It has been 100 years since Sir William Osler outlined his concept of the relationship of the hospital to the university and to the education of physicians and nurses in an address to the Northumberland and Durham Medical Society in England. He stated that the hospital stands "primarily for the cure of the sick and the relief of suffering; secondly, for the study of the problems of disease; and thirdly, for the training of men and of women to serve the public as doctors and nurses. A majority of hospitals deal only with the first of these objects, and incidentally with the third" (Lancet 1911;177:211-3).
Of course, much has changed over the subsequent century, but much remains the same. The integration of the hospital into its role of a teaching institution was difficult even in the Oslerian age of the early 20th century. That relationship has become even more complex in contemporary medicine, in which the hospital has increasingly become the center of community and national health care.
Dr. Osler’s comments came to mind while I was reading a recent article about the development of concierge care in America’s most prestigious hospitals (New York Times, Jan. 22, 2012, p. 3A). A money manager recuperating from back pain is shown relaxing in a $1,600-a-day luxurious hospital room dressed in a spa-type bathrobe in New York City’s Mount Sinai Medical Center, where amenities include gourmet food service. "I have a primary care physician who acts as ringmaster for all my other doctors. And I see no people in training – only the best of the best," the patient said.
The hospital’s spokesperson indicated that the lack of house staff was a result of training limitations and not the preference of the rich patients. Mount Sinai has a long history of excellence in medical education, but the ambience now provided for its wealthy clientele protects them from any intrusion by medical students and house staff.
The American hospital has evolved over the last century from a place of last resort for the poor sick to a high-technology institution created for intensive medical and surgical therapy. Funded initially by community and religious benevolence, the hospital has now become big business and heavily dependent on private insurers, Medicare and Medicaid, and whatever evolves from the new health care laws.
Now divested of minor illnesses and routine surgical procedures that can be dealt with in the outpatient setting, it is filled with critically sick patients.
There has always been a tenuous balance between the goals of the community hospital and its educational responsibilities. The contemporary community hospital has enjoyed a profitable environment fed by private health insurance and sustained by federal dollars. Medicare, since its inception almost 50 years ago, has generously supported education through indirect funding for house staff education. This support has recently been significantly decreased, and realistic forecasts suggest that the previous profit margins will be a thing of the past as the federal and state budget puts constraints on both Medicare and Medicaid. Dr. Osler argued for the hospital financial supporters of teaching faculty and challenged local communities to dig deep into their pockets to support the education of medical students and house staff.
Now, with the increasing development of hospital-centric health care, the hospital has also become the focus of community health. The need to train more health professionals will put more pressure on hospitals to provide facilities for the whole dimension of caregivers, including medical students, house officers, nurses, and a variety of physician assistants. With increases in both the number of medical schools and the matriculating class sizes of current medical schools, more community hospitals will be called upon to provide clinical facilities to provide the training grounds for these new students. These changes will place financial pressures on the hospitals in order to meet that challenge. Even now, fast-track admissions and discharge practice, already a part of the patient experience in many hospitals and a source of their profit margin, adversely affects the quality of medical education.
To cushion the effects of the decrease in private and governmental support for medical education, hospitals will be have to seek other sources of income – like concierge services – in order to meet their social and educational responsibilities.
How they meet both of these challenges in the contemporary entrepreneurial world of health care will require a great degree of agility. But no matter what changes do occur, there will always be room for concierge care.