Chiropractic and Hospitals -- Part I

Wherever humans have formed social groups, some individuals have taken the role of the healer, responsible for preventing disease and curing the sick. Magic and the use of charms, spells, and incantations frequently were employed. Signatures¹ such as a lion's heart to be eaten for courage, or plants with leaves resembling body organs to cure disorders of that organ -- were used worldwide. Throughout the ages, Shamans² and medicine men have discovered valuable information that then was handed down from generation to generation. If possible, the information was kept within the priesthood. Much essential health information escaped, however, to become part of common folklore. Therapies for illness were more easily kept within the bounds of the priesthood. Morphine, quinine, and rauwolfia, all used today, come from ancient, pre-scientific lore. Primitive medicine men learned to set fractures; they even performed such complex procedures as trephination -- boring holes in the skull to treat disease. Throughout recorded history, the rational and the magical approaches have existed side by side.

The earliest known hospitals were built by Hindus in present-day Sri Lanka during the 5th century B.C. The first hospital in the Western Hemisphere was built in Santo Domingo in about 1503. Some 20 years later in Mexico City, Hernando Cortez built the oldest hospital still in existence in the Western Hemisphere.

The hospitals of today have evolved into modern facilities that have three major functions: patient care, education, and medical research. In contrast, the earliest church-run medieval hospitals served primarily as havens for the homeless, the destitute, and those with diseases regarded as hopeless. The same purposes prompted Philadelphia Quakers to establish (1751) the first American general hospital: It was built to care for the sick whose home conditions were considered too inadequate to allow for proper care.

Types of Hospitals³

In the mid 1980s there were over 7,500 hospitals in the United States. Most of these were general medical and surgical-care facilities. Half had fewer than 100 beds. Academic teaching hospitals, which are usually attached to medical schools and have internship and residency programs, accounted for about 10 percent of all hospitals. They were often larger institutions, controlling about 25 percent of the nation's hospital beds.

Hospitals operate under one of three types of ownership. They are either voluntary, conducted as nonprofit public enterprises under private management; government, supported by taxes and sponsored by federal, state, county, or city agencies; or proprietary, profit-making institutions financed by investors. The federal government operates hospitals through the Veterans Administration, the Department of Defense, and the armed services as well as administering Public Health Services and Indian Health Service facilities, prison hospitals, and special institutions run by the Alcohol, Drug Abuse and Mental Health Administration. Every state operates one or more hospitals providing care for the mentally ill, the retarded, and tuberculosis patients.

Nonprofit hospitals may be run by religious groups or associations of citizens. Profit-making hospitals may be owned by individuals, by groups -- often physicians -- or by investor-owned corporations and hospital chains. Since the mid-1970s, hospital chains have proliferated, often through buying or leasing financially pressed municipal or county facilities and university attached teaching hospitals. The chains have the capital to improve often rundown physical and technological facilities. Questions remain, however, about whether they will freely admit uninsured patients, and whether their need to demonstrate profits for their stockholders can be reconciled with their responsibility to provide top-quality medical care and at the teaching hospitals, medical education.

Hospital Organization

The hospital's board of trustees represents the public's interest and bears legal and moral responsibility for all activities that occur within the institution. The trustees set hospital policy and see to the provision and safeguarding of hospital assets. The administrator, the chief of the medical staff, and the chiefs of the various medical services are directly responsible to the trustees who also approve the medical-staff bylaws, the rules that govern the behavior of staff physicians.

The medical staff is usually subdivided into inpatient departments such as medicine, surgery, pediatrics, obstetrics, and psychiatry. Each department has a chief-of-service, and all medical services are overseen by a chief-of-staff, who may be appointed by the trustees or elected by the medical staff. Teaching hospitals maintain a paid staff of physicians, residents, and interns. Otherwise, physicians are not usually hired by a hospital, but instead are granted the privilege of practicing there once their professional qualifications are approved.

Hospital administration is concerned with such matters as finances, plant management, and labor policies.

Attempts to Reduce Health-Care Costs

Hospitals are responding to increasing cost pressures in a number of ways. They have attempted to introduce more-efficient management methods and have joined forces with other hospitals to benefit from joint purchasing and interchange of staff. Proprietary hospitals, in particular, have found greater profits in chain operations. By 1983, for profit, multi-hospital systems had built or acquired more than 1,000 hospital units. Previously many of these had been nonprofit, public facilities. In addition, one third of the nation's nursing homes are now owned by corporations.

Other efforts to reduce costs have involved hospital medical practice. Less-expensive professional workers (such as paramedics and nurse practitioners) have been used in the hope of getting necessary care to patients at a lower cost. On the other hand, "second opinions" on the necessity for hospitalization or surgery have been more effective in improving quality rather than in reducing costs. Hospital peer review, in which doctors reach judgments on the nature and length of hospital care provided by their colleagues, has had a similar effect.

Because of reductions in the number of admissions and overall patient days, hospitals are faced with increasing deficits, and many seek other ways to produce income. Some medical centers are voluntarily considering profit-making ventures such as retirement housing and hospice care for the terminally ill. (These are also areas in which for-profit hospitals are beginning to invest.) Other hospitals are merging in an attempt to introduce cost efficiencies through resource sharing.

Enter the chiropractor.

Footnotes

1. signature (sig'na-chur) -- n. The part of a physician's prescription containing directions to the patient.

    

2. shaman (sha'man) -- n. 1. A priest of shamanism. 2. A medicine man among certain North American Indians [R.< Skt. sramanas.] shamanism -- n. 1. The religious practices of certain native peoples of northern Asia who believe that good and evil spirits pervade the world and can be summoned or hear through inspired priests acting as mediums. 2. A form of primitive spiritualism, such as that practiced among certain North American Indian tribes. shamanist n. shamanistic adj.

    

3. All hospitals must be licensed by the states where they are located and must meet state-set standards of cleanliness and safety. A hospital may seek accreditation from the Joint Commission on Accreditation of Hospitals (JCAH), the industry's official accrediting body. To receive accreditation, it must comply with JCAH standards and pass inspection and investigation by a JCAH survey team. Other accrediting organization evaluate the hospital's clinical laboratories and blood banks.

Editor's Note: Part II of this article will appear in the November 4, 1994. References will be included at that time. Dr. Austin is director of chiropractic at Coast Plaza Doctors Hospital in Southern California.