Abuse Communicable Diseases Aids Births and Deaths Adverse Drug Reactions Physician Competency Incident Reporting Sentinel Events 14 Look Closer, See Me Chapter Review Review Questions Notes Chapter 19 Labor Relations Learning Objectives U.S. Department of Labor Unions and Healthcare Organizations National Labor Relations Act Norris–Laguardia Act Labor–Management Reporting and Disclosure Act Fair Labor Standards Act Civil Rights Act Occupational Safety and Health Act Rehabilitation Act Family and Medical Leave Act State Labor Laws Workers’ Compensation Labor Rights Management Rights Affirmative Action Plan Patient Rights During Labor Disputes Injunctions Administering Collective Bargaining Agreement Discrimination in the Workplace Chapter Review Review Questions Notes Chapter 20 Employment at Will, Rights, and Responsibilities Learning Objectives Employment at Will Public Policy Issues and Termination Termination Unemployment Compensation Wrongful Discharge Defending a Claim for Unfair Discharge Fairness: The Ultimate Test Effective Hiring Practices Employee Rights Employee Responsibilities The Caregiver’s Pledge Chapter Review Review Questions 15 Notes Chapter 21 Professional Liability Insurance Learning Objectives Insurance Policies Insurance Policy Provisions Conditions of Insurance Policies Liability of the Professional Intentional Torts: Coverage Denied Medical Liability Insurance Self-Insurance Trustee Coverage Mandated Medical Staff Insurance Coverage Investigation and Settlement of Claims Chapter Review Review Questions Notes Chapter 22 Managed Care and National Health Insurance Learning Objectives Managed Care Models of Managed Care Organizations Federally Qualified HMO State HMO Laws Case Management Firms Third-Party Administrators Utilization Review Liability for Nonparticipating Hospitals Employee Retirement Income Security Act Reducing Exposure to Liability Health Care Quality Improvement Act of 1986 Ethics in Patient Referral Act (1989) Managed Care and Legal Actions Price Fixing Market Power National Health Insurance Veterans Care Chapter Review Review Questions Notes Author’s Afterword Glossary Index 16 17 18 Epigraph I consider ethics, as well as religion, as supplements to law in the government of man. —Thomas Jefferson, President of the United States (1743–1826) In law a man is guilty when he violates the rights of others. In ethics he is guilty if he only thinks of doing so. —Immanuel Kant, Philosopher (1724−1804) Books are the carriers of civilization. Without books, history is silent, literature dumb, science crippled, thought and speculation at a standstill. I think that there is nothing, not even crime, more opposed to poetry, to philosophy, ay, to life itself than this incessant business. —Henry David Thoreau, Author, Poet, Philosopher (1817–1862) It is curious—curious that physical courage should be so common in the world, and moral courage so rare. —Mark Twain, American Author, Humorist (1835−1910) In civilized life, law floats in a sea of ethics. —Earl Warren, Chief Justice of the United States (1891–1974) How far you go in life depends on your being tender with the young, compassionate with the aged, sympathetic with the striving, and tolerant of the weak and the strong— because someday you will have been all of these. —George Washington Carver, American Inventor (1864–1943) 19 20 Preface He has achieved success who has lived well, laughed often and loved much; who has gained the respect of intelligent men and the love of little children; who has filled his niche and accomplished his task; who has left the world better than he found it, whether by an improved poppy, a perfect poem, or a rescued soul; who has never lacked appreciation of earth’s beauty or failed to express it; who has always looked for the best in others and given them the best he had; whose life was an inspiration; whose memory a benediction. —Bessie Stanley L egal Aspects of Health Care Administration, Thirteenth Edition, as with the previous 12 editions, continues to be the most comprehensive and engaging book encompassing both the legal and ethical issues of healthcare administration. The Thirteenth Edition continues its tradition of providing a solid foundation in a wide range of current healthcare topics in an understandable format that carefully guides the reader through the complex maze of law and ethics, as well as an overview of practical ways to improve quality and safety in the delivery of patient care. As in previous editions, the Thirteenth Edition serves as a valuable tool for both undergraduate and graduate programs. Additionally, as has been well recognized by practicing healthcare professionals, Legal Aspects of Health Care Administration continues to be a valuable reference tool in their day-to-day work activities. The author infuses life into the educational process through legal case studies that have been litigated in the courtroom or reported in the press, as well as real-world healthcare events through “reality checks” experienced by patients and healthcare professionals. The author’s approach inspires dynamic discussion and excitement in the learning process, thus creating an atmosphere of interest and participation, which is conducive to learning. Although the court cases relating examples of malpractice are often mirror images of the failures of medicine, this Thirteenth Edition provides a comprehensive resource from which the reader will learn how the law, ethics, and medicine intertwine. The contents of this book serve as a reminder to its readers of the need to learn from the mistakes and tragedies experienced by others to avoid repeating them. The legal cases and resulting headlines should stand as a reminder of the responsibility that caregivers bear to the profession they have chosen. With revised estimates that as many as 400,000 patients die each year as a result of medical errors, according to a September 2013 study reported in the Journal of Patient Safety, it is mandatory that caregivers be ever mindful of the 21 nature of the life-and-death settings within which they work. At the time of this writing the headlines continue to repeat themselves. For example, on December 4, 2014, an Oregon hospital’s medication error led to the death of a 65-year-old patient. This error resulted in three employees being placed on administrative leave. The knowledge gained here will help prevent caregivers from becoming the next headline. Although there will always be a “next time” for human error, the reader who grasps the contents in this book and understands its lessons will better understand how failures can turn to success and the pain of past mistakes can turn to hope. The application of the knowledge gained from this book and in the classroom learning process will serve to improve the competency of the reader and the quality of life for the patient through an educational process that will help prevent further injury in the healing process. 22 23 About the Book Legal Aspects of Health Care Administration, Thirteenth Edition, lays a strong foundation in both health law and ethics. Chapter 1 begins with a review of hospitals through the ages, providing the reader with an overview of the historical development of hospitals as influenced by medical progress. This allows the reader to see the successes and failures of hospitals through the centuries and how history has a way of repeating itself, thus creating a need to learn from past mistakes in order to prevent repeating them. Chapter 2 continues with an introduction to government, law, and ethics. Chapters 3 and 4 introduce the reader to negligence and intentional torts. Chapter 5 discusses tort reform and risk reduction, thus reducing the costs of health care. Chapter 6 reviews the criminal aspects of health care, and Chapter 7 reviews the basics of contract law as it pertains to healthcare professionals. The reader is then introduced to civil procedure and trial practice in Chapter 8. The reader’s journey continues with a discussion of corporate structure and related legal issues in Chapter 9. A review of medical staff organization and physician liability is covered in Chapter 10, followed by nursing and the law and common nursing practice errors in Chapter 11. Chapter 12 reviews the legal risks of various other hospital departments and healthcare professions. Information management and patient records are reviewed in Chapter 13. Issues related to patient consent, rights, and responsibilities are reviewed in Chapter 14, followed by a discussion of ethical theories, principles, virtues, and values. Chapter 15 concentrates on healthcare ethics, theories, principles, and values. This review is followed by procreation and ethical dilemmas in Chapter 16, and end-of life issues in Chapter 17. Legal reporting requirements are discussed in Chapter 18. Labor relations and employment-at-will, employee rights, and employee responsibilities are reviewed in Chapters 19 and 20, respectively. An overview of professional liability insurance, managed care, and national health insurance is provided in Chapters 21 and 22. The practical application of the law and ethics in the healthcare setting is accomplished by interspersing the thoughts of great minds through Quotes, applicable News Clippings, provider and organizational experiences through Reality Checks, and patient experiences through legal rulings and summaries through Case Law. When reviewing the various cases, the reader should consider both the ethical and legal implications of a dilemma and how they intertwine with one another. It is important to recognize that the decisions in the cases described are generally governed both by applicable state and federal statutes and common law principles. When reviewing a case, the 24 reader must keep in mind that the case law and statutes of one state are not binding in another state. There is no one magical legal or ethics book that can possibly compress into its pages the plethora of issues that have bombarded the healthcare industry. This book is merely a beginning of the study of legal and ethical issues and is an adventure that all caregivers should take. Although there is always much more that could be discussed on any one topic, the reader will understand that this book provides a solid foundation for practical everyday use as well as further study in the law and ethics. Each life is like a novel. Filled with moments of happiness, sadness, crisis, defeat, and triumph. When the last page has been written, will you be happy or saddened by what you read? —Author Unknown The Thirteenth Edition presents real-world life experiences that bring the reader through a journey of learning that provides an effective transitional stage from the classroom to the reality of the everyday work environment. When considering matters of law and ethics, healthcare professionals are usually considering matters of freedom in regard to personal choices, one’s obligations to