Part 23

“In a discussion of professional service, however brief, no thoughtful medical man could forbear some comment on the present general status of clinical medicine and its developments within the last few years. The steady trend towards greater educational requirements, the development of refinements in diagnosis and therapy and the straining after what are believed to be higher scientific standards, creates in many minds some uneasiness as to whether the medical profession may not, by such things, be led astray and forget the very purpose for which clinical medicine exists, that is, the comfort, welfare and relief of the patient. Such a fear is by no means a groundless one. There is always a possibility that the medical man may become so enamored of his refinements and of his scientific methods as to forget that his business is the treatment of the sick. It is a truism so trite as sometimes to be overlooked, that all organization and all methods in clinical medicine have for their ultimate end the care of the patient and everything else must be subordinated to his interests.

Leaving this aside and omitting much, there are some things which may be stated in a general way concerning professional service, understanding that it is presumed such service is administered in hospitals properly constructed, properly located and equipped, and operated for the particular purposes which we have in mind.

1. There are certain broad policies in this matter which are worthy of some comment.

The flexibility of hospitals is a matter of importance. The Public Health Service has divided its hospitals into three general groups, that is, hospitals for general medicine and surgery, for pulmonary tuberculosis and for neuro-psychiatry. We have striven, however, even in these broad groups to make such hospitals available, at least temporarily, for any class of case which seeks admission. This has been especially true with regard to pulmonary tuberculosis and we have been rather insistent that every general hospital should set aside a certain number of its beds for the care of such cases. A similar policy has been followed with regard to neuro-psychiatric disorders. Even if the general hospital can be made no more than a distributing point for these special classes of cases it is, nevertheless, wise that such provision should be made. Consideration has been given to the possibility of adopting a method which was followed by the Army during the war, that is; specializing in hospitals to much greater degree and organizing certain hospitals on such a basis that they might be especially prepared, both in personnel and equipment, to care for one or two classes of disorders. The patients with which we have to deal, however, are by no means so easily transported and so easily congregated in special groups. This method, therefore, while it deserves much consideration, has not been found feasible in our work. Consideration has also been given to the establishment of convalescent hospitals, and while such institutions have much to commend them, they also possess some very serious disadvantages, especially with the class of patients with which we are now dealing. We have opened one such hospital which is still in operation and is giving satisfactory service.

It has been a general policy of the Public Health Service, of course, to seek in every way to establish in all of its hospitals standards of professional service in full accord with the best modern practice. At the same time we have sought to avoid the fostering of radical methods which might verge on the field of fads. We have preferred to adopt a somewhat conservative attitude in this regard and have been unwilling to make use of methods until they had been fairly well tried out and established as useful.

It has also been a policy, as far as possible, to establish a uniformity in professional service, at the same time doing nothing which might interfere with individual initiative. General Uniformity in professional service is desirable not only for administrative reasons, but for professional ones as well.

It goes without saying that we have felt the absolute necessity of establishing a professional service which would be reasonable in cost. The expenditure of money in professional service is, of course, wise. At the same time it has seemed to us that any professional service which could not be justified on the basis of economy was probably more than necessary.

There is one other matter of general interest, which seems to us of the highest importance, and that is the creation in all hospitals, so far as possible, of a broad spirit of human charity and the stimulation of any agency which would help in the creation of such an atmosphere. We have, therefore, done everything we could to assist in the formation of an efficient medical social service and in the furtherance of recreational activities. It has seemed to us that the creation of such an atmosphere in any hospital is a matter worthy of every effort.

One other consideration of general significance is the ideal of not discharging a patient from hospital until he has reached the maximum benefit to be derived from such a form of treatment, and was ready for discharge in a condition which would permit him to return to the outside world prepared to assume, as far as possible, the burdens of daily life and ready to make social readjustments. In other words, it has seemed to us unwise simply to discharge a man upon recovery from an acute or chronic illness without taking pains, through a medical social service, to see that he was readjusted to the community on a basis which would prevent his reversion to a state of ill health and perhaps his readmission to hospital.

