Columbia ^anibers^itpCowx. I ^n tfte Citp of Jgelti gorfe College of ^fjpgicians anb ^urgconjf l^efercnce Urtirarp DISPENSARIES THEIR MANAGEMENT AND DEVELOPMENT A Book for Administrators, Public Health Workers, and All Interested in Better Medical Service for the People By MICHAEL M. DAVIS, Jr., Ph.D. Director of the Boston Dispensary and ANDREW R. WARNER, M.D. Superintendent of Lakeside Hospital^ Cleveland THE MACMILLAN COMPANY 1918 All rights reserved Copyright, 1918 By the MACMILLAN COMPANY Set up and printed. Published September, 1918 1\ ii'^C _J) it) TABLE OF CONTENTS Page Preface v SeCTTION I: HiSTOEICAL Chapter I How Dispensaries Began 1 II The PubHc Health Motive and the Eflaciency Idea 11 III Present Scope and Extent of Dispensaries in the United States 25 Section II: Fundament.'^ Principles Chapter IV Who are Dispensary Patients? 42 V Vilio Should be Dispensary Patients? 59 VI The Ten Essentials of a Chnic 71 VII Medical and Administrative Organization .... 81 VIII Social Service 101 Section III: Technique Chapter IX Dispensary Buildings 121 X Dispensary CHnics: Equipment; Organization; Education and Preventive Medicine 141 XI Dispensary Clinics continued: Specialties and Treatment Clinics; Laboratory; X-Ray De- partment ; Pharmacy 166 XII The Management of an Admission System . . . 192 XIII Records and Statistics 210 XIV Follow-up Systems 233 XV Efficiency Tests 248 XVI Finance 262 Section IV: Specl^l Types Chapter XVII The Out-Patient Department of the Small Hospital 282 XVIII The Pubhc Health Dispensary and the Health Center 297 XIX The Specialty Center and the Pay Clinic. ... 325 ill A-- iv CONTENTS Section V: Public Pboblems Page Chapter XX Dispensaries and the Medical Profession .... 345 XXI The Efficient Dispensary of the Future 360 XXII Financing Better Medical Service 372 XXIII The Organization of Dispensary Service for a Community 382 XXIV Conclusion 400 BiBLIOGBAPHT 406 Suggestions for By-laws and Rules of a Dispensary 415 The Massachusetts Dispensary Law 427 Index 429 PREFACE That fully four million persons, or one in every twenty-five of the population of the United States, are annually receiving medical treatment at Dispen- saries, is a fact of sufficient significance to raise the question why so little attention has been given to these growing institutions. The name ^ 'Dispensary,*^ to which these insti- tutions are historically heirs, suggests merely the giving of medicine. This has perhaps delayed the public mind in grasping the fact that giving medicine has become an incidental activity, and that the chief present function of Dispensaries is furnishing medical advice and treatment. The present generation has indeed witnessed re- markable changes in medical science. There have come new knowledge of the causes of disease and con- sequent progress in ability to prevent as well as cure it; a wonderful advance in remedial and reconstruc- tive surgery to which the present War is giving dra- matic witness; a growth of specialization in medicine to a point previously unknown; and a development of new standards, new institutions for medical educa- tion, and of great foundations for medical research. Are we not perhaps on the threshold of advances in medical service which should follow the progress of medical science? Is it not the call of democracy to place the new resources for health, the new powers to heal and to prevent disease, within the reach of all persons, all classes of society? It is part of the pur- pose of this book to trace how the Dispensary, as one vi PREFACE type of institution providing medical service, has grown in numbers, effectiveness and breadth of func- tion, and how large a part it can and should play in an inclusive, democratic and efficient medical service in the future. More fully, the purpose of this book may be de- scribed as threefold. First, it aims to depict briefly the history and pres- ent extent of Dispensaries in the United States. Except in a very slight way, no space is devoted to developments in other countries. Second, it aims to be a handbook of the equipment, organization and daily conduct of Dispensaries, so as to be of practical service to their superintendents, trustees, physicians, nurses and social workers. With this in view, some chapters go into the practical de- tails which people who are working in Dispensaries particularly need to know. The often neglected problems of the small Dispensary have received atten- tion, as well as those of the larger institutions. Sec- tion III (pp. 121-281) is mostly of this technical nature, and may be omitted by the general reader. In the third place, the book aims to present the Dispensary as a form of organization for rendering efficient medical service to the people. The Dis- pensary has generally been regarded as a form of charity. To a large extent existing Dispensaries are that; and worthily so. But the trend of medical science, and the necessary implications which follow for medical service, create a demand for the practice of medicine through an organized rather than through PREFACE vii an individualistic system such as has prevailed in the past. The Dispensary represents an organized sys- tem for the practice of medicine in the treatment of patients who are able to go to see the doctor, just as the modern hospital represents the organized practice of medicine for patients who are sick enough to be in bed. As an institution for rendering efficient medical service to ambulatory patients, the future Dispensary must be so organized as to help the patient without regard to social class, and benefit the medical profes- sion by rendering the economic position of the average physician more stable and his opportunities for pro- fessional advancement larger and more accessible. Dispensaries have generally depended upon volunteer service by physicians, but this system, with the greatly increased number of Dispensaries, begins to break down of its own weight. Adequate service for patients is essential and to achieve this there must be proper remuneration for physicians, such as rarely obtains in Dispensaries at present. The need for better ser\'ice to all the people in curing and preventing disease is one of the most justified and insistent de- mands of today, and it is our aim to point out how the Dispensary should and will play a large part in answering this demand. The War is bringing great disturbing and yet re- constituting forces to bear upon medicine. Thou- sands of physicians are becoming accustomed to work in an organization instead of as individuals ; hundreds are being trained in specialties of surgery, orthopedics, opthalmology, and syphilology; new lines of medical viii PREFACE research are being instituted and there will be new areas for the practical application of the results of research. Several million soldiers will receive sys- tematic and adequate medical service and learn some- thing of its worth. The general public, and in par- ticular the employers, will understand as never before the economic value of health as an element in the productive efficiency of a people. We may hope that as a result greater power will be given to preventive and curative medicine than at any previous period. We may expect that when soldiers and doctors return to civilian life after the War, many substantial recon- structions of medical service will take place. We may be sure that these changes will be in the direction of medical organization rather than of medical individualism. The Dispensary is the medical organization which must cover the major portion of the field in caring for dis- ease, standing between the Hospital on the one hand which provides for the relatively small proportion of acutely incapacitated patients, and the Public Health Department on the other hand which deals usually with preventive work alone. We" believe that the conditions arising out of the War, as well as the rapid growth of Dispensaries during the years which just preceded, render this book timely, and we hope that it will be of service. Mr. Edward F. Stevens has generously aided in designing and drawing the plans of dispensary build- ings in Chapter IX. A considerable portion of the manuscript was kindly read and helpfully criticised by Dr.'S. S. Goldwater. To both of these friends and PREFACE ix to many other physicians, hospital superintendents and social workers, the authors are under a large obligation. To the Committee on Out-Patient Work of the American Hospital Association, of which the authors have been members, thanks are due for con- structive thought and assistance on the problems of the Dispensary. We feel, also, a debt of gratitude to the Trustees of the Boston Dispensary, who, with un- usual foresight, have made their institution in a meas- ure an experiment station in methods of dispensary administration and have thus enabled many problems to be solved by working them out in practice, which might otherwise have remained much longer within the field of theory. M. M. D., Jr. A. R. W. DISPENSARIES : THEIR MANAGE- MENT AND DEVELOPMENT CHAPTER I HOW DISPENSARIES BEGAN In 1665, the great conflagration which devastated London brought in its fiery train a blessing, for it rid the city of plague. But the germs of poverty cannot be burned up, and the sickness and misery that follow poverty were so apparent to the public- spirited members of the medical profession of London, that in 1687, they voted that all members of the Col- lege of Physicians, their professional organization, should give their services to the poor without charge. In due form they transmitted this resolution to the Lord Mayor and Alderman. When, however, the charitable-minded sought to call the good physicians to the service of the poor, no means was found of providing the medicines which the doctors wished to prescribe. The pharmacists of London were at that time organized as a guild, the so-called Apothecaries' Hall; and Apothecaries' Hall would not lower its prices, even when the College of Physicians requested it on behalf of the poor. The physicians did not sit idle under this monopoly 2 DISPENSARIES in the prescription market. Fifty-three leading spirits signed an agreement on December 22, 1696, to pay ten pounds apiece to Dr. Thomas Burwell, one of their number, which sum Dr. Burwell was to use for medicines for the poor. Thereupon the first Dis- pensary in the English-speaking world was opened in the building of the College of Physicians. The First Dispensary in England During the first five years of its existence, we do not know how many patients the doctors treated, but it is recorded that 20,000 prescriptions were given out. The physicians, however, complained that the dole of medicines was more highly regarded by the pubhc than the freely given services of the physicians. We do not find this first Dispensary mentioned in Addison's Spectator; but if the sentiment of the educated London pubhc could have been gauged, we should probably find that the Dispensary was regarded as a medical soup-kitchen. Medicines and medical service alike were doubtless thought of as a dole to the needy. In the seventeenth century specialists in medicine had not appeared; modern scientific aids to diag- nosis were unknown, treatment was necessarily of symptoms of diseases rather than of causes. The giving of medicines played a larger part in theory and in practice than it does today. The spirit of service characteristic of the medical profession, which led the London doctors of 1696 to establish the first Dispensary in the English-speaking world, is the one HISTORICAL 3 fine continuing element through the whole history of the dispensary movement from this early begin- ning. The later history of this first London Dispensary is obscure; not until the latter part of the eighteenth century are Dispensaries again noticeable in London.^ In 1770 the so-called ^^ General Dispensary^' was started and four years afterward, the ^'Westminster Dispensary^'; in 1779 the ^'London Dispensary/' in 1780 the 'flushing Dispensary" and in 1782 the ''East- ern Dispensary," These institutions were supported mainly by private subscriptions, usually of one guinea; patients were only accepted when recom- mended by a subscriber and it is said that they were required, when discharged from the care of the Dis- pensary, to return thanks to the subscriber by letter. Dr. Lettsom, one of the first physicians of the General Dispensary in London, said, under date of 1801, referring to the five London Dispensaries, "50,000 poor persons are relieved annually, one third of whom are attended at their own dwelHngs: a mode of relief which keeps the branches of the family from being separated and affords the wife an opportunity of nursing the sick husband, or child, or the husband to superintend and protect the sick wife. And by this mode of conveying rehef to the bosoms and houses of the poor, the expense is trivial indeed, as one guinea which is the annual subscription of a governor, affords the means of relief to at least ten patients. " Thus during the latter part of the eighteenth can- 4 DISPENSARIES tury Dispensaries blossomed in the English metrop- oHs.* Dispensaries do not appear to have been established in America until after the Revolution, but within a few years following the conclusion of peace, each of the three chief cities in the United States had, as will be seen, followed the example of London and estab- lished a Dispensary. Dispensaries in the United States The first was started in Philadelphia in 1786. The Philadelphia Dispensary still stands on Independence Square, occupying the same building which was erected in 1801 and which with slight modifications serves for the 30,000 odd patients who pass through it annually. In New York City the New York Dis- pensary was established in 1790 and unlike its Quaker brother has passed from one building to another, enlarging as it moved. The third Dispensary in the country was the Boston Dispensary, established in 1796 at a point on Washington Street, close to the corner of Court Street, on which the restaurant known as Thompson's Spa now stands. Those responsible for the establishment of the Boston Dispensary were familiar with the institutions in New York, Philadel- * By 1850 the number of Dispensaries in London is said to have in- creased to 35. No reference is made here to Dispensaries on the Con- tinent. They do not appear to have affected the early development of Dispensaries in the United States. In the latter part of the nineteenth century, foreign clinics, in which many American physicians studied, had substantial influence upon the procedures of medical education, and thus upon some of the dispensary movements described later in this chapter. HISTORICAL 6 phia and London, as the following statement prepared by a Committee in September, 1796, bears witness i^ ^'It having been found by experience both in Europe and in several of the capital towns in America, that dispensaries for the medical relief of the poor are the most useful among benevolent institutions, a number of gentlemen propose to establish a public Dispensary in the town of Boston, for the relief of the sick poor; which they presume will embrace the following ad- vantages : — 1. The sick, without being pained by a separation from their families, may be attended and relieved in their own houses. 2. The sick can, in this way, be assisted at a less expense to the public than in a hospital. 3. Those who have seen better days may be comforted without being humiliated; and all the poor receive the benefits of a charity, the more refined as it is the more secret." The benevolent desire to help the sick poor thus appears in these quaint phrases as the primary motive leading to the establishment of this institution and it was indeed the underlying and typical motive behind all the early Dispensaries. The London system was maintained in the three earliest American Dispen- saries, requiring that patients be accepted only when recommended by subscribers, printed forms being furnished those contributing five dollars or more a year. In Boston, a subscriber might keep two patients under care for each five dollars annually con- tributed. The aim was to give the subscriber a spirit- ual return for his money as well as to insure ^^worthi- 6 DISPENSARIES ness" in the applicant. That the '^ worthiness" of the applicant was emphasized, appears from the rule which was certainly followed in Boston and probably elsewhere, 'Hhat persons suffering from venereal dis- ease or from the effects of alcohol should not be treated by the Dispensary, as being the victims of their own sensual indulgence. " , The early Boston Dispensary consisted merely of a drug store, with a physician who was to be in attendance daily except Sundays. Ambulatory cases might see him there at 11 o'clock. Patients too sick to come for treatment were to be visited at their homes and to a certain extent these eighteenth century dispensary phy- sicians saw patients at their private offices without charge. Almost the sole elements of expense in the early days were the medicines provided, and of these, at least at the Boston Dispensary, wines or spirits were the largest items among the treasurer's bills. The method / of the early Dispensaries was simply this : a poor I patient had to have a letter from a subscriber, and must present this at the Dispensary during the an- nounced hours ; or the letter of recommendation might be left by some friend or member of the family with the apothecary, so that the doctor should have the name and address, in order to call at the sick person's home. At first only one physician at a time was fur- nished. Dr. John Fleet, the first physician of the Boston Dispensary, for instance, treated 80 patients during the first year. As the city grew in size, more physicians were added and the city was divided, each physician seeing patients only within his own district. HISTORICAL 7 In New York additional Dispensaries were founded early in the nineteenth century, the Northern Dis- pensary (still in existence) in 1827, and the '' Eastern Dispensary '^ in 1832. The city was then more or less equally divided between them. As the communities became larger the earlier system of recommending pa- tients through subscribers became increasingly incon- venient and was gradually given up. Dr. Oliver Wen- dell Holmes, a physician of the Boston Dispensary in 1837, complained in a letter to the Board of Managers that the physicians of the Dispensary were practically compelled to secure tickets signed in blank by sub- scribers. The patients usually appealed to the physi- cian in the first instance and the rule requiring that they then go to the subscriber and secure a recommen- dation for treatment become merely vexatious. The London Dispensaries and the New York Dispensary had already established clinics on the modern principle by which the physician treats ambulatory cases at a given time and place, not in informal conferences at the apothecary shop. Thus the system of recommending patients by subscribers fell into disuse and was finally abandoned, and clinics as we know them today were developed. The Boston Dispensary started these clinics in 1856. A new element which powerfully reinforced the charitable desire to help the sick poor appeared in the dispensary movement during the first part of the nineteenth century, namely, the interest of physicians in acquiring medical experience and in teaching med- ical students at a cHnic. In the. early part of the 8 DISPENSARIES nineteenth century the teaching of medical students was carried on by physicians who took apprentices, as it were, so that the student learned the practice of medicine by taking part in it, under the tutelage and practical guidance of an established physician. In connection with the Boston Dispensary students were allowed to attend patients almost from the beginning, as regulations governing the activities of students appear in the records as early as 1827. With the ad- vance of medical science and the development of medical schools, teaching was reorganized. The em- phasis upon clinical teaching in the latter part of the nineteenth century, instead of mere didactic instruc- tion, has been one of the most powerful factors in increas- ing the number of Dispensaries and improving their work. The desire to provide material for medical students is supplemented in the physician's mind by the endeavor to increase his own skill and knowledge. The teaching motive (or m.edical-experience motive) is the second important force which has shaped the development of Dispensaries. Oliver Wendell Holmes wrote a report to the Boston Dispensary in 1837, after he had been one of its district physicians, and urged the establishment of a clinic, saying:^ — "A consulting-room well attended is one of the most valuable schools for students as well as practitioners of medicine, since many cases of disease may be seen within a very limited time; and, being thus collected, may be com- pared with and illustrate each other. This is one of the legitimate ends of all medical charities. " Very much more recently we see the charitable HISTORICAL 9 motive and the teaching motive balanced in the utter- ance of Sir WiUiam Osier, in his address at the opening of the new Out-Patient building of the Cardiff Hospital in 1908:^— ''That an out-patient department is simply for the relief of the poor — the common idea — is to take an altogether too narrow view of its functions. ... Of course the first and most important (function) is the relief of the poor. ... In acting as the training school for the younger members of the profession, the out-patient department fulfills its second great function. . . . With sufficient staff, there is no reason why just as careful notes should not be taken in these rooms as in the wards, and let me remind the younger physicians in the audience that some of the most brilliant reputations in the profession of this country have been built up upon the solid foundation of notes taken in out-patient departments. Let me urge you to make ample provision for your medical students in the out- patient department, where they see the patients in their native state, so to speak, before they have been scoured and cleansed by the nurses in the ward." The modern demand that medical students be taught diagnosis and treatment of diseases, in the only way in which such practical matters can be learned, i.e., by experience with patients themselves, has re- quired the extensive development of hospitals and Dispensaries in connection with medical schools. The premier hospitals of the country have usually been the teaching hospitals. To make their teaching facilities adequate it has been needful that they develop their Dispensaries or out-patient departments (as a Dispensary connected with a hospital is properly 10 DISPENSARIES called). The teaching motive has been one of the most important stimuli to the development of such great historic out-patient departments as those of the Johns Hopkins Hospital and the Massachusetts Gen- eral Hospital. The desire of medical men to increase their own ex- perience as well as to teach students, has been respon- sible for many Dispensaries, particularly those for special diseases, such as those of the eye, nose, throat and ear. The out-patient departments of lying-in hospitals, special clinics for children, etc., have been established largely because of the desire of a group of specialists to advance their knowledge and technique. This is only possible when a mass of medical material can be gathered together. The public-spirited motive to perform a service for the poor joins with the desire to increase medical experience. The two motives we have thus far analyzed, to do charity and to advance medical knowledge and educa- tion, are responsible for the establishment and develop- ment of the majority of the thousand general Dispen- saries in the country today. In 1800 there were three Dispensaries in the United States. In 1900 there were about 100. Of these perhaps 75 were general Dispen- saries and the remainder were confined to the treat- ment of special diseases. Shortly after 1900 new forces entered the field, developing hundreds of new Dispensaries, and transforming many of the old. These forces are outlined in the next chapter. HEALTH AND EFFICIENCY 11 CHAPTER II THE PUBLIC HEALTH MOTIVE AND THE EFFICIENCY IDEA Militant organizations to combat disease are a new element in public health work. When the growth of scientific knowledge concerning the causation and mode of transmission of a prevalent infectious disease like tuberculosis has reached a certain point, it be- comes evident that power hes in human hands to apply this knowledge for the actual diminution if not control of the malady. The research institutions of the scientist are at this point supplemented by organ- ization for practical case-work in which lay as well as medical men co-operate. Thus upon the scientific foundations laid by Pasteur and Koch, in the last quarter of the nineteenth century, the anti-tubercu- losis campaign arose during the first years of the twentieth. In the United States it assumed organized shape in 1905, when the National Association for the Study and Prevention of Tuberculosis was formed. Progress since that time has been remarkable. To- day there are fifty state-wide anti-tuberculosis organ- izations and over fourteen hundred local associations and committees engaged in the campaign. The program of this movement has included two essential elements : — 12 DISPENSARIES 1. The education of the public: achieved through all sorts of educational propaganda, from lectures and moving picture shows to advertising leaflets and Red Cross Seals: also through the personal educational work of the Visiting Nurse, the chief field agent of the whole campaign. The educa- tional influence upon the medical profession itself is an ad- ditional feature of importance. 2. The increase of facilities for the diagnosis and treatment of the disease. In 1905 there were approximately 600 hos- pital or sanitorium beds for tuberculosis cases in the United States. In 1915 there were over 30,000 beds. In 1905 there were 20 tuberculosis clinics or Dispensaries in the United States; twelve years later there were over 500. It is the eflfect of the anti-tuberculosis movement upon the growth of treatment facilities and particu- larly upon Dispensary clinics that claims our atten- tion. We may note also that in the official program of the National Association, proclaiming what ought to be achieved by 1925, there is included the demand for: — "cUnics in every city or county, so that anyone who sus- pects he has tuberculosis may be examined and treated, free of charge if he cannot afford medical care. " The anti-tuberculosis movement has thus been re- sponsible for the establishment of some five hundred Dispensaries for this disease in the United States and within the next few years the number will run into the thousands, for many states are establishing them by law in every city, town or county. For our purpose we must dwell upon the motive underlying HEALTH AND EFFICIENCY 13 this development. This motive is not that of provid- ing care for the poor, nor medical advantages for physicians or students, but is a direct endeavor to combat disease and promote public health. The Dis- pensary is regarded by the anti-tuberculosis movement as a public health agent, partly educational and partly for the purpose of diagnosing or treating cases of dis- ease. The conscious establishment of dispensary clinics for public health motives may be regarded as having originated in this country through the anti-tuberculosis movement. It has not stopped there, however. Recent years have brought forth other campaigns along the same lines. First may be named the campaign to '^save babies." Starting with some local efforts, it devel- oped in 1909 into the National Association for the Study and Prevention of Infant Mortality. The same two elements appeared as in the anti-tubercu- losis movement, namely, the education of the medi- cal and lay public and the enlargement of facilities for the diagnosis and treatment of babies and little children. Dispensaries and out-patient departments for pediatric work with sick babies have been stimu- lated, but more than that, a great number of new clinics have been founded, for '^well babies," sick babies, or both. In 1915 there were at least 538 such clinics in 141 cities of over 10,000 population in the United States. This is five times as many as existed in 1910. Here also a rapid increase may be expected, for the studies and publications of the United States Children's Bureau, and many private agencies, are 14 DISPENSARIES spreading the movement to prevent infant mortality into the smaller communities and rural districts. Another public health movement of major import has been that to promote the health of school children. Medical school inspection began with the endeavor to control contagious diseases among children in the public schools, but has broadened far beyond its orig- inal scope. Periodical examination of children at once reveals physical defects, particularly of the teeth, eyes, nose and throat ; while many general medical or surgical disorders are also found. The correction of defects of eyesight, the care of the teeth and the removal of enlarged tonsils, require the service of spe- cialists ; and as a considerable proportion of parents of public school children are not able to pay the cost, there is a demand upon dispensary clinics if any exist in the community; or a demand to establish special clinics if the existing provisions are insufficient. Medical school inspection is responsible for the foundation of many dental clinics. A few, like the Forsyth Dental Infirmary in Boston, are large institutions; but most are small local clinics, some in school buildings. A certain number of eye and throat clinics have been established also. In communities wherein Dispen- saries already existed, medical school inspection has supplied a new and powerful stimulus to the dental, eye, throat, ear, orthopedic, and general clinics deal- ing with children. The study of insanity and of mental defects has led to the foundation of national and local Committees on Mental Hygiene. It is now understood that it is HEALTH AND EFFICIENCY 15 desirable to get hold of mental disease in early stages and that there is economy in providing after-care for the discharged patients of insane hospitals. Hence a growing number of psychiatric clinics have been founded. Of these the most prominent are institu- tions like the Phipps Clinic in Baltimore and the Boston Psychopathic Hospital, but in New York and in Massachusetts out-patient clinics for mental dis- eases have been begun in connection with the insane hospitals. Massachusetts has moved among the farthest, establishing a chain of such clinics all over the Commonwealth. The time is approaching when no system of hospitals for the insane will be considered adequate unless it is supplemented by a set of local out-patient clinics for preventive and follow-up work. Interest in controlling and preventing venereal dis- ease has followed the same course. It has led to a national organization and some twenty state societies dealing with the subject. Education, law-enforce- ment, and the treatment and prevention of disease are included in their program. These societies are approach- ing venereal disease from the viewpoint of a health problem. They have been met more than half-way by progressive pubhc health officials, who are actively taking up the venereal problem in New York, Buffalo, Rochester, Cleveland, Chicago and elsewhere. In New York the Associated Out-Patient Clinics have utilized the growing interest in the control of syphihs and gonorrhea to support standards for the equipment and maintenance of venereal clinics. Chnics for diagnosis of these diseases have been started by the 16 DISPENSARIES A Department of Health in the same city and are devel- j oping elsewhere. Clinics for treatment have been \ begun under municipal auspices in Buffalo, and pay I clinics under private auspices in Boston, Brooklyn, I Cleveland and elsewhere. The time is near when we I shall see the demand for out-patient clinics, as health measures for controlling syphilis and gonorrhea, made part of the accepted program of the organizations which are combating these diseases, just as tubercu- losis clinics have been incorporated into the platform I of the anti-tuberculosis campaign.* The report of the British Royal Commission on Venereal Disease in 1915 has led to far-reaching programs for the prophy- laxis and treatment of syphilis and gonorrhea in Great Britain, in which dispensary clinics now play a large part. Economic self-interest has recognized the value of the out-patient clinic in providing care for workmen. In some industrial establishments these clinics are elaborate organizations with permanent salaried med- ical staff; in others, they are merely accident or first- aid rooms. Their motive in either case is to cure disease and to promote health among the workers, be- cause this means the saving of human waste and a higher working efficiency. Thus in many fields we have traced parallel develop- ments. In the case of tuberculosis, in the diseases of school children or of babies, in mental disease, venereal disease, etc., the resources of private medical practice \ * Since this was written, the War program for the treatment and ' control of venereal disease has brought an extraordinary advance. The establishment of clinics and of educational and regulative meas- ures have gone forward apace. HEALTH AND EFFICIENCY 17 have been found insufficient to meet the needs for diagnosis and treatment; and as a result each public health campaign has undertaken and is undertaking to enlarge the facilities of existing dispensary clinics; to raise their standards of administration ; and also to establish new clinics. Dispensaries stimulated by such a motive have dealt with the disease as a public health problem rather than as a problem depending upon the moral or the financial situation of the indi- vidual sufferer. As we shall see, the public health motive influences the method of conducting Dispen- saries — an influence which we shall trace in detail later in this book. With the development of many forms of specialized work and its public health application by means of Dispensaries, nurses and other sociologic methods, there has come, and will progressively come, the prob- lem of organizing these specialties and using them in correlation. It is not possible to continue the devel- opment of clinics, nurses and other machinery for tuberculosis, for acute contagion, for babies, for school children, for mental disease, for venereal dis- ease, for other problems about to appear, in separate and independent organizations. Failure will neces- sarily come from the weight of the machinery. As each special problem becomes recognized as such by society, and the immediate methods of pro- cedure become fairly well understood, it must be in- corporated into the general public health activities of the community. There is no longer need for a mul- tipHcity of special nurses, special cUnics, or special 18 DISPENSARIES organizations. The Health Center Idea, aiming to co-ordinate all the special public health services in each district, represents this needed movement for correla- tion. How it is taking actual shape in many commu- nities later chapters will show. Closely related to the public health motive is an- other conception in the dispensary field which has re- cently become prominent: — the efficiency idea. The conscious study of efficiency in organization has been much exploited in business. Its application to hos- pitals and Dispensaries grew from the thoughtful initiative of a few physicians and superintendents, who as medical men or executive officers saw a need and an opportunity. Efficiency in doing things can be judged only after we have clearly in mind the aim of our accomplish- ment. So long as that aim is chiefly the acquiring of medical experience, we are likely to have, unless special organized provision is made to counteract the tendency, a situation described ten years ago by Dr. Richard C. Cabot^ as follows: — ''In order to make it worth while for an able (and there- fore busy) physician to give tirae to dispensary work, you must allow him the privilege of skimming the cream off the clinic: that is, of controlling and rushing through a rela- tively large number of patients for the sake of the few in- teresting cases to be found in the bunch. The physician takes his pay in this form. He uses a dispensary clinic to furnish interesting cases for teaching or for scientific study. " The paper from which this is quoted, read by Dr. Cabot before the Maryland Medical Society, HEALTH AND EFFICIENCY 19 December 4, 1906, is a landmark in the recent history of dispensary work. The paper as a whole recognizes clearly that securing results in the treatment of the patient is the prime public aim of Dispensary work, and, what is less obvious and more important, that the organization of the Dispensary must be definitely shaped to this end. A superintendent of a great hospital. Dr. S. S. Goldwater, expressed the same idea with a different application, in his equally significant address on ''Dis- pensary Ideals," printed in the American Journal of the Medical Sciences in September, 1907.^ Dr. Gold- water was impressed with the same hurry and over- crowding in dispensary clinics to which Dr. Cabot referred. He also urged efficient treatment and he also suggested certain practical steps towards securing it. Dr. Cabot's proposal was to provide social workers to give individual attention to the case of each patient and thus supplement and counteract the necessarily brief time given by the physician. This personal or case-work method is the characteristic reaction of the clinical physician. Dr. Goldwater's chief proposition was that the number of patient^ should be limited; he even proposed, and actually carried out in Mt. Sinai Hospital, the radical step of preventing more than a certain number of patients going from the admission desk to a clinic within a given time. This proposal was characteristic of an executive and organizer. Attention to personal relationships between the physician and the patient; attention to the organiza- 20 DISPENSARIES tion of the institution as a whole so as to secure effi- ciency in treatment: these two fundamental aspects of efficient work in Dispensaries were thus brought out at practically the same time by two pioneers in the movement for better dispensary service. A fur- ther step was taken in 1912 at the Boston Dispensary,^ where tests were devised for measuring medical effi- ciency in certain aspects. Imperfect as such tests were, they placed a new power in the hands of the physician or the superintendent of a Dispensary, because they gave him means to estimate results and to try out various methods by which results might be improved. The most important feature of any efficiency test is the attitude of mind which it creates in making it. The impersonal judging of results, and the critical experimentation with methods as tested by results, are a sine qua non of scientific progress in any field. The efficiency idea is responsible for the rise of a new conception, namely, that dispensary work is an organized form of medical service which may be broadly applied. The co-operative work of special- ists, in the modern hospital, has impressed many thoughtful physicians with the advantages of the joint use of expensive laboratories and other equipment, and of the opportunity for consultation and team- play which can be best afforded when the various specialists are at work in the same building at the same time. The Dispensary represents the same principles of organization applied to ambulatory instead of to bed cases. Can we not, in the Dispensary, test out HEALTH AND EFFICIENCY 21 the possibilities of organized medical service, as dis- tinguished from the traditional individuahstic service of private practice? In other words, what is the most efficient form of medical organization? The physi- cians and laymen who are working out an answer to these questions are no longer thinking of the Dispen- sary as a place in which medical experience is to be gained or imparted, nor as an institution of charity. That both of these functions have their place, is well recognized, but they are both included in the larger conception of the Dispensary as an organization for the efficient rendering of medical service, either cura- tive (clinical) or preventive (public health) service. The technical methods by which its possibilities shall be developed and also its limitations defined, are the joint task of all those who work thoughtfully in Dis- pensaries, whether as physicians, as lay helpers, or as administrators. The efficiency idea applied to dispensary services comes to full fruition in organizations formed for the co-ordinated practice of medicine on a scientific but business basis. The Mayo Clinic, at Rochester, Minn- esota, is simply a large Dispensary, receiving about the same number of patients per year as the Boston Dispensary, but run as a business enterprise by a group of doctors, with W. J. Mayo and Charles H. Mayo at their head. This institution was not founded as a charity, nor as a center for medical teaching, nor for public health purposes ; although it serves all these aims in certain measure. It was established and is main- tained for the efficient practice of medicine and must 22 DISPENSARIES compete with private practitioners and with other Dispensaries on a basis of efficiency. The Mayo Chnic, and other smaller, less known, but increasing examples of the same type, bear witness to the possi- bilities of the Dispensary as a form of organization for ^Hhe efficient rendering of medical service. ''* Organizations especially formed to advance the technique and standards of dispensary service have recently appeared. First in the field was the Associ- ated Out-Patient Clinics of New York, estabUshed in February, 1912, largely through the interest and initiative of Dr. Goldwater. It is a co-operative association of dispensaries and out-patient depart- ments, its stated purpose being : — (a) To co-ordinate the work of the institutions in New York City. (b) To prevent the abuse of dispensaries by persons not properly entitled to receive treatment. (c) To establish clinical standards. (d) To promote economy and efficiency in the manage- ment of Dispensaries. This Association has published a number of valuable studies and standards relating to various departments * The rapid growth of Dispensaries has naturally given rise to a small number of undesirable institutions. Some of these masquerade as charities, although really conducted for the benefit of their owners or managers. Others are commercial enterprises of an illegitimate or ex- ploitative sort. The public has so direct an interest in any institution which deals or pretends to deal with disease, that all dispensaries should be subject to some supervision or regulation by a local or state authority. The form which such regulation may well take is outlined in Chapter XIII. HEALTH AND EFFICIENCY 23 of Dispensaries, to which reference will be made in other chapters of this book.® Second in order was the Committee on Dispensary Work of the American Hospital Association, organized after the annual convention of that body in September, 1913. This Committee has undertaken: — (a) Studies of the growth in number and extent of Dis- pensaries in the United States. (b) Study of special problems and of different types of Dispensaries. (c) Certain elementary standards of organization and management have been formulated, and promulgated through the publications of the American Hospital Associa- tion. (d) Through an annual questionnaire, new features in dispensary work have been collected and published in the Committee's Annual Report. Thus Dispensary work has entered a self-conscious stage.^ Behind its growth in this country, we have traced four main impelling forces, arranged in the order of their development thus : — (1) The charity motive, interested in the patient as a mem- ber of a dependent group that needs help. (2) The medical motive, interested primarily in diagnosis and in medical teaching. Interest in treatment is not absent but the emphasis has been on the diagnostic side. (3) The public health motive, interested in the patient not as a bundle of diseases, nor as an object of charity, but as a citizen, and establishing dispensaries to further the cure, control and prevention of disease. (4) The economic motive, interested in the co-ordinated 3 24 DISPENSARIES practice of medicine, and utilizing the dispensary organiza- tion as an efficient means to this end. The four motives are in themselves not inconsistent. They supplement one another. They do pull in dif- ferent directions, but they are capable of being co- ordinated and jointly utilized for a common aim. The efficiency idea aims to utilize all of them, each in its place, by applying scientifically the general principles of organization to the special problems of medical institutions. The ultimate guiding forces in Dispen- saries must include the spirit of human service, oppor- tunity to widen medical knowledge and experience, and power to serve the health of the community by efl&cient treatment and aggressive prevention of dis- ease. To show how this analysis is justified through a study of existing Dispensaries and how it illuminates their problems; to indicate the ways in which some of these problems may be solved; and to suggest direc- tions in which Dispensaries may move toward more efficient and more inclusive public service: these are the essential endeavors of this volume. SCOPE AND EXTENT 25 CHAPTER III PRESENT SCOPE AND EXTENT OF DISPENSARIES IN THE UNITED STATES I. What is a Dispensary? When the little doctor in '^V. V/s Eyes'* is pictured by the novelist seated in his office with one poor patient in front of him and a long row of others in the waiting room, the reader may well ask himself whether '^V. V." is not running a Dispensary. But ^'V. V.'' was running his office on his own hook, while a Dispensary, large or small, is essentially an organization. When a person who is in comfortable circumstances becomes seriously ill, his doctor will call to see him in his home. If he is not too ill to venture from the house he will go to see the doctor at the latter's office. A Dispensary is simply an organization with a definitely known system of office hours at which people may go to consult doctors. As we have seen from the historical sketch, Dispensaries began in the English- speaking world as places for distributing medicines, and received their name from this form of dispensa- tion; and they were, and still mostly are, established to receive the poor. Yet neither the distribution of medicines nor the limitation of their service to those unable to pay, are now necessary parts of the definition of a Dispensary, for there are many Dispensaries \ 26 DISPENSARIES which do not furnish medicines, and some which charge fees above the reach of the poor. But the essential definition of a Dispensary today is that it has doctors and an organized system by which patients are received and cared for. Like the hospital, the Dis- pensary is an institution, but the hospital wards re- ceive patients who cannot be up and about, while the Dispensary is for those who can go out to see a doctor, as to a private office. Such patients are called in technical language, ambulatory cases. An institution with an organized system of office hours for the medical examination and treatment of ambulatory cases, is a useful preliminary working definition of a Dispensary, but does not cover all of its essential features. At a small Dispensary treating only a particular disease, such as tuberculosis, and serving only a local area, there may be but a single doctor, who does all the work, much as ^'little V. V." did in Harrison's story. In all but the smallest Dispensaries, however, there are a number of doctors and they are organized in a particular way. There is division of labor among them. The ^'general medical" man or ''internist," the surgeon, the oculist, the laryngologist, the ortho- pedist, the children's specialist, the dentist, the neurol- ogist, and others, work together. Hence efficiency demands that a new element should appear, that of medical organization, and this is twofold : the organiza- tion of equipment and the organization of skill. Modern medicine demands laboratories. X-ray apparatus, microscopes, and instruments of many kinds. This " expensive equipment is available to more doctors, and SCOPE AND EXTENT 27 is available on better terms, if it is concentrated in one building and arranged or '' organized " under one coher- ent plan, than if it is scattered among a dozen or three dozen separate and independent offices. Still more important in modern medicine is the factor of special skill. The comic papers make fun of doctors each of whom treats only one small region of the body, and they depict the plight of the patient who is sent from one specialist to another, while his bills and his confu- sion mount together. There is no good reason to make fun of the specialist, for he is necessary. There is reason to make fun of the use of specialists in an un- organized way. The hospital and the Dispensary stand for the principle of organization, as distin- guished from the very slightly tempered individualism of private practice. We shall trace these contrasts further, and their bearing upon the practice of medicine, in later chapters. Here we may point out how they bear on the definition of a Dispensary. They, in fact, supply one of the essential factors in the definition. A Dispensary is an institution which organizes the professional equipment and special skill of physicians for the diagnosis, treat- ment and prevention of disease among ambulatory patients. This definition will serve us throughout this volume. To avoid misapprehension, certain other terms perhaps require definition, particularly Clinic. A Clinic may be defined as a division of a Dispensary in which a specified group of related diseases are treated. Thus the patients coming to a Dispensary will be 28 DISPENSARIES divided according to their troubles among the Medical, Surgical, Pediatric, Neurological, Opthalmological Clinics, etc. The word Department is sometimes used as if synonymous with Clinic, but is administrative rather than medical. There are also Departments of a Dispensary which are not Clinics at all, such as the Laboratory, the Pharmacy, or Social Service. 2. The Medical Scope of Dispensaries A man slips on the stairs after breakfast one morn- ing, and walks into the Dispensary one hour later with a cut arm and broken collar-bone. An old fellow with a "weak heart" calls often at the Dispensary for the advice and medicine which enable him to work enough to live. The public school doctor finds a child of twelve with poor eyesight and bad teeth. The Dispensary will provide the expert optical and dental service which the parents cannot pay for, and which the child must have to profit by its education. A young working-girl comes with ^'debility." Without care the white plague will lay its hand upon her soon. Pneumonia and typhoid fever, cancer, appendicitis and tuberculosis appear in dispensary clinics. To detect these diseases in early stages when they can be most successfully dealt with; or to secure prompt, efficient hospital care, if this is necessary, saves time, money, suffering, often hfe itself. The earlier acts of the drama of disease are thus those more usually seen at the dispensary clinic, whereas hospital beds and physi- cians treating patients in their own homes, more usu- ally witness disease at its dramatic climax. Of course SCOPE AND EXTENT 29 serious sickness may appear in a Dispensary, calling for reference to a hospital, or to the care of a physician in bed at home. Roughly classified, the typical medical field of the Dispensary may be said to include the following :io 1. Minor surgical accidents. 2. Serious diseases: a. In their early and often preventable stages. b. In chronic or convalescent stages. 3. Certain serious diseases which do not usually require any period of bed treatment; e.g., gonorrhea, syphilis. 4. Diseases of special organs; e.g., the eyes, the ears, the teeth, the throat, etc. 5. Developmental defects of childhood. 6. Minor diseases. Often these, if not properly cared for, will diminish earning capacity, or lessen resisting power, so as to lay the way open to serious disease. A brief summary will show the practical bearing of this enumeration. 1. Minor surgical accidents constitute a considerable part of the '^ medical material" at many Dispensaries. Prompt, efficient treatment of these accidents means the saving of large sums of money by reducing the period during which an employee is incapacitated. 2. Modern medicine has emphasized the importance of diagnosing and treating serious diseases in their early stages whenever possible. In a Dispensary, cancer, heart disease, kidney troubles, digestive and intestinal disorders, and tuberculosis, appear early in their course. Many of the acute functional disorders of earty childhood, particularly the gastro-intestinal and the respiratory, fall within the 30 DISPENSARIES special province of the Dispensary. In an efficiently con- ducted Dispensary with adequate laboratory facilities, accurate and early diagnosis of these troubles is practicable. The Dispensary thus has a function of the utmost import- ance from the standpoint of the public health, and not at all dependent upon its relation to the hospital: the function of detecting serious disease in its early and often preventable stages. 3. There are two diseases, of the first importance, which the Dispensary may almost be said to have for its peculiar province; gonorrhea and syphilis. The complications of gonorrhea and the later manifestations of syphilis bring many patients to hospital wards. Yet, large though the number of these bed-patients is, they represent only a frac- tion of the total who suffer from the venereal scourges. The large majority demand treatment as ambulatory cases. This treatment is secured in one of four ways : 1. From private physicians in their offices. 2. At dispensary clinics. 3. In the offices of advertising doctors, or at medical "institutes" or by correspondence with such ''institutes." 4. Self-treatment — the patient prescribing for himself on advice obtained from friends, from literature, or from drug clerks, with drugs bought at pharmacies. No one knows the relative proportion of patients who secure treatment through each of these four sources, but three points are clear: (a) the last two agencies of treat- ment are thoroughly undesirable; (b) they are widely used; (c) this fact is evidence that the desirable agencies of treatment are, for one reason or another, not adequate to the immediate existing needs. Under the present and the^probable future conditions of SCOPE AND EXTENT 31 private medical practice, American communities may find, as Great Britain is now finding, that the enlargement of Dispensary facilities is the only means by which adequate opportunities for treating venereal disease can be provided. 4, 5 and 6. What are commonly called ''minor diseases" often have more than minor effects upon the health and working efficiency of the sufferer. Such diseases, which do not confine the patient to his bed, fall particularly within the province of the Dispensary: for example, many skin diseases, very troublesome, and in some instances infectious; the common cold and its sequels; nervous disturbances; digestive disorders; septic processes of hands and feet, to- gether with minor surgical injuries; and a large proportion of the diseases and defects of special organs, particularly the throat, nose, ears, eyes and teeth. New demands have come upon the Dispensary because of the growing, sense that ''minor " diseases are important. Medical school inspection and industrial medicine are adding more to this demand than any other factors. When medical school inspection is car- ried out to the extent which now obtains in a number of cities, almost the entire population between the ages of six and fourteen years receive periodical medical examinations, and an enormous number of defects, as well as functional diseases, are revealed. Questionable eyesight, bad teeth, defective hearing, enlarged tonsils, occluded nasal passages, postural defects or malformations are found to be wide- spread. The community at once realizes that it is of little value to spend money in discovering such defects unless it is pre- pared to remedy them after they are found. In every city where medical school inspection has raised this problem, private medical practice has proved itself incapable of solving it. 32 DISPENSARIES The rapid growth of Dispensaries in connection with medical work in industry is based upon the medi- cal importance of the Dispensary field, as just de- scribed, and the economic value of restoring a worker as promptly as possible to health and of keeping him well. 3. Classification of Dispensaries With relation to their medical scope, Dispensaries fall into two obvious types. Some are for the treat- ment of diseases without limitation, although such contagious diseases as diphtheria, scarlet fever, mea- sles, smallpox and whooping-cough are ordinarily excluded. On the other hand, we have Dispensaries which confine themselves to a single disease or to a group of closely related diseases, such as the tubercu- losis Dispensaries, the ^^eye and ear infirmaries," the dental or the psychiatric Dispensary. We may call the one group the general, the other, the special Dispensaries. This distinction involves also one of medical organ- ization. In the general Dispensary, of large size, many specialists are at work together. In the special Dispensary there may be only a single specialty represented. Does such an institution correspond with our definition of a Dispensary, in which there is organization of equipment and organization of skill, among a group of physicians? The best types of special Dispensaries do organize equipment and skill by properly relating the institution to general Dis- pensaries which can supply the needed diagnostic SCOPE AND EXTENT 33 advice, or treatment in certain cases; and also by enlisting the services of specialties closely related to their main line. Thus a tuberculosis Dispensary will make arrangements with another institution so that X-rays can be obtained, and will include in its staff a throat specialist. The difficulty of doing this, particularly in the case of a small local clinic, is often considerable, and offers a serious limitation to the efficiency of special Dispensaries. An eye and ear clinic, for example, is likely to overlook general condi- tions, even when connected with the local trouble, which would be found and treated at a general Dispensary. Later, we shall see reason to believe that the specialized Dispensary along most lines of medical work, is a mistake; that the only desirable field for the special Dispensary is in localized clinics laying especial emphasis upon preventive work, and that these are most efficient when they are grouped to- gether, as a Health Center. In small communities, or in isolated sections of cities, one finds small general Dispensaries, with a single physician holding a clinic at stated periods. Such are not infrequently established in social settle- ment houses. The value of such clinics must be judged in comparison with the other local medical facilities available to the people, and from this stand- point, little Dispensaries of this type are often of great service to a neighborhood. It will generally be found, however, that need for various additional special clinics exists and is in fact often recognized; and that in so far as the means of the organization permit, it 34 DISPENSARIES should relate itself to larger institutions so as to secure X-rays and other advantages, and should have certain locally needed specialties represented in its clinics (particularly the pediatric, opthalmological, laryngo- logical and dental). The proper policy for such Dis- pensaries is discussed in Chapter XVIII. A second distinction of much practical importance is between the Dispensaries connected with hospitals and those which are independent of hospitals. The former may best be called the Out-Patient Depart- ments* while the Dispensaries which are not connected with hospitals will be called in this book Out-Patient Institutions. The term Dispensary will be employed to denote any medical organization treating ambula- tory cases. While all Dispensaries have a responsibility for preventing as well as for treating disease, we may make a distinction between the traditional Dispensary which receives the sick, and the Public Health Dis- pensary whose efforts are confined wholly or largely to prophylactic work. A type of the latter is the Well-Baby Clinic. The Tuberculosis Dispensary, or a Health Center, occupies a middle ground, with the emphasis usually on the prophylactic side. A tendency has arisen, particularly in Public * '^ Out-Patient Department" has sometimes, though rarely, been used to mean patients treated in their homes. The term Out-Patient Department, however, has now come to be much more generally employed to mean a Dispensary attached to a hospital and will be used in this sense in this book. When a hospital gives medical treat- ment to persons in their homes, this division of the institution's work may best be called the Home Patient Department. SCOPE AND EXTENT 35 Health Dispensaries, to limit the patients received to a definite area around the Dispensary. The traditional Dispensary receives patients without restriction as to residence. For certain purposes it will be convenient to refer to a Dispensary serving a defined area as a District Dispensary. We shall also have occasion to refer to the Teaching Dispensary, meaning one in which the instruction of medical students is carried on. Such Dispensaries include those which are under the direct control of medical schools and also those in which there is merely a school affiliation. A graphic summary of these distinctions may be found convenient : — Classification of Dispensakies I. As to Medical Scope: General (treating all diseases) Special (confined to one or a few specialties) II. As to Relation with Other Medical Institutions: Out-Patient Departments (of hospitals) a. < Out-Patient Institutions (separate from a hos- pital) f Teaching (medical students) ' \ Non-teaching III. As to Public Function: r Clinical medicine primarily a. \ Prophylactic work primarily (Public Health Dis- [ pensary) J District Dispensary (serving a definite area) * \ Dispensary unrestricted as to area 36 DISPENSARIES 4. Number and Location of Dispensaries in the United States Early in 1916, the Committee on Dispensary Work of the American Hospital Association, of which one of the authors was Chairman, undertook a post-card census of Dispensaries. The following table, quoted from the Committee's Report, ^^ summarizes the find- ings: DISPENSARIES IN THE UNITED STATES. 1916 Known Addi- tions Esti- mated Total I, Treating General Diseases. — Out-Patient Departments of hospitals . Dispensaries unconnected with hospitals 495 185 150 70 645 255 Total II. Treating Special Diseases III. Public Health Dispensaries. — Tuberculosis Baby Hygiene School Children 680 60 In 1904 20 220 40 900 100 In 1916 500 400 250 Psychiatric, Dental, etc 150 Total 20 1,300 Summary : — General Dispensaries and Out-Patient Depts. Special Dispensaries and Out-Patient Depts. Public Health Dispensaries 900 100 1,300 Grand Total. 2,300 The table suggests the remarkable recent growth of Dispensaries. Practicall}^ all the public health Dis- pensaries are products of the decade preceding 1916. As for the other Dispensaries, in 1800 there were SCOPE AND EXTENT 37 "three out-patient departments and Dispensaries in the United States; in 1904 (when the United States Census made a survey), there were only 150 general Dispensaries; in 1910, when the Census made a second survey, there were 450; in 1916, we know of 700, and undoubtedly there are at least 200 more institutions which did not send the post cards back.'' The ^^ additions estimated '^ for this reason, may be regarded as conservative. It is of interest to observe that nearly one third of the 2,000 odd hospitals in the United States which may be rated as ^' public,^' had out-patient departments in 1916. This is more than double the percentage which prevailed in 1904, when the Census made its first survey. Of course the many private hospitals and the sanitoriums for convalescent cases, rarely have out-patient departments. No data existed in 1916, for making more than a guess at the number of Industrial Dispensaries, and the table is undoubtedly seriously deficient in this respect. Their number has been increasing, during the last two or three years, more rapidly than any other type of Dispensary, even the Public Health Dispensaries. Until a national survey of Health work in industry is made, sufficient to bring out the existence of all these Dispensaries, estimates of their number must remain mere guess-work. The guess may be hazarded that by the close of 1917 there were betw^een 300 and 500 Industrial Dispensaries in the United States, and that the total number of Dispensaries of all classes is ap- proximately 3,000. Another table, showing the location of the Dispen- 38 DISPENSARIES saries of the country, may be quoted from the same Committee Report. "Location of 680 General Dispensaries listed in 1916, by the Committee on Dispensary Work, American Hospital Association — State Number New York 145 Pennsylvania 123 Massachusetts 67 Illinois 45 New Jersey 40 Ohio 30 Missouri 29 Maryland 24 District of Columbia 17 Michigan 17 Connecticut 16 Minneapolis 11 Virginia 10 Rhode Island 9 Wisconsin 8 Twenty-Six Other States 89 Total listed in United States 680 In 1900, New York, Pennsylvania and Massachusetts contained about sixty per cent of all the Dispensaries of the United States; in 1916 they had only forty per cent.'* These figures well illustrate the historical develop- ment of Dispensaries which we have traced in the preceding chapter. The concentration of institutions in the large eastern cities has been due to the fact that all forms of charitable work have been relatively ad- vanced therein and also because each of these communi- ties is a centre of medical education with one, or more than one, medical college. Examination of a map would show that in 1900 the Dispensaries in the United States outside of the Atlantic seaboard we^^ SCOPE AND EXTENT 39 chiefly located in cities where a medical school existed. Development in recent years has made this no longer true, for the realization by hospitals that an out- patient department is of value in following discharged cases and also in serving the community as a whole, has led many institutions, feven hospitals of small size and in small cities, to start out-patient departments. The number of medical schools has diminished nearly fifty per cent during the same period wherein general Dispensaries have increased more than one hundred per cent. __ A different set of forces has been at work in connec- tion with the public health Dispensaries. Their remarkable recent growth has had little connection with medical schools. These Dispensaries have also been started in large cities, but by state law in some cases and private initiative in many others, have been scattered throughout towns and small cities for the sake of the babies, the school children, or the tubercu- losis cases. The location of the industrial Dispensaries has of course been determined more by business con- siderations than by medical or charitable ones. The statistical reports of some Dispensaries are unpublished, of many are inaccessible; and it is im- possible to state accurately the number of patients annually treated by Dispensaries in the United States. Estimating from trustworthy reports of Dispensaries in New York, Boston, and other cities, it is probable that the Dispensaries of the country are recei\dng an- nually between twelve and fifteen million visits from between four and five million individual patients. 