Old and Sick in America by Muriel R. Gillick M.D

Author:Muriel R. Gillick, M.D.
Language: eng
Format: epub
Publisher: The University of North Carolina Press

Fifty Years of the American Hospital

Superficially, the American hospital of 1965 looked very much like its 2015 counterpart. There were more four-bed rooms than today and some giant twenty-five-bed wards. But the long corridors, the central nursing stations, the general bustle of nurses, orderlies, and doctors, are unchanged. Closer inspection reveals more telling changes: computers are everywhere, with nurses wheeling laptops around on portable stands as they make their rounds; many of the physicians and nearly half of the youngest ones are women; and substantial sections of every building are devoted to radiology and endoscopy suites, to interventional cardiology, or to operating rooms. This metamorphosis reflects developments outside of health care. First and foremost, it reflects scientific progress stemming from fields as disparate as chemistry, physics, and computer science. Computerized tomography scanning, which was conducted 353,000 times in hospitalized patients over age sixty-five in 2007, had its origins in radar and weapons technology. Magnetic resonance imaging, another very popular test, relies on nuclear spectroscopy, used by chemists to reveal the structure of molecules. The treatment of myocardial infarction also changed thanks to developments within biology (a new understanding of the role of blood vessels in the development of disease) as well as epidemiology (the power of a longitudinal, population-based study to uncover lifestyle factors responsible for disease).

Along with dramatic leaps forward in medical science were equally profound social changes. Americans lived longer and developed more chronic diseases. Hospitals, however, were set up to handle episodes of acute illness, not to work with primary care doctors to plan for the aftermath of the acute exacerbation of a chronic condition. In the surrounding society, big was better and corporations had an increasingly free hand in conducting business. The widespread growth and consolidation of industry was echoed in health care, with mergers, acquisitions, and the appearance of hospital chains all affecting the patient’s experience of illness.

But even more important to the transformation of the hospital was Medicare, from its original incarnation to the newest version of Medicare ushered in by the Affordable Care Act. The very existence of Medicare forever changed the American hospital, not just by bringing throngs of older patients to its wards, but also by racially integrating hospitals—a prerequisite for accepting federal funds that segregated southern hospitals reluctantly complied with. The institution of prospective payment for Medicare in the early 1980s shortened the average hospital stay for older patients, cramming tests and procedures into a few days, and moving much of what had traditionally been inpatient care out of the hospital altogether. Some types of treatment that were initiated in the acute care hospital, such as hip replacement surgery or antibiotics for pneumonia, were now completed in the skilled nursing facility; other kinds of care, such as colonoscopy screening or cataract surgery, moved to the ambulatory site.

Legislation creating a Medicare hospice program further altered what happened to older patients in the hospital—a growing proportion of older people died at home rather than in the hospital. Restrictions on the number of

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