other sentient beings, or judgments about human character and the right to choose. The author’s objective is to equip the reader with the background knowledge necessary to understand that legal and ethical behavior begins with recognizing that we have alternatives and choices in our behavior. To make good decisions, each individual must first understand that those decisions will only be as good as the knowledge and understanding he or she possesses of right and wrong. This book is not an indictment of any profession or organization. There is a deluge of ethical issues in every aspect of human existence. Although cultural differences, politics, and religion influence who we are, it is all of life’s experiences that affect who we become. IT’S YOUR GAVEL . . . “It’s Your Gavel” boxes offer the reader an opportunity to make their own decisions about actual court cases. Many chapters begin with a case that has been reviewed by the courts in state or federal jurisdictions. After reviewing each case and subsequent relevant material, readers can take on the role of the fact finder and render a decision. Then, at the end of the respective chapters, the actual court findings and reasoning for each case are given in “The Court’s Decision” box. ▸ Case Presentation Format When reviewing the various cases in this book, the reader should consider what happened, why things went wrong, what the relevant legal issues are, and how the event could have been prevented. The reader should also 25 consider how, if one fact in a particular case changed, the outcome might have been different. What would that fact be? The cases presented in the text have been chosen because of the frequency of their occurrence. The general format for each boxed case review is as follows: Title: Each case has a title that signals the type of case to be reviewed. Case Citation: The case citation describes where a court’s opinion in a particular case can be located. It identifies the parties in the case, the text in which the case can be found, the court writing the opinion, and the year in which the case was decided. For example, the case citation of Bouvia v. Superior Court (Glenchur), 225 Cal. Rptr. 297 (Cal. Ct. App. 1986) is described as follows: Bouvia v. Superior Court (Glenchur): Identifies the basic parties involved in the lawsuit 225 Cal. Rptr. 297: Identifies the case as being reported in volume 225 of the California Reporter on page 297 Cal. Ct. App. 1986: Identifies the case as being decided in the California Court of Appeals in 1986 Students who wish to research a specific case should visit a law school library, which provides access to various state and regional reporters. Facts: A review of the material facts of the case is presented. Issues: This is the disputed point or question the judge or jury must decide. The issues discussed in any given case are selected for review based on medical and legal pertinence to the healthcare professional. Although any one case in this text may have multiple issues, emphasis is placed on those issues considered to be more relevant for the reader in the context of the topic being discussed. Holding: The court’s ruling based on the facts, issues, and applicable laws pertaining to a case is summarized. Reason: The rationale for the court’s decision based on the facts, issues, and relevant laws surrounding a case is presented. Author’s Note: This book is not a definitive treatise, but rather a portrait of the ever-evolving story of health care through the study of law and ethics. It is educational in nature and should not be considered a substitute for legal advice on any particular issue. Moreover, each chapter presents an overview, rather than an exhaustive treatment, of the various topics discussed. 26 The author, legal reviewers, and/or the publisher cannot be responsible for any errors or omissions, including additions to, interpretations of, and/or changes in the regulations presented in this book. 27 28 Acknowledgments The author especially acknowledges the staff at Jones & Bartlett Learning, whose guidance and assistance was so important in making this Thirteenth Edition a reality. Special thanks to Mike Brown, Director of Product Management at Jones & Bartlett Learning, who has once again been truly an amazing leader and mentor. I would like to thank Danielle Bessette, Product Specialist, who worked diligently and tirelessly with me on this Thirteenth Edition. I would also especially like to acknowledge Sophie Teague, Senior Marketing Manager, Brooke Haley, Production Assistant, and Merideth Tumasz, Rights & Media Specialist, who worked with me on the Thirteenth Edition. Thank you for allowing me to leave behind this legacy of writing. I am grateful to the very special people in the more than 1,000 hospitals and ambulatory sites from Alaska to Puerto Rico with whom I have consulted, surveyed, and provided education over many years. Their shared experiences have served to remind me of the importance of making this book more valuable in the classroom and as a reference for practicing healthcare professionals. To my students in healthcare law and ethics classes at the New School for Social Research, Molloy College, Long Island University–C.W. Post Campus, Saint Francis College, and Saint Joseph’s College; my intern from Brown University; my resident in hospital administration from The George Washington University; and those I have instructed through the years at various seminars, I will always be indebted for your inspiration. Many thanks are also extended to all of the special people at the National Library of Medicine and the Library of Congress for their guidance over the years in locating research materials. 29 © Hein Nouwers/Shutterstock, Inc. 30 CHAPTER 1 Hospitals Through the Ages I was created at the end of the Renaissance, watched pirates rule the oceans as Ivan the Terrible ruled Russia, and witnessed the arrest of Galileo for believing the Earth revolved around the Sun. —I Am History 31 ▸ LEARNING OBJECTIVES The reader, upon completion of this chapter, will be able to: Explain how societal conflicts due to politics, religion, and warfare have both impeded the growth of hospitals and contributed to their progress. Describe how advances in medicine led to the rise of the modern-day hospital and improved the quality of patient care. Describe how the knowledge gained from best practices (e.g., infection control) can lead to progress while at the same time result in patient harm if not consistently followed over time. We can learn from history how past generations thought and acted, how they responded to the demands of their time and how they solved their problems. We can learn by analogy, not by example, for our circumstances will always be different than theirs were. The main thing history can teach us is that human actions have consequences and that certain choices, once made, cannot be undone. They foreclose the possibility of making other choices and thus they determine future events. —Gerda Lerner 1 This chapter provides the reader with notable historical events, from ancient civilizations to the present time, which continue to revolutionize the delivery of patient care. It provides a review of the advance of civilization as disclosed in the history of hospitals and medical achievements through the ages. A study of the past often reveals errors that then can be avoided, customs that persist only because of tradition, and practices that have been superseded by others that are more effective. The past may also bring to light long-abandoned practices, which may be revived to some advantage. The story of the birth and evolution of the hospital portrays the triumph of civilization over barbarism and the progress of civilization toward an ideal characterized by an interest in the welfare of the community. This chapter reviews some of the most amazing medical discoveries and achievements in the history of medicine. It also describes some of the failures that continue to plague the healthcare industry. The importance of the study of history is undeniable. The Spanish philosopher George Santayana (1863– 1952) recognized this all too well when he said, “Those who do not remember the past are condemned to repeat it.” George Bernard Shaw (1856–1950), an Irish dramatist and socialist, recognized the tragedies of the history of civilization when he said, “If history repeats itself, and the unexpected always happens, how incapable must man be of learning from experience.” Yes, Santayana and Shaw are right: If we do not learn from the mistakes of the past, we are doomed to repeat them. Progress in health care will only prevail so long as advances in medicine are practiced by each new generation. 32 Although the struggle to progress is a road filled with many pitfalls, hope still looms. Martin Makary wrote in the Wall Street Journal that “Medical errors kill enough people to fill four jumbo jets a week . . . To do no harm going forward, we must be able to learn from the harm we have already done.”2 If we do not learn from historical events to those of the present days, we are bound to repeat them. This chapter takes the reader on a journey from the past to the present, from which to spring forward on a better road that returns the people’s trust in the safety net of the nation’s hospital systems. Here, we go “back into the future” to bring forth the fruits of healthier hospitals and healthier lives. Let the reader now travel that road. 33 ▸ EARLY HINDU AND EGYPTIAN HOSPITALS Two ancient civilizations, the Hindu (in what is now India) and the Egyptian, had crude hospitals. Hindu literature reveals that in the 6th century BC, Buddha appointed a physician for every 10 villages and built hospitals for the crippled and the poor. His son, Upatiso, built shelters for the diseased and for pregnant women. These examples probably moved Buddha’s devotees to erect similar hospitals. Despite a lack of records, historians agree that hospitals existed in Ceylon as early as 437 BC. During his reign from 273 to 232 BC, King Asoka built 18 hospitals that hold historical significance because of their similarities to the modern hospital. Attendants gave gentle care to the sick, provided patients with fresh fruits and vegetables, prepared their medicines, gave massages, and maintained their personal cleanliness. Hindu physicians, adept at surgery, were required to take daily baths, keep their hair and nails short, wear white clothes, and promise that they would respect the confidence of their patients. Although bedside care was outstanding for those times, medicine was only beginning to find its way. Egyptian physicians were probably the first to use drugs such as alum, peppermint, castor oil, and opium. In surgery, anesthesia consisted of hitting the patient on the head with a wooden mallet to render the patient unconscious. Surgery was largely limited to fractures, and medical treatment was usually given in the home. Therapy away from home was often available in temples, which functioned as hospitals. 