40 DISPENSARIES The size of particular institutions ranges over the widest Umits. At one extreme are enormous Dispen- saries Uke that of the Mt. Sinai Hospital in New York, receiving nearly a quarter of a million visits in a year; at the other are little Public Health Dispensaries receiving a thousand visits. The Committee on Dispensary Work of the American Hospital Associa- tion tabulated the Reports of 148 Dispensaries in 1914, classifying them as to size, and showing the following : — Receiving over 100,000 visits a year . 9 Receiving 60,000 to 100,000 a year 14 Receiving 30,000 to 60,000 visits a year 18 Receiving 10,000 to 30,000 visits a year 44 Receiving 2,500 to 10,000 visits a year 43 Receiving less than 2,500 a year 20 148 The Public Health Dispensaries would mostly fall into the last two classes. These studies of the nature, history, present types and locations of Dispensaries in the United States will serve as a useful preliminary to this volume. QUESTIONS AHEAD What are the fundamental principles of the organ- ization and management of a Dispensary, and of its relationship to the community? What groups or *' social classes'' of patients do Dispensaries serve? What classes should they serve? How shall the func- tions of the physician, the nurse, the social worker, and the administrative officer, be inter-related so as to make an efficient institution? SCOPE AND EXTENT 41 Some of these questions lead us from general principles into the practical technique of arrangement of rooms, medical and surgical equipment, records, follow-up systems, statistics, and finance. The small Dispensaries, as well as the large ones, must have at- tention and special needs of different types of Dispen- saries must be described. Last, but far from least, arise the broad public problems which dispensary work is now placing before the medical profession and the public. What part are Dispensaries to play in provid- ing medical service to the people in the future? What is to be their place in public health work, in social service, in industry? Conflicting tendencies appear in this field, between the fine tradition of the family physician and the growing dominance of the speciaUsts ; between the desire for individual relationship between patient and doctor and the increasing efficiency of institutional medicine; between uncertain support from private funds and support by taxation with political representation upon the managing board; between enlarging social service and rising objection to ^'charity." — Among such alternatives what future shall come forth? 42 DISPENSARIES CHAPTER IV WHO ARE DISPENSARY PATIENTS? Over four million men, women and children are receiving treatment annually at the Dispensaries of the United States. One might imagine that the Dispensaries could report fully the economic and social groups from which this vast number are drawn. But if one examines Annual Reports or articles about Dispen- saries, one finds that the chief subject of discussion has not been '^ Who are the people that we are treating; what are their needs, and how shall they be treated most efficiently?" but instead ''How shall we keep people from getting treatment?" ' 'Dispensary abuse," by persons able to pay private physicians, has been talked about in this country for over thirty years. The study of dispensary eflSciency and of the social and economic classes coming to Dispensaries comprises as yet only a fraction of the literature on the subject. The rapid growth of Dispensaries in some eastern cities, particularly in New York, during the latter part of the nineteenth century, naturally caused consider- able discussion among the medical profession, and many articles varying in their premises and in their argu- ments appeared. "A Propagator of Pauperism: the Dispensary" was the title of an article by Dr. George F. Shrady, published in 1897 in The Forum.^^ ^^t may be broadly stated," says the article, "as the DISPENSARY PATIENTS 43 result of exhaustive statistical study, that fully fifty per cent of the patients who apply for free medical aid are totally undeserving of such charity. ... In New York City alone there are 116 Dispensaries, each of which is vying with the others in propagating the worst form of pauperism." As an example of another view, we may quote from a paper^3 ^y j)^^ ^^ g^ Thayer in which he cites with general approval an '^ eminent physician," unnamed, as follows : "'My views on dispensary abuse have never been win- nowed and tried out by careful investigation of the subject, but so far I think the chief dispensary abuses are: (1) The abuse of patients by careless doctors and internes. (2) The abuse of opportunities by careless doctors and internes. That any great harm comes from treatment of the folk who can pay, I doubt. ... I think it more than made good, from the point of view of the public good, which is the only point of view that we can take, by the physical, psychical and educational good done by the Dispensary, even for rich patients. I do not believe you can surely weed out the rich, either, by any spotting process.'" It was but slowly that the discussion of ' ' dispensary abuse" led to constructive efforts. What was really needed were facts instead of opinions — facts of the actual social or financial conditions of dispensary patients. At the International Conference of Chari- ties, Correction, and Philanthropy, 1893, in the Sec- tion on ^'Hospitals, Dispensaries and Nursing," Mr. Charles C. Savage reviewed the history of Dispensa- ries, ^^ and stated that one-quarter of the population of 44 DISPENSARIES New York City were receiving dispensary aid (present statistics do not indicate such a proportion). Mr. Savage based this statement on an investigation which he declared had been conducted by the New York Charity Organization Society. From the ninth an- nual report of this organization (page 26) it appears that, in 1884, ''this society undertook to examine for the German Dis- pensary, the ability to pay for treatment of such of its ap- plicants as were referred to us, with the following result: forty-three per cent were found able to pay, twenty-seven per cent were found unable to pay, thirty-per cent gave false or mistaken addresses." ''Each year as it became more widely known that the Dispensary availed itself of our investigations, applications from those who could well afford to pay for advice and treat- ment diminished, until in 1889 the following very different results were reached : Those able to pay declined from forty- three to twenty-three per cent. Those giving false addresses or other evidence of deceit fell from thirty to twenty-five, and correspondingly, those entitled to the benefits of the Dispensary, after thus sifting out the imposters, increased from twenty-seven to fifty-two per cent." Inasmuch as the Charity Organization Society did not investigate all the applicants at the German Dispensary, but only such cases as were referred to it — which unquestionably were the doubtful cases — we can in no way estimate the real meaning of the figures which they reported. As will be seen, an investiga- tion of one thousand cases conducted in 1910-11 led to an entirely different conclusion. DISPENSARY PATIENTS 45 Dr. Shrady's attack, already quoted, was by no means the first of its kind,* and did not find the Dis- pensaries without defenders. 1^ The rapid growth of these institutions in the metropoUs, however, led to considerable agitation, with the result that the well- known law licensing Dispensaries throughout New York State and placing them under the general super- vision of the State Board of Charities was enacted in 1899. The regulations made under this legislation require certain items to be annually reported, records kept, and a registrar on duty at every Dispensary — these being highly valuable features of the law. Applicants whose '^personal appearance" does not indicate that they are ^ indigent'' may be required to sign a form, attesting their income, etc. The penalty for false representation is printed upon the admission card given to every patient. No violations of this appear to have been prosecuted during the fifteen years since the enactment of the law. In 1903 the Hospital Association of Philadelphia caused an investigation of dispensary patients to be made, but we have not been able to obtain a copy of the report. In 1905 a symposium on the subject was published in the Boston Medical and Surgical Journal.^^ Dr. George W. Gay sent out at this time a question- naire to more than four hundred physicians in Boston * Dr. Gurteen, one of the pioneers in the charity organization move- ment in the United States, in his well-known "Handbook of Charity Organization" (1882), described the dispensary system as a ''vast school of pauperism, demoraUzing the poor, educating them in im- provident habits, and teaching them, in one of the most vital depart- ments of life, to be thriftless and improvident" (page 99). 46 DISPENSARIES and vicinity. A large majority of the three hundred odd answers which were received stated that, in the opinion of the physicians, medical charity was abused in the hospitals and Dispensaries in Boston, and that it was practicable to correct it. Such a question- naire, of course, collected only opinions and furnished no facts regarding the extent or character of abuse, nor many concrete suggestions how corrections should be made. In 1907 the Chicago Medical Society appointed a ^'Committee on the Abuse of Medical Charities," which secured co-operation from the Associated Charities of Chicago, and presented a report.^ ^ This indicated that, out of fifty-five Dispensaries said to be treating approximately 500,000 patients a year, only three instituted any ''adequate investigation into the economic capability of their patients." The Com- mittee of the Medical Society, however, made no study of ''economic capability" on its own part. Dr. W. S. Thayer reported in the same year (1907) the results of an investigation by a committee of the Medical and Chirurgical Faculty of Maryland. This, like Dr. Gay's reports, was based on consultation with physicians. The Journal of the American Medical Association, commenting editorially on this report, said: "It would seem to be more to the point if an exact tabulation of Baltimore Dispensaries had been made." Such a tabulation on an extended scale was carried through in 1910 by the Medical Society of the County of New York, which employed Miss Anna Moore, Ph.D., DISPENSARY PATIENTS 47 an investigator trained in the work of the New York Charity Organization Society, to study a thou- sand cases selected at random from the books of thirteen Dispensaries in Manhattan.^^ Miss Moore visited the homes of these patients, but was unable to locate two hundred and twenty-five out of the thousand. The tables submitted by her indicate that of the seven hundred and forty-five patients whom she located and whose financial conditions she studied, six hundred and seventy-two, or ninety per cent, were ^^ worthy of free treatment. " The remaining seventy- three, or approximately ten per cent, seemed : — ''Able to pay for medical treatment under ordinary cir- cumstances. But the margin over and above fixed ex- penditures seems in most cases so slight that in illness demanding continued treatment or the services of a special- ist, to pay a physician would mean for them serious depriva- tion or the incurring of a debt from which afterwards it would be difficult to escape. In fact, in almost every one of these cases, there seemed a very reasonable doubt as to how the case should be regarded." Of the two hundred and fifty-five cases which could not be located at the addresses given. Miss Moore estimates that the addresses probably were given in- correctly with intent to deceive in thirty-two cases, or twelve and one-half per cent. In the remainder, the failure to find the patients was due to incorrect transcription at the Dispensary of name or address (estimated at thirty-four per cent) and to the moving of patients or families between the time their ad- 48 DISPENSARIES dress was recorded at the Dispensary and the time Miss Moore's visit was paid. At the Boston Dispensary studies were begun in November, 1911, and pursued thereafter, covering up to 1914 five groups of patients, 1,881 in all. The primary purpose was, of course, not to estimate the amount of ^ 'abuse,'' but to ascertain how facts as to social and financial conditions of patients could be obtained most accurately and economically, and whether standards could be formulated for judging the eligibility of patients for admission. The conclusions reached by the Boston Dispensary studies,^^ up to 1914, were that not over two per cent of the applicants at this institution could have paid for the medical care they needed at private rates. A further series of studies made during 1914 and 1915, may be summarized as follows: "A tally of 1,414 Boston Dispensary patients showed: — "One hundred and sixty-three, or llVio% had incomes, above the sum assumed by us to be necessary before any balance large enough for much medical service is found. "These 163 cases were then studied apart and the at- tempt made to estimate the cost of private treatment for their sickness. As a result: "Sixty-three (4J%) could have paid at the rate of our evening pay clinics, and were in many instances referred thereto : "Twenty-six (lVio%) could probably have been referred to private practice after diagnosis had been established, but could not have paid the cost of making the diagnosis ; "Sixteen (1J%) were judged able to pay at private rates DISPENSARY PATIENTS 49 for the treatment required. Such judgment must remain a matter of opinion until a more exact measure of the standard of hving in a given locaHty is found and apphed." Dr. Borden S. Veeder, of St. Louis, in a valuable paper^*^ came to about the same conclusion as that reached at the Boston Dispensary and the Presbyte- rian Hospital at Philadelphia,^! namely, that at the Washington University Dispensary with which Dr. Veeder is connected, not over two per cent of the patients could afford private medical care. Says Dr. Veeder: ''This is certainly a small percentage of imposition, and much less, I imagine, than the percentage of the average physician's patients who are 'bad pay.' The cost and time involved thoroughly to investigate every applicant in order to eliminate this two per cent is not worth the effort or expense. It would be comparable with a physician making a careful financial investigation of each patient in order to eliminate two per cent who were bad pay." Thus actual facts secured concerning dispensary clienteles show that so far as so-called ''abuse" is concerned, it is in percentages a negligible factor. The modern Dispensary, we must remember, offers a wide range of medical services, from care for minor general diseases to highly specialized work in opthal- mology, orthopedics, X-ray, etc. A large proportion of the patients at Dispensaries come for special treat- ment, which is particularly expensive at the usual private rates. The cost of the equivalent medical service, did they receive it privately, cannot therefore 50 DISPENSARIES be estimated merely on the basis of the cost per visit to a general practitioner. The studies of dispensary patients above referred to have usually begun with a crude attempt to say what patients are eligible for medical treatment, without defining what ''eligibility" is. The later studies, particularly those of Dr. Veeder and those of the Boston Dispensary, have endeavored to establish certain standards, and to consider the patient with reference to needs as well as to resources. Dr. Veeder for example reviews a series of studies on the cost of living, made by governmental and private bureaus at various times in this country. He then formulates certain standards applicable in his own community, specifying income limits, below which free dispensary treatment may be regarded as suitable. On the question of cost of treatment, however, he points out the wide variations and comes to the con- clusion that, owing to the complexity of the factors involved, each individual case must be settled on its own merits. In the studies made at the Boston Dispensary, these elements of cost of service have been more emphasized. Miss Janet Thornton, Registrar of the Boston Dis- pensary, writing in 1915, made the following sum- mary :22 — ''The factors that seem fundamental may be grouped un- der two headings; which together constitute a general standard by which each particular case can be measured. DISPENSARY PATIENTS 5| I. Income and Expenditure "a. What is the wage scale in the trades and industries of the community? ''b. At what point in the scale is there a theoretical margin above subsistence, or more explicitly, what does it cost in the community to get food and fuel, clothes, and shelter sufficient to maintain well-being and a modicum of leisure and enjoyment (for lacking these basal necessities the finest medical service is all but wasted) ? 2. Medical Need ''a. What average amount of medical care is required in a year to keep an individual or a family in health and working trim? "b. What does it cost in the community to obtain ade- quate treatment for common ailments? ^'Medical institutions have the knowledge to answer accurately the questions under the second heading. Within themselves they have no reliable means to answer fully those under the first, but must turn to scientists who in work-shop, laboratory and household are now studying wages, food and domestic conditions. It does not seem too much to hope that they can soon give us knowledge on which to base at least a minimum requirement for the necessities of life, — food, shelter, etc. Meanwhile it will be helpful to clarify our own minds as to what standards we are using. A good deal of study has been given to the subject at the Boston Dispensary, and a brief statement of our conclusions may be worth attention, in spite of the incompleteness of certain aspects. ''In the last four years not fewer than 75,000 applicants to the Dispensary have been asked most or all of the ques- 52 DISPENSARIES tions on the registration card. Even allowing for error and misstatement there must remain from so many replies a reliable picture in rough design of the social and financial state of these patients. The tables prepared help to define at least the financial phase of the admission problem and to warrant the following averages: — ''Fully three-quarters of all our patients belong to family groups, and more than three-fourths of these families have but one wage-earner. Thirty-seven per cent of families live on $600, or less, forty per cent on $700, or less, seventy per cent on $800, or less, seventy-seven per cent on $900, or less, eighty-three per cent on $1,000 or less per annum; three per cent are dependent on charitable relief; fourteen per cent have over $1,000, i.e., not more than 1,400 new families a year have more than $1,000, while 8,000-9,000 have less than $1,000.* Among those listed as unmarried, there are about 4,000 new patients a year; of whom 78.6 per cent are living on $600 or less a year, i.e., only between 700-800 unmarried applicants out of 4,000 earn over $12 a week. ''It is a general opinion among students of wage-earners' budgets that even small families in this vicinity living on $1,000 or less a year should not be expected to purchase more medical service than that necessary to childbirth and acute illness in the home. As the use of our free District Physicians shows, many families cannot meet even these emergencies. We have seldom, therefore, doubted eligibil- ity or refused treatment at this Dispensary, unless the family * "These estimates include all the earnings of working children. If the income of the chief wage-earner (in most cases the father) is taken, the number having over $1,000 is reduced 3.5 per cent, while ninety- two per cent have $1,000 or less. The wages of children as a rule amount to little more than enough to keep them in condition to fill their positions. Also, though the incomes are based on average wages, no careful attempt is made to estimate unemployment." DISPENSARY PATIENTS 53 income exceeded $1,000. Our rule for the unmarried wage- earner is to weigh carefully the reason for accepting when the income passes $600." Miss Thornton further points out that, owing to the widely varying cost of medical service, the fact that a family is above the income limit just noted merely raises the question of eligibility but does not answer it. Important evidence of the social groups from which dispensary patients are drawn has been furnished by two Commissions appointed by State Legislatures to study Health Insurance. The Social Insurance Com- mission of California, with Dr. I. M. Rubinow as their consulting actuary, investigated the Dispensaries of San Francisco and Los Angeles in 1916.23 Since the conclusions concerning the two cities were practically identical, only those from San Francisco need be quoted. In the following table these are compared with a study undertaken by one of the writers in 1917 at the request of the Social Insurance Commission of Massachusetts.^^ Social Group San Francisco Boston Boston Dispensary No. Per cent No. Per cent Incomes under $14 weekly . . Incomes $14 to $20 Incomes over $20 1,098 581 380 528 22^ 201 444 547 170 35 37.1 45.7 14 2 Unspecified or miscellaneous 3.0 Total 2,587 100 1,196 100 Dependent on Charity 190 7 35 3 54 DISPENSARIES The incomes given in this table are family incomes, including the estimated total of earnings of all gain- fully employed persons in the family. There is a very striking agreement between the two studies, independently made, at the two extremes of the con- tinent. Both indicate that the great bulk of dis- pensary patients are wage-earning families of in- comes sufficient to meet their ordinary expenses, but not to provide for adequate medical service. The incomes of these families are not below those usual among the wage-earning families in American com- munities. Since the general wage statistics of this country in- dicate that not more than one wage-earner in ten has an annual income of over $1,000, it is obvious that a large majority of the families cannot afford to pay for complete medical service. The growing recognition of the importance of adequate medical care as an element in industrial and national efficiency is thus forcing into the foreground the need of supplementing the ordinary resources of private medical practice by forms of organized medical service. Dispensaries are one an- swer to this demand. The practical question may now be raised: What have Dispensaries done and what are Dispensaries doing to deal with the varying elements in their clien- tele or the applicants for admission to their clientele? In reorganizing the Dispensary of Lakeside Hospital and Western Reserve University in 1911, one of the writers attempted to deal with the problem by classify- ing the patients into certain roughly separated but DISPENSARY PATIENTS 65 important divisions as follows: (a) Suitable for ad- mission for treatment in any department until ad- mission is revoked, (b) Suitable for admission in any department for the current sickness only, any other sickness requiring another interview with the admit- ting officer, (c) Suitable for admission for major or special surgery, or for any chronic condition for which the patient cannot be expected to pay the ordinary fees for the treatment needed, (d) Suitable for admission for special examination or consultation only (e.g., X-ray, Wassermann) no treatment being given.^^ In 1913 a questionnaire, sent out under the auspices of the American Hospital Association, included the following inquiries on the subject of dispensary abuse:" '' What is your system of investigation of each new patient to prevent abuse of medical charity? What is your stand- ard of exclusions, i.e., what classes of patients are in practice excluded? How many patients of the total number apply- ing for treatment were thus excluded last year?" ''Of seventy-six institutions, mostly very representative ones, which responded to this questionnaire, only thirty-six stated that any applicants had been excluded. Some of the remaining forty may have forgotten to answer the question, but we may probably infer that in most of the forty cases, not much inquiry is made of applicants, and that few are excluded. The thirty-six institutions which answered the inquiry positively, treated approximately 520,000 out-pa- tients in 1912. One of the thirty-six reported that it ex- cluded twenty per cent of the applicants,* one other reported *"The Superintendent of the institution which, in 1913, reported this high percentage, writes, a year later, as follows: 'The high per- centage of cases turned away (in the report of last year) was due to the 5 56 DISPENSARIES twelve per cent, excluded, another eight per cent. Five of the thirty-six institutions reported between two per cent, and five per cent of applicants excluded; eight sent away between two per cent, and one-half of one per cent, and twenty-one excluded less than one-half of one per cent. The actual practice in thus rejecting such a small proportion of cases has been partly due, no doubt, to lax admitting systems. But there is close similarity in percentages be- tween the Dispensaries just quoted and those institutions previously cited, which had given careful attention to ad- missions. '' The purpose of the particular Dispensary must also be considered. Dr. Veeder, in the article already referred to, has well stated the position of the teaching Dispensary : "The necessity of material for the instruction of medical students is so obvious that there can be no question as to fact that the Dispensary was reorganized and rebuilt, and attracted to it a large number of men employed in automobile works and their famihes. Hence the twenty per cent turned away during the period following reorganization. In the Annual Report, forwarded to you under separate cover, you will note that the social worker turned away one and one-third per cent of the cases. This simply covers the cases referred to her by the admitting officer, who could not decide the standing of these cases at the time of their application. In addition to this number, the admitting officer referred back to private physicians two per cent of first applicants. This Dispensary is thus now rejecting three and one-half per cent of the applicants.' "The reason for rejecting patients at many institutions is not, by any means, only because they are believed to be able to pay physicians. At least half of the cases at the institution reporting eight per cent excluded are turned away because they are at the time of their ap- plication under treatment at another institution. In cities with several Dispensaries this factor accounts for a considerable proportion of the number who are reported as not admitted. " DISPENSARY PATIENTS 57 the right or propriety of any legitimate medical school conducting a Dispensary, provided it has a fixed rule that any patient refusing to act as material for purposes of in- struction is refused admission. Should a teaching clinic lack material for purposes of instruction, it might with propriety lower its standards of admission, as it is not a purely philanthropic institution and the end in view justifies the purposes for which it is done.* It is hardly consistent for a physician who has enjoyed the benefits of a thorough medical education (the average cost of instruction for the four years being around $3,000 and the tuition charges from $600 to $800) to object to a clinic connected with a medical school on the ground that the clinic lessens the financial returns from private practice." The point of view of the public health must, how- ever, be paramount at all times to all other considera- tions. The public health Dispensary, as for example the tuberculosis clinic, must consider first of all medical need, represented by the actual or potential cases of tuberculosis. For the protection of the patient, the family and the community, treatment must be pro- vided. The relation of this treatment to the purposes of medical education, or to private medical practice, must be secondary considerations. The answer to the question which heads this chapter : '^Who are Dispensary Patients?" may now be sum- marized. Dispensary patients include many persons who are below the poverty line, but, in much larger proportion, * The New York State Board of Charities, in its regulations govern- ing the Dispensaries under its control (see page 45), recognizes this principle with respect to admission of patients to teaching clinics. 58 DISPENSARIES are members of families earning the incomes most frequent in American communities. These families are not dependent, and meet their ordinary expenses, but cannot provide margin to cover the expenses of illness or the cost of medical care. Many of these persons do not secure from Dispensaries all of their medical service, but employ physicians from time to time. They usually find it impossible, however, to pay enough to secure complete service and are wholly unable, in most cases, to pay for consultation or for treatment by specialists. The experience of the best administered Dispensaries in the United States shows that only a minute fraction of the applicants at Dis- pensaries comes with the intention to abuse the privi- leges of the institution. The great majority come in good faith, seeking what they believe they need and cannot otherwise secure. The facts indicate that their request for treatment is generally justified and also raise the question whether thousands of persons who are in the same circumstances, but to whom Dispensaries are not at present accessible, have not equal need of their services. DISPENSARY PATIENTS 69 CHAPTER V WHO SHOULD BE DISPENSARY PATIENTS? Is a Dispensary for sick people; or is it only for sick poor? Who are ^'the poor'7 This is a short question needing a long answer. To make a satisfactory response, we must give careful consideration to the fundamental need for medical institutions of the various types. The response to the inquiry which heads this chapter really hinges upon our conception of the Dispensary itself. In earlier chapters we saw that, historically and practically, four different aims can be traced in Dispensaries: — (a) The original Dispensaries were founded because of a charitable desire to help the sick poor by medicines and medical advice. (b) The rise of organized clinical teaching as a part of medical education has caused Dispensaries to be developed as parts of medical schools or under their control. (c) The public health movement has in recent years resulted in the estabhshment of hundreds of Dispensaries for the treatment and especially the prevention of certain diseases. (d) Finally, we have the Dispensaries organized for the co-operative practice of medicine on a scientific but business basis — of which the Mayo Clinic is a type. Each of these aims dominating a Dispensary in- 60 DISPENSARIES volves a somewhat different relationship between it and the medical profession. (1) The typical Dispensary maintained as a charity has depended upon volunteer medical service, although the payment of small salaries has become not uncommon in New York City, and in a few cases elsewhere. (2) The Dispensary attached to a medical school has also been accustomed to secure medical service free, al- though in an increasing proportion of cases, medical schools of standing pay salaries — in some instances, full-time sal- aries — to the clinical as well as the research and the labora- tory staffs; and the men receiving these salaries give, in many instances, a portion of their time to the Dispen- sary. Whether substantial salaries are paid or not to the staff of a Dispensary in a medical school of high standing, it is safe to say that these physicians receive directly or indirectly a financial compensation for their dispensary service. (3) In the Public Health Dispensaries, the medical staff has sometimes been volunteer, but often salaried. (4) In the Mayo Clinic, the type of a Dispensary estab- lished to provide efficient, organized, medical service on a business basis, the physicians receive compensation which must be sufficient to attract and to hold them, in compe- tition with that which they could earn in private practice. Because of the somewhat different aims of these four types of Dispensaries and their different relation- ship to the medical profession, each type may properly maintain a different policy in the reception of patients. (a) The Dispensary carried on as a charity must in general play fair with the community and with the medical DISPENSARY PATIENTS 61 profession. It should treat only those who are unable to pay the cost of the medical service which they need, at the private rates usually charged. This principle was com- paratively simple in apphcation in times when medical practice itself was simple. Medical practice now involves many varied specialties, and increasingly expensive appara- tus and methods of diagnosis and treatment. Hence it becomes more and more difficult to apply this principle accurately. The next pages will be chiefly devoted to this practical problem. (b) The Dispensary which is primarily a teaching institu- tion ordinarily confines its clientele to the same type of patient as the charitable Dispensary. But for the sake of the medical education for which it is maintained, a teaching Dispensary may properly accept any patient whose disease would render him of especial service in teaching students, or in advancing medical knowledge. (c) Dispensaries established for public health purposes, as to combat tuberculosis, must be governed primarily by considerations of public health, which often have nothing to do with the finances of the patients, or of the medical profession either. Where the immediate protection of the community against contagious disease is involved, the patient must be accepted and placed immediately under care, and unless there is complete assurance that this can be done through some other means, as through a private physician, the public health Dispensary must not refuse the case. The same consideration operates in the charitable dispensary, e.g., a man with syphilis in a highly infectious stage, presents himself at the admission desk. He is unmarried, — he earns $25 a week, — he has savings, — he could pay for some treatment in a doctor's private office; but if he is sent away with a reference to one or more skilled 62 DISPENSARIES \ physicians, will he go? He may, but we cannot be sure, and dare the Dispensary send him off without first starting his treatment with a dose of salvarsan, which may largely prevent him from disseminating further infection? (d) A Dispensary, which, like the Mayo Clinic, represents the organized, co-operative effort of a group of physicians, on a business basis, is merely subject to the same conditions as affect physicians in private. The ethics of their institu- tion are the ethics of their profession. If they accept the rich, they may charge what are considered fair professional fees; if they accept the poor, they may do as a private physician in his private office, and take the patient for whatever the patient can pay. There is a hoary misconception concerning the meaning of ''charity." Formerly it was generally conceived as a dole to the destitute. Unless the recipients were unable to make any return except in gratitude, the gift was hardly charity at all. But the modern conception of charity is not a dole, but a service; — a service rendered by an individual, an organization or a community, to persons or groups who could not otherwise obtain the benefit provided. Ability to obtain a benefit depends partly on the income or opportunities of the recipient and partly on the cost of the thing to be obtained. Now the cost of medical service supplied by Dispensaries has changed greatly since the early Dispensaries began their work, and especially during the last fifteen years. The old Dispensaries provided merely the advice of a single physician and medicine. They corre- sponded to the general practitioner before the days DISPENSARY PATIENTS 63 of modern scientific methods of diagnosis. The modern Dispensary provides varied and expensive services and what it offers its patients is to be com- pared not only with the service of the general practi- tioner, but with that of the specialist, the laboratory, or the X-ray man. A very little consideration of the cost of treatment of different diseases shows within what wide limits this ranges. A minor illness might require a couple of office visits to a general practitioner and a little medicine. All this might cost a patient S2.50 or $3.50.* A case of ^indigestion" requiring several examinations, X-ray and care for a considerable period might cost, at a low estimate, $75 for the first six months. A case of syphilis requiring salvarsani injections would cost over $100 for the same period. Examinations of the nose and throat by a specialist and operation for a deviated septum with the neces- sary after-care, would cost $50, or over. Examination of the eyes by an oculist, with provision of glasses not unusually expensive, would cost $10. The super- vision of a little baby subject to digestive upsets might cost $40 to $60 within six months. The diagnosis and supervision of a case of adult tuberculosis at home would cost $25 to $30 during the same period, not including the expense of special food. Complex conditions requiring examinations by a number of different specialists, X-rays and various laboratory * It will be obvious that these statements of medical cost are merely illustrative. They are based on what physicians or specialists would probably charge patients known to be of very moderate means. 64 DISPENSARIES tests might cost $100 or $200 before the diagnosis was reached. Thus the test for the charitable dispensary is not the ability of the patient to pay "a medical fee," but to pay the medical fee required for his particular case at the usual rate charged by competent doctors in his community. In other words, cost of service needed, in relation to the financial ability of the patient, is the real test. The broadening of the range of dispensary service medically has thus greatly broadened its scope with respect to the economic classes in the community. The widely varying kinds of medical and surgical work which now can and should be done, and their widely varying cost, explain why even the charitable Dispensary cannot confine its work to any particular economic and social group at the lower level of the community. The higher paid wage-earners and the small-salaried groups need its services, particularly in the specialties and in difficult cases requiring elab- orate consultation and special tests. The more developed the medical organization of a Dispensary is, and the higher the reputation of its Medical Staff along their various lines, the more surely and the more justly will this institution draw patients from varied classes in the community. Many of the patients may be able to afford ordinary medical fees but need, and feel they ought to have, special service which they could in no way afford to pay for at private rates. This consideration applies par- ticularly to the teaching dispensary attached to a DISPENSARY PATIENTS 65 medical school of high standing. Such a dispensary may well fill more than a local position as a center for diagnosis and consultation as well as for treatment. Fees from Dispensary Patients? The antiquated notion of charity to which we have often referred is responsible for another misconception, namely, that the services of an institution like the Dispensary must be rendered without price. There still exist those who wish to give their charity straight; those who see no distinction between the medical service provided by a hospital or dispensary and the pair of shoes or ^^ grocery order" furnished by a relief society. The gradual passing of this point of view is evidenced by the fact that a majority even of the charitable Dispensaries of this country now charge small fees for admission, treatment or medicine, or for one or all of these. There has been, however, little discussion of the economic and moral founda- tions of the fee system in Dispensaries. It is obvious that whether a Dispensary is founded as a charity, for teaching, or for public health service, it must not charge a fee based merely upon the cost of the service rendered; for in many instances this fee would be too high to help many of those who need it, and the institution would thus defeat its purpose of service. On the other hand, practical experience of Dispensaries, as well as an unprejudiced considera- tion of human nature, bears out the belief that those j who pay something, even ten cents, for what they; receive, take advice or treatment more seriously and \ 66 DISPENSARIES I feel rather better about accepting the service than if ^ they paid nothing. Most people are built this way. Some are different. The dispensary fee system, how- 1 ever, is justly based upon the psychology of the majority. I There is another point of view, namely; that serv- ices like the Dispensary, providing health for the =/ people, ought to be supported by general taxation and be free for all citizens. Whether or not this point of view is sound, most will agree that until medical service is a state function (if that day comes), a Dis- pensary, as a form of medical service, ought to con- form in the general principles of its operation, with the general system for providing medical service in the community. From this standpoint there is no reason why Dispensaries may not on the one hand be private enterprises like the Mayo Clinic; or, on the other hand, be charitable institutions. They cor- respond in the one case to a private school, in the other case to an endowed college. In either instance there is no reason why they may not charge fees. ' What shall be the relation between the patients of a physician in a Dispensary and in private practice? Should patients who can pay the usual private fees for the needed medical service be treated in a Dis- pensary free, or for nominal fees? If such persons apply at a Dispensary for treatment, shall they be referred to private physicians, and in particular to the Staff of the Dispensary itself? What shall a physician do when a patient in the clinic seems to be in sufficiently good circumstances to pay private DISPENSARY PATIENTS 67 office rates? For the protection alike of patient, physician and Dispensary, it is necessary to establish a policy and devise a procedure by which the selection of patients able to pay private fees shall be made by the Dispensary, and the patients themselves be referred in a manner which will be likely to insure them good medical treatment, be just to the medical profession and beneficial to the community. The policy which should govern the situation may be set forth in a few simple rules : — 1. A charitable Dispensary aims to provide the best medical treatment for those who cannot otherwise secure it. It aims not to accept patients who can afford to pay the usual private rates for the medical care which they require. 2. The admitting officer of the Dispensary, under its Superintendent and Trustees, should be responsible for determining the circumstances of the patient and, after consideration of the patient's income, family responsibilities, and the probable cost of the medical treatment required, for deciding whether the patient should be treated in a free clinic, a pay clinic, or in the private office of a physician. 3. The reference of the patient to the proper agent for treatment should be made by the admitting officer, or other administrative official of the Dispensary, not by a member of the Medical Staff. 4. Due records should be made of each case thus referred for treatment outside of the Dispensary. 5. No physician should solicit private practice from patients.* In carrying out such a policy effectively, the chief requisite is a well-organized admission system, under ♦Compare By-laws, pages 415-426. 68 DISPENSARIES a competent head. Most of the difficulties which arise are due to a lack of this. The medical staff must be fully informed of the policy. They should under- stand that, should a patient appear in a clinic whom a physician thinks has not been properly judged by the admission desk, the patient is to be sent back to the admission desk for reconsideration and further refer- ence. The question then arises, to whom shall the admission desk refer a case needing private treat- ment? In general it seems just that such a patient be given the names of one or more members of the staff of the clinic to which his disease would naturally assign him. Cases also arise in which the patient asks at the admission desk for the name of a competent doctor, or himself solicits a physician, in the clinic, for private treatment. When a patient does this the physician should report the fact to the admission desk, or to the representative of the admitting officer in the clinic (the social worker, nurse, or clerk). The admitting office or its representative will then refer the patient to the physician, but due record will be made of the fact upon the patient's record card and elsewhere. Solicitation of private practice by physi- cians in clinics should be regarded by the adminis- trative authorities of the Dispensary and by its Med- ical Staff, as unprofessional conduct. What shall dispensary fees be, how much and how determined? They should clearly follow the traditional ethical rules of the medical profession, ''not refusing service to anyone really needing it, whether the fee levied can be paid or not." But how shall DISPENSARY PATIENTS 69 the general level of the fees be determined, understand- ing that partial or complete remission of fee will always be made in suitable cases? In private medical practice the fee received by the physician is partly a compensation for his medical service and partly payment for the expenses he must meet in maintaining his office, his assistants, his equipment, automobile, etc. In the medical institu- tions the appliances, instruments, laboratory, nursing, etc., are provided for the doctor. When a Dispen- sary not organized for profit does not pay its physi- cians, it may charge fees not averaging more than the cost of the services rendered, excluding any charge for the medical service as such. Were this principle strictly carried out, the physician giving his time in the Dispensary would receive no money, and the fee paid by the patient would no more than meet the strictly administrative expenses. These, on the aver- age, would be less than those required to maintain an equivalent medical service in a single private ofiice. If fees at a Dispensary are on the average higher than the administrative costs, then the clinic becomes a pay clinic and the amount of the fees received above the administrative costs should go to the medical profession, either directly in salaries to the Staff, or in some fashion approved by them, for the advance- ment of medical science or medical education. In practice the usual rates of fees in the charitable Dis- pensaries of this country at the present time cover from one-fifth to one-half the administrative cost.* * Fee schedules for practical use in Dispensaries are on pages 275 et seq. 70 DISPENSARIES Summary The principles outlined in this chapter may be summarized as follows: 1. With the widely varying cost of different medical services at the present time, and the complex char- acter of our population and its needs, the clientele of the Dispensary should not be confined to the '^poor/' or to any single social group. 2. Who then should be dispensary patients? Those who need dispensary service and cannot secure equiva- lent medical service otherwise. 3. Remuneration of dispensary staffs must accom- pany extension of dispensary service above the low income levels of the population. 4. The regulations for admitting patients, the fees for treatment and the compensation for those who do the work, must be thoughtfully adapted to each of the particular groups in the community who need what the Dispensary has to offer. An efficient ad- ministration of the Dispensary according to these policies will confer benefit upon both the public and the medical profession. ESSENTIALS OF A CLINIC 71 CHAPTER VI THE TEN ESSENTIALS OF A CLINIC The purpose of an institution is the determining fact over its organization. After all, organization is only a means to an end. To organize, means merely to arrange certain elements in such ways and in such relation, that they shall operate together efficiently to accomplish certain results. If we see very clearly the ultimate purpose, good organization is likely to follow. The purpose of a Dispensary may be defined as: Service to the community through service to sick people. We must not be content to define this purpose as simply the medical care of patients. That is too narrow a definition, for very often the illness of the man, woman or child who comes to the dispensary door, cannot be dealt with merely as a disease of an individual body. The words that Virchow inscribed over the portal of his great hospital deserve to be placed over the door of every Dispensary, for they describe accurately the thought which this definition aims to convey: '^ Treat Not Only the Disease; Treat Also the Man.'' The man is a citizen as well as a patient. The Dispensary must consider its obligations to the com- 72 DISPENSARIES munity as well as to the individual; and it must labor for prevention as well as for cure of disease. As the clinical symptoms indicate the disease, so the disease may indicate the man — his habits, his living, his work; in cases of contagion his associates or in heredi- tary conditions his antecedents; these in turn may indicate unnecessary faults in industrial or living conditions; they may call for community action, as upon water or milk supply; they may require public regulation of conditions in factories or in tenement- houses. We need consideration of the man as well as of the disease, because only through knowledge of the larger problem can come adequate treatment and permanent results. We plead also for such a con- sideration of the individual patients that we may learn, from them, the symptoms of the diseases of society. It is just as important that a correct diagnosis be made of sociological defect among the unfortunates com- pelled to suffer because of this defect, as it is that a correct diagnosis of the individual patient's disease be made from the medical symptoms presented. There is every reason then to encourage the most thoughtful consideration of the whole problem pre- sented by the patient, in its medical, public-health and sociological aspects. If we conceive the patient in this broad way, we may rightly say that he is the central feature on which all dispensary organization hinges. ''About matters of organization," said Mr. Robert G. Valentine in a notable article," ''we still have much to learn. The truly wise among us are not dogmatic, ESSENTIALS OF A CLINIC 73 but questioners on a pioneer journey. But it seems to be a fairly sound hypothesis that in building up an organization we should build from the bottom up, or to take a military simile, from the firing line back, or to take a factory simile, from the workers back. Take for example the soldier in the trench. The whole military organization of that soldier's country, including its industrial and social aspects, can be tested out by asking, both in the field and at home, whether eveything that is planned and done helps the man in that trench. Everything that does not help him or that hinders him, is worse than unneces- sary." The primary factors in a Dispensary are, therefore, the patient and the doctor, and the final purpose of the whole organization is to render the service of the doctor to the patient most effective, when these two are face to face. If Virchow's broad conception of the patient as a man and a citizen is to be followed as it should be, then, within each clinic, as within the Dispensary as a whole, the elements to be dealt with are not wholly medical, but are also social and administrative. The agents who carry on the actual work are Hkewise not only physicians and nurses, but also social workers, engineers, clerks, cleaners, executives and advisors. This is graphically illustrated in the accompanying diagram. 74 DISPENSARIES DISPENSARY ORGANIZATION Units of Organization, present in every Dis- pensary (depending on the specialties included) Clinics Elements of Organiza- tion, present in each unit Agents of Hon, in ment Organiza- each ele- Medical Doctor Surgical Pediatrics and a dozen or so other Specialties 1. Medical — doing the essential professional work 2. Social — hitching this work up with community forces 3. Administrative — making favorable conditions for the performance of the work f maintaining plant • \ and equipment and ' correlating the various units, ele- V ments and agents ) into an eflicient, harmonious organ- ization In this chapter is outUned the proper internal con- stitution, so to speak, of the unit of dispensary organ- ization, the Clinic. The details of certain of the essential factors are presented later in separate chap- ters. In the succeeding chapter there naturally follows an account of the general organization which should co-ordinate all the clinical units into a working whole. Clinical Laboratory Nurse Attendant Pharmacist X-ray Technician , Masseur, etc. ' Social Workers of the Social Service De- partment Correlated Social Welfare Agencies of the Community ' Board of Trustees, Executive and Med- ical Committees, Executive OflBcer, Assistant Executives, Engineers, Janitors, Cleaners, Clerks, , Orderlies, etc. ESSENTIALS OF A CLINIC 75 The essential requirements of an efficient out- patient clinic are ten: — (1) Medical Staff: Adequate in number for each clinic and effective as to internal organization. (2) Co-operative Organization: A general system of organization for the Dispensary as a whole, which relates the different clinics so as to promote good co-operative work. These two requirements are treated in more detail in Chapter VII. Since the different specialties vary in some degree in what they require of their Staff, as for example, in the number of physicians needed to care properly for a given number of patients, certain details are left to the sections in Chapter X, devoted to each special clinical department. Chapter XII deals with the admission system, a very important element in an efficient co-operative organization. (3) Space and Equipment: Proper space and arrange- ment of the rooms of the clinics, and adequate tech- nical equipment for diagnosis and treatment. Chapter IX treats of the construction and arrangement of dispensary buildings in general; equipment is treated in Chapters X and XL (4) Records: Adequate written records of work done in the clinics. Record forms and methods of filing and utilization are treated in Chapter XIII. (5) A Follow-Up System: A system for the super- vision of the attendance of patients. Without a system of supervising and controlling the attendance of patients, the physicians of a clinic work in the 76 DISPENSARIES \ dark. With it, treatment of patients in a clinic affords opportunities which equal or surpass those in private prac- tice for continuous and effective supervision of cases. This will be dealt with in Chapter XIV. (6) Nursing: Assistance to the physicians in the personal care of patients in the clinics. The general organization of the nursing service will be referred to in Chapter VII. Since the exact requirements for nursing vary widely in different clinics, these will be touched upon in Chapters X and XI under the heading of each department. (7) Social Service: Assistance to the physicians in the education of the patient, and in the control of his environment. To this Chapter VIII is devoted. Some reference is also made to the general organization of Social Service in Chap- ter VII. (8) Executive Assistance: Assistance to the physi- cians in the prompt, orderly and kindly management of the clinics. How this may be provided is discussed in the next Chap- ter and in Chapters X and XI. (9) Clerical Aid: Assistance to the Physicians, Social Workers and Executive Officers with records and other clerical work. (10) Efficiency Tests: Periodical, critical examina- tion of records; estimation and tabulation of medical and social results. ESSENTIALS OF A CLINIC 77 Examples of efficiency tests and methods of pursuing them in chnics are described in Chapter XV. Consider a small medical clinic receiving ten or twelve patients a day. A single physician with one woman assistant, whom we will assume to be a nurse with training in social service, might perform all the work. The physician would spend an average of twenty minutes with each new patient, and five to ten minutes with each old patient, and the clinic would be finished in two hours. The physician and his aide would divide between them all of the different functions indicated in the above list. There are five of these functions which have to be performed by persons: (1) medical, (2) nursing, (3) social, (4) execu- tive, and (5) clerical. In this little clinic, the physi- cian would perform the medical functions and most of the executive functions. The nurse, however, would interview each new patient, take a social his- tory, record temperature and weight, and prepare the women patients for examination. The doctor would do some of the clerical work. His aide would do the nursing and the social work, and a share of the clerical tasks. If the physician's assistant were a nurse with- out social training, he might then secure his social service by calling in, from the Social Service Depart- ment of the institution, a worker to see patients whom he thought presented a social problem. In this case the physician would be performing one of the primary parts of the social worker's function, namely: deciding on a preliminary social diagnosis. 78 DISPENSARIES Thus the five functions which have to be performed by persons, may be split up among several individuals or united in a few. The extent to which specialization among different persons is carried depends on the size of the clinic, and the extent to which trained persons are available to perform the several special- ized duties. This may be seen more readily by contrast between the clinic having ten or twelve patients a day, as described above, and a large medical clinic receiving, say sixty a day. Men and women in these numbers will have to be separated into different rooms, whereas in the very small clinic they may be seen successively, as in a doctor's private office, in the same room. We will assume that the medical staff of this large clinic includes seven physicians; one chief, who is in general charge, and three assistants of whom half work with the men and half with the women patients. A nurse, or a trained attendant, assists with the women pa- tients in preparing them for examination, and attend- ance during examinations when necessary. A social worker is on the women's side and another on the men's side, available for consultation with the patient, and with patient and physician as required. The executive management of this clinic, with so many patients and doctors, may fall, in part, to the chief of the department and certain executive duties must fall to him, since they involve the direction of the assistant physicians. The management of the patients, — however, seeing that they come promptly to the particular physician whom they are to see, at ESSENTIALS OF A CLINIC 79 the time when he is ready to see them; seeing that their records are ready and in order, and all the other details, — should properly fall to a clinic secretary or manager, whose duties are to keep the machinery going and who is in the position of an executive assist- ant to the physician in charge. Such a clinic would be in session from two to three hours. The physician-in-chief would himself see patients upon whom his assistants may desire his opinion, he would see all patients referred for diag- nosis from other departments of the Dispensary, and would in addition, settle a variety of medical or administrative questions which would be referred to him by his medical or lay assistants. The clerical work of the clinic would be performed by a clerk, attached to the clinic, who might spend all her time therein. Assistance from a clerk or stenographer in a central office would be required for writing special records, etc. If the clinic is a teaching clinic, medical students may, in so far as they write down the patient's history or other information under the supervision of their instructor, perform a part of the clerical tasks. Thus, in a clinic of this size the several functions will each be delegated to a particular person or persons. Until recently, out-patient clinics were Hke Topsy, they ''just growed.'' They ran themselves, the doctor thinking particularly about the ''interesting cases" and little about the other cases; the clinic being '^run off " in whatever way the doctors, without trained help, could manage to "run'' it. Now the out-patient clinic is conceived as a place wherein 80 DISPENSARIES serious and efficient medical work can be and is to be done for everyone admitted to it. It is, therefore, essential to have definite organization, and thoughtful planning. Every one of the five functions, medical, nursing, social, executive and clerical, must be thought of and provided for, or efficiency cannot be attained. The details of the distribution of the functions will depend on the size of the clinic, the character of the medical, surgical or special work, the kind of trained persons available and on other considerations. These have been illustrated by describing two typical clinics, widely divergent in size. Equally true is the need of detailed thoughtful consideration of the five other conditions of efficiency: co-operative organization, space and equipment, rec- ords, follow-up system and efficiency tests. Careful analysis of what each clinic of a given institution needs, in each of these respects, is the responsibility not only of its medical staff, but no less of the execu- tive officer and the trustees or advisors of the institu- tion. To each of these points a special chapter is devoted. ORGANIZATION 81 CHAPTER VII THE MEDICAL AND ADMINISTRATIVE ORGANIZA- TION OF A DISPENSARY Whether a Dispensary is large enough to include five hundred persons on its medical, social and admin- istrative staffs, or whether its personnel consists of a doctor, a nurse and a janitor, the elements that need to be organized and the principles of that organization are the same. Of course, the application of the prin- ciples will vary in the extreme. I. General Principles The ultimate authority in the institution is ordi- narily the Board of Trustees. The superintendent is the Board's representative. Where the Dispensary is unconnected with a hospital, the one primary de- mand is that the Board of Trustees shall be interested and the superintendent be competent and be given adequate authority. Where the Dispensary is the out-patient department of a hospital, the same holds true, but the superintendent of a large hospital has not much time to give personally to the out-patient department, and it is then essential that there be a responsible paid representative in the out-patient department, if the organization is to be well worked out. 82 DISPENSARIES But going farther back, the effectiveness of the Dispensary depends not merely upon the medical men, nor upon the purely executive duties of the super- intendent and his subordinates, but upon the way the organization is planned as a whole. In order that the work of a Dispensary be efficient, there must be a competent executive head who has authority. In order that the form of the organization and its policies be well thought out, there must be a policy-forming body which has a definite interest in the Dispensary or the out-patient department. This policy-forming body may be composed of the Trustees and the Super- intendent; or the Trustees, the Superintendent and the members of the Medical Staff; or it may be, as in some institutions it is, composed of a Committee of the Medical Staff acting with the Superintendent, the reserve powers of the Trustees being rarely exercised except in matters of major importance, or except on a recommendation from the active committee. Too often out-patient departments of hospitals have been run second-hand, or at long range, by superintendents who had little time to go into ''the out-patient," or by a Committee of Trustees or medical men, whose interests were almost exclusively in the hospital wards. The two essential requirements of efficient management of either an out-patient institution separate from a hospital, or an out-patient depart- ment of a hospital, are, therefore: 1. The shaping of the Dispensary's policy by an official or a committee who are held responsible for the Dispensary and who have real reason to be interested in it. ORGANIZATION 83 2. The execution of the poHcy and of the details of the Dispensary's work l)y a responsible head with adequate authority. How these principles should be actually worked out, can best be taken up after some preliminary details of dispensary organization have been con- sidered.* 2. Organization of the Medical Units A clinical department has two aspects. It is a medical unit, gathering together the diseases relating to a definite specialty. It is also an administrative unit, and from this standpoint a Dispensary with a given number of patients will be conducted at the maximum of administrative efficiency if it has not more than a certain number of Departments. Exam- ples could be cited of Dispensaries receiving an aver- age of only fifty patients a day, which have as many as sixteen different clinical departments, of which as many as seven to ten may be open at the same time. On the other hand, there are Dispensaries of ten times the size that have not more than nine depart- ments. A Dispensary with only fifty visits a day is, from the administrative standpoint, running its work uneconomically, if it has sixteen departments. Each administrative unit complicates the distribution of patients, and increases, in a definite degree, the labor and expense of all administration. From a medical *In the Appendix (pp. 415-26) are some suggestions for the By-laws of a Dispensary and of an out-patient department, incorporating the principles of this chapter. 