2. With regard to the application of professional service to the actual treatment of sick in our hospitals, we have had in mind, in a general way, some rather definite things. In the organisation of our hospitals, whatever the type, we have arranged all of the professional services to meet the demands of the institution. We have attempted to adjust these professional services, so for as possible, to the need of the particular hospital and the particular class of patient treated therein and then properly to coordinate all of these various services under competent chiefs, supplemented by attending specialists. An organization so established should, we feel, meet any reasonable demands which might be made upon the institution without an undue expenditure in the matter of professional personnel.

We have established many highly specialized services, including dentistry. We have not overlooked such things as occupational therapy and physio-therapy and, of course, have taken care to supply the necessary modern laboratories, X-ray equipment and other matters which are essential in the best modern professional service.

We have, of course, not neglected such necessary accessories, in the proper care of a patient, as good nursing and an adequate system of supplying a well balanced ration, properly prepared and served.

We have believed in doing much of this work that it was a matter of economy as well as expediency to furnish as complete medical examination as possible. These cases are compensable cases and the matter of records as to their physical condition is of especial importance. The veterans’ Bureau has felt the need of careful and complete examinations as well as records which are dependable. Pains have been taken, therefore, so far as possible, to take such examinations and keep such records of all cases.

In some of our hospitals we have felt the need of establishing special services for special classes of cases, but have not extended this any further than was necessary. For example: we have in one of our general hospitals a special service on gastro-enterology. In another we may have a special service on surgery, as applied to tuberculous processes. Similar special services have been located in several places to meet special demands and such a policy will, of necessity, continue.

Most important of all we have striven in every way to secure a qualified medical personnel, a matter of no small difficulty. The demand for competent medical men is greater than the supply. In the operation of such a large hospital system it is by no means easy to secure men skilled in special lines of endeavor. We have, therefore, felt the need many times of establishing some system of educating our medical staffs in various matters and, while funds have not permitted the extension of this system, we have availed ourselves of educational methods as far as possible. Schools of various kinds have been held for short periods of time and men have not infrequently been transferred temporarily to situations where they might acquire a special knowledge. We have also encouraged staff conferences and attempted to supply working libraries and medical magazines to each of our hospitals—all with the idea of stimulating among our entire medical personnel the desire to increase their professional efficiency as much as possible.

3. Finally, we have not overlooked the necessity for research. Our funds have been too limited to do a great deal in this line, but we have felt keenly the responsibility which rested upon us to do all that was possible. Such activities have been carried on in a very small way with the exception of one or two hospitals which might be really called research hospitals, notably such a hospital as the one at Waukesha, Wisconsin, where every effort is devoted to the diagnosis and treatment of a definite class of Neuro-psychiatric disorders. This hospital has been so organized as to permit the very highest type of modern diagnosis and therapy.”

GEN. SAWYER: “This seems to me to be on opportunity to say a thing or to which have been in my mind that I wish to express now. First, this present administration has as one of its ambitions the best Public Health Service in the world. I want you to know that, in your engagements here, trying as they are, behind you is a determination to help to develop an ideal Public Health Service, and every man who is engaged in the service of the Public Health of the United States should feel that he is engaged in the greatest service that can be rendered to his country.

For myself, I have a great ambition that somewhere there should be established a post-graduate training department to which the members of the Public Health Service of the United states could come for post-graduate training. We want to be the highest type of doctors that are to be found anywhere, and so today we have in contemplation the establishment of a post-graduate training school in the city of Washington, to which you can come to provide yourselves and equip yourselves with all the new and better things that from time to time must develop.”

SURGEON DEDMAN: stated that he felt that Dr. Lavinder’s paper was too important to pass up without a comment or two; that one thing he was struck with was the personal contact to be made with the patients themselves. He said he believed this was a very important matter, as the services of a doctor are absolutely worthless until he has gained the patient’s confidence. He felt that the doctor should be looked upon just as the family physician at home. He stated further that when he first entered the work he made the following hospital rules: 1—Kindness, 2—Cheerfulness, and, 3—Duty. Said that the doctors should inject the feeling of friendship into the minds of the men as much as possible. He stated that there ought to be a system of uniform hospital regulations, that some hospital rules are not so drastic as those of other hospitals, and that he believed there should be a uniform regulation so that the disciplinary regulations would be the same in one hospital as in another.