34 ▸ GREEK AND ROMAN HOSPITALS The term hospital derives from the Latin word hospitalis, which relates to guests and their treatment. The word reflects the early use of these institutions not merely as places of healing, but also as havens for the poor and weary travelers. Hospitals first appeared in Greece as aesculapia, named after the Greek god of medicine, Aesculapius. For many centuries, hospitals developed in association with religious institutions, such as the Hindu hospitals opened in Sri Lanka in the 5th century BC and the monastery-based European hospitals of the Middle Ages (5th century to 15th century AD). The Hotel-Dieu in Paris, a monastic hospital founded in 660 AD, is still in operation today. In early Greek and Roman civilization, when medical practices were rife with mysticism and superstitions, temples also were used as hospitals. Every sanctuary had a sacred altar before which the patient, dressed in white, was required to present gifts and offer prayers. If a patient was healed, the cure was credited to miracles and divine visitations. If the patient remained ill or died, he or she was considered to be lacking in purity and unworthy to live. Greek temples provided refuge for the sick. One of these sanctuaries, dedicated to Aesculapius, is said to have existed as early as 1134 BC at Titanus. Ruins attest to the existence of another, more famous Greek temple built several centuries later in the Hieron, or sacred grove, at Epidaurus. Here, physicians ministered to the sick holistically in body and soul. They prescribed medications such as salt, honey, and water from a sacred spring. They gave patients hot and cold baths to promote speedy cures and encouraged long hours of sunshine and sea air, combined with pleasant vistas, as an important part of treatment. The temple hospitals housed libraries and rooms for visitors, attendants, priests, and physicians. The temple at Epidaurus even boasted what might be described as the site of the first clinical records. The columns of the temple were inscribed with the names of patients, brief histories of their cases, and comments as to whether or not they were cured. The aesculapia spread rapidly throughout the Roman Empire, as well as through the Greek world. Although some hospitals were simply spas, others followed the therapy outlined by the leading physicians of the day. Hippocrates, for example, a physician born about 460 BC, advocated medical theories that have startling similarity to those of the present day. He employed the principles of percussion and auscultation, wrote intelligently on fractures, performed numerous surgical operations, and described such conditions as epilepsy, tuberculosis, malaria, and ulcers. He also kept detailed clinical records of many of his patients. Physicians like Hippocrates not only cared for patients in the temples, but also gave instruction to young medical students. 35 36 ▸ HOSPITALS OF THE EARLY CHRISTIAN ERA Christianity and the doctrines preached by Jesus stressing the emotions of love and pity gave impetus to the establishment of hospitals, which, with the advance of Christianity, became integral parts of the church institution. These Christian hospitals, which replaced those of Greece and Rome, were devoted entirely to care of the sick, and accommodated patients in buildings outside the church proper. A decree of Constantine in 335 AD closed the aesculapia and stimulated the building of Christian hospitals, which, during the 4th and 5th centuries, reached the peak of their development. Many were erected by the rulers of the period or by wealthy Romans who had converted to Christianity. By the year 500, most large towns in the Roman Empire had hospitals. Nursing, inspired by religion, was gentle and considerate, but soon began to discard the medical precepts of Hippocrates, Antyllus, and other early Greek physicians because of their pagan origins. Instead, health care turned toward mysticism and theurgy (the working of a divine agency in human affairs) as sources of healing. Hospitals rarely succeeded during the centuries leading to the Middle Ages; only a few existed outside Italian cities. Occasional almshouses in Europe sheltered some of the sick, whereas inns along the Roman roads housed others. No provision appears to have been made for care of the thousands of helpless paupers who had been slaves and were later set free when Christianity was introduced into the Roman Empire. 37 ▸ ISLAMIC HOSPITALS The followers of Mohammed were almost as dedicated as the Christians in caring for the sick. In Baghdad, Cairo, Damascus, Cordova, and many other cities under their control, luxurious hospital accommodations were frequently provided. Harun al-Rashid, the glamorous caliph (a title for a religious or civil ruler claiming succession from Mohammad) of Baghdad (786–809 AD), built a system of hospitals and paid the physicians himself. Medical care in these hospitals was free. Approximately four centuries later, in 1160, a Jewish traveler reported that he had found as many as 60 dispensaries and infirmaries in Baghdad alone. The Persian physician Rhazes, who lived from approximately 850 to 923 AD, was skilled in surgery. He is believed to be the first to use the intestines of sheep for suturing and to cleanse patient wounds with alcohol. He also gave the first rational accounts of smallpox and measles. Islamic physicians like Rhazes received much of their medical knowledge from the persecuted Christian sect known as the Nestorians. Nestorius (Archbishop of Constantinople from April 428 to August 431) was driven into the desert with his followers after having been appointed patriarch of Constantinople and took up the study of medicine. The school at Edessa, in Mesopotamia, with its two large hospitals, eventually came under the control of the Nestorians, where they established a remarkable teaching institution. Eventually driven out of Mesopotamia by the orthodox bishop Cyrus, they fled to Persia, where they established the famous school at Gundishapur, which is considered to be the true starting point of Islamic medicine. Gundishapur was home to the world’s oldest known teaching hospital and also comprised a library and a university. It was located in the present-day province of Khuzestan, in southwestern Iran, not far from the Karun River. Islamic medicine flourished up to about the 15th century. Physicians were acquainted with the possibilities of inhalation anesthesia. They instituted precautions against adulteration of drugs and developed a vast number of new drugs. Islamic countries also built asylums for the mentally ill 1,000 years before such institutions appeared in Europe. The people of Islam made a brilliant start in medicine, but never fulfilled the great promise that glowed in their early work in medical arts and hospitalization was never fulfilled. Wars, politics, superstitions, and a nonprogressive philosophy stunted the growth of a system that had influenced the development of hospitals. 38 ▸ EARLY MILITARY HOSPITALS Engraved on a limestone pillar dating back to the Sumerians (2920 BC) are pictures that depict, among other military procedures, the assemblage of the wounded. The Book of Deuteronomy records that Moses established outstanding rules for military hygiene. Out of the urgency of care for the wounded in battle came much of the impetus for medical progress. Hippocrates is quoted as saying that “war is the only proper school for a surgeon.” Under the Romans, surgery advanced largely because of experience gained through gladiatorial and military surgery. Throughout the centuries, warfare has been a two-edged sword, producing tragic events while providing an environment for the advancement of surgery and medicine. From an ethical point of view, the question arises: What surgical and medical advancements might have been lost due to the failure of mankind to sit at the table of peace and compromise on differences based on logic and reason? 39 ▸ MEDIEVAL HOSPITALS Religion continued to be the most important factor in the establishment of hospitals during the Middle Ages. A number of religious orders created hospitia, or travelers’ rests, and infirmaries adjacent to monasteries provided food and temporary shelter for weary travelers and pilgrims. One of these, the famous alpine hospice of St. Bernard, founded in 962, gave comfort to the weary and sent its renowned dogs to the rescue of lost mountain climbers. The hospital movement grew rapidly during the Crusades, which began in 1096. Military hospital orders sprang up, and accommodations for sick and exhausted crusaders were provided along well-traveled roads. One body of crusaders organized the Hospitallers of the Order of St. John, which in 1099 established in the Holy Land a hospital capable of caring for 2,000 patients. Knights of this order took personal charge of service to patients and often denied themselves so that the sick might have food and medical care. For years, these institutions were the best examples of hospitals of that period. Although physicians cared for physical ailments to afford relief, they rarely attempted to cure the sick. Dissection of a human body would have been sacrilege because the body was created in the image of God. Finally, an active period of hospital growth came during the late 12th and early 13th centuries. In 1198, Pope Innocent III urged hospitals of the Holy Spirit to be subscribed for by the citizenry of many towns. He set an example by founding a model hospital in Rome, known as Santo Spirito, in Sassia. Built in 1204, it survived until 1922, when it was destroyed by fire. In Rome, nine other hospitals were founded shortly after completion of the one in Sassia; it is estimated that in Germany alone, 155 towns had hospitals of the Holy Spirit during early medieval times. Although most hospitals constructed during the Middle Ages were associated with monasteries or founded by religious groups, a few cities, particularly in England, built municipal institutions. Like all hospitals of the period, the buildings were costly and often decorated with colorful tapestries and stained glass windows, but the interiors were frequently little more than large drafty halls with beds lining each side. Some hospitals were arranged on the ward plan, usually built in the shape of a cross. Floors were made of red brick or stone, and the only ventilation came from the cupola in the ceiling. With the spread of leprosy during the 12th and 13th centuries, lazar houses sprang up, supplying additional hospital facilities. Made up of crude structures, lazar houses were usually built on the outskirts of towns and maintained for the segregation of lepers rather than for their treatment. Special groups of attendants, including members of the Order of St. Lazar, nursed the patients. 