84 DISPENSARIES standpoint, it is not desirable to have very few patients in a single department. The reason that many Dis- pensaries, receiving from forty to one hundred patients, have an unduly large number of departments, is because it is often easier to secure the medical serv- ice (this being volunteer) when the title of Chief of a department can be given, than if the same man is invited to come into a larger department as an assistant. The general considerations which should determine the number of different departments are, first, the number of specialties which are actually well recog- nized in the medical practice of the community. To be ''well recognized'^ in a community means that there are local physicians who devote all or almost all of their time to the pursuit of the specialty. Obvi- ously the number of recognized specialties will depend largely on the size of the community, although the existence of a medical school and of a teaching hospital, with a more or less salaried staff, may cause the pres- ence of specialists who would not be supported merely by the private practice of the town. In any Dispensary aiming to deal with general diseases the following three departments are funda- mental : Medical Surgical Pediatric. In some small communities, there may be no physi- cians who confine their private practice to children, ORGANIZATION 85 but there will almost always be some who give special attention to them. The following three should come next: Nose, Throat and Ear Eye Dental. Even in communities of moderate size, these will be recognized as specialties, diseases of the eye being not infrequently cared for by the same men who treat nose, throat and ear. A Dispensary not connected with a teaching insti- stution may wisely draw the line at this point unless there can be found in its community men who are specializing in, and are recognized as competent in, branches such as the following: Neurology Genito-Urinary Gynecology Orthopedics Dermatology Tuberculosis. The alternative to creating a separate department, in many instances, is the assigning of a physician to a special Hne of work within a general department. Thus a man particularly interested in nerve diseases may, as an assistant physician in the general medical department, be assigned all or most of the nerve cases. On the surgical side, given men who have an inclination toward gynecology, genito-urinary or orthopedic work, similar specialization may be devel- 86 DISPENSARIES oped. In this way men may be trained in special lines of work and later, if desirable, a separate de- partment can be created for them. The Dispensary of small size, located in or near a large city, especially should bear this in mind, as in such institutions the pressure is greatest to swell the number of departments beyond the point which can be efficiently maintained by the income of the insti- tution. In the specialization of work within the department there are further possibilities. In this way it is possible for thinking and ambitious men, although in private practice, to assemble sufficient material for the systematic and careful observation necessary for advanced study and research work. Such oppor- tunities will not only make dispensary positions eagerly sought by the highest type of men, but encourage, in fact compel, the most careful considera- tion and treatment of each case, thereby increasing the value of dispensary work to the patient and to the community. In the larger Dispensaries there is also the possibility that if this specialization be developed and through it active, progressive men be attracted to the staff and retained a long time, the work of these men will prove to be a great post-graduate, as well as undergraduate teaching force for the medical profession. A conflict arises between the medical and adminis- trative interests in another way, namely the extent to which the departments shall be operated simul- taneously. For the purposes of co-operative diag- ORGANIZATION 87 nosis and treatment, the Dispensary is most efficient when all departments are at work at the same time, for then consultation is possible by word of mouth as well as by the interchange of records. But this makes demands on the building, and faces the institution, as a rule, with the apparent uneconomy of having a large number of rooms, all used from two to four hours daily and all idle the other four. Some institu- tions, like the Mt. Sinai Hospital in New York, run morning and afternoon clinics, each a complete set, with medical staffs largely or wholly different; but in the main, so long as Dispensaries depend on medical staffs whose members receive little or no salaries for their work, the clinics will be limited to two to four hours of activity a day, and it will often be difficult to secure enough space for their simultaneous operation. But every effort should be made to do so. The list of departments thus far considered does not include those which, like the Laboratory and X-ray, are secondary to clinics : secondary in the sense that patients are not sent to them for diagnosis directly from the admission desk. These departments receive patients (or laboratory specimens taken from patients), when sent by physicians in the primary departments. The vital diagnostic importance of the Laboratory and the X-ray need not be emphasized here; their organization and equipment will be taken up later. A word must also be said of other departments which are not diagnostic in character. Such are Depart- ments for Hydro-therapy, Electro-therapy, Zander, Corrective Gymnastics, and Massage. These Treat- 88 DISPENSARIES ment Departments raise no fundamental problems of medical organization. Given a number of clinical departments, consider their medical staff and internal organization. The first general principle which should apply, to Dispen- saries as to hospitals and all similar institutions, is that the medical staff should be appointed by the governing body of the institution — usually the Board of Trustees. The chief of each department should nominate all assistants, but the acceptance or rejec- tion of all nominations, as well as the power to initiate nominations when necessary, should rest with the Board. Where the Board is composed of laymen, as is frequently the case, a Medical Committee, of the staff itself, or of some consultant body, should be constituted to advise the Board as to the medical standing of candidates or nominees. Experience has shown that the members of a medical staff, even when the number is small, may wisely be divided, according to rank, into definite grades. In large Dispensaries three will be found practically necessary, and four or five will be useful. Highest is the rank of those in charge of clinics, i.e., heads of departments. Under divided services, there may of course be two or more ''heads" to one depart- ment. The title usually attached to this rank is *' Visiting Physician," ''Physician-in-Chief," ''Physi- cian-in-Charge," or simply ''Physician," with corre- sponding denominations on the surgical side. Where the Dispensary is an out-patient department of a hospital, those in active charge of out-patient clinics ORGANIZATION 89 sometimes hold merely the rank of assistants or junior assistants in the hospital, but the better practice is to give the title of '^Physician" or ^^ Visiting Physician" with the suffix, ^Ho Out-Patients," or 'Ho the Dis- pensary." The second rank are '^ Assistant Physicians," or '^ Senior Assistants," those next in authority to the chief of a department, men who will take charge in the chief's absence. These are responsible positions and should be regarded as permanent during satis- factory service. Below this grade are men who receive annual appointments, renewable, but not renewed except when desired by the Chief of the Department. To them the title of '^ Junior Assistant" or '^ Assistant to the Physician" is often given. Men can be given valuable opportunities for training and experience, by appointment to this grade, without committing the institution to a permanent appointment, which many men who wish merely to so some special clinical work for a few years would not desire. In large institutions, there is" use for a fourth grade, sometimes called, '^ Graduate Assistant," elsewhere '^ Unofficial Assistant," etc. These appointments are or should be for short periods only, not more than a year, and are intended to provide for men who are being tried out, or who wish to work for a few months only, in a certain department. These appointments are usually given with less formality than the other grades. Finally, there is usually place for a group of men as 90 DISPENSARIES active Consultants — men who have served their time in the work, or who are eminent in the local profession. The appointment as ''Consultants" of men who give nothing but their names, and who are never called in to consult, should be discouraged. The Trustees should make, and the Superintendent should enforce, the rule that no medical man is allowed to do any work in any clinic without some form of staff appointment. Medical students, graduate or undergraduate, coming from a medical college to an instructor who holds an appointment on the staff of the institution, should be the sole exception to this rule. In former years, the typical internal organization of a clinic was to have a number of physicians as ''chiefs," serving with his assistants, if any, for two or three months. Thus during a year the clinic had from four to six different sets of men in charge. The nominal advantage of such a service is that it gives many men a chance to gain medical knowledge from the clinic. This is much more than counterbalanced by the diminution in quality of service which is insep- arable from such frequent changes. Unification of responsibility under a single head, in continuous charge of the department, is the ideal type of organiza- tion — in a clinic as in anything else. This is entirely compatible with opportunity for many men to work and learn in the cHnic — as many as with the other plan. In the hospital wards, recent years have witnessed the same passage from many short services to con- tinuous single-headed services. Sometimes the head ORGANIZATION 91 of a hospital service is ex-offido head of the corre- sponding clinic in the out-patient department. But such a head rarely does personal work with out- patients. He will indeed unify the medical policy of the clinic in certain broad aspects, and this is a great advantage; but no absentee government by the hospi- tal chief will do the best for the Dispensary. If he has an assistant who has continuous service in the out-patient, the situation is well met. In practice, under the system of volunteer medical service, it may be difficult to realize the ideal of an out-patient clinic under a single head, who gives personal service through- out the year, especially if the Dispensary is not con- nected with a medical school or a large hospital. Every effort should be made to approximate this ideal as nearly as can be. Two chiefs, each on service for six months, are six times better than four ^' chiefs'^ each serving for three months. As few heads to the department as possible, as long services as possible: has been the recent and the right motto. The chief of a department has two problems: first, the determination of the medical policies of the de- partment; and second, the proper execution or super- vision of the actual diagnosis and treatment of patients. In a large out-patient clinic, the burden of detailed, personal work is very considerable. It is much more exacting than the ward work of the hospi- tal. Consequently, it is necessary to devise some system by which neither the chief nor any one assist- ant shall bear the burden for too long a period. This need has sometimes been met by providing a chief 92 DISPENSARIES with four assistants who serve, each for three months (with junior assistants, if the cUnic demands it). The chief himself visits the chnic, either daily or on specified days of the week. Adequate vacation peri- ods must be allowed. Sometimes this plan has been followed with two first assistants, each on for six months. Another form of division is made by having one set of assistants three days a week, and another set for the other three days; each group coming either throughout the year or for six months, making either two or four sets necessary. Such a three-day-a-week service works very well, always provided that both sets of the three-day service are responsible to a single head. Sometimes, despite [the best efforts, patients will come on the wrong day, and often must come because of conditions which require immediate treat- ment. This is likely to involve the two sets of .the service in differences, unless there is a single chief who enforces co-ordination. 3. Outline of the Administrative Organization Certain of the divisions or departments of work in a Dispensary are similar to those of any institution, especially to a hospital: — a. Maintenance of building. b. Purchasing and care of supplies. c. Housekeeping (steward's department), if a Dis- pensary is separate from a hospital, and provides residence for some of its staff. d. Laundry. e. Compounding and dispensing drugs. ORGANIZATION 93 If the Dispensary is an out-patient department of a large hospital, all of the above divisions will be repre- sented in the House service, and the officers in charge of each will of course exercise technical supervision over the appropriate departmental duties in the Dispensary. A small Dispensary, separate from a hospital, would probably have its laundry done outside and would have no one live in the building, except perhaps the janitor; the purchasing and care of sup- plies might take a little of the time of a nurse or some other person. The non-medical professional services rendered in a Dispensary require : — 1. General executive work and supervision. 2. Admission and registration of patients. 3. Nursing. 4. Social service. 5. Clinic management. 6. Clerical service. In a large Dispensary each of these divisions may have its chief. The management of clinics, as has been pointed out in the preceding chapter, involves the super- vision of the general clinic administration, the attend- ance of the Staff, the making and handling of the records, the personal treatment of patients, the follow- up system, etc. This supervision should either be performed by the Superintendent of the Dispensary personally, or with the aid of an assistant who pursues certain details. In a Dispensary or out-patient 94 DISPENSARIES department of moderate size, the duties of the Super- visor of Clinics, in so far as not performed by the Superintendent of the Dispensary, may be assigned to one of the other heads of departments, either the Head Worker of the Social Service Department, or the Head Nurse. Tact, good judgment and a sense for good organization are required, as well as executive ability in details. Clerical service should be organized as one bureau for the entire institution so far as stenographic work is concerned. The clinical clerk, who makes memo- randa on records in the clinic, attends to the follow-up system, to keeping patients in order, etc., is really an assistant in clinic management. The distribution and care of the medical records may either be under the Registrar or the Chief Clerk. The general executive work and supervision is, of course, the duty of the Dispensary Superintendent, who, in the out-patient department of a large hospital, would usually be an Assistant Superintendent of the Hospital. In all out-patient departments there should be carefully held in mind and rigidly applied the prin- ciple of ''Line and Staff" organization. The chief of a hospital bureau, such as a Superintendent of Nurses, the head of the Social Service Department, etc., should exercise professional supervision over the technical work of nursing or social service, and will thus see that the quality of the technique is maintained. This is the staff function of these chiefs. But orders issued to any of the employees of the Dispensary must come ORGANIZATION 95 through the Superintendent of the Dispensary, who is the head of the ''line." If this rule is followed, the Dispensary will be maintained as a really unified and effective working organization. If, however, the head of a hospital bureau is permitted to issue orders in the Dispensary directly, without going through the Superintendent of the Dispensary or Out-Patient Department, the unity of the dispensary organization will suffer and its effectiveness in proportion. It should go without saying, that the Superintendent of the Dispensary should be permanent in office and not be a rotating official chosen in order from the Assistant Superintendents of a large hospital. A dispensary superintendent needs certain qualities not always connected with institutional work. In particular he needs to possess two qualities: First: ability to deal with all kinds of people wisely and tactfully; Second: ability to see the Dispensary's problems from the standpoint of the community, not merely from that of an institution. Different sizes of Dispensaries of course require adaptation in the administrative organization just described. The purchasing of supplies in a Dispensary not connected with a hospital may be in charge of the head nurse or the pharmacist. The superintendent may, in a small Dispensary, act as admitting officer, as registrar, with a clerk to assist him; the superin- tendent may directly oversee clinical management or may delegate much of that to the head worker of the Social Service Department or to the head nurse. 96 DISPENSARIES The admission of patients has not infrequently been assigned to social service. First of all it is important to have clearly in mind the various functions which must be performed. These are alike in all Dispen- saries which treat general diseases. If a proper analysis of functions is made, then the distribution of the functions among the available personnel in an organization of a given size will not be difficult. For example, in a little Dispensary receiving fifty visits a day, a single nurse, one social worker and a clerk may constitute the non-medical staff (besides the janitor, cleaner, etc.). One person must, however, be the head executive. Which shall it be? Generally speaking, a woman with a broad social training will be found the most desirable head, whether her routine duties in the Dispensary are those of a nurse or a social worker. 4. Co-ordinating All Factors The medical staff, while organized for working purposes into its units as clinical departments, must, for the broader purposes of the dispensary manage- ment, be made into a larger unit. Formerly it was often the custom to have an organization of all the physicians, assistant physicians, etc., with their own president, secretary and other officers and committees. This plan has the advantage of getting everybody together, and it also provides a means for social and medical meetings of the whole staff. But it has the serious disadvantage, with a large staff, that the organization is cumbersome. The mixture of chiefs ORGANIZATION 97 and assistants, the latter usually in numerical majority, at meetings, prevents the serious discussion of many problems; and the elections and appointments are likely to be influenced by considerations other than the specific work which the ofiicials or committees are to do. A much better form of medical organiza- tion for a large staff is to recognize the basal principle, viz., that the heads of departments are those upon whom the responsibility for the medical work of the Dispensary really rests. The heads of the depart- ments should therefore form the essential part of the staff organization, if this organization is really to play a responsible part in the management of the Dispensary. The heads of the departments meeting annually, or as necessary, in council, furnish a responsi- ble body and will select any needed committees or aid the trustees in selecting them. When there are ten or more chiefs of departments, a working or executive committee formed of or by the heads of departments will be desirable, and this should rarely exceed five members. In some institutions such a committee, with the superintendent, forms practically the administrative body of the institution, the trustees acting only on major questions of policy, appointments and finance. But it is unfortunate thus to cut off the trustees from the real work of the Dispensary. The ultimately responsible body, the trustees, should regard it as part of their duty to come into active touch with the administration. This may be by means of joint meetings between some of the medical committee and the trustees, or a com- . 98 DISPENSARIES mittee of the trustees. In either case the Superin- tendent should be a member of the group.* The correlation of the Dispensary with other agencies in the community is also a function of its organization. The relationship to the medical agen- /cies, the hospitals, the convalescent homes, the department of health, etc., usually remain undefined. A definite series of understandings can, however, be worked out by which a Dispensary which does not possess a hospital, may facilitate admission of its patients to hospitals or convalescent homes and se- cure the needed follow-up data, therefrom. Suitable understandings with the health department also will promote effective working relations. It is also desira- ble to have an understanding with the other Dis- pensaries in the community, as to policy regarding the admission of patients and the disposition of patients who have been treated recently at one of the other institutions. The relationships of the Dispensary to charitable and social agencies should be worked out through the Social Service Department. As will be seen in Chap- ter VIII, the modes by which non-medical agencies may best use the Dispensary in behalf of their bene- ficiaries, and the modes by which the Dispensary can best use outside welfare agencies in solving the social problems of its patients, are both capable of formu- lation in working agreements between the Dispensary and the outside welfare societies. In the out-patient department of a large general ♦See Appendix, pages 421 and 425. ORGANIZATION 99 hospital, one of the final problems of organization is how the Dispensary shall stand on its own feet. How does the scheme of organization of the medical staff and the administrative officials and employees, as above described, apply to the problem of an out- patient department of a great hospital? Here again, if we follow fundamental principles carefully, the answer will not be difficult. The fundamental prin- ciples are: 1. In making up judgment upon policies, all factors affected by the policy should have representation. 2. Those directly responsible for the dispensary work, should be immediately responsible for the dispensary man- agement. These statements mean, in practice: — 1. The medical staff of the Dispensary (out-patient de- partment), whatever their positions or rank in the institu- tion as a whole, should be organized as a dispensary staff or have a committee of their number serving as a medical committee for the Dispensary. In other words, the heads of departments who are in active service as chiefs of clinics in the out-patient department, should be treated as heads of the departments in the Dispensary for the purpose of forming a Dispensary Medical Committee. If the staff of the hospital wards possesses a responsible medical com- mittee, as it should, the Dispensary Medical Committee will of course be subordinate in matters of general policy to the committee of the House staff. But no activity or interest on the part of House men who do not themselves have personal contact with the problems of the Dispensary, will supply the place, in guiding administration and fur- 100 DISPENSARIES nishing constructive criticism, of the men who are doing the actual out-patient work. 2. The Assistant Superintendent of the hospital, who is assigned to the charge of the Dispensary, should have direct relations to the Dispensary Medical Committee. Whenever important dispensary problems are under con- sideration, he should also have opportunity to confer with the Superintendent of the Hospital and with the medical committee of the House staff. 3. The Trustees, through some of their members, or a special committee, should be in touch with the dispensary Medical Committee and with the dispensary Superintend- ent, either through periodical joint meetings or some other mode of procedure. 4. The executive officers of the departments of the hospi- tal, such as the Superintendent of Nurses, the head of the Social Service Department, etc., should act as staff advisers to the Superintendent of the Dispensary according to the method previously described. 5. The key to successful guidance of policy and administra- tion in any organization is to bring together those who know the facts on which judgment should be based, with those who need to know the facts in order to frame judgment. To do this, in the Dispensary or Out-Patient Department, is the duty of its Superintendent. He should not only be expected to give his own views and the facts in his possession to the officials or committees above him, but also to secure from the heads of medical or executive departments in the Dispensary the facts which they alone know. Personal conferences between such individuals with the responsible committees and officials are often valuable. There is no stimulant like first-hand facts. SOCIAL SERVICE 101 CHAPTER VIII SOCIAL SERVICE Social Service in a hospital or Dispensary means assistance to the physicians in the education of pa- tients and the control of their environment. It means '^assistance to the physicians/^ for it is medical social service. The function of the hospital or Dispensary is medical and it is in pursuit of medical efficiency that the institution enters into social service. Conditions in the patient^s environment often need to be ascertained in order to confirm or suggest a diagno- sis. Conditions of the patient^ s environment as well as his state of mind — his ignorance, his prejudices — need to be altered or controlled in order to render efficient treatment possible. To ascertain facts con- cerning the patient's personality and environment and to apply this knowledge so as to help in achieving medical results, is the scope and function of medical social service in the Dispensary. The pioneer Social Service Department was founded in this country at the Massachusetts General Hospital, in 1906, by Dr. Richard C. Cabot. It began in the Out-Patient Department. Medical social service has been extended into the wards in many hospitals. In some institutions it began therein. But in large part, it has remained a feature of the dispensary work. The special technique of social service in hospitals and 102 DISPENSARIES dispensaries has been well treated in the book by- Miss Ida M. Cannon and has so frequently been dis- cussed in the proceedings of the National Conference of Charities and elsewhere during recent years, that it is unnecessary to enter into details here. Our pur- pose in this Chapter will therefore be to discuss (1) The kinds of work undertaken by social service in a Dispensary. (2) The organization of the social service work. (3) Selecting and training the working staff of a Social Service Department. I. Kinds of Medical Social Work The kinds are infinitely varied. Every conceivable human problem is faced in the course of a year in the Social Service Department of a large Dispensary. A woman needs an operation — but at home are four young children, and the father earns but $12 a week. The mother can neither leave her little ones, nor afford a servant. The doctor may make his diagnosis and advise the operation, but unless the social worker finds out the woman's home situation and secures a friend or relative to act as caretaker, or a charitable agency which will hire one if necessary, the woman will not go to the hospital for what she needs. A man comes with syphilis. His wife and children ought to be examined, and perhaps when they meet the doctor the family situation which faces the physician and the social worker will require the wisdom of Solomon to solve. A mother brings a sick baby wrapped in many clothes and fed on condensed milk. Ignorance and SOCIAL SERVICE 103 not lack of income must be patiently wrestled with. The variety of these problems can be best shown by listing the actual problems faced in 326 consecutive cases taken up by the Social Service Department of a large Dispensary during six consecutive months : Assuring advised hospital care 50 Arranging for convalescent care 34 Procuring institutional care 16 Aiding in diagnosis by investigating past medical-social history .... 36 Securing necessary after-care for children discharged from hospital 46 Arranging and advising for special diet 4 Supervising hygiene 33 Adapting working conditions to patient's physical limitations .... 5 Arranging for examination of persons exposed to a contagious disease 40 Social care for unmarried mothers 10 Securing care for neglected children 9 Securing and supervising the wearing of apparatus 12 Arranging instalment terms for expensive medical treatment .... 7 Arranging for material relief 13 Making special school arrangements for cardiac and chorea cases . . 1 Securing employment 1 Assuring advised dental care 1 Arranging for special treatment in other Out-Patient Departments 3 Supervising attendance at clinic 4 Straightening out financial tangle 1 Total 326 An examination of this list brings out at once certain points of interest: (1) Contrary to a prevalent impression, the presence of acute poverty is not the most frequent cause for taking up a social service case in a hospital or Dispensary. Some of the problems in the preceding list may occur in families of any grade of income. Many will occur in families of small income, well above the poverty line. (2) Education, rather than relief, is the dominating activity of the dispensary social worker in relation to the patient. 8 104 DISPENSARIES (3) Utilization or organization of community resources to achieve results for a patient is the dominating activity of the dispensary social worker in relation to the community. The Social Service Department of a Dispensary serves as a clearing-house through which the charitable, educational, industrial and civic resources of the community are. made useful to help in achieving medical results for various pa- tients. The greater the extent to which the Social Service Department can utilize other agencies to perform these services, the more economical and the more efficient is the Social Service Department in the organized welfare work of its community. It will readily be seen that the work to be done for one patient may be comparatively easy and brief. A little explanation tactfully given in the Dispensary itself may be sufficient to straighten out a difficulty for one patient. For another patient, weeks of work with many home visits, conferences with other agencies, talks with doctors, telephone calls, letters, etc., may be required. Assuring the performance of a needed operation may require only a few minutes' talk with the patient, a letter to the relatives and a telephone call to a hospital, while the social work required for a complex neurological case might be twenty or fifty times this amount. Social service cases have some- times been classified according to the relative quantity of work required; the so-called ^' clinical'^ or ^'slight service cases" having been contrasted with the so- called '' intensive" cases. The idea has been that the former group could be handled by the social worker chiefly or entirely within the clinic or within the dis- SOCIAL SERVICE 105 pensary building, while the ^^ intensive cases" required outside visits. This distinction, however, is only one of degree and cannot be sharply drawn. It is of no fundamental importance. The fundamental job of the medical social worker is social analysis or in the more suggestive medical terminology — social diagnosis. The task of a Social Service Department has nowhere been more distinctly formulated than by Mrs. Elizabeth Richards Day in three sentences written six years ago. '' The medical-social worker is essentially the diagnostician of the patient's social needs. To make this diagnosis she must have the knowledge which investigation yields. To meet these social needs she calls upon those agencies in the community which are best able to cope with the special problem involved." ''There are many instances," Mrs. Day writes further, "where the medical social worker is the most appropriate agent for dealing with the particular problem, teaching hygiene, arranging for hospital, sanitorium and convalescent care. Is it, however, a child to be boarded in the country? A children's society has the equipment to accomplish this best. Is it poverty which makes it impossible to buy the extra diet or surgical appliance? A relief agency will act wisely here. Is it a mother to be instructed in the feeding of her delicate baby? A nurse from a milk station will teach her. Calling on these societies for help does not mean that the medical social worker's responsibility is over. On the contrary it may be just beginning. She must see that the patient returns regularly for treatment at the Dispensary. There is constant reporting back and forth between the societies co-operating in the care of the patient." 106 DISPENSARIES In a large city with many and well developed socie- ties for relief, child-caring, education, etc., the dis- pensary social worker's task in carrying out treatment consists very largely in utilizing these agencies. In a small community or one with poorly developed welfare agencies, the medical social worker may have to go considerably further in performing various outside functions herself, but so far as possible she should aid the under-developed community to establish agencies rather than attach to the medical institution distinctly outside social functions. In a number of cities and not a few small towns, the establishment of a Dispensary came about because a charitable society saw the need of one. A charity organization society perceives the large proportion of poverty which is caused by illness, and the hopeless- ness of the effort to relieve such need unless adequate medical care be secured. A Dispensary started under such auspices usually has its Social Service Depart- ment in the workers of the society itself. Cases also exist in which an old-established Dispensary has asked a charitable society of the city to do its medical-social work and to assign one or more workers to the clinics. These relationships should not obscure the essential distinguishing quality of the Social Service Depart- ment : that it is medical in its reason for being. In the future, we are likely to see the development of public health work along district lines. Thorough organiza- tion of each section of a community is to be expected ; a pubUc Health Center with its visiting nurses may be looked for in each district. These nurses will acquire SOCIAL SERVICE 107 familiarity with the conditions of very many of the families therein, and invaluable personal influence. The Health Centers will serve in many ways to relieve large central hospitals and dispensaries from much detailed case-work in the homes which is now neces- sary. There will remain cases of so specialized a na- ture that the specialist worker from the institution must deal with them. But we may in general look for a slow tendency, for the workers of the Social Service Department to specialize more and more in particular medical fields, to limit their work more and more to medical-social diagnosis, and to carry out social treat- ment only in so far as welfare agencies or district public-health agencies are unable to do it for them. 2. Organization of a Social Service Department In a small Dispensary " Si Social Service Depart- ment " might have one worker. In a large Dispensary there might be twenty. In either case the head of the Department should be responsible to the Superin- tendent of the Dispensary (or hospital), in the same manner as the head of any other department. In many hospitals and dispensaries there exists a Social Service Committee. Sometimes this is a section of the Ladies' Aid Society of the institution. Elsewhere there is a special committee which may include mem- bers of the Board of Trustees of the Hospital, some- times members of the Medical Staff, and of the Ladies' Board. The constituency may be limited to only one or two of these groups or may be still more widely varied. On any such committee the Superintendent 108 DISPENSARIES should be a member. With a Social Service Commit- tee, as with any similar body in an institution, it is important that the duties should be advisory and not include administrative details for which the profes- sional staff should be responsible. In practice, the Social Service Committees are usually of much assistance in a financial way. They are of additional value because contact with the social work informs their members personally about the patients and also raises thought-provoking problems of relationship between the institution and the com- munity. Such a Social Service Committee is there- fore usually desirable both from the standpoint of finance and of general utility. The Head Worker of the Social Service Department should be in the same general relation to the Social Service Committee as the Superintendent of the Hospital is to the Board of Trustees. Ordinarily the Board of Trustees will wisely expect the Social Service Committee to make to the Board recommendations on questions of policy or finance, except when power has been clearly delegated to the Committee. The physician who has charge of a case must, of course, retain the full medical responsibility for it and give to the social worker the medical indications or directions. In the social work appear many problems about which the physician is often little informed. Therefore it is important that the dispensary social worker have a well-recognized right of initiative, pro- vided always that she reports her findings of facts and her suggestions to the physician. No plan for a SOCIAL SERVICE 109 patient should be adopted unless it is based upon the medical opinion and the social facts jointly, as rep- resented by the physician and the social worker together. New Social Service Departments have often grown out of the interest of a particular person or of a physi- cian of the Staff. The first worker in such a Depart- ment naturally starts in the clinic in which this person is most interested, but as such a Department grows, it must decide where and how to assign further work- ers. In a Department of five, ten or twenty social workers, this question of assignment and organization is of the greatest importance. When social service starts in an institution, the physicians of the Staff usually begin by referring to the social workers, cases picked out because of some outstanding or superfici- ally apparent human need. The under-clothed child, the over-burdened widow, illustrate this type of selection. But as soon as the physician sees that the real value of the social service is medical and that its function is to aid in achieving medical results, his selection of cases changes and broadens. The demand for taking social service cases always outruns the money available for providing workers. Selection is necessary. What cases are the most appealing? the most important? How many cases of certain types can a specified number of workers handle? Is it more worth while for them to deal with a large number of cases, or with a smaller number of cases requiring on the average much more individual time? The special interests of particular physicians or the no DISPENSARIES chance preferences of contributors, may supply a temporary answer to these questions. But such con- siderations should not determine them finally. The questions can really be answered by facts. Actual study of different clinics and of different medical types of cases, reveals relative need for social service. A children's clinic or a neurological clinic usually presents a larger proportion of cases needing social service than does a dental or an eye clinic. A survey by a trained social worker can be made of the social problems presented by the patients in a clinic. On the basis of the facts secured, the social work can be intelligently planned for that department or for all the departments actually surveyed. Such studies are the only scientific basis for deciding the places where social work is most needed within an institution, and the kinds of cases with which it can accomplish the best results in proportion to the effort expended. The simple methods used in such surveys are described in Chapter XV, on Efficiency Tests. When Social Service Departments began, the cases usually came to the social workers by reference from the physician. The social workers had their office somewhere in the building and the patients were sent to them by the physicians. A great step was taken when in 1911 the social workers of the Boston Dis- pensary were assigned directly to the clinics. There, being in first-hand contact with the patients, they secured ''social histories," were able to discuss cases with the physicians from the beginning and at once greatly increased the power of the social workers, after SOCIAL SERVICE 111 obtaining facts, to exercise initiative. The convenience and value of social service to the physician was en- hanced. The plan of assigning workers to clinics has spread widely among the Social Service Departments of the United States. In Departments thus organized, with social workers assigned to various clinics, it is usually necessary to retain one or more workers who can take cases from clinics to which there is no social worker specially assigned, or in which the total amount of social service required would not be sufficient to require all of one worker's time. The disadvantage of the assignment of workers to clinics is that the social worker is likely to become involved in the executive management of the clinic, or in clerical duties, to an extent which may seriously diminish the time which she can devote to the work for which she is specially trained — social service. Getting patients to the doctor in the proper order, answering the numerous questions which arise from visitors, patients, etc., attending to records, etc., are all useful functions, but do not belong to a member of the Social Service Department as such. The Dispensary may not be able to provide a clinic with a special clerk, a clinic manager, or other person who can assume execu- tive duties. In this case the Dispensary will have to decide whether the social worker had better perform these functions or not, but it must be clearly recognized that if she does, the amount of social service which she can do will be limited. The alternative, however, is not to go back to the old 112 DISPENSARIES system under which social workers were cut off from direct contact with patients until after the patients had been referred by the physicians. The alternative is the placing of social workers in clinics under condi- tions which shall not tie them down to executive or clerical duties. The development of medical social service has shown that the problems which must be dealt with are varied and highly specialized; hence that there will be a gain in efficiency if the members of the Staff of a large Social Service Department specialize also. Each worker may be confined to a single type of case or a group of closely related types — e.g., chil- dren's cases, industrial cases, venereal disease, neurolog- ical cases, eye cases, etc. Each represents a group in which especial attention will bring the reward of special skill. Assignment of workers according to lines of such practical specialization coincides nearly but not quite with assignment of workers to clinics. A large medical clinic includes certain marked types of cases, such as the gastro-intestinal, the cardiac, the industrial, and numerous others. Each presents peculiar social as well as medical problems and if the clinic and the number of social workers are large enough, the time of at least one worker can be devoted to each type with advantage. The tendency in future Social Service Departments will more and more tend to follow the tendency of medicine itself in developing specialties. Such a degree of specialization faces us with the risk of losing sight of cases in the general clinic which do not fall into any one of the groups to which special workers are assigned. The correctives SOCIAL SERVICE 113 for the dangers of over-specialization in the case of social service are: — (1) The retention of a certain proportion of social workers who are seeking, and are ready to take up, cases which do not fall into any one of the specialized fields. (2) The free and frequent use of the Survey Method — looking over the human material of a clinic at periodic intervals (and of the Dispensary as a whole less frequently) ; in order to classify and re-classify the social needs apparent, arrange them in order of relative magnitude and importance, and adjust the assignment of social workers from time to time so as to accomplish the most with the available staff.* The assignment of social workers will of course be affected not only by the number or apparent impor- tance of the cases presenting certain social needs, but also by the practical possibilities of attaining satis- factory results with the cases. One fundamental con- dition is good medical work. An uninterested or careless physician whose diagnosis is hasty or ill- founded, renders it as hopeless to expect good social work as good medical results for his cases. Conditions outside the Dispensary itself may render social service for certain cases practically a vain attempt. A city in which convalescent facilities were almost absent would gravely limit the effectiveness of social work for one class of patients. A dominant industry in which long hours, low wages and poor working conditions were prevalent would seriously curtail the value of social service in dealing with another large class of *A wide-awake Admission Desk in the charge of a person with social training helps to "spot" patients whose social needs might otherwise be passed over. 114 DISPENSARIES patients. The remedy would have to be sought along other lines than case-work. 3. The Personnel of a Social Service Department One of the overshadowing problems in medical social service is, and long will be, the securing and training of workers. The question often asked, oftener indeed than any other, is : — ' ' What is a trained social worker?" ''Just what does 'training' mean?" A trained social worker means a person who has learned to make critical hut sympathetic judgments of the human problems usually presented, and who has also learned how these can be dealt with effectively in practice. As an example of the questions which face medical and social workers and which need trained social judgment for their answer, we may cite: Shall material relief be obtained for a family for the three or four months during which the father will be in an in- stitution because of sickness, or shall the five children and mother be placed in four different homes of willing relatives during that period; a course to which the mother strenuously objects. Shall a delicate child with kind-hearted but quarrelsome and uneducated parents, be placed in a country home for six months; or shall an attempt be made, through the parents' love for the child, to reconstitute family life suffi- ciently to enable the girl to get well at home? Shall an unmarried pregnant girl of 21 be urged to marry the father of her child if the man is willing but the girl has lost her confidence in him, or shall she be helped to fight her battle of life alone? SOCIAL SERVICE 115 The answers to such questions as these cannot be made merely by a kind heart. Kind hearts in social workers are of just the same value as honesty in bookkeepers. Honesty is essential, but does not teach a clerk how to keep books. A kind heart must be un- der the direction of a cool head, a trained judgment. Trained social judgment involves not only the ability to draw the right conclusion from the facts that are available, but the equally important power of eliciting from the individuals and family concerned all the essential facts upon which correct judgment must be based. Trained analytic judgment, warmed by a broad human sympathy, will enable a conclusion to be reached as to what the exact social problem of the patient is. Then is demanded practical skill in dealing with the patient and his environment and in utilizing the resources of the community, in order to attain actual results. In social work as in medicine, treat- ment follows diagnosis. As examples of practical questions which a medical social worker may face during a course of social treatment, there may be mentioned : By what procedures or by what agencies can a vacation be obtained for a young colored working girl, whom the doctor says ought to be in the country for two months? How shall we get a job for a man with a damaged heart and so give him a definite though necessarily limited earning power? How can we adjust the home life of a neurasthenic woman until she can get physically on her feet again? 116 DISPENSARIES The development of social judgment and of knowl- edge of the technique of social treatment should be based upon training along two lines : (1) Judgment is primarily trained by the critical study of concrete cases and by actual experience in dealing with them under supervision. This training must be fortified by the broader study of social forces and movements. This in turn should be founded on a good general education, in which it is desirable that economics, psychology and biology should have been included. (2) Knowledge of social technique must be based on a study of existing social organizations, the prob- lems faced and the methods employed by, other social workers and agencies. Frequently the question is raised: — should social workers in hospitals or Dispensaries be nurses? If the preceding analysis of the requirements of social work is correct, this question belongs in the considera- tion of secondary qualifications. A nurse's training as such does not supply the essential elements required. Nurses have been successful social workers. So have school teachers and college graduates without medical or nursing training. The practice of many large Social Service Departments in institutions of the highest rank, has shown that social workers who are not nurses can be successful as Staff Workers and as Head Workers. Undoubtedly a nurse's training supplies a certain familiarity with the atmosphere of a medical institu- tion, with the subject-matter dealt with therein, and SOCIAL SERVICE 117 in so far it is valuable to the medical social worker. The practical question is whether three years spent in securing a nurse's training is the most profitable ex- penditure of time for a woman who wishes to take up medical social service. The nursing profession is itself undergoing modification, and particularly de- veloping in the public health field. The educational needs of the public health nurse resemble at many points those of the medical social worker, although the activities of the one will be more and more confined to district service, while the other will more and more work along specialized lines within or for an institution. In the process of modifying the curricula of nursing education, which is now going on, alterations may be produced which will enable courses of study to be prepared in which the institutional nurse, the public health nurse, and the medical social worker, may all share; some parts being in common for all, some differ- ent for each. This is a matter for the future. The immediate question is the development of a supply of trained medical social workers which shall not be far short of the demand, as has been the case in recent years. The point of highest importance is to attract to the field of medical social service people of personal- ity and initiative. 4. How Much Social Service is Needed in a Dispensary? A final question of great importance is, how large a Social Service Department does a Dispensary of a certain size require? Since conditions and needs of patients will vary widely in Dispensaries even within 118 DISPENSARIES the same community, no general answer is possible to this question. With a Dispensary deaUng with certain kinds of diseases, or with certain economic or social groups, social service will be required more than if the clientele is of a different sort. The question can, how- ever, be answered definitely for any particular institu- tion. A study or survey of the patients of a particular clinic, of a group of clinics or of the whole institution, is the method by which an answer can be found. A series of five hundred or more patients in a whole Dispensary or of one hundred to five hundred pa- tients in a particular clinic, may be studied sufficiently to enable their social needs to be classified. It has been found in several charitable Dispensaries, treating a wide range of diseases, that — From twenty per cent to thirty per cent of all the patients will need intensive social case-work in order to achieve suc- cessful medical results; From forty per cent to fifty per cent in addition ought to receive some attention from the Social Service De- partment, of a less intensive character, and From twenty per cent to thirty per cent would not need the attention of social service at all. The number of social workers necessary to deal properly with a given number of cases is a question which must be answered by experiment. When the type of case is known, a medical social worker of experience can give some definite advice as to the number which can usually be handled by a worker within a given period, although considerable limits of variation must be admitted. A neurasthenic patient, SOCIAL SERVICE 119 or one of the difficult family problems sometimes in- volved in a case of syphilis, might require fivefold the time that would be demanded by the task of helping a woman secure an operation or a man to get a job suited to his physical handicaps. One social worker in a Department, therefore, might be able to carry during the course of a year 200 different cases, while another worker no more competent might carry 400 or 500 during the same period. Summary 1. Knowledge of the social needs of the patients in the Dispensary or in the particular clinics, is the foun- dation upon which the character and organization of a Social Service Department should be planned. This knowledge must be secured by clinic studies or sur- veys, or by similar study of the patients of the Dis- pensary as a whole. 2. The medical-social worker is to be held respon- sible first of all for social diagnosis and for securing the facts on which this must be based. 3. The policy in carrying out social treatment should be to utilize as fully as possible all outside agencies of relief, education, childcaring, public health and civic welfare. 4. The assignment of workers to different clinics or to different phases of the work within the Dispensary must be made according to the following principles : a. Personal contact between the worker and numbers of patients promotes initiative and complete handling of needs 120 DISPENSARIES and is furthered by the assignment of workers directly to cUnics. b. The speciaHzation of each worker along the lines of a particular medical problem or closely related group of medi- cal problems promotes efficiency. c. Oversight or neglect of cases which do not fall within the field of any specialized worker must be avoided by period- ical clinic surveys, by the co-operation of the admission desk, and retaining some workers in sufficiently unspecial- ized fields to devote their time flexibly to any case of need. d. Care should be taken to minimize the burden of execu- tive or clerical duties upon social workers assigned to chnics. Otherwise the amount of social work they can do will be unduly Hmited. 5. The Head of the Social Service Department should be responsible to the Superintendent of the Hospital or Dispensary and be held fully responsible for all details of policy and of organization within her department, as well as for case-work. BUILDINGS 121 CHAPTER IX DISPENSARY BUILDINGS Much has been written on institutional construc- tion, but little with reference to the right arrangement and spacing of the different rooms, sections and divi- sions which house the living elements of a Dispensary. I. General Planning of a Large Dispensary The plan of even a new building for a Dispensary must often be determined largely by other considera- tions than the needs of the Dispensary itself. The general layout of the hospital may require a certain wing to be used for the out-patient department, or the particular plot of land available for a Dispensary may determine in advance limits within which the architect must work. One fundamental point should always be held in mind : A Dispensary essentially requires adapta- tion to large numbers of people, each of whom is in the building only a comparatively short time, but many of whom are in the building at certain times all together. Consequently ample air space is essential and plenty of light. As a corollary the square type of building more than two stories high is to be avoided, unless planned so the central portion can be lighted adequately by daylight. When a building of two stories can have a central court, with a large ventilating skylight, a building of 122 DISPENSARIES the square type, as shown in a later plan, may be very acceptable. When a building for a large Dispensary must stand on a restricted plot of ground, and be three or four stories in height, thirty-six to forty feet should be the maximum width. The ''L" or '^U'' PLAN A 5tcoND Flooil Plan 5cAtt. lMM ■ w ■ ■ m ground plan will work out excellently when feasible. Very commonly, in planning a hospital with a number of large units standing out from a certain side of a corridor or administration building, one of the units BUILDINGS 123 will be assigned to the out-patient department. This will therefore be from thirty-six to forty feet in width, two to five stories high, and in length may have to conform to the rest of the hospital plan instead of to the exact space requirements of the Dispensary itself. Plans A, B and C will illustrate some of these points. PLAN A f 12.57- PtOO^-pLAN 5cAi.t gpo m m.m.mit. i^Feer In the basement would be lockers and lavatories for employees, and space for clinic records. The cabinets holding the active records and the alphabetical index make most of the walls of the partition sur- rounding the Cashier and the Admitting Officer. If the Institution is independent of a hospital, the basement must also provide for a phar- macy store-room, general store-room, heating plant and laundry. 124 DISPENSARIES PLAN B Connecting Co'^hwov^ Medical and Suex^ical Clinaic 6cAUE tn.»BWB Mr A typical unit of a large hospital group utilized for a Dispensary. One floor only is shown to illustrate arrangement. Admitting hall and administrative ofl&ces would be on floor below (ground floor); other clinics on floors above and in basement. BUILDINGS 125 In locating an out-patient building with reference to the other buildings of the hospital (when an entire hospital plant is designed as a w^hole), it is to be borne in mind that the Dispensary may receive more pa- 126 DISPENSARIES tients than all the other parts of the hospital put together. Hence its entrance should be as accessible as possible from the main streets, and yet not be so placed as to interfere with the ambulances, automo- biles, patients coming to the wards, or visitors to the wards or private rooms. It is highly important that the laboratories of the hospital and the X-ray depart- ment shall be as accessible as possible to the Dispen- sary, so that examinations of either kind can be made with the least possible transference of patients. On the whole, if the Dispensary is located in one wing of a group of hospital buildings, it is most desir- able to have this wing close to the main administrative portion of the hospital. Large numbers of patients are referred to and from the Dispensary and the wards, and for this and other reasons, it is helpful if the Dispensary be near the administrative offices. The record system of a large Dispensary, requiring the handling of hundreds of clinic records in a day, should be correlated administratively as well as medically with the hospital records, and the record rooms for the hospital and Dispensary are best managed if close together. During recent years, many out-patient depart- ments have been started more or less experimentally, and have to occupy rooms which were formerly as- signed to other purposes. They must fit themselves in as best they can. The foregoing suggestions are written primarily for new buildings, but their applica- tions will be apparent to situations where existing quarters must be utilized for out-patient purposes. BUILDINGS 127 Too frequently out-patient departments have been planned by sections. Each medical, surgical, or special department has received the consideration of the chiefs of its own staff. The staff sketch out the number of rooms and the arrangement they would like. The architect and building committee have these suggestions laid down with considerable force as necessary parts of the building. Then what space is left over, is allotted to admitting and administration. As a consequence, a number of existing Dispensaries, which show excellent arrangements in certain details of clinics, present inadequate provision for the ad- ministrative work. Ample administrative space is one of the first requirements of a Dispensary, particularly if it is likely to grow as most Dispensaries do. It is comparatively easy to add on rooms for additional clinics, or even to put certain clinics in an adjoining room or building, but if an admission hall, record room, or other administrative services are cramped, there will be an increasing burden upon the institution as it grows, and a burden which is often difficult to remedy. In the administrative space we should provide for, — 1. A vestibule, or covered court, where baby carriages can be left in safety from the weather, and j'-et not in the way in the admitting hall itself. A vestibule also saves con- siderable tracking of dirt in the admission hall. 2. Ample waiting space, and space for the chief lines of passage in the main admitting hall. Waiting space must be for new patients in the first instance, who must wait their turn for examination at the admission desk, and they must 128 DISPENSARIES be provided with seats sufficient for the maximum number who are Ukely to be in at any one time. In a cUnic period lasting two hours, between fifty and eighty per cent of the total number of new patients admitted are likely to be seated at admission benches at any one time. Waiting space for old patients may be mostly standing space, as brought out in the chapter on admissions. Sim- ilarly for pharmacy patients, if the sj^stem of distributing medicines is properly expedited. But for both a certain amount of seating space must be provided; about a tenth of the maximum number served. 3. Space for admissions, as brought out in Chapter XII — the admission desk, the cashier's desk, etc., with the Unes of traffic properly planned so as to avoid cross-currents. 4. Record room space. Room enough to store all the clinical records, alphabetical and diagnostic indexes, etc., without taking any more floor space than is necessary, and yet without crowding — as either error wastes time. Space for growth and space outside the admission hall, for storage of the records that are only rarely consulted, are highly important. 