ASST. SURGEON. L. L. WILLIAMS: stated that in reference to uniform disciplinary regulations the character of the patients, the location of the institutions and the construction of the premises are all factors that affect the privileges to be given the patients. Believed there could be no highly organized uniformity of regulations.

In regard to specialized attention, the hospital should be prepared to furnish any sort of special care possible. He stated further that he believed that the specialized patient in a general hospital is better off than if in a special hospital, but that if he had a son who had a special ailment he would much prefer him in a hospital which had upon its staff men in active practice of the kind he was going to need.

CAPT. LOWNDES: said there was always some patient who would go out and make trouble, that he had been investigated by the American Legion, by ladies’ committees and by religious societies, all of whom he invited to come to the hospital, as there was trouble if they were told not to come. He said he had met with two criticisms: one was that the nurses were particularly harsh, to which he replied that he generally had trouble getting the patients to go out as some of them generally fell in love with the nurses; the other that the patients would not pay any attention to the Commanding Officer when he made inspections.

GEN. CUMMING: “The next subject “Nursing” will be presented by the Superintendent of Army Nurses, Major Julia C. Stimson.”

MAJOR STIMSON: read the paper “Nursing”, as given herewith:

“The subject of nursing in relation to the care of the ex-service man is a very big one and can scarcely be handled adequately in the ten minutes allotted to it. There are, however, certain phases of it that can be mentioned.

The response of the nursing profession to the call of the country during the time of war is well known, and the character of the achievements of the 25,000 trained women who entered the government services at that time has been often recounted, but little has been told of the patriotic devotion to duty that has been exhibited by nurses since the Armistice. I have not come today to bring bouquets and laurel wreaths, but I do wish to call attention to the marvelous development of one branch of governmental nursing work under conditions that in many instances were harder to bear than most war conditions, and to ask for the service the recognition and cooperation it deserves. At the present time there are more nurses in the U.S. Public Health Service, (1796), than there are in the combined nursing departments of the Army, (774), and the Navy, (488). The figure given me for the present Public Health nursing staff is about 1800, an expansion from forty odd at the time the service was authorized to care for ex-service men, on March 3, 1919 by Act of Congress. To realize the full meaning of this expansion and the development of the organization required to manage the service, it is only necessary to recall the fact that in the spring of 1919 when the Public Health Service called for volunteers for its Nursing Service, the Army and the Navy were both discharging from their Nurse Corps great numbers of women. In one month alone in that year 2500 nurses were demobilized from the army. They were all tired, worn-out women. You all recall the state of mind of both the soldier and the officer during those months, when morale was at its lowest ebb, because of homesickness, fed-upness, and desire to get back to civil life. Nurses as well as men were full of complaints, and to be freed from governmental control was the thing that to all of them seemed the ultimate good. Moreover, many who came from overseas had been marking time for weeks, awaiting orders for the breaking up of their units, and embarkation, and upon their arrival home they found their communities, which they had left so short of nurses, were clamoring for their services.

Under such conditions was presented the need of the ex-service man. A new federal nursing department asked them to give up their personal desire for freedom, their longed-for plans, and to enter—what? and to do—what? It is hardly necessary to describe the kind of hospitals these nurses were asked to enter, nor the conditions under which they were to live. You would scarcely believe the details that I could tell you unless you, too, have heard the accounts of the able Superintendent of Nurses of the Public Health Service. You know, perhaps, what some of the old Marine hospitals are like, and some of you know some of the old Army hospitals taken over by the Public Health Service were like. You don’t know, I am sure, about the utterly unworthy and unsuitable quarters and messing arrangements for nurses which many staffs have had to endure, and still do endure in some instances. The fact that there are now 1800 nurses in the service bears witness to the clearness of her vision of the need on the part of the Superintendent of the Corps, and her valiant presentation of it, and to the assistance given her by the American Red Cross Nursing Service which has spread the call and facilitated recruiting.

The Nurse Corps of the Army and Navy were old, established departments, with traditions and customs behind them, with a status recognized by all in the service and honored by officers and men alike for their many years of efficient work.