40 The group represented an important social and hygienic movement because their actions served to check the spread of epidemics through isolation. The group is credited for virtually stamping out leprosy. During the same period of hospital growth, three famous London institutions were established: St. Bartholomew’s in 1137, St. Thomas’s before 1207, and St. Mary of Bethlehem in 1247. St. Bartholomew’s, founded by Rahere (reportedly the court jester of Henry I), cared for the sick poor but, unlike many hospitals of that day, was well organized. St. Thomas’s Hospital was founded by a woman who was later canonized St. Mary Overie. It burned in 1207, was rebuilt 6 years later, and was constructed again on a new site in 1228. St. Mary of Bethlehem was the first English hospital to be used exclusively for the mentally ill. The Hotel-Dieu of Paris was probably typical of the better hospitals of the Middle Ages. Built at the beginning of the 13th century, the hospital provided four principal rooms for patients in various stages of disease, as well as a room for convalescents and another for maternity patients. Illustrations by artists of the time show that two persons generally shared one bed. Heavy curtains sometimes hung from canopies over the bed to afford privacy, but this advantage was more than offset by the fact that the draperies, which were never washed, spread infection and prevented free ventilation. The institution was self-contained, maintaining a bakery, herb garden, and farm. Often, patients who had fully recovered remained at the hospital to work on the farm or in the garden for several days in appreciation for the care they had received. 41 ▸ THE “DARK AGE” OF HOSPITALS Pictures and records of hospitals during the Middle Ages illustrate how many hospitals commonly crowded several patients into one bed regardless of the type or seriousness of the illness. A mildly ill patient might be placed in the same bed as an occupant suffering from a contagious disease. A notable exception to the general deterioration in medicine during this era was the effort of those monks who copied by hand and preserved the writings of Hippocrates and other ancient physicians. The great Al-Mansur Hospital, built in Cairo in 1276, struck a contrast to the European institutions of the Middle Ages. It was equipped with separate wards for the more serious diseases and provided outpatient clinics. The handful of hospitals like Al-Mansur would lay the groundwork for hospital progress to come in later centuries. 42 ▸ HOSPITALS OF THE RENAISSANCE During the revival of learning around the close of the 14th century, hundreds of medical hospitals in Western Europe received the new, more inquiring surgeons that the Renaissance produced. New drugs were developed, and anatomy became a recognized study. Ancient Greek writings were printed, and dissection was performed by such masters as Leonardo da Vinci, known as the originator of cross-sectional anatomy, and Andreas Vesalius, author of De Humani Corporis Fabrica (On the Fabric of the Human Body), on human anatomy. Hospitals became more organized. Memoranda from 1569 describe the duties of the medical staff in the civil hospital of Padua, a city that was home to the most famous medical school of the 16th century. These read: There shall be a doctor of physic upon whom rests the duty of visiting all the poor patients in the building, females as well as males; a doctor of surgery whose duty it is to apply ointments to all the poor people in the hospital who have wounds of any kind; and a barber who is competent to do, for the women as well as the men, all the other things that a good surgeon usually does.3 The practice of surgery during the Renaissance became more scientific and progressive. Operations for lithotomy and hernioplasty were undertaken without the use of anesthetics, and surgery was practiced by the long-robe surgeons, a small group who were educated in the universities and permitted to perform all types of operations, and by the short-robe surgeons, the barbers who, in most communities, were allowed only to leech and shave the patient, unless permission was granted to extend the scope of treatment. Both groups were regarded as inferior to physicians. In 1506, a band of long-robe surgeons organized the Royal College of Surgeons of Edinburgh. By 1540, both the long- and short-robe surgeons in England joined to form the Company of Barber-Surgeons of London. In 1528, Thomas Linacre, physician to Henry VIII, founded and became the first president of the Royal College of Physicians of England. Although English physicians were organized during the 16th century, Henry VIII of England ordered that hospitals associated with the Catholic Church be given over to secular uses or destroyed. The sick were turned out into the streets. Conditions in hospitals became so intolerable that the king was petitioned to return one or two buildings for the care of patients. Henry consented and restored St. Bartholomew’s in 1544. Practically the only hope for the sick poor from outlying towns was to journey many miles to London. The dearth of hospitals in England continued throughout the 17th century, when the medical school was developed. The French and the English quickly 43 accepted what had originated in Italy—the first attempt to make medical instruction practical. St. Bartholomew’s took the lead in education by establishing a medical library in 1667 and permitted apprentices to walk the wards for clinical teaching under experienced surgeons. In 1634, an outstanding contribution was made to nursing by the founding of the order of the Daughters of Charity of St. Vincent de Paul. Originating at the Hotel-Dieu of Paris as a small group of village girls who were taught nursing by the nuns, the order grew rapidly and was transplanted to the United States by Mother Seton in 1809. 44 ▸ HOSPITALS OF THE 18TH CENTURY During the 18th century, the building of hospitals began to revive. Because of poverty, the movement made slow progress in England, but a few hospitals were built and supported jointly by parishes. By 1732, there were 115 such institutions in England, some of them a combination of almshouse and hospital. As hospitals grew in number, new advances in health care began. The Royal College of Physicians established a dispensary where medical advice was free and medicines were sold to the needy at cost. Controversies and lawsuits, however, brought an untimely end to this early clinic. Not discouraged by this experience, the Westminster Charitable Society created a similar dispensary in 1715. The same organization, in 1719, founded Westminster Hospital, an infirmary built by voluntary subscription, in which the staff gave its services gratuitously. Ten years later, the Royal College of Physicians in Edinburgh opened the Royal Infirmary. London Hospital, another notable institution, was founded in 1740. Admission of charity patients to the London Hospital was apparently by an admission ticket. Among its historical relics is an admission card that had on the back of the card a representation of a biblical scene drawn by the artist William Hogarth. In 1727, John Theophilus Desaguliers invented a machine for pumping fresh air into and foul air out of rooms. It was first used in prisons and public buildings and later installed in hospitals. Other mechanical improvements for the care of the sick were sadly wanting, but worse was the lack of cleanliness and the crude and careless treatment of patients. In the Elizabethan period, with its materialistic and cold culture, the deterioration of hospital service that had set in under Henry VIII continued. The lowest point in the deterioration of hospitals came during the 18th and first half of the 19th centuries. Considering the increase in knowledge during the 18th century, development of educational opportunities, and steady growth in population and wealth, the few hospitals built at that time were inadequate. As far as hospital progress is concerned, the 18th century was not only decidedly uneventful; it was a period of regression. The full revival did not begin until well after the middle of the 19th century. Antony van Leeuwenhoek (1632–1723) succeeded in making some of the most important discoveries in the history of biology. Although van Leeuwenhoek did not invent the first microscope, he was able to perfect it. His many discoveries included bacteria, free-living and parasitic microscopic protists, sperm cells, blood cells, and microscopic nematodes. His research opened up an entire world of microscopic life. Often referred to as the “father of microbiology,” van Leeuwenhoek had a pronounced influence on the 45 creation of the sciences of cytology, bacteriology, and pathology. His discoveries have forever improved patient care. 46 ▸ EARLY HOSPITALS IN THE UNITED STATES Manhattan Island claims the first account of a hospital in the New World, a hospital that was used in 1663 for sick soldiers. Fifty years later, in Philadelphia, William Penn founded the first almshouse established in the American colonies. The Quakers supported the almshouse, which was open only to members of that faith. However, Philadelphia was rapidly growing and in need of a public almshouse. Such an institution for the aged, the infirm, and persons with mental illness was established in 1732. The institution later became the historic Old Blockley, which, in turn, evolved into the Philadelphia General Hospital. Philadelphia was the site of the first incorporated hospital in America, the Pennsylvania Hospital. Dr. Thomas Bond wanted to provide a place where Philadelphia physicians could treat their private patients. With the aid of Benjamin Franklin, Dr. Bond sought a charter for the Pennsylvania Hospital, which was granted by the Crown in 1751. Franklin assisted in designing the hospital. It included a central administration unit and two wings opened to the public. The first staff consisted of Dr. Phineas Bond, Dr. Lloyd Zachary, and the founder, Dr. Thomas Bond, all of whom gave their services without remuneration for 3 years. Rich in the history of hospitals, Philadelphia is credited with the first quarantine station for immigrants (created in 1743) and the first lying-in hospital (established in 1762), a private institution owned by the noted obstetrician William Shippen. The quality of American health care seemed to be improving. However, by 1775 Dr. John Jones published a book calling attention to the frightful conditions that existed in hospitals. He charged that hospitals abroad were crowded far beyond capacity and that Hotel-Dieu of Paris frequently placed three to five patients in one bed—putting the convalescent with the dying and fracture cases with infectious cases. He estimated that one fifth of the 22,000 patients cared for at Hotel-Dieu died each year. Wounds were washed daily with a sponge that was carried from patient to patient. The infection rate was said to be 100%, and mortality after amputation was as high as 60%. Jones’s call to action had a positive effect on American health care. As late as 1769, New York City, with nearly 300,000 inhabitants, was without hospitals. In 1771, a small group of citizens, Dr. Jones among them, formed the Society of the New York Hospital and obtained a grant to build a hospital. The society purchased a five-acre site and made plans for a model structure that would allow a maximum of eight beds per ward and provide improved ventilation. The hospital fell into the hands of the British troops during the American Revolution and was used as a barracks and military hospital. 