5. Space for executive offices, including social service. A large Dispensary needs a private office for the superintendent of the out-patient department; a suitable room for the medical staff; a staff lavatory; cloak and rest rooms for the nurses, social workers and other employees; social service offices; a stenographer's office; and supply rooms (if the Dispensary is separate from the hospital and cannot use the general hospital supply rooms for its stock of material). The Staff Room need not be close to the admitting hall, nor need the cloak, rest or supply rooms; but the executive offices of the superintendent and of social service should be adjoining or near to the main admitting hall. Broom BUILDINGS 129 closets with slop sinks are important. A room must be provided in the Dispensary, or close by it in the hospital, where the cash received for fees may be taken, counted and checked in privacy and safety. The stenographic service must be located so as to be accessible to those most needing it. 2. Some Details of Construction From the nature of its work, a dispensary building must contain at one time, a large number of people, but people who are up and about. Nevertheless, if the building is more than a story high, fireproof con- struction is desirable. Where a Dispensary is the out-patient department of a hospital, its general style and construction will follow the hospital architecture. The types of plumbing, doors, and partitions found in standard hospital work, for sanitary and for technical reasons, are generally to be preferred in a Dispensary. Rounded corners and other devices which promote easy cleaning and diminish accumulation of dust (radiators which do not touch the floor, for example) should be installed. A Dispensary sometimes is at work only in the daytime, and needs little artificial lighting except for purposes of special examination and operations. When, however, as is the case in a number of institutions, late afternoon or evening clinics are held, good artificial lighting in the waiting- room, corridors, and elsewhere is necessary. The indirect or semi-indirect system is to be preferred. In examining rooms, lighting must be adapted to the special requirements of the physician or surgeon, but with any direct illumination much care should be taken 130 DISPENSARIES in locating the fixtures, so as to avoid lights which will shine directly into the eyes of patient, physician, nurse, or other workers, when they are in their usual positions in the room. Floors in a Dispensary also need to be planned for the special requirements of different parts of the building. In the admitting hall and main corridors they must stand a great deal of traffic, far more than the wards or corridors of a hospital. A wooden floor, well-laid, is durable but not sanitary, and an impervi- ous concrete or tile should be utilized. For operating rooms and other rooms in surgical clinics, where liquids, blood, pus, etc., may be spilled on the floor, a similar impervious flooring is essential. In examin- ing rooms in medical clinics, in history rooms, offices, and in waiting-rooms of particular clinics, where there is only a moderate amount of traffic, linoleum is easier for the feet, amply durable, and more attractive than any of the hard, impervious floorings. The finish of walls and woodwork should receive attention. Washable paint is desirable. Since pa- tients, particularly children, in passing along corridors and in rooms put their hands upon the walls and wood- work, it is well to have a comparatively dark tone to a height of approximately four and a half feet. Above that the color should be as light as possible. Best of all is vitrified tile, up to five feet, but the expense often negatives this. It must be remembered that whereas in the hospital wards, the patients must lie in bed looking at the walls, in the Dispensary no one patient is in the same place for a long period. It is BUILDINGS 131 important that the place be bright, airy and look clean as well as be clean. Light wall tones, preferably- white, are the best, but white requires much more care than even cream, and still more than a light buff. It is desirable, in order that the educational opportuni- ties afforded by the waiting-room be utilized, that places on the walls be provided so that charts, health posters, etc., may be displayed. Cork or linoleum surfaces, flush with the walls, are the best, for then charts of varying size can be put up with thumb tacks, or suspended from hooks. Rooms that are to be used for medical teaching, talks to nurses, social workers, mothers, and other groups of patients, may well be provided with black- boards, which again should be flush with the wall. Benches for patients to sit upon, or chairs, are likely to mar even hard plaster walls severely, when placed with their backs near the wall, as they often must be. This can be largely obviated by rubber pads attached to the backs of the furniture at the proper points, or by projections attached to the legs, so as to strike the wall base and hold the back of the seat away from the wall. Keeping a Dispensary clean is no light matter. Even if mats and scrapers are placed near the en- trance doors, considerable quantities of dirt are necessarily brought in on the feet of those who enter the admission hall. The main corridors show the effect most, but the floors of every hall, corridor and room, used during the clinic period, need to be cleaned after the clinic is over. Vacuum cleaners are practi- 132 DISPENSARIES cally useless for mucli of this. In the clinics where surgical work of any kind is done, liquids on the floor and moist waste need to be wiped or taken up before the floor is scrubbed. The general toilet facilities of the building need to be carefully planned. As brought out in Chapters X and XI, certain clinics must have toilet facilities of their own for special reasons. The medical staff, the officers and employees, must have toilet provisions separate from those used by patients. The general men's toilet should have urinals as well as seats. All toilet seats had best be of the open front type. One or more drinking fountains should be provided. There ought to be one in the main admission hall and at least one additional on each floor. The best type is that in which several streams of water come spouting from the inner side of a circle, converging to form a central uprising stream, so that it is impossible for the lips to touch any metal. It is best when practicable that the water be kept running continuously in the fountain while the clinics are active. Care should be taken to provide steps so that children as well as adults can conveniently use the fountains. In the absence of fountains, individual paper cups should be supplied to clinics so that patients can secure drinking water on request. In a building of more than two stori ? and basement, an elevator is almost essential, and it is highly desir- able even in a low building. It should not be ex- pected that all patients will use the elevator, but those who have cardiac disease, who are lame, or feeble, or BUILDINGS 133 who have a baby to carry, should have the privilege. Elevator passes may be issued if necessary. Ventilation is always a problem when large num- bers of people are gathered together. The merits and defects of artificial ventilation, and the various systems thereof, have been fully treated by others, and need no special discussion here. In a Dispensary, it is possible to get good ventilation ^' naturally,'^ by open- ing windows; but this requires careful planning of seating space, window boards to break drafts, tran- soms running up to the ceiling to take out top air, and above all, constant supervision to make sure that the windows are intelligently opened, closed, and ad- justed to the outside temperature and winds. In practice this is a difficult task. The desideratum is, to have provision for natural and for an exhaust sys- tem of artificial ventilation. 3. Arrangement of Clinics Certain general principles of the arrangement of rooms for use as clinics may be outlined at this point. Division may be made into two heads. Medical and Surgical. A. Medical. A typical medical unit for a clinic includes (1) a waiting corridor; (2) a history cor- ridor, or admitting room; (3) an examining room. In Plan A, showing a two-story Dispensary, of the central hall type, the arrangement of rooms in a Medical Clinic is indicated, on the second floor of the building. The waiting corridor is that around the 134 DISPENSARIES central hall. The patient then passes, called by the clerk or other person, into the inner or history corridor, where the clinical clerk, nurse, social worker, or physi- cian himself, takes the medical and social history. The inner rooms are the examining rooms, into which patients are sent for undressing and physical examina- tion. The history corridor has the advantage of greatly increasing the privacy of the examining room. It also serves as a useful means by which a single clerk or clinic manager can attend to the executive details of even a large clinic, calling the patients from the waiting corridor in suitable order, distributing the patients to those who take the histories, then sending them to the examining rooms as these are ready. In some types of buildings it is difficult to secure a history corridor without making a dark, unventilated space, between the outer room and waiting hall or corridor. In some cases this difficulty can be partly overcome by separating the history corridor from the waiting corridor merely by part partitions, seven feet high. In some types of building, however, and often where rooms originally intended for other purposes must be adapted to the use of a Dispensary, it will be necessary to utilize a single room as an admitting room for an entire clinic, in place of a corridor running across the doors of all the examining rooms. If an admitting room can be surrounded by examining rooms, a very convenient plan is found, but in many cases the examining rooms must be set out in a row next to the history room and the patient after the his- tory has been taken must pass back into the waiting BUILDINGS 135 corridor in order to reach the more distant examining rooms. As a consequence there is less expedition in management, somewhat less privacy, and more bur- dens upon the clinic manager and the physician, than if a history corridor can be used. Part partitions, seven feet high, are suitable in many instances for examining rooms. In a clinic for adults (particularly for women), there should be at least one fully enclosed room where conversation between doctor and patient can be carried on in full privacy. In a children's clinic the need for this is diminished. It is not desirable, however, to have more than two ex- amining booths, separated by part partitions, within a single room. Otherwise the noise carried from one booth to another is likely to be troublesome. B. Surgical. While the arrangements in a Medical, Pediatric, or Neurological Clinic, may be in the main similar, the requirements on the Surgical side must vary widely on account of the highly specialized nature of certain branches of surgery, and the technical equipment demanded. These details are entered into in the next two chapters. In a general Surgical Clinic the arrangements may be not dissimilar to those de- scribed for the Medical, so far as the waiting corridor, history corridor and examining rooms are concerned, but there must be operating rooms in addition. Furthermore, a considerable part of the routine work in most Surgical Clinics consists of dressings, and treatment of wounds or superficial lesions. Brief histories are taken and the examining, treatment and history rooms can be one. It is most desirable, how- 10 136 DISPENSARIES ever, to have a history corridor with the operating room opening from it, a large dressing room also, and one or two small examining rooms. In a Surgical Clinic of small size, the operating room and acces- sories can be so located as to serve for both male and female sections. Plan B shows an arrangement for a section of a large Dispensary of the corridor type. Often the necessity of adapting quarters previously occupied for hospital purposes, will tax the ingenuity of a dispensary manager. A room, about twenty to thirty feet in size, formerly used as a ward, may have to be em- ployed for clinical purposes, despite a highly incon- venient arrangement of doors and windows. When he cannot do the best he knows, the dispensary super- intendent must do the best he can. 4. The Small Dispensary The number of hospitals of moderate size, in small communities, which have undertaken out-patient work in recent years, indicates the desirability of plans for small out-patient departments. Where, for ex- ample, only ten or a dozen rooms are available, the situation must be quite different from what which faces the architect of a large Dispensary. The fol- lowing list of rooms suggests what might be done in quarters in which twelve rooms and a vestibule are available. Vestibule 1. Admission Hall Waiting space with benches BUILDINGS 137 Admitting booth Record booth (might be a small separate room ad- joining the main room) Administration and Social Service room or booth (these may be partitioned off with seven foot partitions from the main room, or merely with screens) 2. Pharmacy: one room 3. Medical Chnic (two rooms: preferably one large 4. room and a second room divided into two rooms or two booths by a part partition) 5. Surgical CHnic (three rooms: (1) History, examin- 6. ing and dressing room; (2) operating room; (3) 7. small examining room) 8, 9. Children's CHnic (same as the Medical) 10. Eye, Ear, Nose and Throat CHnic (two rooms; the 11. operating work under ether can be performed in the Surgical operating room if necessary) 12. Dental CHnic (one room) As indicated in a preceding chapter, the above list of clinics are those most needed. Where the space does not admit of all of these being in operation at one time, climes must double up. Another and important type of Dispensary is the Health Center, described in Chapter XVIII. While this largely emphasizes preventive work, it is likely to in- clude, and more and more in the future will include, a Tuberculosis Clinic for diagnosis and treatment, a Children's Clinic, and examining if not treatment services for adults. The treatment clinics wiU usually be held at other hours than the simply preventive work, and the same rooms can be used over again. 138 DISPENSARIES < BUILDINGS 139 Plan D indicates an arrangement for a Health Center, which will be more intelligible on comparison with the description on pages 315 et seq. Frequently Health Centers must be established in existing buildings, as, for example, in a dwelling house. The arrangement suggested is adaptable to such conditions. 5. Location of Dispensaries People may be brought to a hospital, but they must come to a Dispensary. Accessibility to the population needing its services is an important consideration in fixing a Dispensary^s location. The experience of such notable institutions as the new Dispensary of Washington University, St. Louis, or of the Dispensary of the Medical School of the University of California in San Francisco, is good evidence that an important Dispensary will draw a clientele from every part of a large city and its environs. A teaching Dispensary in particular, or any other Dispensary having on its staff many of the best known physicians of the community, is in considerable measure independent of location within the limits of a city. Proximity of the teaching Dispensary to the medical school is convenient but not necessary. It goes without saying, however, that a Dispensary situated on the outskirts is neither as convenient nor as useful as if more centrally placed. An out-patient department of a hospital need not be an adjacent building, although there are some administrative advantages and economies if it is. But a hospital situated on the edge of a city, or in a well-to-do resi- 140 DISPENSARIES dence section, might well have its out-patient depart- ment at a distance in an industrial section. The com- munity would usually receive thus better medical service than if the out-patient department were con- ducted at the hospital site in an inconvenient location for thousands of people, or on the other hand if it were working in the center of the city as a Dispensary not connected with a hospital at all. The more a Dispensary enters into preventive work, the more it needs to be near the people whom it serves. The serious and difficult cases will go or be sent for miles to see the '' professor doctor" or the specialist. The minor illnesses, and those considered by the patient as only slight — even when really serious — need a Dispensary nearby. The Health Center above all must be brought close to the people, into the very midst of its neighborhood. So, in locating a Dispensary, the managing authori- ties must consider the size, layout and social groupings of the'r community; and the situation of existing hospitals and Dispensaries or of the hospital with which the Dispensary is to be connected. They must weigh the relative advantages of accessibility and quiet ; of a pleasant site versus a location amid tene- ment houses and factories. Considerations of the cost of land in different parts of a city of course enter in. The final decision must be based above all upon a clear conception of the exact scope and character of the work which the particular Dispensary ought to do, and of the relations of this work to the people who need it. CLINICS 141 CHAPTER X DISPENSARY CLINICS: EQUIPMENT; ORGANIZA- TION; EDUCATION AND PREVENTIVE MEDICINE Bearing in mind the necessity of adapting details to institutions of varying size, a brief account may be given of each of the usual clinics into which a Dispen- sary may be divided. In addition to outlines of equipment and management under the title of each clinic, certain general relations to the Staff, to medical students and to patients, are discussed under topical headings. The Laboratory, Pharmacy and certain other divisions of a Dispensary which are not strictly climes, must also receive attention. General Medical Clinic In considerable measure, this clinic is a diagnostic center and clearing-house for adult patients, as the Children's Medical Clinic is for children. The exam- ining rooms must be well lighted and as quiet as pos- sible, and equipped with examining tables. The point is often raised whether it is better to have certain routine tests done within the clinic, rather than in the central Laboratory of the Dispensary. In many clinics it is a routine (and a desirable one) to have a qualitative test for sugar and albumen made of the urine of every new patient, and of old patients from 142 DISPENSARIES time to time when indicated. The simplicity of these tests and of certain others which are frequently made, render it often desirable for a large Medical Clinic to have a room devoted to laboratory work, with a technician, an interne, a medical student, or a member of the Staff, to perform the tests. There must of course be a stethoscope for each phy- sician. Blood-pressure apparatus is necessary, as many as one for every ten new patients on the average clinic day being desirable. Equipment for stomach lavage and other gastroenterological work should be available, and if there is much of this, a special room is a convenience. A cardiograph, because of its expense, will for sometime be available to only a few institutions. In a small Medical Clinic, men and women patients may be called in the order of their arrival, as in a pri- vate office; but in a large clinic, it will be much more convenient to separate the two sexes, so that one set of physicians see the men, and another set see the women patients. New patients may pass through somewhat the following routine: — Weight recorded on the record card; pulse, temperature by mouth and blood-pressure* also recorded; a specimen of urine secured for examination; a history taken by the phy- sician who is to make the examination, or by a student under his direction. The patient then should be sent to the examining room, and instructed to undress sufficiently for the examination. In the management of a large clinic, a nurse (a pupil nurse or trained attend- * Blood-pressure will usually be taken by the physician himself, in the examining room. CLINICS 143 ant is acceptable) may well take the weight, pulse and temperature, secure the specimens of urine from the women patients, and see that they get to the ex- amining room and are encouraged or assisted to pre- pare themselves for examination. In a large clinic theses duties may be divided between the nurse or attendant and a clinic secretary or assistant. The number of patients which should be seen by a medical staff of given size will depend considerably upon the organization of the clinic and the paid, trained assistants available. Where the physician has to do all the work, except securing name, age, address and other data about the patient (which are taken at the Admission Desk) he should allow not less than twenty minutes to the average new case, and preferably thirty minutes. Where data concerning temperature, weight, urine, etc., are secured and re- corded by other persons, and a preliminary history is taken, before the patient is sent to the examining room, the physician need not go to the patient until he is ready for examination, and the actual average time spent by a physician on a new case may be reduced to between fifteen and twenty minutes, without lower- ing of standards. Old patients will usually require from six to twelve minutes of time, depending on the conditions already indicated. The following staff would be desirable for administering properly a Gen- eral Medical Clinic, extending over two hours, and receiving an average of fifty patients, of whom about half would be men and half women, and of whom about one-quarter would be new patients : — 144 DISPENSARIES A Physician-in-Chief ; Four Assistant Physicians; A Nurse, Pupil Nurse, or Trained Attendant; Two Social Workers; A Clinical Clerk or Executive, who calls in the patients in suitable order from the waiting-room; sees that the records get to the doctors when needed; and admin- isters the follow-up system; An additional Woman Attendant or Volunteer on the women's side would be desirable. The part which may be played by medical students in such a clinic, is touched upon in a later section of the next chapter. One of the neglected phases of clinical work, partic- ularly in general medicine, has been the food problems of patients. These have been generally ignored unless the case presented some special medical problem of nutrition as in diabetes or disturbances of the gastro- intestinal tract. Yet probably a large majority of the families of dispensary patients are, through lack of knowledge of food values and of ''home economics,'^ getting food poorly adapted to their needs and more costly than it needs to be. The Food Campaign of this War-time is awakening us all to this, and we may hope to see advisors and workers in dietetics in close contact with dispensary clinics in future. The study of a patient's general condition and environment should not be considered complete unless an approxi- mate food schedule and budget for a week has been obtained. The physician is moreover prone to lay down requirements of diet for patients without suffi- CLINICS 145 cient consideration of the economic aspect. Food such as suits well-to-do private patients is suggested when much less expensive but satisfactory substitutes could be proposed. The dietitian will be of service in the pediatric as well as in the general medical clinic, and elsewhere in the Dispensary, and will be an inval- uable adjunct to the Social Service Department and to the physicians themselves (cf. page 147). Out of a General Medical Clinic often bud certain useful and important sub-divisions. That for Tuber- culosis is referred to hereafter (page 183). Pro- vision for making periodical physical examinations ("Health Surveys") of individuals, should be made, and this form of preventive work should be encour- aged. At some Dispensaries, Gastroenterology has been made a special branch or sub-clinic within the General Medical. So, with much advantage, have Cardiac Diseases. Occupational Diseases have also been made into a special section in a few institutions. It is essential to have a physician especially trained in the industrial relations of disease, and in the diagnosis and treatment of the chief occupational diseases of the community. Skilled social service and in some cases assistance from visiting nurses are essential with most cardiac and occupational cases. Children's Medical or Pediatric Clinic The general arrangement and routine of a Pediatric Clinic follow in many respects those of the Adult Medical. Separation of the sexes for children under fourteen years of age is not necessary in the waiting- 146 DISPENSARIES rooms, but individual examining rooms or booths are required as for adults. Each child is usually accom- panied by its mother, or some older person, and often other children in the family are ^'brought along," so that a Children's Clinic presents a problem of dealing with many persons besides the patients themselves. It is generally convenient in a large clinic, that some room or rooms be set aside for babies, if possible also a separate waiting-room; and a particular nurse, or pupil nurse, assigned to the sole task of weighing the babies and seeing that they are ready for examination. It is of great importance that the Children's Clinic use every possible means to prevent the spread of con- tagious disease. One room should be provided in the clinic where suspicious or actual cases of contagious disease, which slip through the first line of defense at the admission desk, can be immediately isolated. A member of the staff, or preferably a paid assistant, should be given the definite responsibility of seeing that this isolation is carried out and maintained until proper provision is made for the patient. The equipment of a Pediatric Clinic will include the examining tables in the examining rooms, scales for weighing infants, another for older children. Blood-pressure and urine examinations are not usually made as routine in a Children's Clinic, but facilities for performing them, when indicated, should be avail- able. There is usually no need of a departmental laboratory. A large Children's Clinic needs its own toilet. The clinical management, and the number of pa- CLINICS 147 tients in proportion to the size of the staff, may follow closely that of the Adult Medical Clinic, the difference being chiefly due to the fact that the sexes are not separated; that certain of the tests made upon adults are unnecessary as routine; while on the other hand the special problems of dealing with young children, and of explaining situations to their mothers, are unique features of the Pediatric Clinic. For a clinic of an average of fifty children daily, a staff of not less than four physicians, preferably five, one of whom is Physician-in-Chief, should be available, for the usual clinic period of two hours. There should be a nurse, who, if there are many babies, will be assigned entirely to them, otherwise be devoted to the clinic as a whole ; two social workers, and at least one clinical clerk. Another assistant, who may be a volunteer, will be very helpful in the waiting-rooms and corridors. In the Medical and the Pediatric Clinics, the duties of the social workers will be guided by the considera- tions discussed in Chapters VII and VIII. The exact adjustment of the executive, clerical and social service duties among the physicians of the staff, the nurses, the social workers, and the clerical force, should be worked out in each case, according to the following principles: (1) have clerical work done by a paid per- son; (2) concentrate all responsibility for the executive management of the clinic in the hands of one person; (3) have the medical chief of the clinic largely free from routine, for deciding assignment of cases, acting as consultant, and determining medical policy.* * Special divisions of a pediatric clinic for undernourished children ("Nutrition Clinics") and for cardiac cases, have been successfully- worked out and are to be encouraged. 148 DISPENSARIES Neurological Clinic While from one standpoint, neurology is a highly developed specialty, from another standpoint the work of a Neurological Clinic is that of a General Medical Clinic, plus an additional special point of view. In a general Dispensary, a considerable pro- portion of the neurological cases will have been re- ferred from other clinics, and already have a record of ^^ history" and treatment for various diseases or symptoms. Yet even so, not less than a half hour should be allowed on the average for each new patient. The data which should be gathered in the Neurologi- cal Clinic concerning the patient are those required in a Medical Clinic, plus such additional information as is to be secured by the physician himself in conference with the patient and by his physical examination. Eye conditions are so often of importance, that it is a question whether a Neurological Clinic should not be equipped with apparatus for the examination of the eyes, instead of referring patients to the Eye Clinic. Decision on this point must be based on considera- tions of practical convenience, rather than on prin- ciples; such as the inclination of the neurologist and the oculist themselves, the location of the two depart- ments concerned, the executive staff available for securing prompt transfer of the patient and report back. Similarly, the frequency of syphilis of the central nervous system relates the Neurological Department closely to the main department treating syphilis. This will be discussed a little later. The equipment of the Neurological Clinic, besides CLINICS 149 the requisites for general examination, as in a Medical Clinic, should include outfits for testing the special senses, so far as this is not done by means of reference to other special clinics. Wall charts of the body and the nervous system are particularly useful in this clinic. Outfits for examination of the reflexes, includ- ing a hammer for testing the knee-jerk, and a dyna- mometer, are important . Even a very small neurological clinic needs a clerk or executive; a large one needs a nurse (or trained attendant) also. Social Service is a very frequent need in neurological cases and no neu- rological clinic can secure satisfactory results unless a social worker is either attached to the clinic or acces- sible from the general office of the Social Service Department. How far shall psychiatric work be carried on in con- nection with neurology? Many cases referred to the neurologist, particularly children, will involve the question of mental defect, and this can only be de- termined by psychological as well as medical methods. Equipment for Binet-Simon and similar tests, while not particularly expensive, requires highly specialized service, usually paid service, and takes considerable time. Where a special psychiatric clinic in connec- tion with a hospital for the insane or for mental dis- ease is available in the vicinity, it may be more desirable not to carry on these tests in connection with a Neurological Department, but refer them to the other clinic, even if outside the institution. In many Dispensaries, however, no such outside expert facili- ties will be available. The mental hygiene movement 150 DISPENSARIES is likely to create an increasing number of psychiatric clinics, and these clinics will be more efficient when they can be made part of a general Dispensary, than if maintained independently of the general and special clinics which will be of mutual assistance. General Surgical Clinic In all but small surgical clinics, there must be separate room for sexes for dressing and minor surgical procedures. If the Surgical Clinic is only of moderate size, a single operating room, for operations under local or general anesthesia, may be used for both men and women, but in large clinics two operating rooms should be provided, although a single sterilizing equip- ment will suffice. It is desirable, even in very small clinics, to have infected cases dressed in separate rooms from clean cases. The treatment of fractures in out-patient clinics presents special problems. If more than a small amount of such work is required, a special room for fractures is desirable. At least one small room is essential. In regard to operations, general anesthesia should be permitted only (1) after the surgeon in charge has personally passed on the case, and (2) when a suitable recovery room is pro- vided, with a nurse in attendance until the patient is ready to go home. Operations under general anes- thesia should in general not be permitted in an out- patient clinic unless, in addition to the recovery room, facilities are available in the same institution or in the vicinity, whereby the patient can be put into a hospital bed promptly when his condition requires. CLINICS 151 The large amount of radiographic work in connec- tion with a Surgical Clinic renders it convenient if the X-ray Department is located nearby, but this is by no means essential. The examination of pathological tissue specimens, etc., from the Surgical Clinic, will of course be performed in the central laboratory of the Dispensary. Much of the detailed organization of the Surgical Department will depend upon the extent to which specialties are built up within the department, or are separated into special clinics. Thus Orthopedic, Genito-Urinary surgery, Proctology, or Gynaecology, may be run as separate clinics, or as divisions of the Surgical Department. The extent to which the proc- ess of sub-division is carried will depend upon the general considerations of medical organization treated in Chapter VII. It is quite practical to have a mem- ber of the Surgical Department, who becomes espe- cially interested in rectal diseases, for example, or in genito-urinary surgery, have such cases referred to him for a definite period and be assigned a particular room, with suitable equipment, for carrying on these cases. There may be rotation in service among mem- bers of the department along the lines of various specialties, thus affording different men the opportu- nity to broaden their knowledge. Where the degree of specialization in the medical practice of the local community does not justify the creation of a special department for these divisions of surgery, this plan will be of particular advantage. The equipment of a Surgical Clinic, including oper- 11 162 DISPENSARIES ating room, sterilizers, examining tables, dressing tables, instruments, cabinet, etc., involves a multi- plicity of details. The expense for a clinic treating an average of fifty patients daily might range between $1,000 and $2,500, depending upon the elaborateness of the operative procedures on the patients, and the quality of the apparatus purchased. Since a consid- erable proportion of the patients in a general Surgical Clinic come with minor superficial lesions, for the diagnosis and treatment of which general physical examination is not necessary, the organization and procedure in the Surgical Clinic is much simpler than in the Medical. A nurse is of course essential, and if the clinic is large there must be one for the male and one for the female side. In some instances one of the two nurses will give much of her time to the operating room. The patient^s history is generally taken by the surgeon, or an assistant, while the patient is in the dressing room. Cases involving a general physical examination for the determination of diagnosis will, as soon as the situation is clear, be sent to the examin- ing table. There must be careful gradation of responsibilities among the members of the Staff of a large Surgical Out-Patient Department, so that no undue responsi- bility for advising operations or determining diagnoses shall be taken, except by physicians of such rank as are designated by the Chief. Most Dispensaries do not assign a Social Worker to the Surgical Clinic but leave the surgeons to call one in when necessary. Correlation of the work of a CLINICS 153 Surgical Clinic with a Visiting Nursing service is often useful. Relationship between Patients and Physicians in Clinics The establishment of a personal relation of confi- f dence between the patient and the physician is no less important in the clinic than in private practice. The great enemy of this relationship is hurry. The two essentials are time and continuity. There must be time , enough, above all at the first interview, for the physician j to make a thorough examination, and to explain to the patient what the patient ought to know about his \ condition and its treatment. There should be clinical organization such that, on returning to the clinic, the ; patient shall see the same physician again. This isj not always possible, but the clinic can be so organized' that in the main it shall be possible. \ These principles apply to all clinics, but with some- ^ what less force to the Surgical and to some of the specialties, than to the often long-continued health problems faced in a medical, pediatric, or neurological department. In the specialties there are indeed not infrequently long-continued and difficult medical problems to be solved, such as those of syphilis, chronic troubles of the eye, or ear, defects of posture, etc. Personal relationship and continuity of touch between physician and patient is of vital importance in such instances. On the other hand, in a short term opera- tive case, a refraction case, a cut hand or burn, con- tinuity of touch between physician and patient takes care of itself. 154 DISPENSARIES In the organization of a Medical, Pediatric, or Neu- rological Clinic, therefore, the Staff should be so organized that the Chief either (1) sees every new case and assigns it to an assistant for continuous treatment thereafter, advising him concerning the diagnosis, or else (2) holds himself ready to consult with each assist- ant concerning every difficult case, and expects that such consultation will be asked for. Whichever procedure has been followed, each assistant, once hav- ing taken a case, will see the same patient throughout the period of treatment. Where staff services are split up, and one patient must pass from one physician to another, as at the end of a six months' period, there should be a personal consultation between the physi- cians during certain overlapping days near the changes of service, during which the old patients are brought back and both physicians see them jointly. Continuous relationship between a physician and a patient helps toward systematic control of the case. This assists in diminishing or avoiding a disadvantage of the Dispensary, viz., the failure of various special- ties to co-ordinate their work. The patient may some- times be said to fall out of sight amid his diseases! There ought to be one controlling clinic for each case, the physician of which stands in the relationship of family physician to the patient. Through this physi- cian the opinions and procedures of all the specialists who have been called in will be co-ordinated and inter- preted to the patient. The General Medical or the Pediatric Clinic should fulfill this co-ordinating func- tion in many instances. To realize this ideal of CLINICS 155 centralized co-ordinated medical control for each case is not easy; but it is the ideal to strive for. Needs and possibilities in this direction are developed somewhat in Chapter XXI. The Dispensary as an Educational Institution Physicians and medical students, nurses and social workers, trustees and patients, must come to the Dispensary not only to help or be helped, but to learn. The Dispensary should bear an educational relation to each of these groups, and in large measure this education can be organized, so as to be a standing element in the institution's work. The part played by the Dispensary in medical education, graduate and undergraduate, has increased remarkably as medical education has become less didactic and more practical. This is well brought out in the notable report pub- lished by a Committee of the Association of American Medical Colleges in 1916, referring to the teaching functions of a Dispensary : — "After all, the functions of a Dispensary are essentially the same as the functions of a hospital, namely, the ade- quate care of the patient, the instruction of medical students and the advancement of medical knowledge. From most points of view the same conditions hold in the Dispensary as hold in the hospital. Adequate care of the patient must include not only careful examination and proper treatment, but also instruction in methods of life and the prophylaxis of disease. The Dispensary should be the center for the dissemination among the public of knowledge of preventive medicine. In the Dispensary, just as in the hospital, the presence of the medical student not only adds to the effec- 156 DISPENSARIES tive working force, but also stimulates the attending physi- cians to a better type of work. ... A properly equipped and adequately maintained Dispensary is one of the most important factors in clinical instruction." When medical students are taught in large classes, a patient presenting a disease or condition, included within the subject of the lecture, is brought before the class for demonstration. Teaching of this type makes little difference to the conduct of a clinic, as only a few picked cases are used. The more effective and prevailing method is to have students in small sections. These students are either (1) in groups of two to six (more than four is not very desirable). They are brought to patients, or patients are brought to them, in the presence of the instructor. Each student is allowed to make all or part of an ex- amination himself, and then the case is discussed by the group with the instructor. (2) According to another plan, the students are assigned as clinical assistants. They take histories of patients, they make individual examinations, and then the instructor goes over the history and makes his own examination. Such student assistants obviously do some of the routine work of the clinic, but their teacher should give them time for instruction which will fully make up for whatever time they save. If the students are used in such a way as to expedite the clinic, they are not likely to receive the best instruction. The pres- ence of students, however, is a great stimulus to the clinic, because it puts the members of the Staff on their mettle. The Superintendent of the Dispensary CLINICS 157 ought not to expect that the presence of students will enable a staff to do more work in the same time; but it should enable them to do better work. No patient should be used for demonstration or examination by students, except with his consent, or, in the case of children, with the consent of a parent or older person. Certain Dispensaries affiliated with medical schools refuse treatment when patients object to being examined by students. Where the interests of the community demands that a certain patient re- ceive treatment, a Dispensary, whether associated with a medical school or not, must think very carefully before it adopts a policy against treating such cases. As a matter of fact, unwillingness to be used for pur- poses of medical education is infrequent, and usually means that the matter has not been properly presented to the patient. With all but a few exceptional indi- viduals, the patient's consent can be readily won by a frank, but tactful, presentation of the service which the patient can render in return for the service which is furnished him. The value of histories taken by students, and of the records made by them, depends largely upon the de- gree of critical supervision exercised by their instructor. Where students are held up to a high standard, the records which they make are full and careful, and, taken together with the corrections and additions put down by the teacher, give an altogether valuable presentation of the case. Upon the instructor rests the responsibility for achieving this result, and the pressure of the executive management of the Dispen- 158 DISPENSARIES sary, as well as of the Medical School with which the physician is affiliated, should begin and end with him. In post-graduate teaching there is no more impor- tant field than the Dispensary. The physician al- ready in practice who wishes to increase his knowl- edge of diagnosis or treatment in general medicine, or to perfect himself in any specialty of medicine or surgery, finds in the Dispensary an opportunity to deal with large numbers of cases along the lines of his particular interest, and to work under the supervision of a man from whom he can learn at every contact. Thus, the graduate schools of medicine that are now arising in connection with various medical schools depend largely upon out-patient service, as do those polyclinics and other teaching hospitals which seek especially for post-graduate work. The graduate physician is of course given a freer hand in a clinic than an undergraduate student. A group of graduate students may be brought together for conference and informal lectures, but in the main the teaching of graduate students consists in letting them work upon cases, under supervision of the instructor; in other words as clinical assistants. The Dispensary must in the future be utilized largely in the training of specialists, for a considerable proportion of the work required in opthalmology, laryngology, neurology, dermatology, syphilis, gon- orrhea, pediatrics and chronic diseases, is out-patient rather than bed service. Demand is growing for some definite system whereby training in specialties shall be available and as medical education perfects CLINICS 159 itself in this direction, a still larger utilization of the Dispensary must take place. In an even broader way, the Dispensary must be one of the chief means through which the general body of the medical profession shall be kept abreast of the advances in medical science and practice. The Dispensaries and the out-patient departments of hospitals will in the future be centers of periodical, practical education for the local profession, as well as of the more definitely organized courses under the aus- pices of post-graduate medical schools. (Of. page 395 .) The use of a Dispensary in the training of nurses is yet only beginning. Superintendents of training schools have often failed to see the great value of a Dispensary in this connection. Hospital demands have absorbed so much attention, that both the needs and the usefulness of the Dispensary in training nurses have been often obscured. There are signs that this situation is changing. In a Dispensary, pupil nurses meet many diseases which never appear in hospital wards. They learn many treatment procedures which in the future they will need to apply whether in private practice, in institutional work, or as visiting nurses. They are placed in a much more flexible and generalized human relationship with patients and doctors than in the hospital, and have a larger oppor- tunity for display of personality, initiative and execu- tive ability. A pupil nurse should, during the latter part of her training, be utilized in the Dispensary and pass through a number of the clinics, not necessarily through all. Modes in which she can be usefully em- 160 DISPENSARIES ployed have been suggested at various points in these chapters. The training of workers for medical-social service is a recent development. They also must have the experience of direct contact with the medical and human problems of patients. Here again the Dis- pensary provides opportunities without which no medical -social worker can be adequately trained. In the best courses of training for medical-social work, the Dispensaries have been utilized as major factors in providing students with practical experience under supervision. Of course there must be an organized Social Serrice Department to whose workers the students in social service will be suitably assigned. Volunteer Workers in a Dispensary The Dispensary offers unusual opportunities for utilizing not only the good will of volunteers but their personal services. What a volunteer can do depends on the person, for there are exceptional volunteers who undertake and bear large daily responsibilities. On the average the volunteer worker is a young woman who has time, energy, a strong desire to help, and a willingness to give from one-quarter to one-half of her time. Concrete and definite tasks must be offered them, such as : — Ushers in clinics or halls, seeing that patients know where to go, that they come to the doctors in turn, that they get promptly to the right clinic when transferred; Clerical work with records in cHnics, writing transfer slips, follow-up cards, or tabulating statistics; CLINICS 161 Clinic managers or executives (suitable only for picked people) ; Taking patients to hospitals, charitable organisations, etc. (a volunteer with her automobile is often a friend in need) . Visiting patients in their homes in connection with the follow-up system, or to carry a message or a bottle of medi- cine. It is essential that each volunteer be responsible to a particular person for direction and supervision. At some Dispensaries a chief of all volunteers is ap- pointed, at others one professional worker in each clinic directs the volunteers in her department. The wives, daughters or friends of the Trustees often form the nucleus of a body of volunteers, and the number may be greatly increased by the personal efforts of a few interested persons. It is often difficult to hold volunteers during the summer vacations, but some- times college students may be found who will give a month of their vacation to practical service. It is important that every new volunteer be instructed by a responsible person in her general duty toward the Dispensary. The necessity of punctuality and regularity of attendance must be emphasized. In- formation must be given as to contagious disease, prevalent misconceptions should be removed and yet caution inculcated, particularly the washing of hands before eating, when leaving the Dispensary or any place of possible exposure. Care should be exercised in permitting untrained volunteers to do any handling of patients, particularly in skin or surgical clinics. Volunteers often wish 162 DISPENSARIES very much to do dressings, but only those who have had experience and who can be trusted to work on selected cases and under the supervision of a nurse, should be allowed to do this type of work. A set of simple rules covering the preceding and other points should be written down, given to each volunteer, and she should be required to register her name, address, and time promised at the Dispensary, before beginning work. Firm but tactful insistence on conformity with the rules does not drive away any worth-while volunteer, but gains her respect and re- tains her service. Under the right leadership volun- teers develop skill, and grow in devotion and enthu- siasm as they feel themselves advancing in power. A group of effective helpers can be built up of value to the Dispensary and a leavening influence in the com- munity in countless ways. Preventive Medicine in a Dispensary Is there a place in the Dispensary for a division which has not usually been included, namely a Depart- ment of Preventive Medicine or Hygiene? Or, should the Dispensary's endeavor to prevent as well as to cure disease, find its expression in each clinic through the careful individual teaching of each pa- tient, the particular thing which that patient needs to learn and to put into practice? Both questions ought to be answered in the affirma- tive. Every clinic must do the bulk of the preventive work which its patients require, and to make this effective the chief requirements are sufficient time on CLINICS 163 the part of the physicians and a sufficient staff of nurses and social workers to carry out the various details of instruction, by word of mouth in the clinic, or by demonstration in the home. The existence of a Department of Preventive Medicine or Hygiene in a Dispensary might conceivably tend to render other de- partments less interested in educational and preventive service to patients, because of the feeling that this was the responsibility of a special department. But no Department of Hygiene can teach all the patients of a Dispensary. Only the clinic knows the individ- ual problems of its patients. There is, however, a real place for a Department of Hygiene and we may expect to see such develop as the public health func- tions of Dispensaries are brought more fully into view. A Department of Hygiene in a Dispensary would have the responsibility of working out general educa- tional functions, part of which would be undertaken by itself, and part by the several clinics, whose staff would be stimulated and assisted to carry out those forms of instruction which must be adapted to the individual case. Such a Department of Hygiene would have to be under the direction of a physician specially trained and interested in this type of work. Part of the activity of such a Chief would be research. His main field would be less the acquirement of new knowledge than the development of methods by which existing knowledge can be actually applied to human service. The Dispensary brings large numbers of patients together, presenting a great variety of medical and conamunity problems, and offers an almost un- lU DISPENSARIES developed opportunity for teaching the lay, as well as the medical community, how our knowledge concern- ing health can be made to count one hundred per cent in our practical application of it. Some of the obvious topics for such studies are the relation between housing conditions, occupational conditions and disease; the character, cost and method of use of patent medi- cines in self-treatment of various ills; the work of quacks and medical correspondence institutes; the food habits and dietaries of patients of various sex, age, vocational and national groups; the daily hy- giene and habits of life among such groups, as to exer- cise, water-drinking, defecation, sleep. Such are a few of the subjects on which we need more knowledge of the facts, derived from concrete case studies such as can be made among dispensary patients. Only from such knowledge can we tell how and where to apply educational or civic effort in practically effective ways. The second field for a Department of Hygiene would be in the study of methods of Health Education, and the actual educational work itself. Just what is the rela- tive effectiveness of leaflets, exhibits, posters, or the spoken word, in teaching this or that point to one and another type of individual? How shall the educa- tional efforts of a Children's Clinic be made most effective with the agencies at hand? How shall we best ensure that patients do not leave the Pharmacy without knowing just when and how to take their medicines? How shall we best induce the patients of the Dispensary, and also persons outside, to come in for periodical Health Examinations, and to bring their CLINICS 166 children for the same purpose? How, in general, shall we make the Dispensary a center of Health Edu- cation as well as of Medical Service? Great and little foundations for medical research are driving pioneer paths over the hills of knowledge. Must not Depart- ments of practical Hygiene follow, in public health bureaus and in Dispensaries, which shall make the roads broad and safe for democracy, so that democracy will travel? 166 DISPENSARIES CHAPTER XI DISPENSARY CLINICS, CONTINUED: SPECIALTIES AND TREATMENT CLINICS; LABORATORY; X-RAY DEPARTMENT; PHARMACY The Gynaecological Clinic In most large Dispensaries, gynaecology will be separate from general surgery. The department may or may not include obstetrics. In a Dispensary connected with a medical school obstetrical work is usually done in patient's home, by graduate physi- cians or by students under supervision, and also in the hospital for cases needing operative or other special care at delivery. In such Dispensaries, the obstetri- cal work should be unified with gynaecology, for their mutual advantage. The Gynaecological Clinic should therefore provide not only for the diagnosis and treatment of the special '^ diseases of women," but also examination to determine the existence of pregnancy when ques- tioned, and for supervision of the pregnant woman up to the time of confinement. This so-called '^prenatal work" is of increasing importance, and every gynaeco- logical clinic should either conduct it, or be closely correlated with a prenatal clinic, conducted as a public health clinic, in the vicinity. Visiting nursing service in connection with such prenatal work is essential (see pages 303-307) . CLINICS 167 It is essential to have privacy for the individual examination, and a woman attendant present. A graduate nurse must be in charge to insure asepsis. Patients should be seen individually by the physician. He takes the history and questions the patient care- fully about the various problems involved in her case. The patient should then be sent to the examining room or to a separate dressing room. After the nurse or attendant has seen that the patient is ready upon the examining table, the physician will go to the examining room. A staff for a Gynaecological Clinic, receiving thirty patients daily, of whom about five would be new patients, would include two physicians, one graduate nurse, one social worker and a clerk. The addition of a trained attendant would expedite the clinic, as a second patient could be in preparation for examina- tion while the surgeon is examining the first. Should gonorrhea in females be treated in a Gynae- cological Department? Frequently it is. The seque- lae and complications of gonorrhea closely involve the surgical aspects of gynaecology. It is practicable to unify gynaecology with general surgery in the Dis- pensary (under the system of specializing members of the staff referred to on page 151) and to treat all gonorrhea as such in the genito-urinary clinic. The equipment of a Gynaecological Clinic should include at least two small examining rooms, each provided with its own table, and preferably with its own sterilizer for instruments and gloves. Toilet facilities should be very accessible. It is a great 12 168 DISPENSARIES time-saver to have at least one more examining room than there are physicians. Facilities for cystoscopy are essential, and a pelvimeter for examining pregnant women. Unless the number of urine tests required is very large they should be sent to the central labora- tory. Genito-Urinary Clinic The scope of this clinic varies considerably. It is often difficult to draw the line between it and the General Surgical. In some institutions the Genito- Urinary Clinic is for men only, diseases of the genito- urinary system of women going to gynaecology. In other Dispensaries the Genito-Urinary clinic is for both sexes, and gynaecology is either combined with general surgery or is confined to a restricted field. Again, the Genito-Urinary Department sometimes includes the treatment of syphilis and gonorrhea, as the 'Venereal diseases,'' while elsewhere syphilis is treated in connection with dermatology or in a de- partment by itself. Decision as to the proper scope of the Genito-Uri- nary Clinic in any particular institution will depend upon the principles laid down on pages 84 and 151, and partly on the demands made by local public health movements for dealing with gonorrhea and syphilis. If both men and women are treated in the Genito- Urinary Clinic, the two sections must be kept adminis- tratively separate to a large degree, with separate waiting-rooms. If syphilis as well as gonorrhea is treated, the equipment and arrangement specified on CLINICS 169 page 18 must be included, and at least one additional room will be required for men and one for women. Assuming for the moment that only gonorrhea and the surgical aspects of genito-urinary diseases are included within the scope of this clinic, the following may be outlined : Gonorrhea is si disease which requires frequent visits and a fairly long period of treatment, and there- fore the proportion of visits to new patients will be large. Even including those cases which are trans- ferred to other institutions, or which move away from the city, seek treatment elsewhere, or which are *^lost," the average visits per patient among gonorrhea cases should be between fifteen and twenty, and any lower figure should arouse question whether proper supervision and control of the disease is exercised. This test must not be applied to a Genito-Urinary Clinic as a whole, since a certain proportion, some- times a large proportion, of the cases in the clinic are not gonorrhea. The Chief of the clinic should see all new cases. In a large clinic the patient is usually assigned at the first or second visit to an assistant for treatment, if this is of a routine character; but the Chief himself or a designated assistant would ordi- narily attend to a case where the cystoscope was necessary. It is desirable that the Chief, or a spe- cially designated assistant, should see the patient at each revisit, to note progress and indicate further treatment. The same physician thus sees the patient each time, even though a different physician may give the local injection, etc. The presence of a clerk or 170 DISPENSARIES trained attendant to attend to records and details, care for instruments, the follow-up system, etc., is essential unless the clinic is a small one. The equipment for the diagnosis and treatment of gonorrhea will include accessibility to a laboratory for examining smears and urine and making comple- ment-fixation tests. Examining and treatment tables, with irrigators, sounds, catheters, dilators, bougies, etc., are necessary. The cystoscope is essential, and a special room and table for cystoscopy are desirable, though not necessary. Some Genito-Uri- nary Clinics do a good deal of operating under local anesthesia and a special room for this, with operating and instrument tables, etc., will be required. Such a room may also serve for the cystoscopic work. The sterilizing equipment must be carefully looked to. Much the most convenient arrangement is to have the treatment room cut up into a series of small rooms, or booths, so that each patient has a room or compart- ment to himself during treatment. This compart- ment should preferably contain a small instrument sterilizer so that each physician can have his instru- ments, gloves, etc., readily accessible. Much time is saved by such an arrangement and privacy is gained. A utensil sterilizer for the basins, etc., is a necessity in the clinic. There must be a urinal immediately accessible, preferably within the clinic. A clinic providing for three physicians, treating men only, should have a trained attendant or clerk and, if possible, a male social worker, an admission or his- tory room, two treatment rooms or booths with the CLINICS 171 urinal accessible, and a cystoscopy room. If women are also to be treated during the same clinic period, an additional history room, a treatment room and a nurse will be required, The cost of the examining tables, sterilizing equipment, instruments, clerical supplies, follow-up records, etc., for such a clinic, would be between $800 and $1,500. Orthopedic Clinic This specialty has advanced in a remarkable way from a narrow and slightly considered field of medical service to a recognized and highly important branch of remedial, preventive and reconstructive surgery. Its widening applications to the control and promo- tion of the growth of children had been established before the War, while the War itself has brought to greater prominence than ever before the place of orthopedics in the rehabilitation of wounded and crippled soldiers, as well as to men and women in civilian life and industry. It is probable that a large number of physicians will acquire special training in orthopedics as a result of War activities. It is much to be hoped that when the War is over there will be a sufficient supply of such specialists to enable ortho- pedics to be a separate clinic in all but very small Dispensaries, instead of being combined with general surgery. In addition to the usual history room, and examin- ing room, the Orthopedic Clinic requires a special room for plaster work and apparatus for muscle test- ing. It is desirable to take photographs, to record 172 DISPENSARIES postural defects, and to have a frame in which a sub- ject can be placed so as to define certain fixed points for comparison at a later period in the same individual, when photographed thereafter. It is a question how far the Orthopedic Clinic should enter into treatment or leave these to special Treatment Departments, such as the Zander or the Massage. Unless the Dispen- sary is well equipped in the latter respects, the Ortho- pedic Department should be provided with bakers adapted to different|parts of the body, and with at least simple apparatus for corrective gymnastics. The clinic must have a nurse or trained attendant and a considerable portion of the patients will usually need social work, so that a special social worker is desirable as an adjunct to any large Orthopedic Clinic. Cor- rective gymnastics will require a specially trained person at those periods when the gymnastic exercises are to be conducted for individuals or small classes. Apparatus, such as braces, plates, belts, special shoes, corsets, etc., are required by many orthopedic cases. The Dispensary should arrange for their provision through the clinic in such wise as shall ensure the patient's procuring what is needed, and shall enable the orthopedic surgeon to see that the article is of good quality and properly fitted. This can only be done when the apparatus is brought to the clinic before it is given to the patient. Large Dispensaries may sometimes have their own shop for making surgical and orthopedic appliances, but most institutions will make arrangements with one outside. Apparatus will usually be charged for at prices not far CLINICS 173 from cost, and, as indicated on page 274, there should be arrangements for the remission of fees, or for pay- ment in installments when necessary. Eye Clinic In many middle-sized communities the eye, ear, nose, and throat, are treated by a single specialist, but in the larger places the oculist is a specialist by himself. An Ophthalmological Clinic is important, both as an aid in general diagnosis and for special service to those with defect or disease of the eye. The oculist should co-operate particularly with the departments of General Medicine, Neurology, Pedi- atrics, and with the clinic treating syphilis. Defects of eyesight found among children as a result of medical inspection in the public schools usually constitute a considerable proportion of the patients in an Eye Clinic. The majority of these are refraction cases. In some communities eye diseases arising out of special strains or hazards connected with a particular industry raise problems of medical, industrial and social interest. The work of an Eye Clinic naturally divides itself into two divisions: (1) Refraction, the testing of eyesight and fitting of glasses; (2) Pathological, the diagnosis and treatment of eye diseases. In a small clinic a single oculist will perform the whole service; in a large clinic the work will be divided among many. The tendency is for the Chief to take the major part of the pathological work and leave the refraction work to assistants. This division of labor should not be 174 DISPENSARIES carried too far, as it gives too little training to the assistants in the diagnosis and treatment of diseases of the eye. Refraction work, moreover, not infre- quently requires highly skilled judgment and the Chief should be prepared to do his share of it and should always see all questionable cases. Equipment: (1) the usual admitting or history room, (2) a room for eye testing. This must be at least ten feet long, in which case a mirror must be used; or preferably twenty feet long, so that the test cards can be seen at the normal distance for which they are planned. (3) There must be a ^^dark room'' for the examination of the interior of the eye. This can be small, but should be ventilated and not a mere closet. (4) A clinic in which two or more oculists are engaged should have a fourth room for the pathological work. There must be an ophthalmo- scope, ophthalmometer, sets of lenses for eye exami- nations and for fitting glasses, some instruments for minor eye surgery, and eye testing cards (Snellen charts). Instead of these charts the patented mechan- isms, which show only one line of the different size letters at one time, and are under the control of the oculist twenty feet away, are a great convenience. The provision of eye glasses, as of other apparatus which has a commercial sale outside, needs to be kept under careful control. Unless the eye work of the Dispensary is large enough to justify its own shop for cutting and fitting lenses, an arrangement should be made with a local optician to have a representative in the clinic during the active hours. He will take the CLINICS 175 prescription, measure the patient for size of frames, take the order for the kind of frames, and then bring the finished glasses at a later date, on which the patient is told to return. The oculist should see the patient before he leaves the clinic with the glasses, to make sure that the lenses are right and the frames properly fitted. Economical rates for patients and satisfactory clinic administration, are facilitated by such arrange- ments. Payment by installment should be arranged when necessary. Certain patients appear who have a friend or relative in the optical business, and want to have him provide their glasses. This should be permitted when the facts are clear and there should be an understanding with the optician about such cases so that no friction will eventuate. Letting the patients go to any outside optician with their prescription is not satisfactory. There is no control over the prices charged, and it is difficult to make sure that patients get the glasses they should. Sometimes an arrangement is made with a single optician outside, the patients paying the Dispensary and the optician sending his bill at agreed prices. This plan obviates one difficulty, but does not meet others. Not nearly as many patients will actually get their glasses; and it is also much more difficult to have them come back so the oculist can test them. A follow-up system to be sure that the patient actually secures his glasses is always needed in an Eye Clinic. 176 DISPENSARIES Nose, Throat and Ear Clinic Some institutions have a separate clinic for diseases of the ear, but the growing and desirable tendency is to treat ear, nose and throat cases in one clinic. A history room is necessary, as usual, a room for testing hearing, and an examining room or rooms which may best be divided into individual booths, each with a unit equipment. There must be an operating suite, including a recovery room, unless the operations are performed elsewhere in the Dispensary. It is no longer acceptable to operate upon the tonsils without keeping the patient until the next morning, at least. Some Dispensaries separate from a hospital have special beds for this over-night care. The out- patient department of a hospital should have pro- vision in the House for such cases. Tonsillectomy performed on adults frequently requires a longer period of stay. As in the Surgical Clinic, it is a desirable rule that no operation shall be performed unless the Chief of the department has seen the case and given his approval. It is generally desirable for the tonsillectomy cases to remain in the recovery room of the clinic for one to three hours before trans- ference to the ward. It is particularly undesirable to have such patients carried through corridors where many are waiting, for the patient's appearance while recovering from ether may shock many who may be expecting to pass through the same ordeal themselves. Each booth of the examining room should contain (1) a chair and a stool for a doctor and a patient; (2) an instrument table with instruments; (3) the neces- CLINICS 177 sary lighting for the surgeon^s head mirror; and (4) an enameled or agate pail for refuse and expectoration. Better than the pail, but much more expensive, is a flushing basin with running water connections. (5) An individual instrument sterilizer (best electric) for each booth is a great convenience also. The Throat Clinic of course requires a trained nurse, and a large clinic needs a nurse or trained attendant in the examining room and a nurse in the operating room. Operations should usually be done by appoint- ment, and can be put before or after the usual clinic hours. This will economize space and nursing service. Definite records of appointment should be kept, and a follow-up system for these as well as for the chronic non-operative cases. As a rule the proportion of cases needing social service is not large enough to require a special social worker for the clinic. The school nurse should be held responsible for seeing that her children keep their appointments and report for after-care as required. Dental Clinic The diagnostic importance of the dentist to General Medicine, Pediatrics, etc., is so great as to render a Dispensary incomplete without a Dental Department. There is also a mass of routine dental work to be done which usually far exceeds the facilities in the com- munity, and leads to numbers of undesirable ^^ dental parlors.'' Dental Clinics in well-conducted Dispen- saries should take the place of these. The Dental Clinic requires at least two rooms, if 178 DISPENSARIES there is more than a single dentist and one chair. The extraction and other operative work should be performed in one room. If there are a number of dental chairs and several dentists, it is well to have one large room for cleaning, filling, etc., and a smaller room for the extracting and operating. Large clinics will increase these units. A recovery room for patients immediately after extraction or other opera- tions is desirable unless elsewhere accessible. In all but very small clinics, a clerk is essential to attend to the executive details and be responsible for the ar- rangement and care of instruments and supplies. The development of specially trained ^^ dental hygien- ists," or '^nurses" for prophylactic work, is proceeding, and they will doubtless be attached to dental clinics in the future. The equipment of a Dental Clinic involves con- siderable expense. A clinic with four chairs, of modern but not elaborate type, with water connection; electric dental engines, and a set of routine instru- ments and trays for each chair, would cost about $1,500. If more than emergency work is done, a follow-up system is quite important, and patients should be taught to come to the dentist regularly at intervals indicated by him. Fees are usually charged to cover the cost of the materials used. A problem arises in connection with the taking of plates, making false teeth, doing crown and bridge work, etc. The equipment for these is beyond the reach of any but large dental infirmaries, yet adults frequently demand them. A clinic can, however, arrange with an out- CLINICS 179 side dental laboratory to furnish plates and teeth, only the taking of the casts being done in the clinic. Dermatology Physicians who confine their practice to skin dis- eases will usually be found only in the largest cities. A Dermatological Clinic under those conditions may be maintained either independently, or combined with syphilis (page 168). Otherwise it may be made part of general medicine, so far as adults are concerned, and of pediatrics with respect to children, a physician especially interested in skin diseases being detailed to treat skin cases, as a division of the two clinics mentioned. Dermatological work needs good day- light. No artificial lighting is wholly satisfactory. The careful dermatologist in an evening clinic will refer questionable cases by appointment to a daylight hour. Facilities for X-ray and for radium treatments should be available when possible. In a Dermatological Clinic there should be a history room and one examining room for each physician who is on service. Unless the clinic is closely adjacent to a laboratory, there should be provision in the clinic for the dermatologist to use a microscope and to make other tests on skin lesions or specimens. Careful attention to social conditions, and good follow-up work, is necessary for cases of scabies and other infec- tious skin diseases. Syphilis The great variety of local symptoms arising out of this disease cause patients to appear in every depart- 180 DISPENSARIES ment of a Dispensary, with symptoms which are really the result of syphilis. For the sake of clinical effectiveness in diagnosis and treatment, and for the protection of the public health, it is essential that every Dispensary lay down the rule that all syphilis be the responsibility of a single department. Whether this department shall be a special clinic for syphilis, or a Genito-Urinary Department treating syphilis and gonorrhea, or whether it shall be a Department of Dermatology and Syphilis, is a matter for detailed consideration. The department where is placed the responsibility for the treatment of syphilis must depend on the oculist to help with an eye condition, the surgeon, perhaps, with a syphilitic ulcer, the Medical Clinic with a heart condition, the Children's Clinic with a difficult feeding case of congenital syphilis. The Neu- rological Department must have jurisdiction over its special manifestations of the disease. A few institutions have attempted to form a Syphilis Clinic which is practically a department of general medicine in itself, including specialists in ophthal- mology, neurology, internal medicine, etc., but this plan will be practical only in a few large teaching institutions and cannot be generally expected or recommended. These general principles should be laid down: — (1) Concentrate the responsibility for syphilis in a single department ; (2) let its local mani- festations or symptoms be examined or treated in those clinics to which they especially relate; but (3) require the patient to report for constitutional treat- CLINICS 181 ment at periodic intervals, as required by the condi- tion, to the department having the general respon- sibility for syphilis. The department having the primary responsibility for syphilis will thus carry all syphilitic patients on its follow-up system, but some of the same patients will also be carried by other clinics. This relationship is particularly important in dealing with cases of neuro-syphilis. One means of enforcing these principles in practice is through the requirement that the Wassermann test shall be done only through a single department, e.g., the central laboratory, and that the occurrence of a positive Wassermann (or any other test which indicates syphilis) shall automatically cause a patient to be transferred to the department having the pri- mary responsibility for syphilis, the patient being placed on the follow-up system of the Syphilis De- partment. A Syphilis Clinic needs as good light as a Dermato- logical. There must be a history room, an examining room for each physician on service, and a special room for the administration of salvarsan. The staff must have facilities for Wassermann tests, and a dark field microscope for examination of primary lesions. The main Laboratory of the Dispensary may provide these facilities. In many institutions the Wassermann tests will be performed at the labora- tory of the Municipal or State Department of Health, but the clinic itself must provide for the diagnosis of early cases. The growing importance of lumbar puncture in the diagnosis of syphilis of the central 182 DISPENSARIES nervous system renders it essential to have facilities for this. There is still some difference of opinion as to how far it is safe to perform lumbar puncture as an out-patient procedure, the patient going from the building shortly after the operation. Many clinics of standing have had excellent results and no serious drawbacks from the performance of lumbar puncture in this way. But some selection of cases must be made and it is desirable to have facilities for keeping patients over night, although they need not be util- ized for every patient. A nurse is needed to assist in salvarsan injections, and may be made an expert assistant in this technique. The nurse, or a woman attendant, should of course be present at those examinations of female patients where exposure of the body is necessary. Nowhere is a social worker more important than in a clinic treating syphilis, for the most difficult and complex family problems arise. The follow-up system assumes large proportions in a syphilis clinic owing to the protracted period of treatment, and in a large clinic needs a special clerk. Syphilis and gonorrhea are distinct in diagnosis and procedure of treatment, but have a close relation- ship from the public health standpoint. When the two diseases are not dealt with by the same clinic, a satisfactory relationship between the two or three clinics treating them must be worked out. A con- siderable proportion of the gonorrhea cases are in- fected with syphilis and yet this may be overlooked unless special plans are made. The taking of routine CLINICS 183 Wassermann tests of all patients coining with gonor- rhea is to be encouraged. Some system should be worked out in every Dispensary for co-operation on all the public health relationships of venereal disease, as, for example, by a joint committee of members of the staff of the different departments (one, two or three in number), treating syphilis and gonorrhea. The common elements which relate these diseases to the community can then be dealt with according to a single carefully worked out and uniform policy. Tuberculosis This disease is largely referred to in connection with public health work, but a word must be said on its place in the general Dispensary. A special clinic for tuberculosis should be conducted as a Public Health Dispensary clinic, whether it is in a general Dispensary or not. Some large Dispensaries in cities will have no Tuberculosis Clinic because the Department of Health or some other institution has one in the neigh- borhood, as part of the general system of Tuberculosis Clinics in the community. It is most desirable that one of the tuberculosis clinics which belong to such a system shall be located in the general Dispensary. Tuberculosis will appear frequently in any Dispensary, and in several departments, particularly the General Medical, Children's, Surgical and Orthopedic. When there is no special Tuberculosis Clinic, the major portion of pulmonary tuberculosis will, of course, appear in the Medical Department for adults. In view of the great importance of the disease, it is to be 13 184 DISPENSARIES desired that there be a definite system by which a physician especially skilled in its diagnosis shall, as a member of the General Medical Department, have all cases, or at least all questionable cases, referred to him. There should furthermore be a very carefully worked out system by which patients will be re- ferred for treatment and follow-up to the appropriate public health dispensary. Social Service and visiting nursing are essential adjuncts of effective tuberculosis work. Diagnostic Departments The Laboratory and the X-ray Department are not clinics, but are primarily aids to diagnosis. Laboratory In a Laboratory for a Dispensary the minimum facilities provided should be : — Urine tests, qualitative and quantitative, chemical, and bacteriological; blood counts; Widal tests; the simpler bacteriological exam- inations, especially sputum examinations, throat cul- tures; examination of smears for the gonococcus organism; Wassermann tests and complement-fixation tests for gonorrhea; examination of stomach and intestinal contents. Facilities for the examination of pathological tissues are essential in connection with certain forms of surgical out-patient work, but such clinics will usually have access to the Pathological Laboratory of a hospital. In a hospital of moderate size, the main Laboratory of the hospital will serve for the out-patient depart- CLINICS 186 ment; but a local Laboratory for the frequently per- formed routine tests, particularly of urine and blood, should usually be provided, unless the main Labora- tory is very accessible. For the Laboratory of a Dispensary treating a hundred or more patients a day, the apparatus should include sterilizing equipment, incubator, ice chest, bench and sinks adapted for convenient work, the necessary reagents and glassware, a microscope, good daylight, facilities for work by artificial light, a dark stage attachment, and the necessary microscopic acces- sories, etc. The full equipment for a small Laboratory of this type would cost $1,000 to $1,200. Fre- quently the Laboratory of the local or the State De- partment will do free of charge the examinations of sputa, throat or vaginal smears, Widal and Wasser- mann tests. One room, 14 x 20, will suffice, but it is better to have two, one at least 14 x 16, and one smaller room of about 10 x 12. The Laboratory Staff must include a well-trained pathologist. In a Dispensary which carries on only one set of chnics daily, he may be on part time. In a large Dispensary, it is practically essential that there be a paid technician, on full time duty. It is hardly possible to overestimate the stimulating influence of good Laboratory work upon the clinicians of a Dispensary. The personahty of the Pathologist as well as his equipment is an important factor in developing the usefulness of the Laboratory to its fullest capacity. 186 DISPENSARIES X-ray Department The X-ray Department is used to some extent for therapeutic purposes, but its major service is in diagnosis. The cost of the needed equipment can hardly be below $2,500, and more satisfactory results may be expected for $3,000 or over. An out-patient department will be served by the same X-ray equip- ment as that used for the House cases. A large majority of all X-ray cases are ambulatory patients. The full details of X-ray equipment given in several standard works relating to hospitals renders detail unnecessary here, but something may be said on the administrative aspects. The large institutions may expect to have a roent- genologist who specializes in this work, and who will have one or more assistants, either physicians or lay technicians. The use of lay technicians for operat- ing machines under medical direction is increasing. In the small institutions, the problem of a Staff for the X-ray Department is often a difficult one. The expense of X-ray service is too great for the average patient at a charitable dispensary, to meet more than a fraction of the cost of taking and developing a plate. At prices of supplies such as prevailed before the war, the cost per plate generally ranged from 35 to 50 cents for a 5 X 7 plate to $1.00 to $1.25 for a 14 x 17 size, these figures including allowances for salaries and for depreciation of equipment as well as materials used. Fees of 50 cents or $1.00 per plate will have to be remitted for a considerable proportion of dispensary patients at most institutions. CLINICS 187 The financial burden can be lightened and an addi- tional service rendered by combining with the chari- table work a Consultation Division of the X-ray Department. There are of course many private patients of physicians who can afford good fees for X-ray service. There are also a large number of persons in every community who can afford to pay their physician, but who cannot afford to pay high fees for X-rays. The usual private rates for radiog- raphy are beyond them. The X-ray Department of a hospital or Dispensary should be open to such patients, when referred by their physician — brought in by him personally or sent with a letter. The fees charged should sufficiently cover the full cost. The patients should be sent back to their physicians with the X-ray plates. Such a use of the X-ray Depart- ment is of very considerable service to patients; it is a benefit to the local medical profession, and it will be of substantial assistance to the finances of the X-ray Department. Treatment Departments Out of the Pharmacy sprang the title '^ Dispensary," but with the advance of medical science and the relatively diminishing use of drugs, the Pharmacy has sunk to a minor place. But its function is still highly important. In even a small Dispensary a licensed graduate pharmacist must be in charge, although in the out- patient department the drugs may be compounded in the hospital Pharmacy and brought to the Dispen- sary merely for giving out. In a large Dispensary, the 188 DISPENSARIES Pharmacy should be located in the admission hall so as to be most accessible, and it should be con- venient to the exits, as a majority of patients going to the Pharmacy do so when they are through in the clinics and ready to leave the building. The window, or counter, whence the drugs are delivered, must be located with these conditions in mind. There must be waiting space for patients, but it is not necessary to have seats for the total number of patients who may be expected to wait at the Pharmacy at one time. With sufficient staff, few cases need wait long for their prescriptions. Some seating space is essential. The prescription blanks used should be such as will minimize the risk of error in giving out medicines. Most Dispensaries will use a formulary, so that physicians will put down merely a letter or a number designating one of the more usual prescriptions, the contents of the prescription being specified on a printed list, which is in the possession of the Pharmacy and of each physician (also posted in each clinic). These stock prescriptions are usually compounded in quantity, and dispensed from large containers as required. A formulary saves much time, but should not prevent other medicines or prescriptions being secured. Formularies should be periodically revised. It should be a general rule, in the interest of economi- cal and wise use of medicine, that not more than one week's supply should be given a patient except in unusual cases. It must be borne in mind, however, that patients who do not need to return to see the doctor for two weeks or more, and who live at a dis- CLINICS 189 tance, may properly be given a larger amount of needed medicines. Providing accurate and easily understood directions with the medicine is essential. The use of the phrase *'as directed'^ on the label should be forbidden. Directions should be printed, stamped, or plainly written on a suitable label or elsewhere on the con- tainer, and the patient should be instructed verbally how to take the medicine. Any question from him should be answered. Unless these requirements are carefully attended to, much of the benefit of medicine furnished, particularly to ignorant patients, will be lost. A Pharmacy needs a fairly generous allotment of space, but it is often practicable to put on the main floor only a comparatively small room for dispensing, while the compounding room is either that of the hospital Pharmacy, or is on the basement floor of the Dispensary, connected with the dispensing room by a stairway and dumb-waiter. Comparatively little work may have to be done in the compounding room during the active period of the clinics. Where two sets of clinics are run daily, there must be additional provision in the Pharmacy staff to keep up with the work. If fees are charged for medicines, according to principles laid down in other chapters, it may be expected that at least the cost of all the materials, — drugs, bottles and other containers — will come back. Probably somewhat more may be returned, even though no patient is refused medicine, at reduced rate or free, when he cannot pay the regular fee« 190 DISPENSARIES Massage The value of this department is considerable if well conducted. For equipment merely tables are re- quired. There must be privacy, as exposure of the body is often necessary. The rooms used for a Medi- cal Clinic are well adapted to massage, if it is neces- sary to make a combination and use the same rooms at different hours for two purposes. Electro-Therapeutic Department Not infrequently the Neurological Clinic has ap- paratus for treatment by electricity in various forms, but sometimes this is put in a separate division or department. The development and value of electro- therapeutic treatment will depend chiefly on the presence of a physician who is particularly interested and expert in its use. With such a man it proves well worth while, providing the somewhat expensive apparatus is available. Not very much floor space is required. Zander and Physical Gymnastics A full outfit for Zander treatment is expensive and needs special direction by an expert. Physical gymnastics adapted to the correction of various defects, as of posture, or for strengthening muscles undeveloped because of paralysis or other causes, are much more easily provided by small institutions. The Orthopedic Department, with its special interest in those defects which can be dealt with by physical gymnastics, may often be able to supervise, or even CLINICS 191 train a special technician for this service. The War will undoubtedly lead to a considerable increase in the number of persons who are skilled in medical gymnas- tics. The equipment required can cost anything from a small sum to a very large amount, but a competent person can secure excellent results in certain troubles of children, — postural and structural defects, muscu- lar atrophies, etc., — with very simple apparatus. Hydrotherapy The special value of such a department in connec- tion with neurological and psychiatric institutions is well recognized; but its field is much broader. Instal- lations are expensive and a specially trained, compe- tent person must be in charge. Operation of Treatment Departments One essential principle must be borne in mind in operating the treatment departments. They ordi- narily take no patients from the dispensary admission desk, but receive them only on reference from other clinics. It is essential that the patient should report back to the physician or surgeon who referred them to the treatment department, at such periodical inter- vals as he indicates. A definite system to effectuate such reporting must be worked out. Records must be kept in the treatment department, indicating what has been done at each visit paid by the patient, and the result of the examination by the surgeon or physician in charge of the case must be entered there, as well as on the record of the case in the referring clinic. 192 DISPENSARIES CHAPTER XII THE MANAGEMENT OF A DISPENSARY ADMIT- TING SYSTEM Many of the problems of admitting patients and of managing records and statistics are the same in every Dispensary, whether it be a large pay clinic, like the Mayo Clinic, or a charitable Dispensary treat- ing only the very poor. Methods must of course be adapted to the social, as well as the medical charac- teristics of the clientele. This chapter will relate chiefly to the conditions ordinarily found in chari- table Dispensaries, and the adaptations necessary for large Dispensaries of other types will readily suggest themselves. The problem of the small Dispensary is treated separately (pages 282-296). In a large Dispensary, every day brings a human stream. A hundred, maybe a thousand, men, women and children, will pass through the portals within a few hours. Each one brings his problem. It may be only a child whose teeth need cleaning, or it may be a girl, alone in the world, who is bearing the burden of unmarried maternity ; or a baby with pneumonia, a working man with a cut hand, a woman with symp- toms which may prove trivial or which may be cancer; people whose hearts, stomachs, or nerves have gone wrong; people whose eyes, throats or ears need atten- tion to make them work right ; people who have never ADMISSION SYSTEM 193 known anything but dire poverty; people for whom a sudden misfortune has wrecked former comfort; people who can pay their way usually and who wish to do so always, but whose resources break under the emergency of sickness. The medical and social prob- lems which may be found in five hundred units of the human stream that rolls through the dispensary doors are as varied as life itself. Too often, the reception of these vivid human units at a Dispensary has been left in the hands of a clerk who assigns them hastily to the clinics. This is wrong. As an old proverb says, to save at the gate is to suffer in the house. Careful, thoughtful admission of patients by trained hands promotes the medical and social efficiency of the entire institution. The functions of a properly organized admitting system are: 1. Social Placement, i.e., deciding as to the economic and social condition of each patient (or family). This renders possible (1) decision whether the patient should be treated in a free clinic, a pay clinic or a private office; (2) determina- tion of the fee to be charged or remitted ; (3) indicating any outstanding social need and starting to alleviate it. 2. Medical Placement, i.e., assigning each patient to the clinic appropriate to his complaint. This also involves the exclusion of diseases not accepted for treatment in the par- ticular Dispensary, — e.g., the common contagious diseases of children. 3. Identification. Securing and keeping accurate identi- fying data for each individual. 4. Collection of Fees, if fees are charged. 5. Statistics of Attendance. These are natm-ally made 194 DISPENSARIES at the admission desks, and should be part of the responsi- bility of the admission system. Two additional functions are so closely connected with these that they may well be included under the duties of the Admission Department, viz. : 6. Custody of Records. The clinical and other records concerning patients may be filed and cared for by this department. 7. Inquiries. Requests for records or information con- cerning patients should be looked into by this department, and the superintendent or other official supplied with the data required for an answer. This group of functions makes a body of naturally coherent duties which even in a small Dispensary will call for the time of one competent person, and in a large institution will demand a staff of several per- sons under a well-trained departmental head. Part of the common failure in dispensaries, i.e., to secure wise admissions, full and accurate statistics, and care- ful filing of records, has been due to failure to combine related duties so as to make enough of a job to render the employment of a trained person worth while. The admission system as now outlined includes two main functions: first, admitting proper; and second, the closely connected function of recording and caring for the data arising out of the admitting. The title of ''Department of Admission and Registration'' may well be given to this division of a Dispensary's work. The procedure of admission can best be illustrated by a diagram which tells its own story: — • ADMISSION SYSTEM 195 TO CLINICS It must be understood that the arrangement in this sketch is wholly diagrammatic ; the actual placing of the desks, record room, etc., in a Dispensary are not indicated, only their relationships. The actual spac- ing must be governed by the floor plan of the admis- sion hall; but the essential order and relations of the different parts must be preserved if satisfactory work is to result. The actual operation of the admission system is greatly facilitated by a well-designed set of cards and 196 DISPENSARIES forms. A set of typical forms, printed below with a few words of explanation for each, will be a practical way of rendering this chapter useful. FORMS USED IN THE ADMISSION AND REGISTRATION SYSTEM OF A DISPENSARY Form Designation Used At No. 1 Distribu- Desk No. 1 tion sups 2 Clinio SUps Desk No. 2 For the Purpose of Dividing the incoming stream into (a) Old Pa- tients (b) New Patients (c) Lost ("ard Patients, and of keeping (b) and (c) in order of arrival. Furnishing a memo- randum of the patients sent to each cUnic, and a receipt for the fee, if a fee is levied. The numbers on the slips enable the clinic man- ager to call patients in order of arrival; and also serve to give the Registrar immediate statistics of daily clinic attendance. Remarks Slips are numbered or let- tered serially. Numbers given to new patients en- able these to be called to the Admission Desk in or- der of arrival. Men and women may be separated, if desired, by givmg out numbers in odd and even series. Lost card patients may be given the letter series. Patients who "know the ropes," from previous vis- its, or who show their ad- mission cards at Desk No. 1 , go at once to the Cashier's Desk (No. 2) and, after paying a fee, if such is required, receive their clinic slip, which they must show at the clinic in order to be admitted. New patients, after being passed by Desk 4, go to Desk 2 and follow the same routine. The set of slips for each clinic may be numbered from 1 up each day, or in a cumula- tive series. The Cashier keeps the stub, gives the patient the slip, stamping both with the date and fee f)aid. Clinic slips are col- ected at the end of each clinic period. By counting the stubs and the slips, each furnishes a check upon the other, and also upon the cash. There will al- ways be found a certain small proportion of pa- tients who elope, — jthat is, get their clinic slips and even pay for them, but for one reason or another fail to go to the clinic. The stubs from these patients will be found but not the slips. In some institutions, the cash register has been used. This is a convenience, but does not furnish any essential check upon the cash. ADMISSION SYSTEM 197 Admifleion Desks No. 4 Card (5, etc.) 4 Clinic Record Desk No. 4 in Clinic and Record Room 5 Index Card Record Room Fee Re- mission Slip Desk No. 4 and by cer- tain ofi&cials of Dispensary 7 Free Pass Desk No. 4 and by cer- tain officials of Dispensary Serving the patient as a voucher for his admis- sion (and first fee, if any) ; enabling him to show this at later visits, giving patient informa- tion, in some cases, as to hours, days, or rules of clinics. Recording the medical record of the patient and certain personal and social data. A per- manent record. Constituting an index (alphabetical) to all patients who have been treated in the Dispen- sary at any time. Remitting a fee, in whole or part. Good on one day only. It is wise not to print on the slip the words "Fee Remission,.' ' or the like, but to use a distinguish- ing color. Similarly with No. 7. Enabling a patient to secure a series of fee re- missions for a specified period during which it is judged such remis- sions are necessary. Issued to patient at first visit, after inquiry at ad- mission desk. Numbered serially, the number being that under which all the patient's clinic records are filed. If lost by an old patient, is reissued with former number. The card should be of board or linen so as to be durable. Data above second red line filled out at Desk No. 4 at patient's first visit. Serial number the same as on Satient's admission card, ledical record filled out in clinic. A patient treated also in other clinics may have a separate card for each clinic, but aU are filed in Record Room under same number. Filled out from the data taken at Desk 4 ; filed alpha- betically in Record Room. In the form shown, the data are copied out (prefer- ably typewritten) from the upper half of the clinic record, the copying being done after the clinics are over for the day and the records have come back to the Record Room. Issued by Registrar or ad- mitting officers, or by social workers or other officials authorized to sign them. Shown by patient at Desk 2, and accepted by cashier in lieu of fee. Cashier stamps cUnic slip and stub for the amount paid, or as "Free" and keeps the Re- mission Slip with the stub as a cashier's voucher. Used as No. 6, except that patient retains the Pass, until its expiration. At each visit, on presenting the Pass to the proper officer a fee remission slip is given out, for use on that day. Free passes are rarely to be given for more than one month; a re-inquiry being then made before renewal. 198 DISPENSARIES Form No. 1 A Dispensary re- ceiving only twenty- five patients a day can use all these forms to advantage, except No. 1, which will be needed only when the number of patients in a two-hour admission period exceeds one hundred. As will be shown in Chapter XIII, this system prac- tically keeps the sta- tistics of attendance of the Dispensary with a minimum of labor in counting. It also furnishes a daily check on the cash received from fees. So far as possible, all fees should be col- lected at the cashier's desk in the Admission Hall. In some cases it is con- venient to have fees collected in the clinic, e.g., a pa- tient may have to be in the den- tist's chair before the character Children's Room 310 3rd Floor Date ^... Paid ^... No CHILDREN'S Room 310 Form No. 2 ADMISSION SYSTEM 199 DISPENSARY Street, Patient's Name Age. No. _ Address Dept Date. Dept Date. Dept-... _ Date. Dept...... _ „... Date. Dept _ , Date.. Dept Date. Dept .-. Date. Morning Clinics Hours _ . ^,. . Evening Clinics KEEP THIS CARD If you do, not bring this card with you when you come to the Dispensary, you must pay ten cents for a new card. Form No. 3 of the work is determined, and if there is a fee for an extraction or an operation, the patient should not have to leave the chair to go to the Admission Desk, and then return, wasting the dentist^s time. Similarly with fees for eye glasses. Certain specified fees may therefore be taken in a clinic, with a suitable check provided therein, and all the money should be turned over promptly at the close of the clinic to the central office. The most interesting section of the Admission System relates to the new patients. The interview with the person applying for treatment for the first time determines the patient's impression of the Dis- pensary and inspires confidence or the reverse. From the medical standpoint, correct reference of the patient to the proper clinics depends considerably upon the 200 DISPENSARIES - . . . . 'Olf pensary Name Age yrs mos. INO. Addrfift 8. M. W D. Came to Parent Birthclflce tJ S A NaliWtv Name of Parent Hnshand. Wife nrrn nf Patient (I».r,^„A 9- ■Wlcly Rale Oec'n of Head of Housthold I No. UtiemDlovmenl Children . No No Married Workinir " t . .Others deoendent. contribulitiB PAlienI cnmnlainsof - Previou* Ttealmrtl (Prf«iJt» dttkr, ipur Uttyvlai, itct^im^fia). Reason foi Change Dept. Daie Social Service S.S.No 1 V«» I No _^ - V IMafnosis Uifrn vwi) _Bl»«npsi$ {jw *..) - - Form No. 4 ADMISSION SYSTEM 201 Patient's Name Age yrs. mos. No. Address Social Status Birthplace Race or Color / Name of Father, Husband, Etc. Remarks Dept. Date Dept, Date Dept. Date Dept Date Dept. Date Dept. Date Dept. Date Dept. Date DISPENSARY REGISTRATION CARD Form No. 5 original interview at the Admission Desk. Adequate identifying information* and facts concerning the social condition of the patient are also of importance *Identifying Data: Name and address alone are not adequate as identifying information. Age is useful. Of especial help is the name of a parent of the patient, or if the patient is of middle age or elderly, the name of the husband, wife, or some other adult member of the family, will be sufl&cient, with the name, address, and age of .the patient himself, to identify him, even in a very large institution. Many similar names are found and securing the right spelling is difBcult, especially when many foreigners are included. These conditions compHcate the filing of the index cards in an alphabetical file, and as the alphabetical index to patients is of the greatest importance, a system of securing the necessary information must be devised. With certain nationalities, Syrians for example, patients do not know an English rendering of their name, and there is often no way of finding out. Other difficulties present themselves with such names as Smith or Cohen, which are often spelled in many different ways. At some dispensaries, the expedient has been used of filing certain names by sound; therefore Cohen and Kohn would be filed as one, the patient being identified by the first name and by the additional discriminating information above mentioned. 202 DISPENSARIES DISPENSARY Patient* t Name- Signed- Form No. 6 Ezpires. DISPENSARY Patient's Neune- Signed- Form No. 7 ADMISSION SYSTEM 203 from both medical and administrative standpoints. The first essential is a trained and competent inquiry at the Admission Desk. The medical placement of the patient in the proper clinic depends chiefly on eliciting at the Admission Desk a correct statement of symptoms. Whether or not the admitting officer is a physician, physical examination of the patient is not possible to any large extent in connection with the Admission Desk. In some institutions, examining rooms or booths are provided, but the number of cases in which an exam- ination is actually made never exceeds a small per- centage of the total. Many institutions find it simpler to send these cases to the Medical or the Children's Clinic, with a request that the clinic make an examination, and then refer the case, no clinical record being opened until the question of location is determined. The chief difficulty in having a physi- cian at the Admission Desk is that the young physician, usually an interne, has had no special training in dealing with people. He is not usually assigned to the admission work permanently, and does not look forward to acquiring skill in such a service. A well educated, permanent, lay admitting officer, under medical supervision, may be specially trained for the task, and will frequently be found to do better than the physician who can be secured for such work. Where a physician with the needed personal qualifica- tions can be permanently assigned to the task of the Admitting Desk and sufficiently paid, that is another question. One admitting officer cannot pass more 204 DISPENSARIES than fifteen new patients per hour and do proper work. Hence in a large Dispensary more than one admission desk is desirable. It is well when there are two, that one be a man and one a woman. Waiting benches should be provided sufficient to seat the maxi- mum number of new patients that will be found at any one time. Old patients pass quickly to the Cashier's desk and have to wait but a very short period. Many waiting benches are not therefore necessary for them, but a certain amount of seating space should be provided for the few that have to wait long for one reason or another, or for those that ought not to stand at all because they are lame, feeble or carrying babies. The exclusion of patients having contagious disease must be provided for in the admission system. Where there are many children among the patients, this is of the greatest importance. Certain Dispensaries have adopted the excellent system of having all children diverted from the main stream of incoming traffic, and pass by a physician, who looks at each child's throat, eyes, and the skin of the face and neck. Sus- picious cases are put aside for careful examination. Sometimes as high as two per cent of all the children entering the doors have been taken out in this way; although this proportion is probably much higher than average. In most Dispensaries, the children pass to the general admission desks along with the adults, and the admitting officers are responsible for picking out cases of probable or possible contagious disease. A trained lay officer becomes after a time as expert as ADMISSION SYSTEM 205 the average interne in ''spotting'' the cases and put- ting them aside for examination by a pediatrician. Under any circumstances there must be an isolation room or booth, near the admission desks, in which such children can be detained until a positive or negative diagnosis is made. The child is then either admitted to the Dispensary, or else sent home or to a hospital for contagious diseases. The questions to be asked of the new patient at the Admission Desk and the record that should be made are indicated on the ''clinic record" (No. 4) of the preceding set of forms. Information gathered at the Admission Desk concerning the patient's social con- dition may be useful to the Social Service Department, and may, at the discretion of the admitting officer, be transmitted to the proper social worker. This social information, while often thought of as merely for the purpose of determining the patient's admission or exclusion, can and ought to be used for many con- structive purposes. The previous medical treatment which the patient has received should always be asked for. Treatment simultaneously or recently received at another Dispensary in the same city is good reason for rejecting the patient, unless some unusual cir- cumstance is manifest. Treatment by a private physician should lead to the reference of the patient back to that physician, unless good reason appears to the contrary. Of course many patients are referred to a Dispensary by private physicians for special treatment, for consultation, or because the patient has no more money. Unless the Dispensaries of a 206 DISPENSARIES city have by mutual arrangement districted the area, previous treatment at another Dispensary for some disease other than the one for which the patient now applies should not of itself be ground for rejection. The admitting officer should be able to talk with j each new patient in a position which gives a sense of privacy. A screen partly around the admission desk will accomplish this and is more expeditious than a separate room. The late comers, reason for whose tardiness must be satisfactory to the admitting officer, present a some- what vexatious problem. The remission of fees is a problem in itself and should, so far as possible, be made the responsibility of the admission desk. Trans- fers or re-admissions are still another important duty of the admitting officers. Under no circumstances should a patient who has received treatment in one clinic be allowed to go to another clinic merely because of his own request. The general rule should be that such transfers should be made on the direction of the physician of the clinic that has already treated the patient.* The staff required for an admitting system may be briefly outlined. * Certain exceptions are convenient, e.g., a patient who had been treated in 1915 in an Eye CHnic and comes in 1917 with a cut finger, might be sent by the admitting officer directly to the Surgical Depart- ment. A patient might have a tooth pulled in the Dental Department on Monday, and apply for admission to the Eye Department a week later. Thus, the general rule should be: transfer only by physician; but certain specified exceptions can be formulated and their application left to the discretion of the admitting officer. ADMISSION SYSTEM 207 Most essential is a competent head. The head of the admission department may well be designated Registrar. For a Dispensary receiving an average of three hundred visits per day, of which about one-third would be reportable by the New Patients' Desk (new persons and re-admissions), the following persons in the admission department would be necessary : — 1. Registrar: taking general charge of admissions and herself (or himself) doing duty at one of the two admission desks for new patients. 2. Assistant Registrar: doing duty at the other admission desk for new patients. The assistant could devote his or her time after admitting hours to other duties. 3. Head record clerk: on duty in the central record room, taking out records during cHnic periods and filing, etc., thereafter. 4. Assistant record clerk. 5. Index and lost card clerk. A special person is neces- sary at the lost card desk during the admission period and the same person might well have charge of typewriting the index cards (which ought to be typewritten and not hand- written), and of the alphabetical index under the direction of the head record clerk. 6. Cashier: responsible for receiving money during the cHnic period and afterward assisting in the record room or elsewhere. 7. Page : taking records during the clinic period through- f out the Dispensary. This may be a boy or young man who j can assist in other work in the hospital or Dispensary after/ the admission period is over. Where there is not an ample! supply of orderlies, two pages would be more desirable. 8. Usher: Man or girl near the front door, dividing old from new patients. This person may perform other duties, 208 DISPENSARIES such as that of information clerk, telephone operator, etc. The arrangement of the hall may possibly render a special usher unnecessary. For each additional one hundred average visits per day, it will be necessary to add an additional record clerk during the clinic period to take out records promptly when pressure comes. For each additional twenty-five new cases (new persons and re-admissions) per day it will be necessary to add an additional desk or lengthen the period. The number of pages will depend on the arrangement of the building and the mechanical devices which may be introduced for carrying records. An important section of the duty of the Registrar is to provide and take charge of the statistics of at- tendance. All statistics should be under her charge, whether prepared by the workers in her own division or by persons in the clinics. The technique of keep- ing statistics and reporting thereon is discussed in Chapter XIII. A further and useful function of a well-organized admitting system is answering inquiries concerning patients, whether received from patients themselves, their friends, or in relation to court cases. These inquiries come partly by mail and partly by personal inquiry and by telephone. While the Dispensary is often under no legal obligation to furnish records or information, and for the sake of the patient must sometimes withhold it, it is the duty of the institution to co-operate in any manner that may benefit the patient or may avoid injustice to some interested ADMISSION SYSTEM 209 party. The Registrar or an assistant may be desig- nated by the superintendent to look up records, and either be given the power to answer inquiries in cer- tain specified cases, or to report the facts to the super- intendent, or other designated officer, who will decide what is to be done. Taking the admission system as a whole, it will be seen that a considerable body of useful and important functions, — medical, administrative and social, — can be collected, as it were, and made a Department. It is useful to do this in a large Dispensary because thus a sufficient body of duties can be gathered together to warrant the employment of a specially trained and competent head. Thoughtful and accurate admitting, good records, useful statistics, and helpful relation- ships to outside institutions, largely depend upon this department and upon the person in charge of it. 210 DISPENSARIES CHAPTER XIII RECORDS AND STATISTICS Records in a Dispensary are of four kinds: (1) Case Records of individual patients, medical, social, and administrative; (2) Records showing bulk of work, i.e.. Statistics; (3) Records analyzing character and results of work, i.e., Efficiency Records; and (4) Administrative Records as of expenditures, income, and purchases and use of supplies.* I. Case Records These may again be divided into three types; first the permanent medical record of individual cases, each containing the diagnosis and course of treatment of a patient in one or more clinics; second, records of the Social Service Department, containing social data, analyses and treatment; third, temporary or adminis- trative records which are used to facilitate the various procedures of transfer, inquiry, etc., conducted from the different clinics, the laboratories, etc. There has been much detailed discussion of the most desirable form for medical records. Formerly Dis- pensary records were usually kept in books; each patient had a line. This was, of course, before there * Type (3) is treated in the chapter on Efficiency Tests; type (4) in the chapter on Finance. RECORDS AND STATISTICS 211 was any idea of continuous supervision of treatment or of doing more, in most cases, than to relieve symp- toms by giving a prescription. As the standard of Dispensary work advanced, especially in teaching institutions, spaces with several lines were often ruled off on the pages of the book. Thus not only name, address and prescription, but diagnosis and treatment could be entered. But the only satisfactory and now almost the universal method in Dispensaries of stand- ing, is the card record. The tendency has been towards the adoption of a I form of card approximately 6 inches wide and 9 inches y high. A very wide card is not so convenient to write on as a narrower one. Too large a card is incon- venient and one too small is wasteful of time and stationery. (See sample form, page 200.) Some teaching Dispensaries of high rank use a paper folder, giving four pages, and thus ample space for j detailed entries; the paper, when not in use, being [ protected by an envelope or a heavy folder. But for the average Dispensary the card is better. Even in the teaching Dispensary, the proportion of cases re- quiring very full records is not large, so that the in- convenience of several cards needed for a relatively few cases may well be overbalanced by the greater convenience of the card system for the average case. A multitude of different forms, each used in one or more representative Dispensaries, might be described. We shall, however, confine this discussion to certain principles. With the increased requirements for thor- ough medical work in Dispensaries, there was for a 212 DISPENSARIES time a tendency toward very detailed printed forms. All the items which might be recorded in a complete physical examination would be printed on the cards with spaces left for writing in or checking. But with longer experience both in medical teaching and in management of clinics, the detailed record form has been largely abandoned and now usually only a few printed headings are found. The printed headings, if ' in great detail, do not admit of adapting space to varied cases, one of which will require much writing under item A and little under item B, while another case may need just the reverse. To a considerable extent the printed headings may be replaced by the I use of rubber stamps, with much gain in time and space. Each stamp contains an item or a set of items, with space after each for filling in or checking the findings. Special examinations which are not per- formed on every case can each have their rubber stamp in the clinics needing them. Diagrams of the chest, teeth, etc., if on rubber stamps, can be impressed on the particular part of the record card where they are most convenient. So with stamps for laboratory \ reports, etc. This rubber stamp plan can be devel- oped quite extensively and renders the use of a moder- , ate-sized card with a few printed items on it, adaptable to many different clinics or purposes. The medical student also is placed more on his own responsibility by a card with a few items than with one that has each heading for the examination printed before his eyes. The social or identifying items can be reduced to much greater uniformity than the medical, and the RECORDS AND STATISTICS 213 problem is therefore simpler. They can well be printed on the record card, or, as in some Dispensaries, on a special card. Where the card records for each pa- tient are filed in a folder or envelope, the social items have sometimes been printed on the outside of this cover. As indicated in Chapter XII, it is desirable that the identifying information concerning the pa- tient, the identifying number, and certain social items, be taken and recorded at the central admission desk rather than in the clinics. In a large Dispensary, the great number of records raises at once the problem of filing and distribution. In the old type of Dispensary each doctor looked up his own set of records, or each clinic had its set; there was no uniform system of filing and no way of telling in how many different clinics a patient was receiving treatment. The Massachusetts General Hospital was a pioneer in establishing a central record room in ] which all the clinical records are kept and from which they are distributed daily as the patients come in. ' From the standpoint of the specialist who is simply interested in seeing what particular cases in his own line are being treated and what treatment is followed, there are certain advantages in having all the records of his own specialty filed in his own clinic in chronologi- cal order. But from the standpoint of an institution as a whole, for the best play of co-operative diagnosis, and for the utmost benefit to the patient, an assembling in one group of all the medical information concerning each patient, is undoubtedly essential. The advantages of a central record room are partly 214 DISPENSARIES administrative; they make a single person or group of persons responsible for filing records and for keeping them in good condition. A higher value is the pos- sibility of centralizing all the medical information pertaining to each patient. The patient is the unit of treatment, not the clinic. If the patient needs ex- amination and treatment in two clinics, all the records made in each clinic (usually each on a separate card) are put together in a folder or by some binding device, and filed in the central room. When sent to any clinic at the next visit of this patient, they are sent together. Thus the physician in each clinic has opportunity to see the diagnosis and treatment of every other depart- ment. Attempts have been made in some institutions to use a single record card, instead of a separate card for each clinic. At each visit of a patient the clinic to which he goes writes the record of treatment on the next blank space on the card. So many practical disadvantages seem attached to this plan that it can- not be recommended. It must be borne in mind that there are three re- lationships between clinics, with respect to the joint examination or treatment of a patient : (1) Consultation, i.e., Doctor in Clinic A takes patient personally to Doctor in Clinic B, or sends for Doctor in Clinic B to come to see the patient in Clinic A. The two doctors talk over the case, and a record of Doctor B's opin- ion is made directly on the card in Clinic A. (2) Refer, i.e., the patient is sent with a ''Refer" slip from Clinic A to Clinic B. This is the same as Consultation, except that the doctors do not meet personally. In this RECORDS AND STATISTICS 215 case, the record card from Clinic A is sent via the central record room to Clinic B, and the doctor enters his opinion thereon. The patient may be treated thereafter in both clinics, and if he is treated in B, a new clinic card is opened. (3) Transfer, i.e.. Doctor in Clinic A thinks the patient needs treatment in Clinic B instead of in A. The patient goes to Clinic B with a "Transfer" SHp. The record from Clinic A goes to B also, and if B accepts the patient for treatment, B opens a new card for the patient in that clinic. The patient then ceases to go to A. A's card will contain a final entry: ''Date: Transferred to Clinic B." It is possible to maintain a fairly adequate system of correlating clinics without a central filing system, pro- vided the following principles are adhered to: (1) Each patient must be given a single identifying num- ber which his record in every clinic contains. The clinic records are filed according to this number in each clinic. (2) The patient is given an admission card on which is stamped his number and also the name of every clinic to which he is sent. If he begins in the Medical Clinic, and later must be transferred to the Orthopedic, the name of the latter clinic must be stamped on his admission card (at the Cashier's desk) at the time of the transfer. The physician by looking at this admission card each time the patient comes in can see what clinics the patient has been in and can send for the records, if he desires information from the physicians of the other departments. (3) There must be an index card made at the first visit, with the num- ber and identifying data concerning the patient and the name of the clinic to which he is sent. If he goes afterward to other clinics, their names are also stamped 15 216 DISPENSARIES on the index card. The index cards are filed in a central alphabetical file; they furnish an index to all the records in the Dispensary, although it may be neces- sary to hunt in several different clinics to assemble all the records about any one patient. It may be pointed out that the three preceding principles all apply to the central record system also, and these three principles are in fact the basis of any good plan of Dispensary records. With a central record room, all the records of each patient are kept together. The alphabetical index furnishes adminis- trative control. Entering the list of all the patient's clinics on his admission card is no longer necessary, though at times it is a convenience. The details of management of the record room and the staff required have been already treated in the preceding chapter. The records of the Social Service Department may be regarded as those of a special clinic. ^'Social Service '' should be entered on the index and admission card, as if the patient went to a dental or surgical clinic. The frequency with which social records on active cases must be consulted is one reason why the social case records have usually been filed separately from the medical records. In most instances they are filed in a separate number series. In many social cases the records involve descriptive details, copies of correspondence, etc., and are bulky, and it has not been thought desirable to burden the clinic doctors by having these social records accompany the medical records to the clinic. RECORDS AND STATISTICS 217 The record forms which have been found useful in Social Service Departments are fully treated in Miss Cannon's book. The third type of case records are for temporary administrative service only, instead of being perma- nent records. The chief forms may be listed as follows : (1) The Refer, already defined. Where there is a central record system, the record card of the referring clinic automatically comes back at the patient's next visit, thus furnishing the doctor with the report de- sired. Where there is not a central system, the Refer must contain a stub on which the report must be written. (2) Transfer. The Refer and Transfer Slips are often combined, by having a bracketed heading like the following, the physician checking the one desired. J Referred for Diagnosis and Report \ Ph V \ Transferred for Diagnosis and Treatment . . / Where there is no central record system, a Refer- Transfer blank in the following form (No. 8) has been found useful. The small stub is kept in the original clinic until the report returns, furnishing a check. The missing reports can be periodically hunted out. With a central record system the stub can also be used, but will usually be unnecessary. (3) X-ray Refer. A useful form is printed here- with (No. 9). (4) Laboratory Refer. This must be adaptable to various types of specimens, such as blood-counts, urines, stomach contents, Wassermanns, etc. Several 218 DISPENSARIES S I § i i o o > ^ S S •8 2 -: 3 ? S ! H e o RECORDS AND STATISTICS 219 H "■■"■ 1 H Cl "i e 3 ft a « >4 • u • o PS ■* 3 .a I • • ft ^ 'O g H P ® g o 3 • tf ;; 5 A « S^'h-ceS'-'"^'^ o © I 1 6 ;3 «: ) V cu a O : F 220 DISPENSARIES different forms, or a single form with appropriate headings and spaces, may be used. The single form is preferable. Since the Laboratory must render a report, the type of form just described for the Trans- fer is the best. Gummed slips for the Laboratory re- port form have been used, to be pasted on the clinic record card, saving copying. But they are likely to be inconvenient and a better plan is the use of a rubber stamp, which minimizes writing and time. 1 (5) Hospital Refer. In a Dispensary which is the Out-Patient Department of a hospital, sending the patient into the wards requires merely the usual *^ Refer" blank, although more elaborate forms, including medical and social data concerning the patient, are in use. When a Dispensary is not con- nected with a hospital, or for any reason must send a patient to a hospital outside, a different form should be used. The example printed will indicate the points covered, viz., definiteness of reference; provision of information wanted by the hospital admitting officer; provision for report, so that the Dispensary learns whether the patient actually reached the hospital and was admitted. The return slip, when sent back by the hospital, covers this need. Considerable attention has been recently devoted to the proper relation of the Dispensary records to those of the hospital of which the Dispensary is a part. There should be a complete interchange of information between the two branches of the institution. The pa- tient, not the department, should be the unit. When the patient goes to the hospital ward, the Dispensary RECORDS AND STATISTICS 221 2000-lMS — ^ Dispensary (Date) To Admitting PHvsiaAN: This patient (Name) Addresa = ;.. , (Stpect. Number and Town) is recommended for admission to Hospital from No Diagnosis .191 Department of Dispensary. M. D. Superintendent ITo Name...,. Address DETACH THIS SLIP. FIl,!, OUT AND RETURN Superintendent of Dispensary No : Admission Diagnosis _^-_ Has been admitted to Ward _ „ Service to-day Date ! ^ ^..191 Form No. 10 222 DISPENSARIES record should follow him so that all desired information can be noted by the interne and the attending physi- cian. In some cases the information wanted is copied out on the ward record. In a few institutions, the hospital record and the Dispensary record of the same case are filed together. This has many practical disadvantages. The number of Dispensary cases usually is much larger than the ward cases. Many hospital cases never enter the Dispensary, and vice versa. The forms and sizes of cards convenient for hospital records are not on the whole those which have been found most advantageous for a Dispensary. Special conditions in a particular institution may per- haps render desirable the joint filing of hospital and Dispensary records; but as a rule they had best be separate. Of course the alphabetical index to pa- tients could be for the institution as a whole, and should indicate all the clinics as well as the hospital (or the wards) in which the patient has been cared for at any time. The separate filing of ward and Dis- pensary records is not inconsistent with having a single record room for both branches of the work. As a general policy for relating the hospital and out-patient department records the following may be outlined : — When a patient passes from the out-patient department to a ward, the dispensary records should be sent to the latter and examined by the interne and, if necessary, by the attending physician. Notes are put upon the hospital record, after which the dispensary record is returned to its file. On the discharge of any patient from the hospital to RECORDS AND STATISTICS 223 the out-patient department, the hospital record should be sent to the appropriate out-patient clinic, and should be examined there by the man who has charge of the patient. He in turn may make such notes as desired on the Dispen- sary record and then the hospital copy should be returned to its own file. Some institutions have an Out-Patient Summary, usually very brief, sent with the patient from the Dispensary to the ward, and a Ward Summary sent in the reverse direction; instead of sending the full record. The latter plan is to be preferred. In administering a Dispensary record system there should be kept in mind a cardinal point mentioned in preceding chapters, viz., a responsible, trained person in charge of the records. The Registrar may be this person, although the record system of an out-patient department may be so unified with that of the hospital that the librarian of the latter will have supervision of the dispensary records also. Since the Registrar will devote a considerable portion of time to the admis- sion of patients, there must be a first lieutenant in the record room itself, i.e., a chief clerk. This is a not unimportant position in a large Dispensary, calling for quick, accurate and conscientious executive work. A record system in a Dispensary does not reach its maximum of mechanical perfection or of medical usefulness unless there is skilled supervision of the content of the records. No record should be filed until it has been examined for the accurate entry of the identifying data. This can be done by one or more of the record and file clerks. Beyond this, there ought to be periodical examinations of the records in each 224 DISPENSARIES clinic by a physician, who will criticise the medical content. Ideally this should be done by the chief physician, but when this is impossible, another person should do the reading and call to the attention of the head of the clinic each instance of certain defects, designated in advance. The proper filling out of a definite diagnosis, the entry of the essential details of physical examinations, and the recording of treatment or condition at each visit, should be especially looked for. 2. Dispensary Statistics What is the essential unit for measuring Dispensary work? In Out-Patient Department reports there usually appear such terms as ''New Patients" and ''Old Patients." These are ambiguous. "New Pa- tients" may mean persons who have come to the Dispensary for the first time in their lives during the current year, or again it may mean persons who have come to a particular clinic for the first time. In Dispensaries where each clinic keeps its own statistics, if a patient has gone during a year to three clinics for the first time, he will be recorded three times as a new patient. "Old Patients" may mean persons who are going to the same clinic a second time, or those who are going to a new clinic. The confusion exists chiefly because there are two factors to be kept in mind: first, the Dispensary as a whole; second, each clinic as a depart- ment. There are really five items we ought to know, as the basal data for measuring the bulk of a Dispen- sary's work during any specified period. RECORDS AND STATISTICS 225 (1) New Persons: The number of different in- dividuals admitted as patients for the first time to the Dispensary as a whole. (2) New Clinic Patients: The number of different individuals admitted for the first time to each clinic. (3) Total Persons: The number of different in- dividuals treated in the Dispensary as a whole during the period covered. (4) Total Clinic Patients: The number of different individuals treated in each clinic during the period. It will be noted that the sum of the '^New Clinic Patients" (2) for all clinics will not be the same as ''New Persons" (1) in the Dispensary. Likewise the ''Total Clinic Patients" (4) summed together for all clinics, is much larger than the "Total Persons" (3) for the Dispensary as a whole, during the same period. There is one figure, however, which is not ambiguous, and that is (5) Total visits, i.e., the number of treatments given patients. These are properly recorded by clinics, for the clinic is the unit in which treatment is given; but the sum of all visits to clinics gives the total of treatments in the Dispensary as a whole. This is the fundamental unit of dispensary work. Even in a poorly organized Dispensary, "Total Visits" can be easily and accurately kept. The total of attendance at each clinic, each session, added all together, gives the figure for the institution. "New Persons" is not difficult to keep if there is a good central admitting system, with adequate identify- ing information recorded and an alphabetical index. 