47 During postwar reconstruction, the New York Hospital broadened its services. Under the supervision of Dr. Valentine Seaman, the hospital began providing instruction in nursing, and in 1779, it introduced vaccination in the United States and established an ambulance service. Other early American hospitals of historic interest include the first psychiatric hospital in the New World, founded in Williamsburg, Virginia, in 1773, and a branch of federal hospitals created by the passage of the U.S. Marine Hospital Service Act in 1798. Under this act, two marine hospitals were established in 1802: one in Boston and another in Norfolk, Virginia. The Massachusetts General Hospital (MGH), which pioneered many improvements in medicine, originated in Boston. Its first patient, admitted in 1821, was a 30-year-old sailor. More than a decade earlier, two Boston doctors had appealed to the city’s “wealthiest and most influential citizens” to establish a general hospital. The War of 1812 delayed the dream, but on July 4, 1818, the cornerstone was finally laid. The original building, designed by Boston’s leading architect, Charles Bulfinch, is still in use. One of the world’s leading centers of medical research and treatment has grown up around it. The original domed operating amphitheater, where anesthesia was first publicly demonstrated in 1846, is now a Registered National Historic Landmark. MGH has achieved countless medical milestones, including the first successful reattachment of a human limb.4 In 1832, the Boston Lying-In Hospital opened its doors to women unable to afford in-home medical care. It was one of the nation’s first maternity hospitals, made possible because of fundraising appeals to individuals and charitable organizations. Despite the increased number of institutions providing care for the sick, the first half of the 19th century stands as a dark period in hospital history. Surgeons of the day had sufficient knowledge of anatomy to lead them to perform many ordinary operations, and as a result, more surgery was most likely undertaken than during any previous era. Although the medieval and ancient surgeons had sought to keep wounds clean, even using wine in an attempt to accomplish this purpose, 19th-century surgeons believed suppuration (the production and discharge of pus) to be desirable and encouraged it. Hospital wards were filled with discharging wounds, which made the atmosphere offensive enough to warrant the use of perfume. Some patient wards had multiple patients with multiple conditions allowing for the spread of infections, as depicted in FIGURE 1-1. 48 FIGURE 1-1 Patient ward. © chippix/Shutterstock Nurses of that period are said to have used snuff to make conditions tolerable. Surgeons wore their operating coats for months without washing. The same bed linens served several patients. Pain, hemorrhage, infection, and gangrene infested the wards. Mortality from surgical operations rated as high as 90– 100%. Nathan Smith, in the second decade of that century, advocated a bichloride of mercury solution for reducing infection, but his ideas were ignored. 49 ▸ LATE 19TH CENTURY RENAISSANCE Florence Nightingale, the famous English nurse, began her career by training at Kaiserswerth on the Rhine in a hospital and deaconess home established in 1836 by Theodor Fliedner and his wife. Florence Nightingale wrote disparagingly of her training there, particularly of the hygiene practiced. Returning to England, she put her own ideas of nursing into effect and rapidly acquired a reputation for efficient work. By 1854, during the Crimean War, the English government, disturbed by reports of conditions among the sick and wounded soldiers, selected Florence Nightingale as the one person capable of improving patient care. Upon her arrival at the military hospital in Crimea with a small band of nurses whom she had assembled, she found that the sick were lying on canvas sheets in the midst of dirt and vermin. There was neither laundry nor hospital clothing and beds were made of straw. She proceeded to establish order and cleanliness. She organized diet kitchens, a laundry service, and departments of supplies, often using her own funds to finance her projects. Ten days after her arrival, the newly established kitchens were feeding 1,000 soldiers. Within 3 months, 10,000 soldiers were receiving clothing, food, and medicine. As a result of her work, the death rate substantially declined. She has been credited with observing: A good nursing staff will perform their duties more or less satisfactorily under every disadvantage. But while doing so, their head will always try to improve their surroundings, in such a way as to liberate them from subsidiary work, and enable them to devote their time more exclusively to the care of the sick.5 Because of her organizational skills, many consider Florence Nightingale to be the first true healthcare administrator. Later she extended her administrative duties to include planning the details of sanitary engineering in a new military hospital. As the field of nursing continued to progress, so did medicine. Dr. Crawford Williamson Long first used ether as an anesthetic in 1842 to remove a small tumor from the neck of a patient. He did not publish any accounts of his work until later. However, the discovery of an anesthetic is often attributed to Dr. W.T.G. Morgan, a dentist who developed sulfuric ether and arranged for the first hospital operation under anesthesia at MGH in 1846. Although not put to practical use immediately, ether soon took away some of the horror that hospitals had engendered in the public mind. Sir James Simpson first used chloroform as an anesthetic in 1847 for an obstetrical case in England. 50 The year 1847 was the year that the American Medical Association (AMA) was founded under the leadership of Dr. Nathan Smith Davis. The association, among its main objectives, strived to improve medical education, but most of the organization’s tangible efforts in education began at the close of the century. The AMA was a strong advocate for establishing a code of ethics, promoting public health measures, and improving the status of medicine. The culmination of Florence Nightingale’s work came in 1860, after her return to England. There, she established the Nightingale School of Nursing at the St. Thomas’s Hospital. From this school, a group of 15 nurses graduated in 1863. They later became the pioneer leaders of nurse training. In 1886, the Royal British Nurses’ Association (RBNA) was formed. The RBNA worked toward establishing a standard of technical excellence in nursing. A charter granted to the RBNA in 1893 denied nurses a register, although it did agree to maintain a list of persons who could apply to have their name entered thereon as nurses.6 The first formally organized American nursing schools were established in 1872 at the New England Hospital for Women and Children in Boston (Brigham and Women’s Hospital), and then in 1873 at Bellevue, New Haven, and Massachusetts General Hospitals. In 1884, Alice Fisher was appointed as the first head of nurse training at Philadelphia Hospital’s (renamed as the Philadelphia General Hospital in 1902) nurses’ training program. She had the distinction of being the first Nightingale-trained nurse recruited to Philadelphia upon recommendation by Florence Nightingale. Mrs. Bedford Fenwick, a nurse leader in the English nurse registration movement, traveled to Chicago in 1893 to arrange for nursing exhibits to be displayed in the women’s building at the World’s Fair. This event showcased America’s social, cultural, and scientific advances and its growing cultural parity with Western Europe. This was the first major exposition in which women played a prominent role. Integral to the fair was a series of Congresses that provided an international platform for discussion of social issues. The Congress on Hospitals, Dispensaries, and Nursing, a section of the International Congress of Charities, Correction, and Philanthropy, particularly focused on health care issues.”7 As part of the Congress on Hospitals and Dispensaries, the nursing section included papers on establishing standards in hospital training schools, the establishment of a nurses association, and nurse registration. The group formulated plans to improve nursing curriculum and hospital administration in the first concerted attempt to improve hospitals through a national organization. 51 Progress in Infection Control Dr. Ignaz Philipp Semmelweis of Vienna, Austria, unknowingly laid the foundation for Louis Pasteur’s later work. In 1847, at the Vienna Lying-In Hospital, Europe’s largest teaching obstetrical department, he boldly declared that the alarming number of deaths from puerperal fever was a result of infection transmitted by students who came directly from the dissecting room to take care of maternity patients. “Puerperal fever is due to an infection, most often of the placental site within the uterus. If the infection involves the bloodstream, it constitutes puerperal sepsis.”8 Semmelweis noted that Division 1 of the hospital was a medical student–teaching service and Division 2 was used for midwife trainees. Maternal deaths for Division 1 averaged 10%, whereas the rate for Division 2 averaged 3%. Medical students performed autopsies; midwives did not. As a result of these findings, an order was posted on May 15, 1847, requiring all students to scrub their hands in chlorinated lime until the cadaver smell was gone. The order was later revised to include hand washing between patients. Despite having made bitter enemies, Semmelweis had the satisfaction of seeing the mortality rate in his obstetrical cases drop from 9.92% to 1.27% as a result of the aseptic technique he developed. A few years later, Louis Pasteur, a French chemist and microbiologist, demonstrated the scientific reason for Semmelweis’s success when he proved that bacteria were produced by reproduction and not by spontaneous generation, as was then generally believed. From his work came the origin of modern bacteriology and clinical laboratories. Despite the attention given to the control of infections in hospitals, adherence to hand-washing protocols continues to be a problem well into the 21st century, as noted by the following reality check and depicted in FIGURE 1-2. 