226 DISPENSARIES This item is chiefly of interest as an indication of the spread of the Dispensary's work each year. Where a serial number is issued to each new person, the dif- ference between the first and last number issued during any period gives the number of new persons. ^'New Clinic Patients" is also easy to secure, for a patient automatically makes a record at the time of first admission to any clinic, whether by transfer or from the admission desk. In the admission system described (Chapter XII), the cashier's clinic slip stubs (see page 196) give the total visits; while the admission desk index cards give the new clinic patients. ^^ Total Persons" and ^^ Total Clinic Patients" are interesting items but troublesome to obtain. They require that a special entry be made the first time (dur- ing each year) that a patient enters a clinic or the Dispensary as a whole. Individuals must be discrim- inated as such and the same person entered only once each year. One method of doing this is to put upon the patient's record card, when it passes out of the cen- tral record room to a clinic, a small '' signal" (the col- ored steel '* signals" are best). Such a signal is also put on a new record card, when made out for a new person. The number of signals used on any day is the number of different individuals (or '^ Total Per- sons") treated on that day, and so on for a month or year. If the signals are colored according to clinics, the number of each color used will give the '^ Total Clinic Patients" in each clinic. Even this plan in- volves much labor, more than may be justified by the value of the information secured. RECORDS AND STATISTICS 227 In practice^ Dispensaries should secure and record at least : — 1. Total Visits. 2. New Persons, 3. New Clinic Patients. Methods of recording and utilizing this information are treated later in this^chapter and in the chapter on Efficiency Tests. The ordinary work of the admission desk renders it easy to secure certain other statistics of much interest. Patients may be classified by sex, age, color, occupa- tion, nationality, marital condition, etc. How far shall we go in recording and tabulating these items? In general, the principle to follow should be : — 1. Record only what is useful for a definite purpose. 2. Use what you record. Otherwise do not record it. 3. Tabulate as statistics only such records as give inform- ation possessing public value or guiding power over admin- istration. Patients' sex and ages, [for example, should be ac- curately recorded for medical purposes. To tabulate ages in detail for an annual report, however, would rarely be of value. Classification into '^men, women and children" is usually suflScient. Occupations, when accurately recorded by industry and process, are of high value in correlation with disease. If loosely recorded and published, as in many annual reports, merely as a long list by themselves, they are as a rule not worth the paper they are printed on. A general Dispensary should record and tabulate at least the following : — 228 DISPENSARIES New Persons should be subdivided by clinics and by Age and Sex. A certain age, usually 12, 14 or 16 (the legal working age in the state) is taken as the dividing line between ^'Adults" and ^'Children." All persons above this age should be tabulated as Men or Women; all under this age as '^ Children, '' their classification into sex being usually unnecessary. Color is important to record and tabulate in some sections of the country ; elsewhere its tabulation would be of littleValue. Nationality* (rather than birthplace) is almost al- ways useful and important. It may be tabulated for the Dispensary as a whole. Occupation should be accurately recorded, but tabu- lated only in so far, or in such particular clinics, as will make the data significant and useful. How can the statistics of attendance, etc., be most economically and accurately recorded and tabulated? In the discussion of the admission system, it was shown how the daily record of attendance would be readily kept at the desks of the admitting officer and of the cashier. The tabulation form printed on the opposite page has been found useful for recording these data. On this can be built up the entire yearly statistics as fol- lows : — * In recording Nationality, use a practical, not a technical definition. Thus, Syrians should be recorded as such, not as Turks; Jews as Russian Jews, Pohsh Jews, etc., not merely as Russians or Poles. Persons born in America of foreign parents should be suitably recorded, as in the United States Census. 5 Month of ,19 ATIENTS Former Dept. Total Visits INTERCHANGE OF s Year Previously here this Year TRANSFER P en TOTAL l»Kdbr Amwered to Ua- aaswercd Ob Spoilt *""-! l~- Dav Average Visits per Patient way .rivciogc y .0 ic> j i^ Fort Dispensary SfofJcfir-oI Rpnr>rf fnr Dfinnrtmfint Hiirinff Mnnth nf 19 Physician nr Siirgpon in Charge, T)r. Assistants Days of Month NEW PATIENTS OLD PATIENTS Total Patienia to a Deft. OLD PATIENTS B.lurnini 10 Fora.r D.p.. Total Vllila INTERCHANGE OF TRANSFERS By Admiiiioo Desk By Transfer from Physician First Time This Year Previously liere tliis Year M.= Women a,i,d,„ TOTAL M.. w™,. Childr., TOTAL Mc, Children M.n W.n,.n Child,.. TOTAL kmH, Ajumd Jr^ Swdl. 1 2 ^-~^ s • ^ ■q-.; ..[,7 "l" i2. Hi U" i» • «| » 1« tT «» ■ » »0 r»» Form No. 13 (goes on a 3 x 5 card) FOLLOW-UP SYSTEMS 239 A date index is merely a filing arrangement in which the cards are filed under the date on which the patients are expected to return. Date indexes of many kinds have been devised; the most obvious is simply the card filing drawer with colored dividers marking the days of the month. The patients who are to return on a certain date have their cards put just behind the divider indicating that date. The visible indexes have many points of practical convenience though they are slightly more expensive to install. The ''Index Visi- ble/^ invented by Prof. Irving Fisher, has a strip of metal on which the date cards are attached by a simple device. One strip can be used for each day of the month, or in a small clinic each strip may be divided so as to allow for several days. The ''Rand" visible system gives practically the same result as the other with a different mechanical arrangement. When a patient first comes to the clinic the date card is filled out with the patient's name and identi- fying number; and this date card, if filled out by a clerk, goes to the physician with the patient's medical record. If the physician fills out the date card him- self, he has it already in hand. In either case he marks on the card a check or line on the date on which he desires the patient's return. If the patient is to be discharged or is to be transferred finally to another clinic or institution, the word "discharged" is written on the date card. The date card then goes back to the filing cabinet and is either put into the file under the date of the patient's expected return or is filed away with the cards of discharged patients. 240 DISPENSARIES In a large clinic it is generally desirable to have a date division for each day of the month. Thirty-one divisions plus a few additional ones for extra cards, etc., will be enough. In a small clinic, or where the diseases treated are such that they do not have to be followed up closely by days, a division by weeks may be preferable. The scheme can be readily adapted to long-term chronic cases as well as to cases of acute disease. In any case the operation of the date index is as follows: On each clinic day the patients who return have their date cards looked up and taken out of the index. These cards go to the doctor and are again marked, either ^^ discharged" or with the date of the next desired return. When a patient does not return on the day, or during the week indicated, the date card of course remains in its place in the index. Thus at the end of the day (or week) the names of all pa- tients who have not returned are known. Then the follow-up efforts may begin and a post-card or a letter be sent to the patient. It is a distinct aid in promoting the return of patients to give each an Appointment Card as a memorandum, and the same may also serve educational ends. An example of such a card is given below (Form No. 14). Generally it is desirable to wait from three days to a week after the date on which the patient was sup- posed to return before sending the post-card, as weather or other conditions may have delayed the patient from coming on the exact day. Cases which are medically urgent can be so marked by the physi- FOLLOW-UP SYSTEMS 241 DISPENSARY: Please return on To see the Doctor in the Dept, KEEP THIS APPOINTMENT! A visit at the time the Doctor advises may save many visits later on. The Doctor asks you this for your benefit. roan 7» sii-«-i» Form No 14. The man who runs a big factory has oilers and mechanics who go over every machine regularly. They do not waut until a machine breaks down. Sickness means that the machinery of our body has' broken down somewhere. Most people do not go to a doctor until this happens. This is a mistake. If every grown-up person whether he were sick or well, went to a doctor once a year, and every child were taken to a doctor once in six months, a great deal of sickness would be prevented and life would be prolonged. See a doctor at regular intervals, to examine you and give you advice for your health. Form No. 14 (reverse aide) 242 DISPENSARIES cian or certain diagnoses can be understood to be always urgent, so as to start follow-up without waiting the usual period. In a large clinic the follow-up system requires the assistance of a clerk. A post-card or letter sent to the patient and not causing him to return, may be followed by a second notice. In some clinics a reply post-card has been sent in certain instances, in order to furnish information as to why the patient did not return and what the condition is. But the reply post-cards should be used with selected cases only, if at all. After one card or letter has failed, it is well to have the case considered again by the physician, or to have the cases classified according to gravity of diseases; the point being to determine which cases shall be dropped and which further followed. The home visit, made by a social worker, visiting nurse, or a well- supervised volunteer, is the final resort after the mails have proven ineffectual. Post-cards, in which only a few items had to be filled in, have been generally employed by Dispen- saries, in their follow-up systems; except in clinics treating venereal disease (see below). Letter forms are however distinctly more effectual, and cost only a very little more, in stationery and labor. Since the War, rates of postage on post-cards and letters are the same within the local district. Multigraphed letter forms can be cheaply prepared, and adapted to a variety of cases by suitable wording. The Boston Dispensary uses about ten different forms, in three series; one designed for children, one for adults, and FOLLOW-UP SYSTEMS 243 the third for venereal cases. Within each series the different forms are meant for different types of cases, acute, chronic, needing laboratory tests, etc. Two sample forms are printed herewith. DISPENSARY Street and Number Department Room No To: Please return to see the Doctor before 10 A. M. on Bring your Dispensary admission card with you. Form No. 15. Bear The Doctor wants you to return to the Clinic on of next week. If you are well, or if for any other reason you do not plan to return, please send a letter so we will know how you are. This notice is sent to you for the sake of your health. Very truly yours, Dispensary Clinic. By Date 191.. Form No. 16. The reasons which patients give for not returning when asked to do so are well worth noting. The 244 DISPENSARIES reason stated may not always be the real one, but it indicates the state of mind of the patient and some- thing of the impression actually produced by the advice given at his last visit to the clinic. Valuable suggestions for more efficient clinic management may be secured from such data. It is found that of the patients who are told to come back for treatment from seventy-five per cent to over ninety per cent may be brought back by a follow-up system. The proportion will vary in different com- munities and in different clinics of the same Dispen- sary. The mails will bring back the majority. Home visits should not be necessary in more than ten per cent to twenty per cent of the cases. j' In certain types of cases, as of gonorrhea or syphilis, 'the use of post-cards is questionable. Here letters should always be used instead. Some Dispensaries have a special envelope for these cases not bearing the name of the institution, but merely a post-office box or a street number. Inasmuch as incorrect or falsely given addresses of patients are an item which should be known, it is important that all letters should carry some address on the envelope so that if unde- livered the post-office will return them. The superintendent who has to look to the expense account will bear in mind that where a fee for each visit is charged the patient, the follow-up system pays for itself in considerable measure. The date cards cost about $5 per thousand and a visible index from $8 to $25, depending on size. Not over half the time of a clerk will be necessary for the follow-up FOLLOW-UP SYSTEMS 245 system in a large clinic. The total current expense properly chargeable to the system would range from seventy cents to one dollar per day including post- cards and salary, in a clinic receiving an average of fifty visits. It may readily be seen that if patients pay ten cents per visit and if, as in most cases, three- quarters pay the fee, a comparatively small addition to the number of return visits would more than pay for the follow-up service. The cost of the care of the additional patients will also have to be met, but there is little extra expense in caring for a moderate number of extra patients since all fixed charges are covered. This assumes that medicines are charged for at fees that cover the cost. The follow-up system in a clinic, as will be seen, includes elements of mere clerical work and also questions requiring judgment. The physician will decide some of the latter, but others he may not have time for. The detailed execution of the daily follow- up routine should be left to a clerk, but she should be supervised closely by another person, a nurse espe- cially trained for such medical-social tasks, or (more usually in practice) by a social worker. Decision upon the various cases, as to dropping or continuing them, sending further post-cards, etc., depends so much on the physician's or social worker's personal knowledge of the case that it cannot wisely be taken away from the clinic and put in a central office for the whole Dispensary. The purely clerical duties of addressing post-cards, etc., can be centralized with advantage, but the follow-up system as a whole will 246 DISPENSARIES be made mechanical if taken out of the hands of those who have direct knowledge of the patients. The actual effect of a follow-up system in promot- ing clinical efficiency is remarkable. It secures con- tinuity of treatment in the large proportion of cases; it places the '^medical material" of an out-patient clinic under the control of the physician; it renders possible the systematic study and treatment of chronic cases. The contrast between a clinic with and with- out a follow-up system can be partially shown by statistics. Many more illustrations could be given. "BEFORE AND AFTER TAKING"" A Follow-up System In Relation to Visits Per cent of gonorrheal patients making more than 1 or 2 visits A/r 1 n n nv •« / 1911-12 (before) 37.6% Male G. U. Climc | ^q^^_^^ ^^^^^^^ > ^g ^^^ Per cent of patients making more than 1 or 2 visits ,, J. , ^,. . / 1914 (before) 51% Medical Chmc | ^^^^ \^^^^^^ [ ^^g In Relation to Advice Per cent of patients who secured glasses advised ^ ^,. . ( 1911-12 (before) 50% bye Clmic <^ 1914-15 (after) 97% Per cent of patients who secured operation advised /-. 1 • ir^r • / 1913 (before) 7% secured it Gynaecological Chmc | ^g^^ y^^^^ [ ^5^^ ^^^^^^ ^^ Of all means of bringing the patient back to the clinic, one stands out supreme. No post-card, no home visit, is as effective as the definite impression made by the doctor upon the patient, especially at the first visit. Explanations by the doctor to the patient FOLLOW-UP SYSTEMS 247 of the desirability of return, of the importance of curing the disease, and an explicit indication of the date on which a return is desired, make all the differ- ence in the world in promoting the patient's revisit. A distinct element in the value of the date card sent in to the doctor lies in its unconscious stimulation to him, leading to definite decisions as to the need, char- acter and dates of future treatment. With an organ- ized follow-up system, the physician's power as a teacher and guide is enhanced; surpassing that in private practice, except where an intimate relation- ship as family physician exists. The clinic is no longer passive, but is rendered a militant agent for achieving cure of disease and for promoting health. 17 248 DISPENSARIES CHAPTER XV EFFICIENCY TESTS We need efficiency tests, because in Dispensaries as everywhere else we must have facts as well as faith. Are we living up to a high professional stand- ard in the care of patients? Only impersonal exam- ination of the work done for these patients can answer this question. Are we giving adequate service to the poor in whose behalf we solicit charitable contribu- tions? Unless we make efficiency tests we can only respond by quoting utterances of gratitude. We cannot tell how many patients were not ^' grateful.'^ Efficiency tests of Dispensary work are not difficult in method. Their execution is sometimes laborious; sometimes quick and easy. It depends upon what and how much we are testing. This chapter will briefly review some of the methods which have been found profitable and economical of application, and which have been used in several institutions for the purpose of informing physicians, administrators and trustees, of the results they were achieving in their dispensary work. The most useful rough-and-ready test is the exam- ination of the number of visits paid by patients. Visits per patient is a useful test of work done, a test which, like an inexact yardstick, must be used with EFFICIENCY TESTS 249 caution and checked by a discriminating sense before final conclusions are drawn. Visits per patient can be determined in two ways. We have recorded, let us say, the total attendance at a clinic ; we also have the number of new clinic patients, that is, the number of new persons sent to the clinic, plus transfers thereto. The number of visits divided by the number of new clinic patients gives the visit per patient. In the institution as a whole, the total of all visits should be divided by the number of new clinic patients. The following table gives some actual clinic figures as illustrations : — Clinic Total Visits New Clinic Patients Average Visits per Patient Average Visits per Patient in Same Clinic in a Later Year Children's Medical Surgical , Gynaecological . . . . Dental Genito-Urinary. . . 14,071 3,322 4.2 11,658 3,215 3.6 7,029 1,249 5.6 4,100 2,630 1.6 11,181 1,513 7.4 4.6 4.0 7.5 1.6 12.7 \ The differences between clinics depend largely upon the nature of the diseases treated. How does '^Aver- age Visits per Patient" test efficiency? The last column of the table indicates the answer. If we com- pare the visits per patient in the same chnic, one year with another, and see an increase, we are evidently getting either a change in the medical constitution of the clinic (i.e., different diseases to be treated), or a difference in the character of the medical work. If patients are coming back more frequently for treat- 250 DISPENSARIES ment, they are presumably securing better treatment. The increase in the number of visits per patient in the same clinic as compared with the preceding year, is as a rule proof of an improvement. All but one of the clinics in the above table underwent certain changes during the period between the two computations. Thus, the Children's Medical and the Genito-Urinary clinics mentioned established a follow-up system, there being no other change in staff or equipment. The Gynaecological Clinic introduced a social worker and a follow-up system as well. The Dental Depart- ment, which shows no change in visits per patient, remained just the same in arrangements and in staff. The Surgical Department reorganized its Staff, sub- stituting long services instead of frequently changing ones, thus bringing about more continuous treatment of patients. Such tests are very suggestive and easy to make. It is best to begin such tests with a consideration of diseases under treatment. Obviously in some dis- eases a single or a few treatments may be sufficient to secure satisfactory results; in others, there is a long period of medical supervision necessary and many visits should be paid to the clinic. Thus for any refined testing of results the diagnosis must be kept in mind. An extract from a paper prepared by one of the writers for the American Medical Association in 1912 will illustrate this concretely :^° — "In a genito-urinary clinic the records of the new cases of gonorrhea were tabulated for six months, the tabulation being made after the six months were over so that nothing EFFICIENCY TESTS 251 was known about the test during the progress of the work. The number of visits paid by each patient, as shown by the records, which in this cUnic are kept by a paid clerk, are given in Table 1. The total number of patients was 450, nearly all of whom had acute gonorrhea. TABLE 1.— NUMBER OF VISITS TO A CLINIC BY FOUR HUN- DRED AND FIFTY GONORRHEA PATIENTS No. of No. of Visits Patients Percentage 1 215 47.8 2 70 15.6 285 63.4 3 32 7.1 4 32 7.1 5. 16 3.6 80 17.8 6 to 8 29 6.4 9 to 12 18 4.0 Over 12 38 8.4 . — 85 18.8 *'It will doubtless be agreed that small results can be obtained in a patient with active gonorrhea from a single visit to the clinic, and that if nearly one-half of these 450 patients paid one visit and never came back, there is a serious waste of the physician's time and of the institution's money. *' These figures are particularly interesting because in 1902 two of the surgeons then in charge of this same cUnic made for a different purpose a study of the treatments for a period of two months, and of 130 patients with acute gonorrhea found that eighty, or 61.5 per cent, paid only one or two visits. This is almost identical with 63.3, the percentage obtained by this study made ten years later. I shall touch later on some probable causes and correctives for this waste. Certainly we should have similar figures from a number of genito-urinary clinics and try every possible method to see 252 DISPENSARIES if the proportion of wasted effort cannot be diminished. The growing demand for deaUng effectively with the prob- lem of venereal disease renders the efficiency of genito- urinary clinics a matter of public importance. They need to be efficient as curative and prophylactic agents, and as safe and sane substitutes for the advertising quack. "Another illustration exemplifies the value of these statistical tests in judging relative efficiency. In a clinic for diseases of the eye, two quarterly services were com- pared and the number of visits per patient tabulated, sim- ilarly, for the two services. Without going into all the details, I will summarize the tabulation as follows : "In iritis cases the average number of visits during one service was 5.8, in the other service 10.6. "In cases of phlyctenular keratitis the average number of visits during one service was 4.7, during the other service 8.5. "In 473 cases representing six of the acute eye diseases including those just named (the cases being almost equally divided between the two services), the average number of visits paid per patient during one service was 2.4, during the other service 4.0. When each of the six diseases is tabulated separately the comparison makes in every case in favor of one service and against the other, the difference ranging from 25 per cent to over 100 per cent, in the average number of visits paid per patient. "During one service (to illustrate further) 50 per cent of the patients with iritis paid no more than two or three visits; during the other service 80 per cent paid more than six visits. We may question whether successful treatment of an acute case of iritis can be given in two or three visits; we may be sure that twice that number of treatments is not too much to insure control of the disease and saving of the eyesight. The figures I have given do not determine the EFFICIENCY TESTS 253 responsibility for the difference in efficiency, but they do raise the question pointedly." Since ejQficiency tests have|been talked about in Dispensaries, Annual Reports have begun to show the average number of visits of patients in the Dispensary as a whole, and even to state the figure for particular clinics. An increase in the number of visits per patient is pointed out with satisfaction. This is a hopeful sign. A word of precaution is here offered against comparing visits per patient between different Dispensaries. Average visits per patient, for all clinics together in a large Dispensary, is a figure made up of many different elements, which will not be the same as those in another institution. For example, at one Dispensary there may be a large surgical clinic containing many minor accident cases which are treated two or three times and no more. Another Dispensary will have a great proportion of children, feeding cases and chronic medical disorders, each of which ought to be seen many times. Another Dis- pensary will have large treatment clinics for hydro- therapy or massage. Such clinics receive no patients except on reference from other clinics. Therefore the number of visits is swelled, but not the number of new persons. Another institution will have a large dental clinic doing emergency work, rarely seeing the same patient more than once or twice; or large eye clinics doing refraction, where the patients are usually fitted with eyeglasses and discharged in two visits. Thus, comparison between different Dispensaries, based merely on the average number of visits per 254 DISPENSARIES patient of an institution as a whole, is a very unsafe indication of quality of work. When, however, we compare the same institution with itself year after year, knowing as we do that the list of clinics and their general constitution has remained the same, we have a distinctly useful comparison. If we compare a particular type of clinic with an- other of the same kind in a different institution, we have a little more trustworthy comparison for indi- cating quality of work. But here again caution must be exercised, for two clinics bearing the same general title may vary in medical constitution. Only when we compare average visits per patient having the same diagnosis is it fairly safe to compare clinics of different institutions. To minimize liability to error and to promote uniformity, the following recommendations are urged upon the consideration of all Dispensaries and out- patient departments: — 1. In the Annual Report, print the list of clinics in the out-patient department; opposite the name of each clinic (a) the number of new clinic patients; (b) the total visits; (c) the average visits per patient (i.e. (b) divided by (a) ). 2. The number of new clinic patients, the total number of visits, and the average visits per patient for the institu- tion as a whole, should be printed on the same page, at the foot of the column of cUnics. 3. It is likely to promote ill-founded comparisons between institutions to publish the figures for the Dispensary as a whole without the figures for the separate clinics; or to print merely the visits per patient without giving the two figures upon which this is based. EFFICIENCY TESTS 255 4. In all comparisons between different clinics or different institutions, when visits per patient are utilized, it is desira- ble to compare cases of the same or similar diagnosis. The actual work of making efficiency tests based on visits per patient is readily illustrated by the form below. The medical record cards are selected in consecutive order or in any desired group and can be rapidly tallied. FORM FOR TABULATING VISITS PER OUT-PATIENT, CLASSIFIED BY DIAGNOSIS Efficiency Tests in Depabtment for months of 191 Number of Visits per Patient Diagnosis One Two Three Four Five Six, Seven, Eight Nine, ^Ten, Eleven, Twelve Over Twelve Total Number of Cases N.B. The grouping of Visits into columns is illustrative merely. In many cases it would be desirable to have 3-5 visits in one column and to have "Over Twelve" sub-divided. Form No. 17. For purposes of laying the finger upon particular points of difficulty in a clinic, and especially in finding wasted work, a simple tabulation of patients who pay only one or two visits is often of value. A large number of records may be rapidly run through, tally- 256 DISPENSARIES ing the number in which only one visit has been made, and in which only two have been made. The per- centage which these constitute of the total number of cases is likely to be significant. This is the quickest rough-and-ready method of pointing out the need of a follow-up system or of checking up the efficiency of one already established. As this plan requires little work in tabulation, it is a good beginning, and is sure to impress the medical staff of a clinic, or the superin- tendent, with the proportion of patients who come only once and fail to return for treatment even when their diseases clearly require further visits. The selection of records for the purposes of these efficiency tests is simple when the medical records are kept in each clinic, filed chronologically in the order of the patients' first admission. A batch of records running over one m^onth, two months, six months or a year, may be picked out in a moment and tabulated on one of the above forms or on some simplified form, if only the one-visit cases are to be noted. It is per- fectly safe to let a mere clerk tabulate the number of visits per case as long as this clerk is given a ruled tabulation form and specific instructions for using it. Where a Dispensary has a central record system and tens of thousands of cases a year, the cases of each clinic or those of a given diagnosis cannot readily be segre- gated unless there is a diagnosis index. When no diagnosis index exists, the only way of studying cases according to diagnosis is to keep a special index for a period of the particular diagnoses desired. The cards used in the standard follow-up system, described EFFICIENCY TESTS 257 in Chapter XIII, also furnish a ready Index to all the cases treated in a clinic during any specified period of time. Sometimes cases may be selected without regard to clinics, simply taking the five hundred or thousand cases arbitrarily and tabulating them as they come, tabulating only certain diagnoses if desired. Purely statistical '^efficiency tests ^' like those just described are necessarily inadequate. Much more scientific and far-reaching are what may be called the personal type of efficiency test. The following form has been found practically useful and exemplifies the idea and method (No. 18) : The medical records of a given diagnosis, or of a group of closely related diagnoses, must be selected. The physician who treated the cases, or some other physician, will then examine the records and classify each case according to result shown. These are tallied on the form. The correlation between the number of visits and the results achieved is usually very sug- gestive. Comparison of different methods of treat- ment can be made in this way. The estimation of medical results cannot of course be made always, or often, merely by reading the record card. The outcome of the case may be ascer- tainable only by sending for the patient to come in for an examination, or by sending a visitor to the home to ascertain certain facts, or by doing both. Studies of medical results necessarily involve time and expense. The studies conducted by Mr. Henry C. Wright, under the auspices of a Committee of the 258 DISPENSARIES O n p I? H P H <«3 o u Q < Q W t— ( Em t— I CQ o CQ p CQ o l-H Q rt Mas B i § £ ^ .5 W ^ Q u Ah H 3 01 M W S n^ « O ^ I— I '-' CO a t» +s i^ ^• %' O < b. V ''*. «?i «3 284 DISPENSARIES discharge and more thorough cure of patients. When hospitals of this type are located in a large city, how- ever, it is probably better that they confine their at- tention to private work entirely, and that they do not undertake ^'ward" or ''charity" work at all, unless they undertake enough of it to make more than a show in the Annual Report. Certain hospitals have established out-patient de- partments entirely for work on their own discharged cases, even when these cases are private patients of local physicians. Such out-patient clinics, mostly for surgical dressings, are referred to in connection with Pay Clinics. This chapter, however, will deal chiefly with the hospital in the community of moderate or small size. Such a hospital may be the only one in the town, or there may be one or two others. Unusual local conditions aside, it may be laid down as a general rule that a hospital of this type needs an out-patient department for its own sake, and that the community needs one very much indeed. All that has been said of the functions of a Dispensary, and of the difficulty with which skilled medical service can be secured in adequate extent by the mass of the people, will be sufficient to indicate the foundation of the first two of the four ''reasons" stated at the opening of this chapter. There are some communities which proudly insist that they "have no poor. " That is not so remarkable as it sounds, even in America. As a matter of fact the real question is not whether there are "poor" people in the community, but whether there are people SMALL aUT-PATIENT DEPARTMENT 285 who cannot afford enough medical service when they need it, particularly in the specialties. The superin- tendent and trustees of the hospital in the small city must not think of medical service on the basis of acute or serious illness only. Any physician will follow the splendid traditions of the medical profession and an- swer a call to the bed of one who is critically ill, whether or not remuneration is in sight. But when sickness has not progressed so far that the appeal to the physi- cian seems to the patient or his friends a necessity, or when an illness does not apparently threaten life, but only diminishes comfort and working efficiency, the situation is entirely different. In such cases a self- respecting but poor family does not readily seek medi- cal aid from a private physician, because they face the embarrassment of going to a medical man whom they do not know and asking him for a personal favor. For such cases a properly conducted Dispensary can per- form a great service, preventing suffering, keeping wage-earners at work, and often obviating an onset of grave disease due to diminished resistive power. A woman entered a Dispensary complaining of certain troublesome pelvic symptoms which, though not by any means serious, had been increasing suf- ficiently to disturb her usual routine. She might have dosed herseK with patent medicines and waited some months before she was really ''sick.'' It was fortu- nate she did not wait, for gynecological examination indicated, what operation proved to be, cancer. On referring the patient to the hospital, a bit of malignant tissue, no bigger than one's little finger, was excised. 286 DISPENSARIES A hospital without a Dispensary would have received that woman, if at all, when it was too late to save her life, at least without a dangerous and certainly mutilat- ing operation. To perceive the need for an out-patient department, the superintendent and the trustees need to look be- yond the four walls of the institution. They may well remember that the community supports the hospital, and that their primary duty is to see how the hospital can serve the community in any medical way. It is no credit to the insight or initiative of hospitals that in many communities outside agencies have had to establish independent Dispensaries, or to wait and urge for years that the hospital establish one. A whole chain of southern cities, beginning with Memphis, started Dispensaries through their charity organization societies, instead of their hospitals. The latter in- stitutions have in some instances waked up and taken over the Dispensary as they should. In many towns District Nursing Associations have fulfilled the same pioneer function. This criticism is, however, fully balanced, or over- balanced, by the striking growth of out-patient de- partments among the hospitals of the United States, as shown by the statistics in Chapter IV. Some local physicians would smile audibly at the notion that the hospital in their city needed an out- patient department for the benefit of the medical profession. If physicians in a town fear the competi- tion of an out-patient department with their private practice, it means either that they do not understand SMALL OUT-PATIENT DEPARTMENT 287 how a good Dispensary can be run, or that they do not believe that their hospital is capable of running such a Dispensary. A well-equipped Dispensary will aid the local pro- fession and the public, by providing certain diagnostic facilities which would otherwise be accessible to but few. Consultation with experts in laryngology, op- thalmology, surgery, etc., offers an opportunity to patients for better diagnosis and to local physicians for self -improvement. The laboratory of the local out-patient department, if equipped as it should be, ought to be available to patients who are sent by their practitioners, for analyses of urine, stomach contents, blood-counts or other chemical or bacteriological tests which require an expert clinical pathologist. So with tissue specimens, as in cases of possible cancer. Suitable fees should be charged for such service, and the patients should be admitted merely for the test desired, not to the clinic. The function of the X-ray Department, along the same line, is equally important. The equipment for Roentgenological work is too expensive for almost any individual practitioner in a small community. The cost of taking plates is high enough at best, and is practically prohibitive for the mass of the people unless the work is done in an institution which can reduce the fixed charges to a minimum and even do some work for less than cost. The X-ray service of the out-patient department of a small hospital should be available at cost for people of moderate means. These patients should be sent by their physicians, 288 DISPENSARIES whether or not the latter are members of the Dispensary- staff. The patients should be admitted for X-ray- only, not to the Glinic. Of course such an X-ray- Department will do work for private patients in the hospital at fees which are considerably above cost; and for ward cases or for general Dispensary patients for fees which are not more than cost and which are remitted in whole or in part when the patient cannot pay. The combination of the private, semi-private and ^^ charitable" work may make an X-ray Depart- ment pay its expenses and at the same time perform a broad and valuable service. The particular clinics which are most needed by the community, or those which it is most expedient to undertake first, are matters for local study. The service of oculists or laryngologists, for instance, may be almost inaccessible to the mass of the town's population. The few men specializing along these lines have most of their time filled by private work, with patients of the well-to-do classes. A Throat and Ear Clinic, or an Eye Clinic, may be a boon to the community. The work of the school doctors and nurses for the children in the public schools, also, would be probably much assisted by them. Local reasons for pediatric, orthopedic, surgical and general medical clinics, will appear in addition to general rea- sons for an out-patient department as a whole. SMALL OUT-PATIENT DEPARTMENT ^80 Organization and Management of the Small Out-Patient Department 1. Rooms and Equipment. In the chapter on build- ings, a suggestion for a plan of an out-patient depart- ment of a small hospital will be found. It is desirable that all clinics be open at the same time, as in this manner the patient secures the maximum benefit of consultation and co-operative diagnosis. In starting an out-patient department in quarters which had been planned for some other purpose, and which include all the space the existing hospital buildings can spare, it is not always possible to carry on all cHnics during the same hours. This difficulty can be partly avoided by noting the second requirement carefully. Most of what has been said (Chapter X) about the equipment of particular clinics in the large Dispensary applies here, with obvious alterations in detail. Cer- tain points will be reiterated because of their special importance. Should a Dispensary receive an average number of visits of, say, 40 or 50 a day, the range in number would probably be between 15 and 80 and sufficient space for the maximum number must be provided in admitting halls and in waiting-rooms. Separation of the sexes in the waiting-rooms is essential, unless the rooms are so placed as to be constantly under the eye of some responsible person or are part of a public hall where persons are frequently passing. The main ad- mission door should be as accessible as possible from the street, and it is convenient to have a vestibule so 290 DISPENSARIES that baby carriages can be left sheltered from the weather, yet not in the admission hall itself. In too many clinics the surgical side gets the lion^s share and the medical is neglected. The importance of providing the medical clinic with a microscope, blood-pressure apparatus and facilities for making the ordinary urine tests, can hardly be over-estimated. The general laboratory of the hospital should be ac- cessible to the Out-Patient Department, but since it is desirable that all medical patients should have certain routine laboratory examinations made, it may be more convenient to make the routine tests for albumin and sugar in the clinic itself, or close by. The use of the X-ray for diagnosis is no longer confined to surgical clinics, and the X-ray facilities of the hospital should be made accessible to all clinics of the Out-Patient Department, as fully as possible. 2. Medical Staff and Services. Have as few clinical departments as possible, and have as long services in each department as possible. As pointed out in the chapter on organization, a small Dispensary, treating perhaps 50 patients a day and having ten different departments, loads itself down with a burden of administration and enhances the difficulty of securing real medi- cal team work. The medical, surgical and children's departments are fundamental. The following ad- ditional clinics should usually be provided for: (1) Eye; (2) Ear, Nose and Throat (one clinic); (3) Dental. Orthopedics is of great and growing importance not only as a branch of surgery, but also as an agent in SMALL OUT-PATIENT DEPARTMENT 291 presentive and reconstructive medicine. This is par- ticularly the case in connection with postural and structural defects among children, and with the rehabilitation of wage-earners after certain accidents. Few cities of moderate size have had physicians with special training in orthopedics, and clinics as well as the community at large have had to do without this service. The War is causing a large number of physi- cians to receive orthopedic training and is also calling its value to public attention as never before. We may hope that after the close of the War orthopedics can be much more fully represented in Dispensaries in the smaller communities than has thus far been practicable. In some of these Dispensaries it will be wiser to have the orthopedist work as a member of the general surgical clinic than as head of an independent depart- ment. Decision on this point must be based in each case upon a careful weighing of all factors in the im- mediate local situation. The provision of special clinics for tuberculosis, syphilis and gonorrhea, should be considered as part of the public health provisions in the community ; and the hospital should co-operate in the development of these with the public health authorities, or with a voluntary body such as a tuberculosis society. An outgrowth of the children's clinic may be a well ba- bies' clinic co-operating with a local baby welfare as- sociation or with the Department of Health. The out-patient services should be intimately cor- related with those in the hospital. The best plan is that one of the chief assistants in the hospital service 292 DISPENSARIES should be the chief of the out-patient service in the corresponding clinic, medical or surgical. There are out-patient departments in which this system pre- vails nominally, but in which the so-called '^ chief* gives no real attention to the out-patient department. This is valueless. 3. Admissions and Fees. The general principles brought out in previous chapters apply fully. Always it is necessary that the responsibility for admitting patients be concentrated in the hands of one person. Usually it is best that, in the small out-patient depart- ment, this person be a member of the Social Service Department; the member if the ^'Department" has only one worker. A paid clerk is an administrative necessity unless the Dispensary is very small indeed. The clerk should be on duty during clinic hours to help with the admissions, fees and records, and may do record work at other hours if required, or assist elsewhere in the hospital. The desirability and practicabiUty of a Fee System need not be re-argued. The admitting officer should be responsible for remitting fees. 4. Records, The form of clinic records may follow those used in large Dispensaries. The alphabetical index to all patients is of vital importance. The clinic records are best filed by number and kept near the admission desk. Thence they may be distributed to the clinics as the patients go in. The follow-up system described for large Dispensaries can be fol- lowed closely in small ones, except that where the total daily attendance averages under 100, a single SMALL OUT-PATIENT DEPARTMENT 293 follow-up index at the admission desk might serve all clinics, instead of having separate indexes in each clinic. The statistical record forms described for large Dispensaries require little or no modification in the small institution except that there will be fewer clinics. 5, Nursing and Social Service. The hospital should assign a graduate nurse to the out-patient department if there is any surgical work to be done. A pupil nurse may be assigned to the medical, the children's department, etc., to assist in preparing patients for examination, weighing babies, etc. Out-patient work is valuable experience for nurses in training. Certain conditions are seen which do not appear in the hospital wards. The nurse learns how to deal with patients who are not flat on their backs. The pupil's executive ability, if she has any, will be brought out in the clinic. The need for organized Social Service in the small Out-Pat ient Department is as great as in the larger. The opportunity for service in the community of moderate size is often greater, or at least the results will be more apparent. A few practical hints may be given concerning the salaried staff in a small Out-Patient Department. If a small Out-Patient Department can employ only one full-time salaried person, this person should be a trained social worker who has also had a nurse's training. She should have charge of the admissions as registrar, and supervision of the executive details of the Dispensary. 294 DISPENSARIES If a Dispensary is large enough to require, and wise enough to afford, two or more salaried persons, the person possessing the joint training of a social worker and a nurse (the training of a social worker does not mean a month or two of observation in some well- established social service department, but a really extended and adequate course of training) should, as before, be responsible for the general supervision of the executive work of the Dispensary and should take charge of the admitting. She should be responsible to the superintendent of the hospital. The second person employed should be a graduate nurse who does nursing work only, and who is responsible to the execu- tive. If one or more pupil nurses are then detailed to the Dispensary, they come under this graduate nurse, subject to the educational oversight of the superin- tendent of nurses. The graduate nurse should take charge of the medical and surgical supplies used in the Dispensary, be responsible^for the care of instruments, etc. Should there be need, an assistant social worker doing only social work should be provided, who will have no executive responsibility, but merely do case work. A clerk to assist the executive head of the Dispensary, keeping statistics, filing, and doing clerical work on the medical and social-service records, may be needed even before any other salaried assistant will be. 6. Cost and Finance. Even a small Out-Patient Department cannot be run for nothing, and a good Out-Patient Department cannot be run for next to nothing ! The best unit of expense is the average cost SMALL OUT-PATIENT DEPARTMENT 295 per visit, obtained by dividing the total expense of the Out-Patient Department by the whole number of visits paid by all patients. If the hospital keeps pro- per accounts and charges to the Out-Patient Depart- ment its fair share of the general hospital expenses, as well as the special expenses for the Dispensary, the cost per visit should not be expected to be less than 40 cents. The fees charged patients may be expected to bring back thirty to fifty per cent of the expense, at a Dispensary doing primarily charitable work, with an unsalaried medical staff. In raising funds, success depends on doing good work and telling the public about it intelligently and per- sistently. This is particularly true in the small community. Dispensary work makes a strong appeal, because it is concrete, because it deals with large numbers, because it relieves suffering in very obvious ways, and because it is preventive and can be put before men who give not only because their hearts are touched, but because their heads approve. A well- managed out-patient service ought to develop new lines of public interest and support for the hospital as a whole. 7. General organization of the Small Out-Patient Department. Do not expect to maintain a Dispensary successfully, to have it do work that is worth serious medical consideration, or stand intelligent public criticism, if the Out-Patient Department is allowed to run itself with the medical head of each clinic changing every few months and running his own little kingdom by himself. The principle of organization should b^ 20 296 DISPENSARIES to centralize the executive control as fully as possible, even in a small Dispensary, by employing such an executive as has been suggested, and to leave to the physician full responsibility for his proper work, the diagnosis and treatment of patients. There should be a special Dispensary Committee of the Trustees, and a Dispensary Committee of the Medical Staff. The executive of the Dispensary should be directly re- sponsible to the superintendent of the hospital. Efficient dealing with numbers of people requires organization. The first demand of efficient organiza- tion is a head. PUBLIC HEALTH DISPENSARY 297 CHAPTER XVIII PUBLIC HEALTH DISPENSARIES AND HEALTH CENTERS We have seen that for the past fifteen years the pub- lic health motive has been one of the active forces creating Dispensaries. From 1905 to 1916, more than a thousand Dispensaries were established as a result of it. It remains to consider the different types, and the administrative methods, of Dispensaries of this class. The Tuberculosis Dispensary The growth of tuberculosis Dispensaries, from about 20 in 1905 to 500 in 1916, has taken place in response to the demand for dealing with a serious and prevalent disease, despite the fact that private medical practice, already in the field, was supposed to be coping with it. The medical profession, as well as the general public, has favored the tuberculosis Dispensary, It has been recognized that the expense of diagnosing and treating tuberculosis is too heavy for many to bear. It has also been perceived that in dealing with such a disease, private medical practice falls short because it cannot be militant. The tuberculosis Dispensary set a standard for all public health Dis- pensaries and all future public health campaigns, by dropping the passive or receptive attitude of the 298 DISPENSARIES traditional Dispensary and doing instead what the advertising men call ^'going out after the business.'^ It did and does this partly through distributing literature, putting up posters, holding lectures and exhibits; but still more effectively by employing a field agent, — the uncommercial traveler of public health work — the visiting nurse. In Pennsylvania, a few years ago, a tuberculosis Dispensary was established by law in every county of the state. In many of the smaller places, starting the '' Dispensary" consisted merely in engaging a physi- cian to hold certain advertised office hours for tubercu- losis cases, no charge being made to such patients. The equipment was merely that of the physician's private office, with the very important addition that a visiting nurse of the state service was provided as his assistant. The provision of this nurse was in fact the essential creative element in the Dispensary, rendering it an active educational force. The arrangement and equipment of a tuberculosis Dispensary may be extremely simple. An admitting room and an examining room, where there is reason- ably good light, and comparative quiet, are essential. A large tuberculosis Dispensary would have a large admitting room where twenty-five or more patients could wait at one time, and several examining rooms. Even in a small clinic it is desirable to have two ex- amining rooms. These need not be more than six by eight feet, although a slightly larger size is more con- venient. Even with only one physician, it saves time to have two rooms. A patient can be prepared for PUBLIC HEALTH DISPENSARY 299 examination in one room, while the physician is en- gaged in the other. The visiting nurse should be in attendance at the clinic, to take a history from new patients, start the record card, and pass it on to the physician. Details of organization and management of tuberculosis Dispensaries have been treated in many of the publications of the National Association for the Study and Prevention of Tuberculosis, of local anti-tuberculosis societies, and in the useful handbook of Miss F. Elizabeth Crowell. The differential diagnosis of tuberculosis in ques- tionable cases often requires skill and facilities not at the command of the small clinics thus described. There have been established a few large tuberculosis Dispensaries equipped for research, such as the Henry Phipps Institute in Philadelphia, but the number of these will remain small. Most will be, and should be, attached to general hospitals. In a large city, all local tuberculosis Dispensaries should be affiliated, and there should be such relations with the general hospitals and out-patient departments as shall enable any form of special examination to be readily secured. That the whole system of local tuberculosis clinics and hospitals should be under one management, that of the Department of Health, is indubitably best. The operation of a tuberculosis Dispensary is a branch of public health work. The visiting nurse is to follow up cases into their homes. She is to in- vestigate the families, she is to bring in all the members of the family of a tuberculosis patient for examination. The nurse arranges the details in getting a patient into 300 DISPENSARIES a sanitorium; she serves as a link between the sanito- rium and the home when the patient is discharged. It is good general policy that sanitoriums, when lo- cated at a distance from congested districts, should not send their own workers to do detailed follow-up work, but should utilize their social workers merely to make connecting links between the discharged pa- tient and the tuberculosis Dispensary nearest to the patient's home. **Baby Clinics" Out-Patient clinics for babies and young children have been quite generally established as departments of general Dispensaries, and in connection with special hospitals for babies and children. The public health clinic for babies is not primarily for the treatment of the sick, but is to keep babies well. Sometimes these clinics are called ''Well Baby Clinics"; sometimes ''Infant Welfare Stations ''; and sometimes "Baby Welfare Consultation Stations.'' The term "Milk Station" is being rapidly superseded by other terms. In all, the essential equipment consists of a few rooms for seeing the babies and their mothers, scales, and a few other inexpensive articles. The Staff required is the same as at the tuberculosis Dispensary, — the doctor and the visiting nurse. Historically, "baby clinics" usually began as efforts to prevent infant mortality by providing pure milk. They were milk stations, at which milk of good quality was sold at cost, or given away free when the price could not be paid. Inasmuch as the best milk for PUBLIC HEALTH DISPENSARY 301 a little baby is the mother^s milk, it was soon seen that distributing cows' milk was, in a measure, a discourage- ment to breast feeding, or at least that it was an in- adequate and partial method of meeting the larger need of the situation. The baby clinic, as such, de- veloped to supply the really essential needs, namely, medical supervision of the health of the baby and the practical education of the mother in its feeding and care. The doctor must diagnose the case and outline the plan for teaching the mother. The nurse is the doctor's right hand in making the program for care effective, by her contact with the mother in the clinic and in the home. The baby clinic has a local clientele. Only a very small proportion of mothers can or will bring their babies more than a few blocks away from where they live. Experience has demonstrated that while a mother anxious about a sick baby will go a longdistance to a clinic or hospital, preventive work such as in the well baby clinic must be brought close to the home. As to equipment, a small baby clinic can manage with a single room large enough, say, for several mothers to wait as the doctor examines their babies one by one. But for convenient and efficient working, the baby clinic should include the following: First, an admission room, where the mothers may sit com- fortably; second, a clinic room where the doctor has his place for seeing the babies individually, and where they can be weighed and examined; third, a milk laboratory or demonstration room where the processes of modifying milk can be explained. The admission 302 DISPENSARIES room, or preferably the demonstration room, should be large enough and be so arranged that a group of mothers may be gathered together for a talk by the doctor. The walls and tables along one side of the same room should be available for pictures and ex- hibits of baby clothes, etc. It is evident from this description that the rooms used by a medical clinic in a general Dispensary can be readily adapted to the purpose of a baby welfare clinic, but of course the mothers and babies must have the exclusive use of them during the hours the baby clinic is in operation. Publications of the New York Milk Committee have shown how a floor of a typical tenement or house can be arranged for the use of a baby clinic. The doctor's part in the baby clinic is generally confined to periodical examination of the baby and advice to the mother. This is usually once a week, but may be less frequent when the baby is older or is getting on without trouble. In the pediatric depart- ments of general Dispensaries, the same type of work is often carried on as part of the clinic, or as a separate branch of the clinic; sick babies being also treated. In the local Baby Clinic, however, the physician is usually not allowed to give treatment to sick babies. The Baby Clinics have thus endeavored to avoid competition with the medical profession of the locality, and have invited them to send difficult feeding cases, with the understanding that no sick cases would be treated. Separation between the function of the doctor in the clinic and the doctor in the home may be PUBLIC HEALTH DISPENSARY 303 necessary under some circumstances and for a tem- porary period, but is not a permanently satisfactory relation on either side. The Milk Station is very frequently combined with the Baby Welfare Clinic, the milk being usually sold at cost. The milk is delivered daily at the clinic, suitably iced, and can be had by the families at speci- fied hours. Sometimes the milk is furnished modified according to the formula prescribed by the doctor. A central laboratory may put up the formulae in bottles ready for delivery at the station, but the far better plan is to provide whole milk and to have the nurse teach the mother in her home how to modify this milk herself. At first thought, it might seem that often this could not be done, but the experience of many cities has conclusively demonstrated that the plan of home modification is not only practical, but in a large majority of cases is in every way beneficial. The whole trend of Baby Clinics, however, has been away from the mere provision of milk and toward emphasis on breast feeding. Every effort is made to persuade mothers to nurse their babies and to get and keep the mothers in such physical condition that they can nurse them. Herein, as we shall see, the public health Dispensary for babies comes close to that for obstetrical and prenatal care. Prenatal or Pregnancy Clinics Historically, the development of the infant welfare campaign in this country began with the baby, often merely with providing pure milk for babies. It has 304 DISPENSARIES come to emphasize education more than milk; and is advancing to include obstetrical and prenatal care. The emphasis of the infant welfare campaign has shifted, and must further shift, from milk to mother- hood. The Federal Children's Bureau has devoted much attention to the subject of prenatal and ob- stetrical care, in the endeavor to waken the public to a sense of the magnitude of unnecessary suffering and death among mothers and babies, and the pos- sibility of largely alleviating this. The purpose and method to be followed are in brief : — ^^ (1) The Preg- (1) By making proper medical examination, pelvic nancy measm-ements, etc., of pregnant women before con- Clinic finement (when possible, some months before), to decide whether normal delivery is possible or likely, and to give such medical advice as may be indicated for the comfort and safety of all women, and in partic- ular when hospital care and operation are necessary. (2) Prenatal (2) By visits from a trained visiting nurse and Nursing reports to the physician, during the course of preg- nancy, to instruct the mother and father in the hygiene of pregnancy, and to make the best possible prepara- tion of the home for the sake of the coming child. (3) Obstetrical (3) By expert medical care at confinement, to Care minimize the risks to mother and child. (4) Post-Par- (4) By frequent visits from the nurse during the tem Care two weeks or so following confinement, to provide needed bedside care to the mother and give the baby the best start possible. Items (1) and (2) include ^'prenatal care,'' a purely preventive and educational service. It may of course be provided either in conjunction with or independently of (3) and (4) . The obstetrical care (3) may be given by a private physician, under whom the visiting nurse PUBLIC HEALTH DISPENSARY 305 gives the post-partem care. Visiting nursing associa- tions seem, as yet, rarely able to provide a nurse to be present at the confinement, owing to the expense and the administrative difficulty of combining such a serv- ice with the nurses^ other work. Efforts are being made in this direction. The pregnancy clinic itself is the initial and guiding factor in this chain of preventive service. Its minimum equipment should include a waiting-room of suitable size, a smaller ''history room," and an examining room. The last must have a gynecological examining table and a sterilizer for the examining instruments. While a patient is being prepared by the nurse for local examination, the doctor may be in another room (the ''history room") taking the history of a new case, or giving his advice to a patient whom he has already examined. The doctor's examination may reveal that the ex- pectant mother is not likely to have a normal delivery, and he may therefore advise a hospital. The nurse helps the patient and her family to arrange for this. In any event the nurse visits the home regularly, as a rule about every ten days, to watch the mother's condition, teach her what she needs to know about the care of herself and of the coming child, and, when necessary, to aid (or secure aid) in such prenatal de- tails as baby-clothes, linen, etc. Once a month, or as directed by the physician, a specimen of urine is ex- amined. It is of course desirable that the prenatal service shall begin early in pregnancy. Subsequent visits of the expectant mother to the clinic may be 306 DISPENSARIES made if advised by the nurse, and are usually desired by the physician at least once during the last few weeks of pregnancy. The pregnancy clinic and prenatal work are most efficient when connected with a hospital to which ill or operative cases may be sent promptly and without break in medical supervision. The prenatal and obstetrical service may obviously be made part of a medical educational system, as is done with great advantage in a number of cities. A pregnancy clinic is influenced by location, but its range is not nearly so small as that of the baby clinics. Obviously, a system of prenatal clinics in a community bears a close relation to the well-baby clinics. The same rooms can be adapted to both uses at different hours. The visiting nursing staff ought to be the same. Dr. J. Whitridge Williams,^^ from an extensive study of cases, estimates that the application of proper standards of prenatal and obstetrical service would reduce the infantile mortality (up to two weeks after birth) to fifty per cent of that which it would be with- out such care. Actual field work in Boston and New York has produced an average reduction of fully this amount, and in some years of much more. The reduc- tion in infantile death-rate extends throughout the whole of the first year, for the baby is given a better start and breast feeding especially is promoted. The extension of prenatal care, and of pregnancy clinics, to reach a larger proportion of expectant mothers everywhere, — usually the rural districts are most of all PUBLIC HEALTH DISPENSARY 307 in need, — is capable of reducing the present staggering waste of maternal and of infant life.* School Children's Clinics In the systems of medical school inspection which have swept over the country within recent years, the first problem that usually called the doctor into the school building was that of contagious disease. The work has rapidly broadened to include the detection and the remedy of physical defects. To find out children with poor eyesight, bad teeth, enlarged ton- sils, diseased hearts, or faulty posture, requires physi- cal examination. In the best systems of medical school inspection, this is a periodical examination. But the detection of physical defects takes us only a httle way. The defects detected cry for remedy. In some cases, the parents are sufficiently awake to the situation when it is called to their attention, and are sufficiently well provided with this world's goods to have a private physician or surgeon. But in a large proportion of cases the money is lacking. The special- ized services which are generally required are all relatively expensive. Here is a peculiarly suitable field for the clinic. In communities where Dispen- saries are in existence, school children are sent thither for care. Such children constitute as much as twenty per cent of the entire clientele of some large Dispen- saries. Where there are no general Dispensaries, or where the number has been inadequate and the loca- *The Children's Bureau estimates that in 1913 there were at least 15,000 deaths of women from conditions directly caused by childbirth, nearly all preventable. Publication^No. 19 (1917). 308 DISPENSARIES tions inconvenient, special school children's clinics have been established. Sometimes these have been put into public school buildings themselves; sometimes they have been added to existing Dispensaries, and opened at hours suited to the children. In some cities, however, the wise rule has been adopted that being away from school for the purpose of being treated for a defect discovered by the school physician or teacher does not count as a school '^ absence. '^ The equipment of a school children's clinic for eye, throat, or dental work, follows that outlined in Chapter X. A large element in efficiency, here as in other public health clinics, is the visiting nurse. The school nurse makes the difference between getting things done and merely recommending that they be done. In the oft-quoted experience of New York City, the percentage of the school physicians' recom- mendations which were carried out was found to be six per cent before the introduction of school nurses; thereafter it rose to eighty-four per cent! The dis- pensary clinic is a vital factor, for either in the small town or the large city, dependence on private practice for the various special services required never yields more than a small percentage of the possible results. Psychiatric Clinics A movement for Mental Hygiene, now well organ- ized on a national scale, has pursued a course similar in many respects to the anti-tuberculosis campaign. Educational work has been developed, and a program for (1) the medical supervision of ambulatory cases of PUBLIC HEALTH DISPENSARY 309 mental disease, particularly in their early stages; (2) for following up patients discharged from psychopathic or insane hospitals; and (3) for thorough examination and diagnosis of cases of suspected mental disease and defect. This program has necessarily led to the establish- ment of psychiatric clinics. A few large special hospitals have been founded, such as the Phipps In- stitute in Baltimore and the Psychopathic Hospital in Boston, for diagnosis, treatment and research. In both of these institutions, very great emphasis has been laid upon the out-patient department. For the purpose of diagnosis of early cases and for^medical supervision of psychopathic cases in the community, a number of special local clinics have been established. In Massachusetts, each of the State Hospitals for the Insane has an out-patient clinic, either in the hospital itself or the nearest city; these clinics providing both for the after-care of discharged patients living in the neighborhood, and for the examination of persons who come voluntarily or who are referred to the specialist. For the efficient conduct of the follow-up and educa- tional work connected with such clinics, connection with a public health nursing service is as essential as in the other types of clinics just described. The psychiatric clinic bears a close relationship to the problem of the defective and the delinquent. In the juvenile court and in the prison, there is need for the detection and classification of mental diseases, and especially of mental defects. Examining clinics in connection with courts and the prisons are rapidly 310 DISPENSARIES developing and are certain to have a profound influence over the treatment of delinquents. In the public school the special examination of children to determine their mental condition is an outgrowth of the general medical examination. A specialist being necessary to determine the mental grade of the child, clinics have been established for this service.* The Industrial Clinic By this is meant a clinic, or a set of clinics constitut- ing a Dispensary, maintained in an industrial or com- mercial establishment for the prevention and cure of disease among the employees. Many business men have come to appreciate that health in the worker is one of the most important elements in industrial efficiency. Workmen's compensation laws have stim- ulated the ''Safety First" movement, and the prompt and efficient care of accidents. Indirectly this has helped to advance other forms of health work in in- dustry. Such industrial health work covers a wide range, such as: — (1) First aid. This may mean merely "first aid boxes," with or without a nurse in attendance. (2) A surgical clinic for temporary aid, dressings, and the immediate care of minor accidents and emergencies. (3) A definite medical staff: a physician or surgeon at- tending at periodic intervals, or a permanent staff of physi- cians examining and treating employees. * On the equipment and administration of psychiatric cHnics, see the publications of the National Committee on Mental Hygiene, also of various State Committees, and those of the Sub-Committee on Clinics of the New York Committee on Feeble-mindedness, 105 East 22d Street, New York City. PUBLIC HEALTH DISPENSARY 311 (4) Specialists, such as dentists, oculists, etc., providing service which may be particularly needed among the work- ers in a certain industry or group. (5) Hospital beds as part of the industrial health estab- lishment. These are usually found only in large industries, or in isolated plants. Sometimes beds in an outside hospital are contracted for. (6) A public health nurse, "industrial visiting nurse" so-called, who may give part of her time to work in the factory or shop itself, and part to visiting in the homes of employees, following up accident cases, helping in bedside care, etc. Medical or surgical facilities may exist without a nurse, and on the other hand, public health nurses are pro- vided in some establishments without any physician in attendance. (7) Educational work: distribution of health leaflets; posters, talks, etc. Obviously certain phases of the work just mentioned take the industry much farther than others into health service. Large isolated plants, such as the Colorado Fuel and Iron Company, practically constitute the only organized resource in the community. Its workers and their families are the community. In another large steel works, not so isolated, there has been es- tablished a completely equipped dispensary building with a few hospital beds. There is a permanent staff of at least four physicians, a large staff of nurses, some serving in the hospital, others visiting in the homes, and there is an arrangement with an outside hospital for caring for serious illness for which the emergency beds in the dispensary building are not suited. Every employee is examined at the time of application for 21 312 DISPENSARIES employment, and treatment for accident or any other illness arising while the employee is at work, is pro- vided. Facilities for caring for illness in their homes are likely to develop also. More than one large com- mercial enterprise maintains a clinic with a nurse al- ways in attendance and a physician visiting at certain times. Those who suffer from minor illness can have prompt attention, and those who wish to consult the physician may do so at the specified hours. Large establishments have naturally been the first to develop this ^ industrial medicine.'' Its growth is vividly pictured in The Modern Hospital for August, 1916, and its technical results have been described in many professional articles, some of which are indicated in the bibliography. Without doubt there exists a great future for the industrial physician and industrial public health nurse, co-ordinated through the indus- trial clinic. The technical equipment and organization of in- dustrial clinics is of course similar to that of clinics for medical or surgical purposes in a general Dispensary. The chief obstacles thus far encountered to further extension are: (1) the expense, which usually is paid by the employer, and (2) the objection on the part of the employees to physical examination. Industrial clinics may exist without any requirement that there be medical examination of employees. The workers often fear that medical examination may be used by an employer as an excuse for discharging an employee, or penalizing him for activity in trade unions or other- wise. This is a problem of industry and not of public PUBLIC HEALTH DISPENSARY 313 health or medicine. Certainly the full benefits of skilled medical work, preventive and curative, through industrial clinics, can only be realized if the workers as well as the employers have a share in the responsi- bility and the management. Venereal Clinics The technique of clinics for syphilis and gonorrhea has been already discussed. The extension of such clinics is part of a militant campaign against these diseases. These diseases have been long attacked from the standpoint of the moralist. More recently the public health attitude has come to the fore. The modern Social Hygiene movement, while not neglect- ing the educational, moral and other relationships of the venereal diseases and of the sex problem, has pushed forward the health aspect as one of the chief elements in its program. Educational, prophylactic and administrative measures against syphilis and gonorrhea are necessary, but measures for their prompt and efl&cient treatment must also be provided on an adequate scale. The system of clinics devised in the Scandinavian countries has been made known in this country particularly by Flexner's book, and has ex- ercised a substantial influence. More recently, the Report of the British Royal Commission on Venereal Diseases has led to a well-worked-out program for the prophylaxis and treatment of syphilis and gonorrhea in Great Britain. An extensive system of clinics is part of the scheme. The War has advanced this pro- gram enormously in Great Britain and in the United 314 DISPENSARIES States, to an extent which would hardly have been believed possible a few years ago. j Laboratory facilities for the Wassermann test and for the diagnosis of gonorrhea, have been made ac- ; cessible to the whole medical profession in many lo- l calities by the State or City Department of Health. I Diagnostic clinics, at which patients may present ' themselves for examination, and a report be sent to their physicians, have also been established, as in New York. Valuable as these facilities are, they can go only a little way. Syphilis and gonorrhea are infec- tious diseases. They are highly prevalent. Their treatment by efficient modern methods is expensive. The diagnosis and treatment also requires special skill on the part of the physician or surgeon, skill that is not usually possessed by the general practitioner. The great bulk of the treatment of these diseases is ambulatory. It is a special field for the Dispensary rather than for the hospital, the proportion of bed cases to the total number of cases requiring treatment being small. The cost of treatment by private medi- cal practice, and the limited amount of special skill available for the diagnosis and treatment, render the development of treatment clinics for syphilis and gonorrhea a necessary part of a program for dealing with these diseases effectively. Investigation of existing Dispensaries in New York City revealed the fact that a majority of the venereal clinics, a few years ago, were poorly equipped, poorly managed and inefficient. No comparison of inefficient clinics with the average efficiency in private practice PUBLIC HEALTH DISPENSARY 315 has been available or could easily be made. The work of a certain small number of clinics, however, ^ has demonstrated that efficient treatment of syphilis and gonorrhea in dispensary clinics is possible. The equipment and technique of organization and manage- ment has been worked out. Efficient treatment in such clinics, even if the medical staffs are paid, is relatively economical compared with the minimum cost of skilled care in private treatment. We may anticipate that an extensive system of such clinics will be instituted in the near future in many parts of this country. The self-supporting pay clinic for syphilis and gonorrhea has been demonstrated as a possibility and is likely to develop somewhat. But the general health movement will insist on the provision of facili- ties for treating syphilis and gonorrhea under condi- tions such as will render the clinics most widely ac- cessible. If venereal clinics are to charge nominal fees, or be free, the expense involved will necessitate public rather than private support. The Health Center We might trace the rise of other public health move- ments which have led to the establishment of special clinics, — dental clinics or inebriety chnics, for ex- ample. But it will be sufficient, after our review of several different types of public health Dispensaries, if we summarize their common qualities. 1. The public health Dispensary has a militant purpose. It is not merely passive. It aims to get hold of cases of disease, or to get into touch with people 316 DISPENSARIES who are likely to contract disease. It aims to prevent as well as to cure. 2. The typical public health Dispensary is local in its reach. This is partly because preventive work must be brought closer to people than work that is primarily curative, and partly because more effective educa- tional work can be done when the personal relation- ships between doctors, nurses and patients are em- phasized. This can best be done by neighborhood connection. 3. The public health nurse is a characteristic com- mon factor. She is the field agent in the preventive, educational and curative work of all forms of public health clinics. Every one of the chief public health movements of recent years has given rise to a special group of public health clinics. Each of these public health movements has developed as the result of the special interest of a particular group of people, — the doctors and the lay- men particularly concerned with tuberculosis, the pediatricians, the psychiatrists. Each of these public health movements and its clinics has developed a special technique and has trained, or tried to train, a special group of doctors and nurses to carry out the technique effectively. So far, so good. During the period wherein these different pubUc health movements have been growing and experimenting, in order to decide upon the methods that will yield the best results with their particular problem, such development of technique along special- ized lines was undoubtedly necessary. But since these PUBLIC HEALTH DISPENSARY 317 movements are local in application, particularly as regards clinics and visiting nurses, a number of sepa- rate groups of doctors and nurses must work with people in the same district and visit homes within the same area. The question naturally arises whether some combination of administrative or field staff could not be made of the different clinics in a district; also whether, if a number of different doctors and nurses are dealing with the same family at the same time, for several special purposes, there is not some risk that families may suffer from educational confusion. The advance of the campaigns against tuberculosis, infant mortahty, diseases of school children, etc., has been rapid. For that very reason, each public health movement must now face the problems of co-ordina- tion as well as the pleasures of growth. In the early stages of these movements, when local clinics were started and doctors and public health nurses were set at work, the basic idea was service in a specialty, — tuberculosis, pediatrics, dentistry, etc. The specialty was the unit. Now another conception is beginning to dominate, — the population unit: service to all the people within a defined district. A new test of work has therefore arisen, — the One Hundred Per Cent Idea. In its beginnings, the anti-tuberculosis movement tried to get hold of whatever tuberculosis cases it could. Results were measured by what was accomplished for these cases. Later, after the problem had been more deeply studied, a new aim was defined : to ascertain the number of tuberculosis cases in the com- munity, and in each district; then to reach all these 318 DISPENSARIES cases, or at least to estimate the results of the work in terms of all the cases which should have been reached. So the infant welfare movement began with such babies as came to its clinics and ^^milk stations"; later it advanced to reckoning the total number of babies in the district, and aiming to reach them all. To have a special set of school doctors and nurses, another set of infant welfare doctors and nurses, still another of obstetrical and ^^ prenatal'^ doctors and nurses, and so on, — all working in the same area, all visiting in the homes in the same area, — raises the question as to whether the organization cannot be simplified. The diagnostic ability of a specialist in tuberculosis or pediatrics may be required in the clinic for certain cases. But in carrying out educational work in the home, cannot a single properly trained visiting nurse serve several doctors? Cannot duplica- tion of plant and administrative service be avoided? Cannot the broad unity of all forms of public health work be emphasized visibly before the eyes of a district? The Health Center Idea is the answer to this question. The Health Center is based on two main principles: first, the population unit; second, local co-ordination. The Health Center Idea may be said to mean : doing things for everybody, and doing things together, within a given district. More specifically, it is public health work which involves 1. A population unit, i.e., (a) The area and population covered is defined ; (b) The aim is to reach all the population so far as the health services offered apply; PUBLIC HEALTH DISPENSARY 319 (c) The results are measured by the one hundred per cent test, that is, not the number of per- sons reached effectively, but the proportion of the population which is reached effectively. 2. The co-ordination of local effort, especially, (a) Of the medical and sanitary services within the district; (b) Of the nursing services, involving correlation or combination of various nursing specialties; (c) Of social services, involving correlation or combination of neighborhood forces, and of the social agencies at work in the neigh- borhood ; (d) The local headquarters and clinics of all forms of public health work for a district to be within a single building. 3. A local administrative unit, involving, (a) A local administrative head; (b) Supervision of all special services by special- ists working administratively through the local head. Bringing different health services together in a single building is in itself an indirect means of co- ordinating them. Co-operation is promoted, almost enforced; co-ordination is suggested and facilitated. Bringing all the health activities under a single ad- ministrative control in the same building for a district takes us much farther still. A general sense of need for co-ordination of local health movements has led to a variety of Health Centers. Some incorporate only a few of all the principles above enumerated; others are more far- 320 DISPENSARIES reaching and complete. The Health Center estab- lished in 1915 by Dr. S. S. Goldwater, then Health Commissioner of New York City, was comprehensive in character, as the following outline shows : — HEALTH DISTRICT NO. 1— NEW YORK CITY HEALTH DEPARTMENT Functions Performed 1. Prenatal work 2. Infant's milk sta- tion 3. Examination of children, pre- school age 4. Medical inspec- tion of school children 5. Supervision of midwives and fomidlings 6. Tuberculosis sup- ervision 7. Other infectious diseases 8. Food inspection 9. General sanita- tion 10. Public health edu- cation District Staff Health Officer of Dis- trict (part time) In full local adminis- trative charge Medical Inspector (part time) Fimctions 2, 3, 4 Three nurses, Func- tions 1-7 One Nurse's Assistant, Function 2 Food inspector (part time) Sanitary inspector (part time) Supervising Staff Health Commissioner or Deputy Bureau Chiefs of 1. Child Hygiene 2. Preventable Dis- eases 3. Food Inspection 4. Sanitation 5. Public Health Edu- cation This single center was established as a model or as an experiment and the health work in the remainder of the city was not thereby changed. In contrast to the method employed in New York, Cleveland has approached the problem in a different way; it has chosen to develop the health center idea evenly throughout the whole city. The city of Cleveland has been divided into eight health districts PUBLIC HEALTH DISPENSARY 321 of approximately equal population. In each district there has been established a central office or health center. Eventually each district will have a full-time physician who will also be a deputy health officer, but as yet this plan is only partly accomplished. Each district office now has a supervising head nurse, and two stenographers. The statistics for the district are collected, tabulated and kept in these district offices. Each district is divided into eight to ten sub- districts in each of which is one nurse responsible to the supervising nurse of the district. Each nurse now carries out in her sub-district the following lines of work : (1) Contagious disease; (2) child hygiene; (3) tu- berculosis; (4) some supervision of parochial school pupils; (5) general sanitation, housing, etc. In one district some general home nursing is done, but in the other districts the Visiting Nurse Association (a voluntary organization) carries on this branch of the work. In the near future it is planned to add to these, venereal disease and prenatal work. In each district there is maintained a tuberculosis Dispensary at the health center and also a babies^ prophylactic Dispensary. Sick babies are referred to the family physician or to the central clinic of the Babies' Dispensary and Hospital. It is planned to add soon prenatal clinics and prophylactic and advisory clinics for venereal diseases. For active treatment venereal cases will be referred to established treat- ment Dispensaries. These clinics are manned partly by full-time city physicians and partly by part-time physicians under the direction of the bureau chiefs. 322 DISPENSARIES In the central office, acting as supervisors of the district dispensary work and as the cabinet for the health commissioner, are expert bureau chiefs. It has been recognized that private or voluntary organizations are necessary not only to establish the work and to demonstrate its claim for municipal sup- port, but to keep progressive investigating organiza- tions in existence. One district of Cleveland has there- fore been turned over to voluntary organizations, in- cluding Western Reserve University, but the records of this district are kept uniform with the other dis- tricts. By giving over one district to the voluntary organizations, it is planned to keep these organizations alive and active and give them opportunity to develop any new or better methods or to carry out any form of sociologic research. The district operated by the voluntary agencies is known as the ''University'^ district and it is used by the University for all practical and field work of its classes in sociology, public health nursing, etc. It is planned that the bureau chiefs shall be University instructors, which will connect the health department not only with the social courses of the University, but also with the Medical School. Beginning with 1917 the mortality and morbidity records will be tabulated on the basis of these districts so that the public health of the eight districts may be separately compared and considered. Many volun- tary organizations are still doing special work for people residing anywhere in Cleveland, but more and more this work is becoming in nature supplementary to the work of the health centers or districts. PUBLIC HEALTH DISPENSARY 323 The Buffalo Department of Health has a chain of Health Centers in which certain clinics do not only- preventive work, but curative also. In Dayton, Ohio, combination of nursing services has taken place, the staff of the Health Department and of the private Visiting Nursing Association being pooled under a single administrative head. Movements in this direc- tion in many other cities might be described. Health Centers established by private organizations, as in Philadelphia, have been taken over by the city. The participation of the people of the district in the manage- ment or support of the local health services has also been urged, as in the Health Center of the Bowling Green Neighborhood Association, New York (origi- nally founded by the New York Milk Committee), and in the far-reaching plan for a district Social Unit Organization, now developing in Cincinnati under Mr. and Mrs. Wilbur C. Phillips. Many and varied illustrations of the Health Center idea are now arising all over the country. The extent to which a visiting nurse can efficiently perform various public health functions is perhaps a question. It must be borne in mind that educational work, whether in connection with a case of tuberculosis or infant welfare, is much the same in its broad human relationships. Certain technical procedures must be mastered but these are simple. They must be simple, else patients or mothers will not grasp them. The problem of maintaining adequate technical standards in tuberculosis, baby welfare, or other forms of visiting nursing service, when a single nurse is performing 324 DISPENSARIES various functions, is a problem of training in the first place, and of supervision in the second. The future will help to solve this problem, but it goes without saying that to prevent the multiplication of special services in a district, some steps must be taken. In small towns, and still more in rural communities, the problem sometimes solves itself, because visiting nursing service often begins with a single nurse who ^^does all she can." Of necessity she performs a variety of functions. In any community, the com- bination of local health and preventive services within a single building for each district, ought to be insisted upon, whether the organizations conducting the various activities are public or private, or both. So far as clinics are concerned, there are direct economies in use of plant. So far as administra- tion and nursing services are concerned, a single building by no means implies a single head or a unified staff of nurses, but is the best means of opening the way to gradual development of the technique of local co-ordination of these various health activities. A single Health Headquarters for each district, moreover, brings the work of public and private health organiza- tions home to the people in much more tangible and impressive fashion than is possible when each of the different activities have headquarters scattered over the same area. They tend to bring before the minds of the people not only Health Services, but a Health Ideal. PAY CLINIC 325 CHAPTER XIX THE SPECIAL DISPENSARY AND THE PAY CLINIC There was included in the classification of Dispen- saries made in Chapter III a small group of Special Dispensaries, confining their attention to a single disease or a group of closely related diseases. The most frequent of these institutions are Dispensaries dealing with : — The Special Dispensary Diseases of the Eye Diseases of the Ear, Nose and Throat Diseases of the Eye, Ear, Nose and Throat Children's Diseases Orthopedics Gynaecology Neurology Psychiatry '^Skin and Cancer" Dentistry Certain of the public health Dispensaries which were dealt with in the last chapter limit their work to some of the above diseases, but these are not included here. The large Special Dispensaries of course exist chiefly in the great cities. They have contributed in many instances substantially to the advancement of a specialty, bringing together a group of physicians or 326 DISPENSARIES surgeons interested in a particular phase of medical work, and providing excellent equipment for the ad- vancement of specialist technique. Reference to the statistics of the growth of Dispensaries in Chapter III indicates that the large Special Dispensary has not increased in numbers nearly as fast as the General Dispensary. The number in fact, so far as can be ascertained, is probably not more than fifty per cent greater today than fifteen years ago, whereas the number of General Dispensaries has at least quad- rupled during the same period. There are indeed good reasons why large Special Dispensaries are not to be encouraged in most in- stances. Their essential weakness consists in inability to take an all-round view of the patient, and to relate special conditions to general conditions. All the general conditions, for example, which may influence a disease of the eye, or which may be influenced by eye diseases, must be referred to another institution for treatment, if the patient presents himself at a special opthalmological Dispensary. From the strictly medical standpoint, moreover, there is serious dif- ficulty of making an adequate diagnosis in complex cases due to the lack of the necessary consultant or specialists within the institution. Some of the large Special Dispensaries have in a measure made up for this by establishing a group of consultants, but this effort on their part is merely a recognition of the fundamental principle that such work as the Specialist Dispensaries have attempted would be better done if these clinics were part of a general institution. This PAY CLINIC 327 is true even of pediatric Dispensaries attached to children's hospitals, although a number of such in- stitutions have built up for themselves complete consulting staffs, or a complete set of specialist clinics for children, so that they are in fact general Dispensaries dealing only with children. The peculiar problems presented by mental disease render such special institutions as the Phipps Institute in Balti- more or the Psychopathic Hospital of Boston'desirable as research centers, if nothing else, but these institu- tions must and do provide within their own staffs for the necessary specialists. Much further develop- ment of large Special Dispensaries as independent institutions is hardly to be looked for. We have already seen, however, that there are likely to be more special public health clinics for school children, and other local clinics providing specialist service in districts or communities otherwise un- provided for. Special treatment clinics should be so located that they will be reasonably accessible to the people needing their services. This principle of localization must be carefully worked out and applied with differing force to different specialties. In pro- portion as the need for a certain specialty is wide- spread, in the same proportion should the treatment cUnics be localized. This therefore appUes particu- larly to dental clinics. Monumental buildings to which all the children of a city are supposed to be brought for prophylactic and curative dental service cannot be as desirable from the standpoint of benefit to the people as a system of many local dental clinics. 22 328 DISPENSARIES So far as well-equipped centers for dental study and research are concerned, the stronger dental schools ought to provide this in sufficient measure, and the clinics established primarily to provide dental service for the people should be localized. Much is also to be said in favor of combining special treatment clinics with the Health Centers. Particularly needed are special clinics (for school children and adults) dealing with diseases of the eye, ear, nose and throat, and dental clinics. The Health Center of the future may well be also a Specialty Center, including such clinics as those for tuberculosis, babies, prenatal service, general examinations for children, and the various specialized treatment clinics already described. If the program for dealing with venereal disease follows in the United States the same course which it is taking in Great Britain, clinics for treating syphilis and gonorrhea will be localized to some extent and will be associated with a certain number of the specialty centers as well as with the larger central medical in- stitutions. The expense of specialists' service at the rates usu- ally charged in private offices has, as already pointed out, rendered it difficult for a large part of the popula- tion to secure it except through medical institutions. A large part of specialist service is out-patient rather than bedside work. It is noteworthy that in many of the specialties there exist not only physicians treating the disease but also purely commercial ventures, selling remedies without diagnosis. Thus opticians provide glasses, throwing in an ^^examination'' free. All sorts PAY CLINIC 329 of apparatus for relieving deafness can be bought over the counter. The orthopedist must compete with the purveyor of footplates, braces, elastic stockings, etc. A great variety of patented and unpatented medicines are offered for affections of the throat and nose, the nervous system, or the venereal diseases. If the people as a whole are to understand what modern medicine has to offer and are to reap its benefits, then the resources of modern medicine, including the spe- cialists when necessary, must be within their means. Otherv/ise self-diagnosis and self-treatment must be the main resource of most people, particularly in the more expensive specialties. In other words, it is of particular importance that diagnosis and treatment by specialists shall somehow be brought more within the reach of the general public. The charitable Dispensary does this, but the hours at which the charitable clinics have usually been held are not convenient to working people. They are generally during working hours and there- fore involve loss of time and wages. Furthermore, a large number of people do not wish to accept medical charity, or to enter any charitable institution and receive that for which they make no corresponding return. The Pay Clinic The Pay Clinic is one answer to the problem just stated. While Pay Clinics are by no means neces- sarily confined to the specialties, they have developed thus far chiefly within this field, A Pay Clinic may he 330 DISPENSARIES defined as a clinic* in which a fee is charged patients corresponding with the cost of the service rendered, in- cluding compensation for the physician. A Pay Clinic must aim to be self-supporting, although this need not interfere with the acceptance of certain free or part- paying patients, any more than a doctor in private practice refuses such. In fact, the Pay Clinic is or should be in much the same relation to the patient and to the community as the doctor who supports himself by the practice of medicine. It offers a service, not a charity; it expects a return sufficient to render it self-sustaining; its staff, medical and lay, must re- ceive compensation, in money and opportunity, suf- ficient to attract and retain them. It is simply the co-operative practice of medicine on a business basis. We see this exemplified very clearly in the Mayo Clinic, at Rochester, Minnesota. Several less known organizations, as in Los Angeles, are following the same line. At the other extreme of worthiness are disreputable Pay Clinics run by questionable physi- cians, or quacks, such as advertise themselves in some cities. Such enterprises are rightly frowned upon, and should be regulated by law, because the merely commercial exploitation of ill-health for private profit is against public policy. The maintenance of high scientific standards and of a spirit of public service, such as generally characterize individualistic medical practice, is essential in Pay Clinics if they are not to be merely commercial ventures. Regulation by the proper public authority, under a suitable law as * Or if there is a group of clinics, we may speak of a Pay Dispensary. PAY CLINIC 331 proposed in Chapter XXII, is desirable for all Dis- pensaries whether pay or charitable. The Pay Clinic established as a public service en- terprise or '^ self-supporting philanthropy," is a recent development. Naturally these clinics have been opened during the late afternoon or the evening hours, inasmuch as they aim to serve wage-earners to whom the usual day-time clinics mean loss of pay and some- times the threatened loss of a job. The first such clinic was for Eye Diseases, instituted at the Boston Dispensary in April, 1913. The same institution opened a Genito-Urinary Pay Clinic in March of the next year, a few months later a Syphilis Pay Clinic, in 1916 a Nose, Throat and Ear Pay Clinic, and in 1917 a Pay Clinic for General Medical and Surgical diseases. The Brooklyn Hospital opened Pay Clinics for syphilis and gonorrhea in 1915, an institution in Chicago opened one in 1916, and Lakeside Hospital, Cleveland, a sim- ilar clinic in 1917. At the time of this writing the Pay Clinic idea appears to be under serious discussion in many other institutions. The chief differences between these clinics and those which we have already studied are on the financial side. At the Boston Dispensary patients are charged $1.00 for the first visit, 50 cents for later visits; medi- cines, eye-glasses, etc., being extra, priced at fees some- what above cost. At the Pay Clinics of the Booklyn Hospital the fee is $1.00 a visit, but medicines (except salvarsan) are furnished without additional charge. As to medical compensation the chief of a clinic operat- ing three evenings a week is salaried, at more than one 332 DISPENSARIES of the institutions mentioned, at the rate of $1,000 a year, the assistants at half this amount, or less in some cases. For clinics running two evenings weekly the chief has usually received $5 per clinic. One Pay Clinic has not paid medical salaries but instead has given to the staff, as a group, a certain share of the gross income of the clinic, to be divided as the staff determines. Most of the other Pay Clinics have fol- lowed the plan of paying definite medical salaries, which seems more dignified and satisfactory. Several Pay Clinics have been started for purposes of diagnosis only, the most notable being that at the Massachusetts General Hospital, begun in 1915. This was closed shortly after the entrance of the United States into the War. To this and to other diagnostic clinics, patients can be admitted only when referred by a physician, who requests an opinion and report. The Massachusetts General Hospital Diag- nostic Clinic charged a flat rate of five dollars to the patient, plus certain extras, such as X-rays when necessary. There are obvious limitations upon a clinic which confines its work to diagnosis only and will not undertake treatment. Its value, however, is also obvious, providing as it does a center of organized equipment and organized skill which would otherwise be rarely accessible to the mass of physicians or patients in the community. The development of such clinics will nevertheless be slow, so long as the mass of patients are not informed enough to demand them and the mass of physicians not ready enough to trust them. The possible loss of a patient from a PAY CLINIC 333 physician's private practice is a serious deterring in- fluence against sending that patient to a diagnostic cUnic. If such a clinic were so organized as to be essentially a co-operative association of a large number of physicians, this difficulty would be obviated and the service of the clinic greatly broadened. The purposes of a diagnostic clinic can be fulfilled by a clinic which provides treatment in the usual way, but which also admits patients, on request of a physician, for diagnosis only, pledging to send them back to their doctor with the opinion desired. The equipment and management of Pay Chnics need no special attention here. The sense that pa- tients are paying their way creates a somewhat dif- ferent psychological attitude toward them on the part of those administering the medical and executive work of the clinic. More individual attention and greater dignity for the patient follow as a natural result. Where Pay Clinics and free clinics (or clinics with nominal fees) are maintained in the same building at different hours, there is a considerable problem of shifting, in both directions. A man, for example, who has been out of work, and attending the day-time clinic, secures a job and at once desires to attend the Pay Clinic, held at hours which do not interfere with his daily work or wage. Conversely, the loss of a job may cause a shift in the opposite direction. The record system of the pay and free clinics within the same institution should therefore be integrated, that is, be conducted as one system, just as are the records of the different clinics of the free Dispensary. Then, 334 DISPENSARIES whether or not the medical staff of the two sets of clinics is the same, the physician of the Pay Clinic will see all the records made in the corresponding free clinics at the time of the patient's transfer to the pay side; and vice versa. The Pay Clinic may be appraised from three aspects, those of the institution, of the doctor and of the public. The Pay Clinic and the Public 1. From the standpoint of the public, consider first the specialty of opthalmology. If anything is the matter with our eyes, or if, for instance, we need glasses, we can secure attention from one of several sources: (1) an oculist at his private office; (2) a clinic connected with a medical institution, where the patients meet the oculist instead of at his office; (3) an optician or optometrist, who will test the eyesight and provide glasses, if he persuades the patient that glasses are needed; (4) the shop, selling eye-glasses over the counter without examination of the eyes. One has merely to try on various pairs until one finds a pair which suits. The cost of these four facilities varies widely. Assuming that we require eye-glasses, which is the most common reason why people seek care for the eyes, the cost of the oculist's services and of the eye-glasses will be from $8.00 to $25.00, according to his reputation and the kind of glasses purchased. At a clinic, as- suming that merely nominal fees are charged and the glasses are sold at about cost, the cost would be from PAY CLINIC 335 $1.50 to $4.00 or $5.00. The optometrist or optician will charge a patient from $2.00 to $10.00. The price supposedly includes glasses only, the examination being nominally free. At the shop, eye-glasses — such as they are, may be purchased over the counter for from 10 cents up to $1.00 or more per pair. Thus the scale ranges from $25.00 down to 10 cents as the cost of a pair of eye-glasses fitted, more or less, to the wearer. We pay our money and take our choice. Such is the actual economic situation. What is the social result? The ideal would be the services of a skilled oculist for every person needing any care for the eyes; but the price is too high and the price must remain high because, in private practice, an oculist cannot live unless he charges such fees. A well- trained man must make his living by charging these rates to that small section of the community which can afford them. The remainder of the community is not ordinarily reached by such services. The number of individual oculists is scanty and when unorganized is necessarily too high-priced. The optometrist or optician, or the shop selling eye-glasses over the counter, ought not to exist at all except under the supervision of medical men; for eyesight is too pre- cious to be spoiled by the meddling of inadequately trained hands. The remedy is to organize the medical service. This means to establish clinics.* We have such clinics, but they are supposed to be only for the poor. The people who cannot pay $8.00, $10.00 or * This does not mean eliminating the optician, whose services can and should be utihzed in such an organization. 336 DISPENSARIES $20.00, but who would pay $3.00, $4.00 or even $5.00, if they knew they were getting good service, and who often pay similar amounts to opticians, are left in the lurch. They cannot get skilled medical service for the eyes. These middle-class people are the majority in every community. Take another special field: Venereal Diseases. From the standpoint of the public, there are four kinds of treatment for syphilis and gonorrhea, namely : 1. Private medical practice. 2. Hospitals and Dispensaries, chiefly the latter. 3. Quacks, or so-called ''Medical Institutes." 4. Treatment by patients themselves, usually with medicines or apparatus bought at drug stores. We may call this last self-treatment. Quack treatment and self-treatment are undesirable facilities. They should be limited, and, if possible, abolished. We can diminish the amount of quack treatment considerably by prosecuting individuals and by preventing quack advertising; but while we are diminishing the amount of treatment by quacks, we must open up more of the desirable facilities for treatment and make them accessible to more people. Otherwise, shutting down on the quacks will merely increase the already vast amount of self-treatment. In studies made of patients applying at the Boston Dispensary Genito-Urinary Pay Clinics," including three series of cases totalling about five hundred in number, it was found that previous to coming to the clinic (for gonorrhea) twenty per cent had been to private physicians, usually leaving because they had PAY CLINIC 337 no more money ; ten to fifteen per cent had previously been in other hospitals and Dispensaries; about twenty per cent had been to quacks, and about one-third had depended on self -treatment. The remaining propor- tion had had no previous treatment, mostly coming with fresh infections. Thus, fifty per cent and more of these cases of gonorrhea had had no reputable medical attendance previous to coming to the clinic, and the successful treatment of their disease had been delayed, in some instances materially hindered, there- by. From the standpoint of cost of treatment, syphilis and gonorrhea are expensive diseases. Treatment of either syphilis or gonorrhea, during the first six months, according to methods followed by physicians who are regarded as experts in these diseases, would cost fully $200.00, if the usual rates of such physicians were charged, or somewhat over $100.00 if the same methods were pursued, but the office rate of the general practitioner were in effect. The cost of medicines is a large additional item, since at drug-store prices be- fore the War these would have amounted to $2.00 a week, or more. All these are minimum rather than maximum figures. Not more than one family in ten has an annual income of over $1,200.00, and the average wage of the individual wage-earner does not exceed half of that amount. Out of such incomes the expense of adequate private medical treatment for sj^hilis and gonorrhea cannot be met. Treatment is begun but often discontinued because the financial burden is too heavy. Hence there is a large field here 338 DISPENSARIES for clinics. For certain considerable groups in the community, the pay clinic, rather than the charity clinic, is desirable. In the wider field of general medicine, suppose we picked ten sick people at random, paying no attention to '' social classes. '' To provide adequate medical care for the needs of these people might cost $5.00 in the case of one, $500.00 in the case of another, and perhaps the man who had only the $5.00 purse might have the $500.00 disease! At any rate, the cost of adequate medical care would often be far beyond the patient's means, even in the cases of people who do not ordinarily think of going to Dispensaries. Now, the public can be divided into three groups from this standpoint. First, those who can pay any- thing for what they need: the rich; second, those who can pay nothing, or practically nothing: the poor; and third, those who can pay something, who are most of us. Those who can and will pay some- thing are by far the largest class in the community, and how big that class is, and how big the '' something'' which they can pay, is the important question. But it cannot be answered offhand, nor can it be answered in general terms, for the problem has too many ele- ments in it; — number of people, age, occupation, in- come, medical needs, cost of medical service and in- stitutional resources of the community — all have to be studied. Those who can pay something for medical service but who cannot meet any serious emergency, or any long-continued drain, are the class in the com- PAY CLINIC 339 munity, who at the present day get the poorest medical service. In communities where hospital and dis- pensary service have been well developed the poor are provided for, largely through the same physicians who serve the rich. But the middle group of the commu- nity is not to be reached by the ordinary clinic; and to meet the need of this middle group is the function of the pay clinic. The Pay Clinic in Relation to the Doctor 2. Let us now consider the Pay Clinics from the standpoint of the physician. On the financial side, it is essential to bear in mind that the fees received by the physicians in private practice are a gross and not a net income. When a physician works in his private office, the rent, the equipment, the nurse and other assistants, the lighting, heat, records, and the doctor's automobile, must all be paid for. When the physician works in a Dispensary, all the plant, equipment and attendants are provided. Out of the gross income of a physician in private practice in a large city, a not unreasonable estimate indicates that half goes to meet the expenses of the doctor's business, leaving only half as a net income for the support of the physician and his family. There are of course instances where the percentage would be lower, others where it would be higher, but on the whole, referring at least to medi- cal practice in cities, it is believed that a fifty per cent estimate is not too high. The physician in the Pay Clinic must therefore bear in mind that the salary which he receives for his service 340 DISPENSARIES in the clinic is a net income. If a physician were employed at full-time service, at the rate of S5.00 for a two-hour clinic and were actually engaged at this rate for a total of seven hours a day altogether, he would receive compensation at this rate amounting to $5,250.00 a year as his net income, this being equiva- lent to a private '^ practice" of $10,500.00 annually. The illustration is not given to suggest that physicians be engaged in this fashion, but merely to indicate the financial basis of medical salaries in Pay Clinics and to point the contrast between the gross income of private practice and the net income of such salaries. Nor need any loss of dignity be consequent upon the service of the physician in a Pay Clinic, any more than upon the part of a professor in the faculty of a university. Sometimes there has been said to be an undesirable competition between private practice and Pay Clinics. If the preceding analysis of the relation between the cost of treating diseases in a Dispensary, and the circumstances of many sufferers, is correct, then the Pay Clinic is not providing treatment for those who would otherwise secure adequate care from private practice. The salaries received by physicians in Pay Clinics should exceed and probably will exceed the amount which the same patients would pay to physi- cians were the Pay Clinics not in existence. This can be demonstrated, especially where medicines or ap- paratus have to be purchased. For example, in the Boston Dispensary Genito-Urinary Clinic, or Syphilis Clinic, the total cost to the patient of treatment over an average period is not greater, and is often less than PAY CLINIC 341 the amount which the patient would have to pay for the drugs alone if purchased at the prices charged in drug stores. Yet out of what the patient pays, fully half is paid back to the physicians, and this amount, if the patient had not had the clinic, would all have gone to the drug store or the quack. In the Boston Dispensary Eye Clinic, it is similarly true that the usual retail prices for eye-glasses alone are greater than the total expense of the admission fee to the clinic plus the glasses, sold at the slight advance above cost. The real difficulty raised by Pay Clinics is not that they fail to turn into the medical profession as much income as would ordinarily go from the same patients to the medical profession. The nub of the difficulty is rather that the income would go to certain physicians rather than to certain others. A wide- spread organization of Pay Clinics, bringing in large numbers of physicians, as directors of clinics and as assistants, would remove the last objection. The cure for the competition between Pay Clinics and private practice, so far as it exists at all, is more Pay Clinics. The Pay Clinic and the Dispensary 3. Finally, we may look upon Pay Clinics from the standpoint of the Dispensaries maintaining them. The following table shows the financial results from certain Pay Clinics over a period of years, comparing income and outgo: — 342 DISPENSARIES BOSTON DISPENSARY Running Period of Time Covered Expenses* Income Eye Clinic April, 1913 to Oct., 1917 $2,877.64 $3,067.74 Geni to-Urinary Clinic March, 1914 to Oct., 1917 16,291 . 54 22,282 . 24 JSkin and Syphilis i Clinic Aug., 1914 to Oct., 1917 3,341.44 4,820.30 Nose, Throat and Ear Clinic Sept., 1916 to Oct., 1917 1,458.48 1,523.80 Pay Clinics treating general medical cases involve a wide variety of work and must be carefully studied out in order to solve the problems of management and finance. Surgical Pay Clinics will in the future be largely compensation clinics of the kind already de- scribed, treating industrial accident cases and paying their staff salaries or fees, preferably salaries, in due ratio to the work done. To the ordinary Dispensary doing charitable work, the establishment of Pay Clinics opens a new field, a wider clientele and avenue of public service. It will be found that the reaction of the Pay Clinic upon the '^free clinic" is favorable. There is a stimulus to efficient service, rising out of the new psychological relation between doctor and patient, and between the doctor and the institution. Pay Clinics versus Free Clinics The maintenance of Pay Clinics outside of working hours at once raises the question of those patients who can ill afford to lose time and wages, yet who have heavy family responsibilities or do not earn enough to meet Pay Clinic fees. Can such patients be taken free * Include all elements of actual outlay, but not an allowance for over- head supervision, rental of space, or insurance. PAY CLINIC 343 or for part pay? The answer to this question cannot be based wholly on financial grounds. Is it possible to have, side by side in the clinic, patients who are paying a dollar or fifty cents, and others who pay twenty-five cents or nothing? If one patient learns of the other's situation, will not the one desire ad- mission for the lower fee, especially when the two patients are given just the same service? Evening Pay Clinics and evening free clinics might be run on the same evening in the same building, at the same time or just after one another. But could they be thrown together and run as one? Without doubt, a certain proportion, not a very large propor- tion, of free or part paying patients can be included among the paying patients of a Pay Clinic, but it is difficult to see how the proportion can equal or exceed fifty per cent. By careful administration this obstacle might be overcome, but under ordinary conditions, in a large clinic, the possibility of such a combination seems very questionable. There is a further objection where a Pay Clinic is established in a Dispensary build- ing already identified as a charitable institution, be- cause there are groups in the community not well situated financially, and certainly needing the treat- ment provided by a Pay Clinic, who would, however, be unwilling to go to an institution which bore the ^Haint of charity, '' even if they paid their way. Cooperative Pay Clinics Why should not Pay Clinics be established by a group of physicians, coming together for co-operative 23 344 DISPENSARIES work and having their offices so situated that joint equipment can be arranged? The difficulty in these instances will usually be a defective centralized ad- ministration. This, as our analysis of dispensary or- ganization and management has shown, is vital to the best co-operative work among physicians, and to the efficient management of the records, laboratories, etc. Where a group of physicians actually established an organization with adequate equipment and complete administrative machinery, the difficulty would be overcome, and we should have Pay Clinics like the Mayo Clinic, which the rich, the well-to-do, and those of very small means might all attend. In the case of clinics for syphilis and gonorrhea we may rather expect that these diseases will pass so much under public control (as tuberculosis has done) that treatment will be provided at public expense. The field of Pay Clinics for venereal diseases will thus be restricted if not abolished, although a clinic supported by general taxation is a Pay Clinic in a certain sense, if so ad- ministered as to receive a variety of social classes and not merely ^Hhe poor.'^ In general medicine, however, and in most of the specialties, there would seem to be a considerable future field for Pay Clinics, partly as divisions of general Dispensaries and partly as private enterprises of groups of physicians. The encouragement of Pay Clinics of either type is a meas- ure of progress in the development of co-operative medical practice on a democratic basis. THE MEDICAL PROFESSION 345 CHAPTER XX DISPENSARIES AND THE MEDICAL PROFESSION Are Dispensaries to increase or decrease in numbers, scope and influence? Are they to provide medical service for a larger proportion of the population than they do today? What is to be their future relation to the medical profession? The answers to these questions depend partly upon the growth and trend of medical science and practice and partly upon economic conditions in society. These factors must be analyzed separately. In this chapter we shall treat the medical factor; in Chapter XXI, the economic. The Passing of the **Family Physician" 1. In former times the general practitioner was the family physician. Today the general practitioner remains, but the family physician, treating a particu- lar family continuously, and in close touch with all the members, has almost disappeared. The reasons for this frequently discussed and often regretted change appear to be partly the growth of specialization in medicine, and partly the greater mobility and com- plexity of our population and of modern life itself. The rise of speciahzation in medicine, to which we have so often referred, is responsible for taking large fields of medical service out of the province of the 346 DISPENSARIES general practitioner, and therefore making it much more difficult for any one physician to provide integral medical service for a family. This is the case to a considerable extent even in small communities, and much more so in large cities. In all but the very small communities the general practitioners do little in specialties such as the eye, ear, nose and throat, orthopedics, gynaecology, etc. Those who need treat- ment by specialists seek them out, or go to a hospital or Dispensary, and do not expect such service from their general practitioner. On another side, the close relationship between a physician and a family has been made more difficult because of the less stable character of our population. People in large cities frequently change their residence, and even in small communities move about much more than in former times. The old neighborhood rela- tionships have largely broken up, and this affects the close touch of a physician with a family. Further- more, the influx of numbers of immigrants has made our population heterogeneous. The new peoples have brought few physicians of their own races with them. The young men of their race enter only slowly into the medical profession, and the immigrants have had to depend largely upon native physicians already in practice. The rise of a family physician system among such immigrant groups was hardly to be ex- pected and has not occurred, even where the financial condition of the immigrants was such as to enable them to employ private doctors. THE MEDICAL PROFESSION 347 The Increase of Specialization 2. Both because of the advance in specialization and the greater heterogeneity and mobility of our population, the family physician system has broken down. The close connection between one doctor and one family gave to the physician a knowledge of family traits and conditions in a degree which had high medi- cal as well as human value. Can this loss be re- placed? The general practitioner must now treat the patient largely in families where he has no such long-founded knowledge and he must compete, as he frequently complains, with the two groups which have arisen out of the growth of modern medicine, — the specialists and the medical institutions (hospitals and Dispensaries) . This complaint is natural, for in a measure it is true. But the competition of the specialist and of the medi- cal institution depends much less upon the intent of either of these sinners, than upon the forces which have called them into being and which are today develop- ing them with unexampled rapidity. These forces are essentially those of medical science. Medical knowledge has been enormously enlarged. Medical and surgical technique has been advanced at a bewil- dering rate. No one man can now master more than a fraction of the existing field of medicine. Special- ization is necessary. The physician's power to diag- nose and cure disease is enhanced^ but his needs for technical equipment are also increased beyond any- thing known formerly. The expense of professional equipment and the demand for special skill are two 348 DISPENSAEIES results of the progress of medical science which have had major effects upon the character of medical serv- ice, and which are chiefly responsible for bringing about the changes above described. Consider some illustrations of the expensiveness of modern equipment. A stethoscope is within the reach of every physician. An apparatus for taking the blood-pressure costs $25.00. Many a young doctor has to think twice before investing in one. A microscope with needed attachments costs $75.00 to $100.00; and if the doctor is to employ it for many kinds of examinations, he needs special training in its use. The laboratories of Health Departments will help the doctor out in many tests, chiefly in contagious diseases, and commercial laboratories will do whatever else he wants, but these are expensive for his patient. A cystoscope is necessary for the diagnosis of many relatively common troubles, but this instrument is expensive, and special skill is necessary to use it with- out danger to the patient. The apparatus and train- ing requisite for stud^dng the gastric or intestinal con- tents are quite out of the reach of men who cannot spend both money and time. An X-ray equipment means an investment of $1,000.00 to $3,000.00, and few doctors would have enough cases to use it to more than a fraction of its capacity. Such apparatus is too expensive to lie idle, and should be kept in full use by being at the service of a number of physicians. These illustrations could be multiplied. 