52 FIGURE 1-2 Patient Room. © Monkey Business Images/Shutterstock FAILURE TO FOLLOW HAND HYGIENE GUIDELINES Sheri was a healthy 30-year-old female until she suddenly experienced neck pain with a numbness radiating down her left arm. She was diagnosed with cervical rib outlet syndrome and agreed to a surgical procedure by Dr. Botchit for removal of her first cervical rib. Sheri was admitted to a postsurgical care unit at a major teaching hospital. Upon entering her assigned four-bed room, she and her husband Bill observed a bloody suction bottle hanging from the wall at the head of her assigned bed. The bed rails were rusting with dried bloody body fluids from a previous patient. They were uneasy about having a surgical procedure performed but they decided the physician’s skills were more important than an unclean room. Bill commented, “Well, at least the sheets appear clean.” Elda, the first patient on the left upon entering the room greeted Sheri and Bill. She said, “The room isn’t very clean is it? Could you watch out for the nurses?” She then smiled as she removed Tylenol from her bedside table. She took a few and said, “I don’t want my doctor to cancel my surgery, so I have to lower my temperature before the nurses retake my temperature. I think I have an infection. I have waited so long to get my surgery scheduled. I am just so worried my surgery will be canceled.” 53 The morning following surgery, a third-year resident entered the room with three first-year residents and beginning with Elda, examined each of four postsurgical patients. Elda was a postsurgical amputee, who was later diagnosed with a staph infection. Sheri was the fourth patient to be examined in the room. Even though each of the patient’s wounds had been examined and dressings changed, the physicians failed to change their surgical gloves between patients. Following examination of Sheri, they proceeded to remove their gloves and tossed them in Sheri’s bedside wastebasket. They then washed their hands at the only sink in the room, which was by Sheri’s bedside. Sheri’s temperature began to rise. Bill asked if a wound culture had been taken. Carol, the nurse manager after checking Sheri’s chart said, said, “No culture was ordered.” He asked, “Can you please have a culture ordered?” The nurse replied that she would call Dr. Green to see if he would order a blood culture.” Bill asked, “Who is Dr. Green?” Carol replied, “Dr. Green is covering for Dr. Botchit while he is on vacation. Dr. Botchit left on a family skiing trip the day after surgery to Aspen, Colorado.” Bill learned the following day that the blood tests came back positive for a staph infection and learned that no antibiotics had been prescribed by Dr. Green. Bill became increasingly concerned about the lack of care and went back to the nursing station to describe his concern about the lack of treatment for Sheri. Carol suggested that he call Dr. Green. Bill placed a call to Dr. Green and relayed his concern about his wife’s deteriorating health. Dr. Green returning Bill’s call said, “I hear you are unhappy with my care. I am merely providing coverage for Dr. Botchit. I have my own patients to be concerned with and treat.” Bill replied, ”Well if you are covering for another physician you need to address my wife’s infection.” Dr. Green replied, “I am doing a favor for Dr. Botchit by covering his patients as well as mine. I will get to the hospital when I can!” Upon returning to his wife’s bedside, Sheri looked up at him and said, “The priest was here and administered last rites to me.” Looking at his mother-inlaw, who was trying to be strong, holding back the tears, Bill devotedly said, “I will fix this.” He called Dr. Field, who he knew was a physician educator at the medical center, and explained his concerns. Dr. Field said, “I can help. I will get a team of infectious disease specialists to Sheri’s bedside. They are the best in the city, probably the world. But please do not use my name in any dispute that you may have with Dr. Botchit or Dr. Green.” Sheri survived but the staph infection had taken its toll on her immune system. 54 Sheri and Bill never thought much about it at the time, but in hindsight, Elda’s infection was most likely the contributing factor to the staph infections that eventually affected the other three patients in the room. History repeated itself. Despite being adopted by the hospital, the CDC handwashing guidelines, which could have helped prevent the infection, were not followed,. This reality check illustrates how the failure to follow established protocols in the prevention of infections can have disastrous consequences for patients. Progress in the delivery of patient care can move forward only as long as complacency does not stymie progress. This case also provides an important lesson for patients who treat themselves, masking their physical symptoms, as in this case where the patient took Tylenol to hide her fever, an indicator that the patient may have an active infection. Staff should be alert to patients who self-treat and confiscate all home and store bought medications upon admission to the hospital. The lessons here also apply to family members, who must not honor patient requests for medications. This reality check serves as a reminder that history continues to repeat itself. Strict adherence to CDC guidelines and hospital policy must become the norm and not the exception for acceptable hand hygiene in order to prevent the spread of infection by both caregivers and patients. The Joint Commission’s (TJC) 2017 Hospital Accreditation Standards recognize the importance of complying with hand hygiene guidelines. The standards require hospitals and other accredited TJC organizations to follow current CDC or World Health Organization guidelines for hand hygiene.9 When hand-washing guidelines have to be declared a TJC national patient safety goal, it would appear that caregivers have much to learn from Dr. Semmelweis, who determined in 1847 that poor hand-washing technique can be attributed to being a major cause of hospital-acquired infections. Dr. Ernst von Bergmann’s introduction of steam sterilization in 1886 and Dr. William Stewart Halsted’s introduction of rubber gloves in 1890 aided in reducing the incidence of hospital-acquired infections. By the end of the century, Dr. Joseph Lister carried Pasteur’s work a step further and showed that wound healing could be hastened by using antiseptics to destroy disease-bearing organisms and by preventing contaminated air from coming into contact with these wounds. Lister was not content with obtaining better results in his own surgical cases; he devoted his life to proving that suppuration is dangerous and that it could be prevented or reduced by the use of antiseptics to destroy disease-bearing organisms. Despite his successful work and eloquent pleas, his colleagues persisted in following their old methods. Years after his discovery, they continued to deride him and his 55 technique, which consisted of spraying carbolic solution so profusely about the operating room that both surgeons and patients were drenched. The use of antiseptics and the techniques of using them continued to improve. Eventually even the skeptics were impressed by the clinical results in reducing infection rates. Surgeons, at last, realized that they could undertake major operations with less fear of morbidity and mortality. Discovery of Anesthesia As the 19th century neared its close, surgery was becoming more frequent. The discovery of anesthesia and the principle of antiseptics were two of the most significant influences in the development of surgical procedures in the modern hospital. Anesthesia improved pain control, and hygiene practices helped reduce the incidence of surgical site infections. Although patients did not immediately flock to hospitals as a result of these discoveries, these innovations set the stage for the remarkable growth of the 20th century. Modern Hospital Laboratory The study of cytology originated around the middle of the 19th century and influenced the development of the modern hospital clinical laboratory. The cell theory was first advanced in 1839 by the German anatomist Theodor Schwann and was further developed by Dr. Jacob Henle, whose writings on microscopic anatomy appeared in 1850. Rudolf Virchow, known as the Father of Pathology, was the most eminent proponent of the cell theory. His studies in cellular pathology supported further research in the etiology of disease. Changing Hospital Structure With nursing, anesthesia, infection control, and cytology under way, a change in hospital structure began in the last quarter of the 19th century. Buildings of the Civil War days were still in use, with as many as 25 to 50 beds in a ward with little provision for segregating patients. In New York City in 1871, Roosevelt Hospital was constructed on the lines of a one-story pavilion with small wards, and this set the style for a new type of architecture that came to be known as the American plan. A noteworthy feature was ventilation by means of openings in the roof, which was an improvement in hospital construction. Hospitals had been characterized by a lack of provision for ventilation. Dr. W.G. Wylie, writing in 1877, said he favored this type of building, but he advocated that it be a temporary structure only, to be destroyed when it became infected. As noted in the following reality check, hospital construction and building maintenance programs are essential in preventing the spread of infections. All caregivers must be observant of the cleanliness of the environment within which they care for patients. FIGURE 1-3 illustrates the not so uncommon finding of soiled vents and ducts by those who inspect hospitals. Such findings contribute to the spread of infections between staff and patients. Caregivers 56 who observe such issues should notify designated staff members who are responsible for ensuring the correction of such environmental deficiencies. FIGURE 1-3 Soiled vents and ducts. © decoplus/Shutterstock STERILE SUPPLY STORAGE Mark was assigned a 3-day survey at Anytown Medical Center (AMC). During a tour of the hospital’s facilities, Robin, AMC’s survey coordinator, Bill, the building engineer, and Jack, the maintenance supervisor, accompanied Mark. While conducting the building tour, Mark had asked to see the neonatal intensive care unit (NICU). After being introduced to Helen, the NICU nurse manager, Mark and Robin gowned up to enter into the nursery with Helen. Bill and Jack waited in the hospital corridor. Mark noticed during his tour of the nursery a door marked “Sterile Supply Storage.” Mark looked at Helen and asked, “Can we enter the storage room?” Helen replied, “Sure thing.” Upon entry to the room Mark observed that cardboard boxes marked “sterile supply” were stored on the floor. He glanced up at the ceiling tiles and noticed that they were damp and had green and black mold. Mark asked for a flashlight to look at the air vents and ducts. He observed a significant amount of mold on the exhaust vents. He shined the flashlight up into the vent and observed that the air ducts had a buildup of mold. Robin, somewhat concerned, said, “We can get this all cleaned up before the end of the survey.” Mark said, “I am also concerned 57 that the sterile supplies stored on the floor, even though in cardboard boxes, have been compromised. The cardboard boxes are damp from mopping of the floor. Let’s go out to the corridor and speak to Bill and Jack. After Mark described what he saw in the clean storage area, Bill replied, “Oh, there was a toilet that overflowed in a patient bathroom a few weeks ago in the floor above. Jack interrupting said, “Well, I do not recall seeing a maintenance slip from the NICU describing the problem.” The risks of infection in healthcare settings require healthcare organizations to provide continuing education and training for caregivers. Documentation of in-service training should be placed in employee personnel files. It is important for managers to be alert to and correct hazardous conditions observed in the working environment. Both hospital surveyors (e.g., TJC) and state inspectors, as part of their training, are required to observe the working environment and employees who may breach infection control protocols, such as following proper hand hygiene prior to caring for each patient. Breaches in protocol that are observed are included in both state and TJC formal reports pertaining to the hospital’s compliance with infection control standards. Hospitals are required to develop, implement, monitor, and improve the environment to help prevent the spread of infections. Changing Hospital Function Promoted by the wealth of bacteriologic discoveries, hospitals began to care for patients with communicable diseases. During the decade from 1880 to 1890, the tubercle bacillus was discovered, and Louis Pasteur developed vaccines for anthrax and rabies. He also developed the process for pasteurization. Robert Koch isolated the cholera bacillus, diphtheria was first treated with antitoxin, the tetanus bacillus and the parasite of malarial fever were isolated, and inoculation for rabies was successful. “On March 24, 1882, Robert Koch announced to the Berlin Physiological Society that he had discovered the cause of tuberculosis.”10 Treatment of patients with some of these infections necessitated isolation, and hospitals were the logical place for observation of communicable diseases. Consequently, at the end of the century, in addition to their many surgical cases, hospitals were crowded with large numbers of patients suffering from scarlet fever, diphtheria, typhoid, and smallpox, all of which were contagious diseases. Discovery of the X-Ray Wilhelm Conrad Röntgen’s discovery of the X-ray in 1895 was a major scientific achievement. The first use of the X-ray symbolizes the beginning of the period that necessitated equipment so costly that the average practitioner could not afford to install it. The natural result was the founding of community hospitals in which physicians could jointly use such equipment. Nineteenth- 58 century inventions also included the clinical thermometer, the laryngoscope, the Hermann von Helmholtz ophthalmoscope, and innumerable other aids that have led to more accurate diagnoses. Although the medical and nursing professions of the later half of the 19th century did not reap the full reward of their discoveries, they provided the 20th century with a firm foundation upon which to build. 59 ▸ 20TH-CENTURY PROGRESS The treatment of metabolic diseases and nutritional deficiencies, the importance of vitamins, and the therapy of glandular extracts played an important role in the advancement of medicine in the 20th century. As early as 1906, Frederick Gowland Hopkins began investigations into vitamins. Two years later, Carlos Finlay produced experimental rickets by means of a vitamin-deficient diet. This, in turn, was followed by Kurt Huldschinsky’s discovery that rickets could be treated successfully with ultraviolet light. In quick succession came Casimir Funk’s work with vitamins, Elmer McCollum’s discovery of vitamins A and B, Joseph Goldberger’s work in the prevention of pellagra, and Harry Steenbock’s irradiation of foods and oils. Other outstanding contributions to the science of nutrition include Frederick Banting’s introduction of insulin in 1922, the studies in anemia carried out by Dr. George Hoyt Whipple and Dr. Frieda Robscheit-Robbins, a pathologist who worked with Dr. Whipple. This led to Dr. George R. Minot and Dr. William P. Murphy’s successful treatment of pernicious anemia. This achievement was considered a major advancement in the treatment of noninfectious diseases. As a result of their research, Hoyt, Minot, and Murphy were awarded the Nobel Prize in Physiology or Medicine. Dr. Willem Einthoven invented the electrocardiograph (ECG) in 1903. The machine measures the electrical changes that occur during contractions of the heart muscle. The ECG records these graphically, thus allowing the physician to diagnose abnormalities in a patient’s heartbeat. He coined the term electrocardiogram for this process, marking the beginning of an era of diagnostic and therapeutic aids. Shortly after that invention came the first basal metabolism apparatus, then the Wassermann (August Von) test in 1906, and tests for pancreatic function. Invention of the fluoroscopic screen followed in 1908. Subsequently, the introduction of blood tests and examinations of numerous body secretions required well-equipped and varied laboratories. Concurrent with this progress in the field of internal medicine was the introduction of radium for the treatment of malignant growths, increasing the use of the clinical laboratory for microscopic examination of pathologic tissue and developments in antibiotics. The result of these many new aids was the conquest of diseases formerly regarded as incurable, which in turn, resulted in improved public confidence in hospitals. The discovery of the structure of DNA is by far one of the most famous scientific discoveries of the 20th century. The discovery in 1953 of the double helix, the twisted-ladder structure of deoxyribonucleic acid (DNA), by James Watson and Francis Crick marked a milestone in the history of science and gave rise to modern molecular biology, which is largely concerned with understanding how genes control the chemical processes within cells. In short order, their discovery yielded ground-breaking insights into the genetic code and protein synthesis. 60 During the 1970s and 1980s, it helped to produce new and powerful scientific techniques, specifically recombinant DNA research, genetic engineering, rapid gene sequencing, and monoclonal antibodies, techniques on which today’s multi-billion dollar biotechnology industry is founded. Major current advances in science, namely genetic fingerprinting and modern forensics, the mapping of the human genome, and the promise, yet unfulfilled, of gene therapy, all have their origins in Watson and Crick’s inspired work.11 The 20th century was also characterized by rapid growth in nursing education. The earlier schools were maintained almost entirely to secure nursing service at a low cost. The nurse’s duties were often menial, hours long, and classroom and laboratory study almost entirely lacking. Nurses themselves had begun to organize for educational reforms. By 1910, training increasingly emphasized theoretical studies. This movement was largely a result of the work of organizations such as the American Nurses Association and the National League for Nursing, along with the organization of the Committee on the Grading of Nursing Schools. In 1943, the U.S. Cadet Nurse Corps was organized to spur enrollment of student nurses in nursing schools to help meet the shortages caused by enlistment of graduate nurses for military service. As a result, efforts increased to train practical nurses and nurses’ aides in order to relieve the shortage of graduate nurses. Reform in medical education began early in the century and was almost wholly a result of the efforts of the Council on Medical Education and Hospitals, which was established in 1905 by the AMA. Immediately after its organization, this council began inspection of medical schools. The council, by establishing standards and by grading the schools, brought about gradual elimination of most of the unethical, commercial, and unqualified institutions. A great stimulus to the profession of hospital administration has been the work of the American Hospital Association. Organized in 1899 as the Association of Hospital Superintendents, it took its present name in 1907. Since its inception, the organization has concerned itself particularly with the problems of hospital management. As early as 1910, the association held educational programs for hospital chief executive officers and trustees. The American College of Surgeons was founded in 1913 under the leadership of Dr. Franklin H. Martin, the first director general of the organization. One of the most dramatic achievements of the American College of Surgeons was the hospital standardization movement that began in 1918. The founders drew up what was known as “The Minimum Standard,” a veritable constitution for hospitals, setting forth requirements for the proper care of the sick. An annual survey of all hospitals having 25 or more beds made the standard effective. When the first survey was conducted, only 89 hospitals in the United States and Canada could meet the requirements. 61 The hospital standardization movement focused its efforts on the patient, with the goal of providing the patient with the best professional, scientific, and humanitarian care possible. The growth of this movement is remarkable, given that participation in hospital standardization programs is voluntary. Following several name changes over the years, The Joint Commission today conducts unannounced accreditation surveys, with emphasis on ongoing improvements in the quality of patient care. The years following 1929 will long be remembered as one of the most trying periods in the history of hospitals. Due to critical economic conditions, many institutions found it difficult to keep their doors open. A declining bed occupancy and an ever-increasing charity load, coupled with steadily decreasing revenues from endowments and other sources of income, created hardships on private institutions. Fortunately, however, every economic crisis brings forth new ideas and means and methods of organization to benefit humanity. In the latter half of the 20th century, competition among hospitals began to grow as for-profit hospital chains began to spring up and compete with nonprofit organizations. Advances in medical technology, such as computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) scanners, and robotic surgery, as well as an ever-growing list of new medications, have revolutionized the practice of medicine. During this period, less invasive surgical procedures and a trend toward care in outpatient settings has reduced the need for lengthy stays in hospitals and various long-term care facilities. Laparoscopic surgery, performed through one or more small incisions using small tubes and tiny cameras and surgical instruments, has proven to be one of the remarkable movements forward in the history of surgical procedures. 62 ▸ HEALTH CARE AND HOSPITALS IN THE 21ST CENTURY So how safe is your hospital? Two new rating systems help you check before you check in. Hospital safety score (hospitalsafetyscore.org), launched in June (2012), assigns grades of A, B, C, D or F to more than 2,600 U.S. hospitals based on 26 safety measures and standards—from handwashing policies to foreign objects left in body cavities after surgery. Nearly half of the hospitals received a C or lower. —Bill Hogan12 The struggle for hospitals to survive continues well into the 21st century but the news is not always kind. In the nation’s capital, one would dream that it would represent the “model city of hope” for the healthcare system. But all to often we learn of its failures and not its progress. Howard University Hospital, for example, opened its doors in 1863 as Freedman’s hospital, and it provided care to the freed African American slaves. It soon “became an incubator for some of the brightest African American slaves.” But over the past decade, the once-grand hospital that was the go-to place for the city’s middle-class black patients has been beset by financial troubles, empty beds, and an exodus of respected physicians and administrators, many of whom said they are fed up with the way it is run.”13 This follows the closure of DC General Hospital, which many had hoped would be rebuilt. Other hospitals, including the VA system, have struggled and continue to struggle, some even to survive. The overflow of patients into the city’s remaining hospitals affects the ability of those hospitals to handle the needs of patients. Many physicians now tell their patients, “My goal is to get you in and out of the hospital as fast as I can. I don’t want you to get sicker.” The challenges remain as history repeats itself. RURAL AMERICA’S DYING HOSPITALS . . . Nearly 80 have closed since 2010, including 9 in Tennessee, more than in any state but Texas. Many more are considered fragile—downstream victims of federal health policies, shifts in medical practice, and the limited tolerance of distant corporate owners for empty beds and financial losses. In every rural community, the ripple effects of a lost hospital are profound, reverberating beyond the inability of would-be patients to get immediate care. —Amy Goldstein, The Washington Post, April 12, 2017 63 The delivery of health care in the modern hospital continues to be the revolutionary product of a long and arduous struggle. The continuing stream of new medicines and treatments, as well as legal, financial, and human resource issues, continues to test the healthcare system. Many of today’s healthcare challenges have carried over from the 20th century. The challenges include exorbitant malpractice awards, excessive insurance premiums, high expectations of society for miracle drugs and miracle cures, fairly balancing the mistakes of caregivers with the numerous successful events, negative press that increases public fear, and numerous ethical dilemmas involving abortion, human cloning, physician-assisted suicide, how to fairly distribute limited resources, and the dwindling number of rural hospitals, are but a few of the challenges of the 21st century. According to a study written by Sy Mukherjee in ThinkProgress, there is an increased risk of dying in rural hospitals. Critical access hospitals (CAHs) are medical providers located in America’s most isolated regions, serving rural communities that do not otherwise have easily available access to care. Since the closest alternatives to these hospitals are usually over 35 miles away, they provide an essential resource for Americans living in secluded communities—and therefore receive enhanced funding from the federal government to carry out their work. But according to a Harvard School of Public Health study, death rates at these hospitals are significantly higher than national averages— and are on the rise.14 As advances in medicine rapidly move the nation’s healthcare system in the direction of high-cost care and treatment, small rural hospitals are increasingly unable to meet the challenges of both procuring expensive capital equipment and attracting qualified specialists. This, in turn, is leading to the demise of rural hospitals’ ability to provide the more complex care available in modern medical centers. Translational Medicine Translational medicine began to be recognized as a significant development at the end of the 20th century and well into the 21st century. Both the researcher and the practitioner began to better understand the importance of knowing each other’s contribution in the healing process. The translation of biomedical discovery into clinical benefit is the essence of translational medicine, which continued to experience remarkable growth in 2012. The University of Dundee, Scot., for example, received almost £12 million ($19.2 million) for the completion of a Centre for Translational and Interdisciplinary Research, and a £24 million ($38.4 million) Institute for Translational Medicine was slated for development in Birmingham, Eng. Scientists continued to work to coordinate the 64 application of new scientific knowledge in clinical practice with basic observations and questions in the laboratory.15 Minimally Invasive Surgery The ever-evolving precision of minimally invasive surgery (MIS) will catapult medicine into a limitless future of exotic discoveries. MIS allows physicians to use a variety of techniques to operate with less damage to body tissues than with open surgery and is believed by some surgeons to be more noteworthy than the discovery of anesthesia. MIS is associated with less pain, a shorter hospital stay, fewer complications and medical errors, while improving the accuracy of complex surgical procedures. Decision making during surgery often involves thousands of pieces of information that are considered during a surgical procedure. This can lead to increased physician fatigue and the possibility of human error. MIS reduces the fatigue factor by assisting the surgeon in the decision-making process by reducing the time required for a surgical procedure, and the surgeon concentrates on the surgical skills necessary for completing a successful surgery. The bells and whistles and blinking lights become less of a distraction, by allowing the surgeon to concentrate on the surgical field (e.g., patient’s abdomen). Robotic surgery provides a magnified 3-D view of the surgical site and helps the surgeon operate with precision, flexibility, and control. The popular da Vinci System robotic equipment is used for cardiac, colorectal, general, gynecologic, head and neck, thoracic, and urologic surgical procedures. It allows surgeons to operate through several small incisions with enhanced vision, precision, and control inside the human body.16 Surgical Simulation Training Advances in surgical simulation training (SST) will enhance the training of residents, enabling them to transition more effectively to performing more precise surgical procedures with fewer errors and improved patient outcomes. Pilots are trained in a simulator before ever flying a plane. Surgeons have historically been in the dark stages of SST, even though “they are in charge of carrying out the procedures that may either save or kill the patient at hand.”17 The patient will one day no longer be the experimental subject in the hands of a surgeon-in-training. Surgical simulation, so long waited for, will produce a generation of surgeons who have practiced surgical procedures, just as pilots do before flying a plane. Social Media Impacts on Caregivers The advent of social media has raised concern among caregivers and hospitals. Patients post both positive and negatives reviews on the World Wide Web (e.g., Healthgrades, Facebook, GooglePlus, Twitter, YELP, ZocDoc). Reviews may include long waits and rude staff members, which can affect a physician’s social media ratings. Patients who complete multiple forms prior to an office visit often discover the physician has not reviewed them. 65 Instead, the physician conducts a hurried review of the documents at the time of a patient’s scheduled appointment, reviewing with patients the ailments with which they are familiar and not addressing or leaving less time to discuss the patient’s current concerns, reason for being there, and the treatment plan. Unfortunately, patients who experience long waits to see their physicians often tarnish their physician’s reputation by posting negative remarks. It is not the wait time that should be judged. It is the skills of a physician in diagnosis and presentation of treatment options that makes the difference in the quality of life. Not only are physicians impacted by the challenges of social media, but hospitals are also concerned with their image in the community. All care organizations and caregivers must be sensitive to the fact that social media will not go away, and the concerns of patients need to be addressed in a positive way by addressing the concerns of the community. National Health Insurance The Patient Protection and Affordable Care Act (PPACA), passed by Congress and signed by President Barack Obama on March 23, 2010, was designed to ensure that more Americans receive healthcare benefits. The costs, however, associated with national health insurance continue to rise. Insurance premiums have risen by as much as 10% in 2017 for those who are not eligible for subsidies. “Aetna, Humana and United HealthCare Group said they would stop selling Obamacare policies in most states next year, citing financial losses due to a flood of older, sicker enrollees and not enough young, healthy people to offset the costs.”18 As healthcare politics continue to rage on in Congress, the greatest health challenge of the 21st century requires that each member of society take a more responsible and proactive role in his or her health and well-being by maintaining a healthy lifestyle. Boutique Medicine The problem of accessibility to care is further exacerbated by an increasing number of physicians who turn to boutique medicine, a plan of care whereby a patient pays an annual retainer fee in exchange for expedited access to a physician for health care. As a result, physicians who elect to practice boutique medicine find it necessary to limit the number of patients they can treat due to the need to be readily available to patients in their practice. In other words, increased access leads to fewer patients, and arguably, better care for thos…

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