3. What has been said concerning equipment is equally true with respect to the speciaUzed skill and THE MEDICAL PROFESSION 349 training now needed. This applies to laboratory work, X-ray work, and to the use of various instruments for general diagnosis. When we enter the field of the specialists, such as the oculist, the laryngologist, the orthopedist, et cetera, — a vast technique appears in which the use of special apparatus is one element, and special skill of hand and mind is the other. The average practitioner and the average patient are largely deprived of these facilities. Therefore, opti- cians and optometrists flourish, oculist's services being so limited. The dealer in braces, foot-plates, etc., does a thriving business at a high rate of profit because the orthopedist can reach but few. Above all, vendors of patent medicines sell thousands of con- coctions for millions of dollars, largely because even those physicians who had modern training in diagnosis, have not, after they enter practice, the facilities for using their training effectively with the average pa- tient, or for securing for their patients the services of specialists, because the patients cannot afford the specialists' private rates. In other words, the prog- ress of medical science calls for an increasing invest- ment of capital in the form of equipment, and of time in acquiring special training. The average physician cannot supply the needed capital nor give the neces- sary time. The doctor suffers and so do his patients. What is the remedy? Organization versus Individualism 4. The remedy is twofold. On the one hand, there must be specialization in various branches of medi- 350 DISPENSARIES cine, so that the need for special skill may be confined to a field sufficiently narrow to enable the average man to master it. Second, there must be co-operative in- stead of individual provision and use of equipment. In medicine as in business, organization must replace individualism. No one even slightly familiar with the vast existing mass of medical knowledge and with its rapid growth, can believe that any less development of specializa- tion than exists today in the practice of medicine is possible in the future. No fair-minded person can fail to admit that specialization reveals possibilities of efficient diagnosis, treatment and prevention of disease which were previously unknown. It must be admitted with equal frankness that with specializa- tion we face the risk of breaking or diminishing the individual interest and close relationship between patient and doctor which were the central source of power in the traditional family physician system. But in medicine, as in industry, specialization re- quires organization to develop maximum efficiency. With the advance of medical science, and the rise of specialties, there has begun to develop medical organi- zation. We see this most concretely incorporated in the hospitals. Dispensaries, and public health depart- ments. The Dispensary was originally a place in which an individual physician might look at and give prescriptions to a series of patients. Today, well- managed Dispensaries are centers for co-operative medical practice. So the hospital was once, not a medical organization, but merely a medical hotel. In- THE MEDICAL PROFESSION 351 dividual doctors treated their patients, each for him- self, with no central medical organization and no more consultation or co-ordination in practice than if the patient had been cared for at home. Such is the sit- uation in many private hospitals today. The modern hospital is not a medical hotel; the modern Dispen- sary is not a medical soup-kitchen. Each is, first and foremost, a medical organization. Co-operative medi- cal practice has its home therein, and its essentials, as stated in an early chapter of this volume, are two: — the organization of equipment and the organization of skill. Specialist Medical Practice 5. Medical organization indeed exists to a certain extent among physicians in private practice. Many persons now and then employ consultants or special- ists and when a general practitioner refers a patient to a specialist or a consultant, he follows the medical organization developed within the profession. The opinions of the consultant or specialist are given to the family physician or general practitioner and by him interpreted to the patient, with recommendations. Treatment, as well as advice, may be furnished by one or more of the specialists. The relationship between the different physicians, and their interchange of opinions and recommendations, takes place in per- sonal conversation, by correspondence, or over the telephone. The patients, if very ill, may be visited at home by one or more of the co-operative group or, may be seen in a hospital by them. If the case is 352 DISPENSARIES ambulatory, the patient may go from one physician's office to another. This is what we may call specialist medical practice. It is utilized by all social classes on occasion, but it is the prevalent and typical form among the well-to-do and the wealthy. The method is necessarily expensive and elite. It is time-consum- ing for the physicians, for (except the unusually pop- ular men who are over-run by patients) the doctor must work discontinuously. It requires the mainte- nance of many separate offices, with inevitable dupli- cation of plant, of paid assistants, and of professional equipment. Cooperative Medical Practice 6. In what we will designate co-operative practice^ in the hospital and the Dispensary, we have simi- lar professional relationships between the physicians, but we have these physicians brought together within a single building or a group of connected buildings. The equipment is pooled and under centralized con- trol. The same control applies to the admission of patients and to the finances, thus setting the physi- cians free for their one professional duty — medical work with patients. The administrative machinery for dealing with records and for interchange of in- formation, minimizes time and expense. Diagnostic and therapeutic facilities can be provided on a scale otherwise unavailable, except to a few doctors. The opportunities for study and for mutual consultations, in a well-equipped hospital or Dispensary, are superior to what they can be even in the most expensive type THE MEDICAL PROFESSION 363 of specialist practice through separate physicians' offices. The general public and a number of physicians do not as yet understand the nature and advantage of this new type of medical work. They still think of the hospital as a medical hotel, and lookfdown upon the Dispensary as a medical soup-kitchen! The con- ception of the hospital and the Dispensary as institu- tions in which highly efficient medical service can be rendered because of the organization and equipment which are possible therein, is beginning to pervade the profession and to penetrate among the general public. But the general practitioner has raised an indictment against the hospital and the Dispensary. He has de- clared that they are ''taking practice away from him and his brethren in the medical profession, without providing remuneration in return. Is this charge well-founded? If so, how shall it be met? 7. The rapid growth of Dispensaries in recent years has doubtless been largely due to the increased use of specialists by those of small means. The average self- supporting wage-earning family or the small business man calls in a general practitioner at times of serious or discommoding illness. Consultation can rarely be afforded and the people are so little familiar with the trend of modern medicine that if a physician were to suggest a consultation, they would often suspect a con- fession of weakness on his part, and be inclined to leave him, perhaps for a less conscientious man. The mass of the people can rarely pay for specialists and cannot afford at all the advice of a group of specialists, 354 DISPENSARIES such as the well-to-do secure. An analysis of the at- tendance at various representative Dispensaries in New York City and Boston shows that fifty per cent or more of the attendance is in clinics dealing with the specialties, i.e., other than the general medical, pedi- atric, and surgical clinics. ^^ Persons whose incomes place them at or below the poverty line secure their general medical service through the Dispensaries, but many families who ordinarily employ the private physician as a general practitioner now secure the special services which they need through the Dispen- saries, coming on their own initiative or, less fre- quently, at the suggestion of their physicians. The Dispensary is thus providing general medical service for the lower economic levels of the population, and specialists' service to a considerable number of individuals from somewhat higher economic levels. So long as the Dispensary was not only regarded, but actually was, a soup-kitchen for the destitute, it was properly provided for by volunteer medical service. The destitute constitute a small part of any popula- tion and must be cared for by medical charity in one form or another ; but when the Dispensary grew from a medical soup-kitchen into a form of medical prac- tice, the relationship to the profession was radically altered and this should have been recognized by a change in the financial relationship between the insti- tutions and their medical staffs. THE MEDICAL PROFESSION 355 Remuneration of Medical Staffs The lay public is still imbued with the tradition that '^ doctors give their services to charitable hospitals and Dispensaries.'' Popular understanding of the changed relationship of these institutions is necessary, and must be brought about by every available means; for only as the general public comprehends the potentialities for human service which lie in co-operative medical practice can the financial support for its extension be secured, and the medical profession be adequately remunerated. 8. Why has the change not been more widely rec- ognized as yet? In considerable measure because the situation has been obscured through the enlarged use of the Dispensary by teaching institutions. The teaching Dispensary often does furnish its medical staff remuneration of a real nature, even without salary. Opportunities for study, for the acquirement of prestige through research and publication, are a frequent by-product of a position on the staff of an important teaching Dispensary. Furthermore, the teaching of medical students is in itself an important contribution to a doctor's prestige, and later, when the students are in practice, they are likely to supply re- munerative consultations. The teaching Dispen- saries have been the centers of progress in Dispensary work. They have led the way. Other Dispensaries have followed them, and have continued the tradition of unpaid medical service. In medical schools of high standing there is a strong tendency to transform un- 356 DISPENSARIES paid into paid medical staffs for the purpose of secur- ing efficiency in medical research and in teaching. Medical teaching today, in all the clinical branches, means medical practice; that is, the treatment of cases of disease. If the best equipped Dispensaries, under the auspices of medical schools of high stand- ing, are finding that paid medical staffs are a require- ment of efficiency, certainly Dispensaries not fortunate enough to have such teaching connections should find this true also. The continuance of unpaid medical staffs in Dispensary service is incompatible with either the best efficiency in co-operative practice or with justice to the medical profession. How shall the consequent financial burden be met by Dispensaries? As shown in the chapter on Fi- nance, the payment of salaries to medical staffs means doubling the expense as compared with a Dis- pensary that has volunteer medical service. The Pay Clinic, charging fees to cover the full cost, including medical salaries, may be a partial answer to this ques- tion, but a much broader solution to the financial problem must be found. This is discussed in the next chapter. Democratizing Cooperative Medical Practice 9. Looking further at the Dispensary, from the standpoint of medical organization, we may perceive another serious deficiency in the present relationship between Dispensaries and the medical profession. Only a small proportion of physicians share in the facilities offered by Dispensaries for diagnosis and THE MEDICAL PROFESSION 357 treatment of patients, and for medical advancement. In Boston, a city where medical institutions are im- usually well developed, an examination of the reports of the institutions showed that in 1915, slightly less than twenty-five per cent of the 2,800 physicians of Greater Boston were attached to the staffs of hospitals and Dispensaries. Seventy-seven per cent appeared to have no such connection. In New York, where Dispensaries have probably developed further than anywhere else in the United States, data published in the Journal of the American Medical Association, June 9, 1917, showed that thirty- seven and a half per cent of the physicians in New York City gave some work to its 106 Dispensaries. A certain number of additional men were members of hospital staffs. It is safe to say that considerably less than fifty per cent of the physicians of New York City are on the staffs of its medical institutions. In most communities, the proportion of physicians who have access to modern institutional facilities for diagnosis and treatment would be much smaller. The Dispensary, therefore, needs not only to be made more efficient by improvements in the internal organization and by adequate financial support, but also to be democratized in its relationship to the medi- cal and the lay community. The advantages of Dis- pensaries need to reach all the people who need them and all the doctors who know how to use them. 358 DISPENSARIES Trend Toward more Dispensary Work 10. In considering the relationship of the general practitioner to the Dispensary, it is well to bear in mind that an increasing proportion of medical work has to deal with ambulatory rather than bed cases. Too much of the doctor's service in ordinary general practice among the masses of the population is bedside work for the acutely sick. The pressure of the move- ment for public health education is largely in the direction of encouraging people to go to the doctor in early stages of disease, when symptoms just begin to be prominent. In proportion as this develops the doctor will see ambulatory rather than bed cases. Moreover, the work of many specialists is chiefly with ambulatory patients. This is true to a large extent of the oculist, the laryngologist, the orthopedist, the dermatologist, the neurologist, and the dentist. We may also mention the development of industrial medicine as an additional force behind the public health propaganda, tending to bring patients to the doctor in the ambulatory and therefore early stages of disease. The increase in the relative importance of ambula- tory work is of the greatest significance for the future of the Dispensary, and in fact for the organization of medical practice itself. Work with ambulatory pa- tients is capable of a high degree of organization in such a manner as to promote economy of time on the part of both patients and doctors, and also economy in the provision and administration of professional equipment. The same tendencies tend to make it THE MEDICAL PROFESSION 359 more advantageous, financially and medically, for work to be done at the doctor's office or in the medical institution (Dispensary) rather than in the patient's home. More and more does the doctor need to work where his professional equipment is. Medical forces, conjoined with public health and industrial move- ments, are thus combining to create favorable condi- tions for increase of Dispensary work in the future. Three Problems 11. The analysis of this chapter leaves us with three problems, to which Chapters XXI, XXII and XXIII are respectively devoted: — 1. How shall Dispensaries be so organized internally as to be medically efficient in diagnosis and treatment, and comfortable and dignified for the patient? 2. How shall there be secured proper financial support for the maintenance of these Dispensaries, including ade- quate remuneration for the medical staff? 3. How shall Dispensaries be fitted into the medical and social organization of their communities so that their ad- vantages shall be available 'Ho all the patients who need them and all the doctors who know how to use them"? 24 360 DISPENSARIES CHAPTER XXI THE EFFICIENT DISPENSARY OF THE FUTURE In the best Dispensaries today, a high degree of proficiency in different branches of medicine and surgery may be found. PecuHar excellence in one branch of work will be developed in one institution, while another of equally high general standing will have laid especial stress upon another branch. The important part which the interests of medical teach- ing have played in developing Dispensaries has led to occasional over-emphasis upon diagnosis as com- pared with the problems of treatment. But in recent years this emphasis has shifted, and something at least approaching a proper balance has now been established in the minds of the leaders in Dispensary service. The chief deficiencies found even in the best Dis- pensaries at the present time are these: — 1. A medical organization not sufficiently centralized, so that the patient is, as it were, divided up between clinics without adequate central medical control and interpreta- tion. 2. Too much hurry, too little comfort, too little dignity for the patient. 3. Lack of adaptation to the needs of a clientele of wage- earners. THE EFFICIENT DISPENSARY 361 Centralized Medical Control 1. The first of these deficiencies is due in large part to carrying over into the work of the Dispensary the habit of medical organization established in private specialist practice. It is fair to say that in the best Dispensaries the medical organization is substan- tially better than in private speciaHst practice. In only a few experimental instances as yet, however, have Dispensaries attained the ideal of securing for the patients an initial general medical examination, with continuous further control and interpretation by the general medical authority of all other medical and surgical specialist data. Each patient needs to have (with certain exceptions hereafter noted) a single physician, who will usually be the general medical man (or in the case of children the pediatrician). This physician should be the one whom he will see to secure the interpretation and advice which may come either from this physician's examination or from the specialists to whom the patient is referred. The same patient should normally see the same physician at each visit. Exceptions may of course be made in this central- ized system of medical control and interpretation in the case of some highly specialized or temporary disorders; minor surgical injuries are an example. Comparatively few laymen yet appreciate the value of regular medical examination, and on going to a medical institution would be surprised, possibly antagonistic, if they were asked to receive a general medical examination, whereas they went to see the 362 DISPENSARIES ''eye doctor" or the dentist. The carrying out of the principle of central medical control for a patient must therefore be tempered with common sense, and the advancement of the principle in practice will depend upon the education of the general public, as well as upon better organization within the medical profession and the medical institutions themselves. Dignity and Comfort for Patients 2. The second great deficiency — the overcrowding, hurry, lack of comfort and dignity for the patient — will largely take care of itself as Dispensaries are democratized and medical staffs are properly remun- erated. Patients who are merely ' ' ob j ects of charity, ' ' or '^clinical material," will be treated as such, hu- manely but without any extreme regard for personal privacy or dignity. This is true in all but exceptional cases. If Dispensaries should be supported either by fees from patients themselves or by insurance funds to which patients contribute at least part, or by public funds, which the patients as citizens feel they have a share in providing, there would naturally be produced a substantial difference in the point of view from which the patient is regarded. Adequate compensa- tion for the medical staff will relieve the average physician from the necessity of hurrying in order to get to his remunerative work in private practice. His strong professional instinct for treating people well, as human beings as well as patients, will assert itself with a double force in the clinic when the present unnatural pressure upon the unpaid Dispensary phy- THE EFFICIENT DISPENSARY 363 sician is relieved. We may therefore look to better attention to the individual patient, to more privacy, less hurry and more dignity, largely as an indirect result of other changes. This indirect result, however, is of vital importance, and the forces which may bring it about indirectly must be assisted by direct educa- tional effort. A system of volunteer medical service obviously prevents any physician from giving more than a small fraction of a day to a dispensary clinic. With a salaried service, clinics could be open for longer pe- riods, sometimes continuously, and the concentration of many patients within a short period of time could be greatly diminished. The expensive equipment of a modern medical institution ought to be utilized as continuously as possible Adapting Clinics to Wage-Earners 3. Mpst Dispensaries serve wage-earners and their families, yet most maintain clinics only during work- ing hours. A very serious loss in time and wages falls upon employed men and women through attend- ance at a clinic. Investigation made at one clinic indicated an average wage loss of seventy-five cents and as this included many women patients, a figure covering men alone would be much higher. More- over, in the case of diseases requiring frequent visits to the doctor, repeated absence from work may cause not only loss of wages but the threatened or actual loss of a job. Thus the evening pay clinics described in Chapter XIX have an economic foundation. 364 DISPENSARIES Obviously so long as medical staffs are unpaid, clinics must be ''run'' at hours most convenient to them. But as we progress toward regarding Dis- pensaries as agencies of health service rather than as charities, the economy of holding clinics after working hours will be more and more apparent. Whether as free clinics or pay clinics. Dispensaries which conduct some or all of their work for adults during the late afternoon or evening hours are a necessity for the future. In the preceding chapters of this book, we have gone into the various technical questions of organization of medical staff, the equipment and management of clinics, etc. It is not necessary to rehearse these, but it will be useful to summarize briefly the general requirements for the efficient Dispensary of the future : What an Efficient Dispensary Needs 1. A medical staff properly remunerated for its services. 2. A medical organization facilitating co-operative diag- nosis and treatment, and also providing central medical control in each patient's case, data to be interpreted for and to the patient by a single physician with whom the patient early establishes certain personal relations. 3. Central administrative control of all branches of the Dispensary service, carried out by a strong executive officer, under a board or committees in which the medical interests of the staff and the interests of the lay community are both represented. 4. Administrative organization such as will secure reason- able comfort, privacy and dignity for the individual patient. 5. Buildings and equipment of proper standards. THE EFFICIENT DISPENSARY 365 In addition to these fundamental requisites, the following more technical requirements may be men- tioned, recapitulating previous chapters. 6. Good nursing; adequate clerical help; a staff (social service) for stud3'ing the social problems of patients and assisting the physicians in the education of patients and the control of their environment necessary to secure the best medical results. 7. The linking up of the dispensary service, through the medium of this social service staff, with educational, chari- table, public health, industrial and other community resources. 8. A good admission system. 9. A good central record system. 10. A follow-up system for the supervision and control of attendance. 11. Periodical efficiency tests. 12. Annual accounting and reports to the pubhc of work done, expenses incurred, and results secured. Future Types of Dispensaries Following the consideration of the '^efficient Dis- pensary" in this general way, we may examine the various existing types of Dispensaries with reference to their probable future. No one can doubt the large future growth of the public health Dispensary, both in its present types, dealing with tuberculosis, babies, etc., and in types adapted to other diseases and medi- cal problems. With little doubt the co-ordination of different branches of public health work will cause the public health Dispensaries of the future to take chiefly the form of Health Centers, each serving a district of 366 DISPENSARIES specified area and uniting in one building, with more or less centralized administrative organization, the various branches of clinical and prophylactic health work which may be carried on for that district. The chief present question is the extent to which the medical, nursing and social services, in the various specialties, can be unified administratively. Our analysis of the trend of medical service has emphasized the importance of adequate professional equipment, and suggests the advantage of the out- patient department of a hospital, as against the out- patient institution separate from a hospital. The Health Centre and the small District Dispensary, confining attention to minor diseases and to certain specialized lines of clinical work, may well have a permanent future. But where difficult diagnostic work is required, or even where a large group of gen- eral diseases is to be properly diagnosed and treated, the advantages of making a Dispensary part of a hospital organization are so great as to leave little future for any large out-patient institution separate from a hospital. Of course an institution which is under the control of a separate corporation, but which is organized as part of a medical school, and which is in practical administrative unification with a hospital, complies with the requirement above laid down. Actual and not merely formal combination between the out-patient institution and the hospital is the requisite. It is not necessary that the out-pa- tient institution shall be immediately contiguous to the hospital in order to secure its advantages. The THE EFFICIENT DISPENSARY 367 important point is that there shall be unification of the medical organization between the out-patient institution and the hospital, and while propinquity is an advantage it is not an essential. In many com- munities it will be desirable to have only a single hospital, or a very few hospitals, but several well- equipped Dispensaries. The needs of serving a certain area by a local well-equipped Dispensary may thus require that a single hospital have more than one branch of its out-patient department. We may also anticipate that large specialized Dispensaries will not be developed further to any great extent. We have noticed in the review of the growth of Dispensaries, in the early chapters, that the eye and ear institutions, the neurological, ortho- pedic, nose and throat, and gynaecological Dispen- saries, confining their attentions to a narrow specialty, have not grown to any large extent, whereas the gen- eral Dispensaries have increased with great rapidity. This is as it should be. The industrial Dispensary undoubtedly has a large future. Its chief present limitation is its exclusive control by the employer. There is a growing opposi- tion among working people to periodical medical examinations or other medical work, which employees fear may be used by an employer to discriminate among workmen for other reasons than industrial efficiency. However little or much this fear may be grounded, the fact that it exists remains, and it appears to be increasing rather than diminishing. The industrial Dispensary, and the related forms of 368 DISPENSARIES medical work which are growing up along with it, such as periodic examinations of working forces, may encounter serious social obstacles unless its control and supervision can be democratized* It is possible that a health insurance system, such as exists in Germany or England, might take the industrial Dispensary under the control of its local fund. To these funds the worker and the employer contribute financially under the foreign systems, and share jointly in the management. This is by no means the only method by which co-operative support and control of industrial Dis- pensaries could be secured. Many existing voluntary insurance funds in industrial establishments in the United States are supported partly by the employer and partly by the workers. Joint control should follow joint support; and in the long run there would be a substantial benefit to the employer from greater co-operation, on the part of the workers, in the health programs which the physicians of the industrial medi- cal staff lay down. Public Regulation of Dispensaries What of the commercial Dispensary? Will there be more than one Mayo Clinic? Will every large city have such clinics in the future? Very possibly they will develop, as the advantages of such co-operative medical practice, for all social classes become more generally perceived. The commercial Dispensary of the cheap type, such as appears to a certain extent in some cities, is not likely to penetrate far beyond the THE EFFICIENT DISPENSARY 369 fringe of medical service. It can with difficulty compete against public service institutions, supported by state funds or endowments. Public regulation of all forms of organized medical service, including Dispensaries, will, however, be necessary, as has already been found to be the case in some states and cities. Only thus can ^' quack" enterprises be effect- ively crushed out; only thus can undesirable enter- prises for commercial exploitation of the sick, through Dispensaries or otherwise, be kept under control. The health department of the state, or possibly in some cases of a city, should have the power to license all Dispensaries, should be required to make at least an annual inspection, and should be empowered to prescribe the general standards of the building, equip- ment, sanitation and operation of the institution. Regulation in New York State has been attempted through the State Board of Charities, but this plan has serious disadvantages. It does not cover the commercial Dispensaries, and it places the Dispensary in the position of being regulated if it is a charity, but of being without public control if it is a commercial enterprise. A State Board of Charity may well be given sufficient power to see that where charitable funds exist in Dispensaries, as in any other institu- tions, these funds shall be properly managed. But the general power to supervise all types of Dispensaries, as medical institutions, should be vested in a public health authority. A law just passed (March, 1918) in Massachusetts requires all Dispensaries to be 370 DISPENSARIES licensed by the State Department of Health. The operation of this act should be watched closely.* The Teaching Dispensary of the Future The advance of Dispensaries along the lines here indicated will be in no way incompatible with their utilization in education. In a properly conducted clinic, the teaching of medical students proves of benefit to the patients, not a detriment. The dis- advantages which are now sometimes apparent in teaching clinics are due to the same causes which at present limit the efficiency of all clinics, these being chiefly the lack of a right point of view toward the patient and of adequate organization and remunera- tion of the medical staff. The best medical teaching will conform in spirit and in practice with the best organized Dispensaries of the future. The aim must be to train doctors for their beneficent public function of healing and of preventing disease. The out- patient clinic must be not only for observation of symptoms and for experience in diagnosis, but must be a school in the treatment of human beings. To teach people what they need and how to do what they should for the benefit of their own health, is more and more part of the doctor's task in private practice. To understand people and to know how to deal with them: these the doctor must learn. The out-patient clinic furnishes admirable opportunity for conjoint training in the human and the medical factors together. The teaching Dispensary of the future will be organ- ized so as to develop both these values, and in thus * The text of this law is printed in the Appendix, p. 427. THE EFFICIENT DISPENSARY 371 * organizing it will maintain the right point of view toward the patient and the right conditions of general efficiency. Nor does the program for the future Dispensary run counter to the spirit of charity which is the tradi- tional foundation of the whole Dispensary movement, and which is the animating force behind a large part of its present manifestations. We have already traced a broadened conception in charity. We see an ad- vanced development of this in educational institu- tions. Many of these were originally founded as charities, for the ^^poor." But the moving and char- acteristic spirit in the college, the endowed technical school, even the southern school supported out of contributions from the North, is a spirit of public service so dominant and pervasive that a student without means can pay a fee covering far less than the cost of his education, or can accept a scholarship, without sense of dependence. The animating spirit is charity in that large sense in which Saint Paul used the term. Medical institutions are likely to run a parallel course. We are beginning to regard medical service, for the preservation and restoration of health, as a public necessity as well as an individual need. For the same reasons we are coming to look upon the medical institution, the hospital or the Dispensary, as a center of public service, a charity in the meaning of a service but not in the meaning of a dole. The spirit of public service, which is the goal if not the apotheosis of charity, will animate and control the medical institution of the future. 372 DISPENSARIES CHAPTER XXII FINANCING BETTER MEDICAL SERVICE Is the financial situation of the medical profession satisfactory? There are no general data as to the incomes derived from individualistic practice by the mass of doctors. Some men achieve large incomes, no doubt, but the indications are that the average is not high. It is certain that a young physician without private means has a long road to travel before he can attain an assured financial position. This is particu- larly true if he wishes to keep up his scientific work begun in the medical school and during his hospital interneship; for while he is likely to have time on his hands during the early years of practice, he may lack opportunity, unless he possess very unusual ability. Would a larger and more general participation in the work of medical institutions, and in co-operative medical practice, improve the financial outlook and status of the rank and file of the medical profession? The answer is, ^^Yes. '^ In fact, there is no other general method by which such improvement can be brought about simultaneously with an enlargement of service to the public. A higher average income, a more stable income, a larger professional opportunity for the average physician who has had a good training to start with: these desiderata can only arise out of more comprehensive organization of medical service FINANCING SERVICE 373 than exists today. And such organization means essentially more work done in medical institutions; more co-operative practice. By reason of the in- creasing demand for technical equipment, and for a longer period of professional training for the physician, medical service is becoming inevitably more expensive under conditions of private competitive practice. The only way to lower its cost under these conditions is to cheapen it in quality. But if the conditions are altered so that there is co-operative provision and use of equipment, and co-operative organization of skill, the quality of service can be maintained, and in fact the average quality improved; while the economies of organization would permit of a larger average re- muneration for the medical man. The desire of doctors to have better conditions for their profession and the desire of the general public for better medical service, are wholly compatible and tend in the same direction. From the standpoint of the public, the study of the economic factors underly- ing present-day medicine requires an analysis of the cost of medical service and the modes in which this is and might be borne by the community. Family Budgets We have seen in a previous chapter an illustrative list of the cost of treating a number of common diseases, the expense ranging from a few dollars to hundreds of dollars, without considering major surgical operations or nursing service. Previous to the War, when the cost of living was much lower than it is today, careful studies 374 DISPENSARIES of family budgets in several cities ^^ demonstrated that a typical family of five persons required at least $850.00 to $900.00 income in a year to maintain mere physical efficiency. After the expenses of food, shelter, cloth- ing, fuel and light, and other necessaries had been allowed for, the amount available in such a budget for the care of health was estimated at from $18.00 to $25.00 a year, this including medical, dental, and nursing service and also medicine. This is obviously insufficient for providing medical care in a single case of serious or prolonged illness, even if this illness is not of the wage-earner himself, so that the income of the family remains unaffected. When the wage- earner, or one of the wage-earners, in such a family is stricken, income wholly or partly stops. Such budget studies have been chiefly concerned in pointing out minimum standards. An income of $1,000.00 or $1,200.00 a year for a similar family would provide, not a surplus, but merely a slightly better standard of living, with some opportunity for educa- tional advantages such as every American believes should be part of the heritage of all citizens. Even before the War, an income of $1,000.00 could hardly include provision for a serious illness of any member of the family, much less in the chief wage-earner. The rise in cost of living since the War renders all the pre- ceding estimates much below the present truth. These budget studies lead us to two important con- clusions : 1. Families with incomes of from $900.00 to $1,200.00, while generally above the poverty line, cannot on the average FINANCING SERVICE 375 provide sufficient margin to meet the cost of serious or prolonged illness, or especially expensive services, even when these do not affect the chief wage-earner. 2. In such families there usually is, however, a small margin, enough to meet all or a large part of the cost of needed medical care, if the burden of occasional illness could be distributed by either taxation or insurance. We may observe the parallel between medical serv- ice and education. Both are practically universal needs. Experience has proven that the cost of provid- ing education for all children cannot, or will not be borne, if left to the initiative of individual families; and that the education, if provided in this way, would be neither universal nor effective. Distributing the Burden of Illness Medical service, like education, is needed by only a small part of the population at one time. If all pay a little each year, a fund can be created sufficient to meet the expense of caring for the relatively small proportion who are sick during any one period. Each individual who is capable of self-support may be expected, in the long run, to pay his fair average share. This distribution of the cost of medical service (and the cost of meeting the living expenses of the family during the illness of the wage-earner) now falls entirely upon the individual family itself. The public already recognizes a certain responsibility in some cases. When a family is destitute, medical service is provided as a charity in hospitals and Dispensaries or through the generous aid of individual physicians. But so 25 376 DISPENSARIES long as the burden of illness falls upon the sick person, or the sick person's family, at the time of illness when the ability to bear the burden is least, we cannot ex- pect that the cost of efficient medical service can be met generally by the individual alone. The distribution of the economic burden of illness is now in fact proceeding, though slowly. This prog- ress is taking place partly through the extension of health activities by the state and partly through the development of social insurance. There is continued increase in public appropriations for health work. This appears in hospitals and Dispensaries supported by city or state funds, in the enlarging scope of public health departments and in more medical service in educational, charitable and penal institutions. It is noticeable that public health appropriations tend to be for preventive work rather than curative ; yet both are extending under public auspices. There is also a growing trend toward Health Insur- ance. Voluntary agencies such as fraternal orders, sick benefit societies, trade unions, and industrial establishments themselves, are giving more and more attention to providing cash benefits for the support of the worker and his family during sickness, and also, in some cases, to the provision of medical care. There is, moreover, appearing a demand for a general system of Health Insurance, under state supervision or control, reaching a large proportion of the wage-earners and others of limited means. Such systems are in opera- tion in most countries abroad. Nine states are at present studying this question through official com- FINANCING SERVICE 377 missions, and a number of voluntary bodies are at work. There is little doubt that some wider utiliza- tion of the principle of insurance for meeting the costs of illness and for providing medical service, will be worked out in some states of this country within the next few years. A considerable extension of voluntary insurance groups for providing cash benefits during illness and the expenses of medical service, may be looked for, as well as the establishment of systems under public auspices. Use of Funds for Medical Service To what specific purposes are the funds for ^^financ- ing better medical service'^ to be devoted? These purposes are threefold, so far as the care of illness is concerned : 1. The provision of diagnostic and therapeutic equipment, in hospitals or in Dispensaries of various types, or in labora- tories. 2. The expenses of maintaining and administering the equipment efficiently. 3. Most important of all, the personal service of physi- cians. At the present time, the responsibility for providing the first and the second rests (so far as individualistic private practice is concerned) wholly upon the shoulders of the medical man. Since, as we have seen, the in- creasing requirements for equipment demand a larger investment of capital than the average medical man can meet, the consequence is that the average physi- cian has to work, in private practice, with an inade- 378 DISPENSARIES quate equipment. The funds necessary for remedy- ing this deficiency may naturally come, to a consider- able degree, from the public at large. Precedents have been already established in providing diagnostic laboratories. At least, it may be expected that the purposes to which public funds are devoted, so far as public funds are utilized in financing better medical service, will tend to be for the provision of professional equipment and for its administration, earlier than for direct payment of personal services of physicians in treating illness. The public already does the latter, but only in cases of recognized dependency, in hospi- tals, Dispensaries, or under the charge of departments dealing with the legally designated '^poor." To pay directly for the personal services of physicians in treating illness among the population at large, would be state medical service, and while many believe this will be the final goal of medical development, it is not likely to be the starting-point of change from the present individualistic system. An exception has already been made in the case of contagious disease, for which most communities provide treatment at public expense, and indeed in- sist upon it, unless satisfactory private care is known to be provided. Tuberculosis is rapidly coming to be dealt with in the same way. The venereal diseases may soon follow the same course, particularly because of the expensiveness of their effective treatment. FINANCING SERVICE 379 Health Insurance Just as the provision of equipment has been generally regarded as the responsibility of the individual physi- cian, so the provision for the physician's personal service, in time of illness, has been the responsibility of the individual patient. And just as we have seen that the growing demand for technical equipment renders the average individual physician no longer able to provide it to an adequate extent; so we have seen that the growing cost and rising standards of medical care render it no longer possible for the aver- age patient to meet his needs as a merely individual responsibility. By utilizing the principle of mutual insurance, however, the individual can continue to bear a definite or average share of the burden, as a self-supporting member of a group, and yet not run the risk of being crushed by an undue weight at any one moment. The principle of insurance has a moral as well as an economic foundation. The advancement of mutual insurance under in- dustrial, fraternal, state, or even commercial auspices, will obviously imply the expenditure of funds for the personal services of physicians, in giving general medical care; also for cash benefits to the insured person or his family during the period of illness or of incapacity. The endeavor of mutual insurance groups to furnish adequate service to their members should lead to the utilization of the methods of co-operative medical practice as fully as possible. We already see the industrial hospital and Dispensary as examples. They are only beginnings, for if by co-operative provi- 380 DISPENSARIES sion of equipment and medical organization a greater efficiency in curing and preventing disease can be attained, there is a financial incentive for insurance groups to develop this type of medical service. Uses for Public Funds There are two means which we have indicated as practicable for meeting the costs of good medical service for the community. First, the provision of funds by public taxation, which is likely to advance along the lines of furnishing diagnostic facilities and of establishing and maintaining medical institutions, whose resources would be available to physicians generally. The provision of complete medical service by public funds is likely to proceed only as demanded by definite considerations of public health, in respect to certain diseases or to the peculiar needs of certain localities. The lack of medical facilities in sparsely settled districts or the proved needs of a certain section of a large city, might cause extensive public provision of medical facilities for these areas. The growing in- terest in good obstetrical service, for example, may possibly lead to provision, by public funds, for many rural areas and for industrial districts in cities. In such sections many child-bearing women now lack adequate care. To summarize: — The central principle by which the cost of better medical service for the whole community can be financed is the distribution of the burden of illness so that this does not FINANCING SERVICE 381 fall upon an individual or family at the very moment when their ability to bear it is less than usual. Such a distribution of the burden is not inconsistent with the maintenance of individual responsibility for self-support, or for the payment, by the individual, of at least his fair average share of the total community's burden. The methods by which the distribution can be achieved are either by mutual insurance or by public taxation. Both methods are likely to be followed, each to cover a portion of the field. 382 DISPENSARIES CHAPTER XXIII ORGANIZING DISPENSARY SERVICE FOR A COMMUNITY The proportion of doctors to population in the United States is about one to every 750 souls. This ratio is from two to four times as high as that which prevailed in most countries of Europe before the War. But such an average figure covers wide variations. A visitor from Mars might expect that at least as much medical service would be required in sparsely settled districts as in cities, in proportion to popula- tion, in fact rather more, because of the greater dis- tances to be covered. But the earthly statistician finds just the reverse to be true. In not a few large cities, there is one doctor to every 350 or 400 people. In rural sections the proportion is often as low as one to every 1,500 or 2,000. In many large industrial communities, even in Eastern States, the ratio is not over one to 1,000. The higher proportions in large cities are due in part to the presence of many special- ists, and do not therefore imply quite as wide a dis- crepancy in the ratio of general practitioners; but the almost entire absence of specialists in rural districts, and their very scanty presence in communities of moderate size, is a serious limitation upon the ade- quacy of medical service. The studies of the Federal Children's Bureau are showing how restricted are the facilities for obstetrical care in the smaller communi- COMMUNITY ORGANIZATION 383 ties, and how unfortunate are the effects. Those in- terested in hospitals are pointing out what inadequate facilities for surgical operation and for hospital care of grave medical diseases, are found as a rule in the small towns and in agricultural sections.'*^ These insufficiencies of medical service are of three kinds, between which it is important to discriminate: — (1) An insufficient number of general practitioners; (2) Insufficient diagnostic and therapeutic facilities for the general practitioners to enable them to do the best work; (3) An insufficient number of specialists. Shortage of General Practitioners (1) The cause of an insufficient number of general practitioners is primarily economic. A comfortable residential suburb has an ample supply of doctors. A mill town of the same size has half the number. Yet the need of the latter for general medical service is if anything greater than that of the former. If provision for the education of children were left to individual initiative, we should have a similar situation, probably still more accentuated than in the case of medical service. We remedy the evil in educa- tion, to a large extent, by public provision of facilities. This means, essentially, distributing the economic burden over a group sufficiently large to enable a fairly high average standard of service to be main- tained over the whole area. In medical service, as we have pointed out in Chap- ter XXII, the same principle of distribution of the economic burden must be applied if the needs of the 384 DISPENSARIES public are to be met ; but it is by no means necessary to turn the whole matter over to public funds. Other ways and means of ''financing better medical service" have been already discussed. By one method or an- other, or in part by all together, the distribution of the economic burden must take place. This will render the sums available for paying the costs of medical service bear a relation rather to the number of the population than to the presence of a certain proportion of the well-to-do. Need for medical care, on the aver- age, varies in proportion to population. The com- munity should see to it that provision of medical serv- ice is adjusted in proportion to need. Inadequate Professional Equipment (2) Physicians will not be attracted, however, merely by the chance of more certain remuneration. The professional facilities for medical study and ad- vancement, offered in the large city, have substantial drawing power for men of the best type. The paucity of diagnostic and therapeutic facilities in many communities must be remedied. This requires es- sentially the provision of institutional, i.e., co-opera- tive facilities, and means hospitals, Dispensaries, and the enlargement of public health departments. The funds secured for medical service by public appropriation or by mutual insurance must go in part to the direct payment of doctors for personal service, and in part to their indirect payment through the co- operative provision of adequate technical equipment and of means for its efficient administration and upkeep. COMMUNITY ORGANIZATION 385 Lack of Specialists Outside of Cities (3) The lack of specialists outside of the larger centers must be dealt with in a somewhat different manner, for somewhat different causes for the defi- ciency exist . In a small community the cases requiring an oculist or an orthopedist might not be sufficient to keep him busy, even if all were able to pay the usual rates. A certain town might need only half an oculist, but the next town might be too far away for a man to practice conveniently in both. Under these conditions neither town would have any oculist at all. The proportion of the population requiring specialist service varies widely among the different specialties. Dentistry is a frequent and practically a universal need. A much smaller number of persons will, in an average year, need an oculist or a surgeon. The specialist is even more dependent than the general practitioner upon professional equipment, in the way of apparatus and skilled assistance. Co- operative provision and administration of equipment is still more necessary, if specialists are to be available outside of a few large centers ; and furthermore, in the smaller communities, some system of visiting special- ists must be organized, when a locality would require only the part time of a man. This principle is not new. It has been carried out in the case of tubercu- losis and psychiatric clinics, with speciaHsts visiting in the smaller communities and holding clinics at stated intervals. The principle must be much more widely extended if adequate medical service is to be provided for the whole people. 386 DISPENSARIES The City and the Town We have contrasted the large city with the small town, to the disadvantage of the latter in respect to medical service. The divergence in facilities is seen to be much less, however, through another method of comparison. In a town, most people cannot secure specialist service because there are no specialists. But in a large city, where specialists exist in plenty, the mass of the population cannot obtain their services except through charitable medical institutions. The well-to-do pay the specialists high enough fees to enable them to earn a living in part of their working time, and to spend some of the rest of their time in charitable practice among those who are less fortunate financially. For the middle classes, the self-support- ing wage-earners and small-business men, this situa- tion largely means, as we have seen, that specialist service is sought only in case of grave need, for these people do not wish to accept charity. The mass of general practitioners, furthermore, who work in the large city without access to the diagnostic facilities of any medical institution, and who have not the means to provide expensive equipment for themselves, can- not give their patients the best of modern medicine, the best that many of them learned in medical school, any more than the ''country doctor" can. Thus the contrast between the large city and the small town is much less marked than appears at first glance. How shall we apply the principles of ''financing bet- ter medical service," and the principles for organizing COMMUNITY ORGANIZATION 387 ^Hhe efficient Dispensary of the future" to the exist- ing Dispensaries, so many of which require help for their improvement; and also to new Dispensaries which should be established where they are needed? Modes of Improving Existing Dispensaries The practical problem which faces the typical chari- table Dispensary now in existence in the large city is to secure sufficient funds to provide adequate equipment, sufficient administrative force, and in particular salaries for its medical staff. Reasonably good equip- ment is found in a number of institutions and ade- quate administrative force in a somewhat smaller proportion. The largest obligation ahead is in secur- ing funds for the staff salaries. Several measures maybe taken by such Dispensaries. The extension of Pay Clinics is one of them. These may be most readily started in the specialties, wherein self-support is easiest, medical opposition is practically absent, and where a large number of middle class families need a service otherwise quite beyond their means. The problem of Pay Clinics in the specialties is simpler than in general medicine, as has been pointed out, but consultant service in general medicine will be found practicable under conditions wherein a treat- ment clinic for general cases might not be. The reaction of a number of Pay Clinics upon the medical organization will be direct and useful. The same staff will probably be engaged in the Pay Chnics as in the clinics charging nominal fees or no fees. The pay- ment of certain salaries for the pay-clinic work, will 388 DISPENSARIES assist in knitting the medical organization tighter, and in elevating clinic standards all along the line. Establishing relationships between industrial medi- cal work and general charitable Dispensaries is another and more important step in a forward direction. The growth of '^compensation clinics," so-called, accepting industrial accident cases under workmen's compensa- tion laws, has already been referred to. The develop- ment of industrial Dispensaries has taken place, and necessarily must take place, chiefly in large business establishments; but as the movement for health work in industry advances and more employers appreciate its business as well as its humanitarian value, smaller firms will wish to undertake it. One of the most effective modes in which they can do so is to make an arrangement with a well-organized general Dispensary. The lines which such an arrangement could take may follow closely those already laid down in the compensa- tion clinics. Such service would result in transferring a considerable amount of free medical work now under- taken by physicians as charity, to work for which remuneration is received. Next, general Dispensaries may make arrangements with mutual insurance groups, now providing some form of medical care, for rendering service to their members. Dispensaries must insist upon proper payment, both for the medical salaries and the ad- ministrative costs. Such arrangements might re- late to general clinics, or to the specialties most needed by the members of the insurance group. Furthermore, Dispensaries should be placed in the COMMUNITY ORGANIZATION 389 same financial relation to public dependents as the hospitals. In many cities and towns persons for whose support the public authorities are responsible, are given medical service in private hospitals, which are reimbursed at an agreed rate from the public funds. In so far as this system of repayment to hospitals prevails in any community, there is no reason why the same system should not apply to patients of a similar class who receive care in a Dispensary or out- patient department. It is in fact illogical and unjust, that repayment should be made in one case and not in the other. The public as a rule has not yet fully understood the prevalence and importance of Dis- pensary care, or perhaps appreciated that it costs anything. Dispensaries should be reimbursed at a fair rate for the cost of the treatment given to public dependents. The rate of payment can be readily estimated if proper accounts are kept. It should as a rule be at a fiat rate for an average visit, plus an agreed allowance for special services like operations. X-rays, and medicines. The public authorities should make such reimbursements only when the Dispensary^s clinics are maintained at a proper standard. Such a policy would be of great financial benefit to Dispensaries and out-patient departments, and it would further provide a means for improving their service, under public inspection and supervision. Hospitals and Dispensaries should lay this request before the proper public authorities in every commu- nity wherein repayment for care in private institu- tions on a case basis is usual. To estabhsh the policy 390 DISPENSARIES may require some effort at first but the effort would be worth while. Finally, the development of public health clinics will undoubtedly extend into general Dispensaries. We already see this in the case of certain tuberculosis clinics. It will probably come about in the case of dental clinics, and in clinics treating syphilis or gonor- rhea. Provision by public funds of equipment, of salvarsan, or of subsidies for meeting the general costs of treating cases of venereal diseases : — these are mat- ters for consideration in the near future. Similarly the utilization of dental clinics already established, for the purpose of treatment of mouth defects in children on a much larger scale than has thus far been undertaken, must soon come to be a practical matter facing municipal bodies. In all these five ways, and perhaps in others, exist- ing Dispensaries supported by endowment, or by charitable contributions, or by both, should and will move towards the treatment of patients as a public service rather than as a charity, and will provide salaries for their medical staff in growing measure. Some of the strongest Dispensaries, particularly those connected with medical schools or large city hospitals, may secure funds through their own efforts, sufficient to provide a permanent salaried staff in their out-patient departments and wards. But it is much to be desired that even such out-patient departments shall maintain sufficient relations between their working staff and the general practicing profession of their communities. The local profession should not COMMUNITY ORGANIZATION 391 be cut off from the facilities which the out-patient department provides. In a considerable number of cities in this country, particularly outside of the Eastern states, there are but few Dispensaries at present. The number has been increasing, and the increases in the future are likely to proceed largely out of public health or eco- nomic motives. The new Dispensaries will often start as industrial Dispensaries, and we may expect to see such Dispensaries round out so as not to limit their service merely to the employees in a particular indus- try. The members of the families of the workers will often come to be included; nor need the Dispensary stop there. In a community wherein the workers in an industry comprise the majority of the population, an industrial Dispensary might well serve all the popula- tion, possibly charging a special fee to those not em- ployed in the industry. Such industrial Dispensaries will usually be established with salaried medical staffs. We may also look forward to seeing insurance groups establish their own hospitals and Dispensaries, as well as make arrangements with existing institutions. The present rapid increase in the number of public health Dispensaries is certain to go on and the Health Centers will include not only tuberculosis, baby welfare, prena- tal clinics, and other preventive departments, but also treatment clinics, particularly in certain specialties. Community Organization of Dispensaries We have thus suggested several ways whereby the financial and administrative program which we have 26 392 DISPENSARIES outlined for Dispensaries of the future may practically work itself out of the existing situation. A further problem is the relationship between different types of Dispensaries. From the standpoint of a city as a whole, we may indicate three types : — 1. The Health Center, doing primarily preventive work, and entering into treatment work only along certain rather limited Lines. 2. The District Dispensary, as it may be called, equipped to do good general Dispensary work. 3. The Teaching Dispensary, providing facilities for the diagnosis of the most difficult and rare cases and for medical education and research. Localization of activity should be carried out in varying proportion in each of these types. Preventive work must be localized more than curative. The public health Dispensaries or Health Centers should be organized on a neighborhood basis. Some health officers regard a population of perhaps 10,000 as a working unit for a Health Center, but regard must be paid to area and to congestion of population, some- times to other local conditions, as well as to mere numbers. Many of the existing Health Centers have included districts of from 25,000 to 40,000 persons, but these have usually been in congested areas. What we have called the District Dispensary is simply the well-organized and equipped Dispensary, which would ideally confine its work to a given section of the city. In adapting an existing dispensary situa- tion to this principle of districting, many dijSiculties will be found. In an immediate procedure it is at COMMUNITY ORGANIZATION 393 least important to minimize the number of Dis- pensaries which are endeavoring to undertake research and advanced scientific work. In the very largest cities more than one such institution may be de- sirable; in other large communities, below the million in population, usually a single important central hospital, in which there is an out-patient department, is all that can and should be equipped upon a scale requisite to do the most advanced medical work. Such an institution would render diagnostic service on the most difficult problem cases coming from the community and from its environs, perhaps from the entire state. Certain of the state university hospitals in the West do this today. Such central institutions must be so related to the other Dispensaries and to the general medical profession, that the full value of the medical information secured as a result of the study given each case shall go back to the referring physician or institution, whether the case is referred merely for consultation, or for consultation and treat- ment. The existence of only a single Teaching Dis- pensary in a city does not imply the absence of all medical teaching in the District Dispensaries and Health Centers. These should also be used in the educational plan; but all as part of one plan rather than each as an independent unit. Only thus can the maximum economy of scientific and financial resources be attained. We have already called attention to the fact that only a small proportion of the medical profession, even in those cities wherein out-patient service has devel- 394 DISPENSARIES oped farthest, are on the staff of the different Dis- pensaries. The expansion of Dispensary work in quantity, and its improvement in quahty, faces a practical difficulty, due to the fact that the medical profession is not homogeneous. Until the rapid re- form in medical education began in 1909, a large number of commercial medical schools were turning out annually numbers of poorly trained physicians. The number of such medical schools has been greatly reduced in the past eight years. In 1909 there were 166 medical schools in the country; today there are less than 90. The reduction has been in the com- mercial schools or in schools too weak financially to maintain a proper standard. Much higher standards in medical education exist today, and they are con- tinuing to advance. But physicians who have al- ready been licensed to practice, and who have devel- oped their clientele, will continue in the profession. The wide variations in skill, training and personality which exist, raise difficulties in bringing about an organization of medical institutions that would call into clinic service the entire local profession. No one would expect quite that stage to be reached. The growth of Dispensaries must, however, mean that a larger and larger proportion of the medical profes- sion is brought into clinic service. This would be greatly facilitated not only by the payment of medical salaries, but also by a growing comprehension among the public of the value of the diagnostic equipment which an institution can provide and the benefits of consultation and co-operative work among physicians. COMMUNITY ORGANIZATION 396 There is now some prestige attached to membership in the medical staff of a hospital or Dispensary. But so long as a majority of doctors are not on these staffs, the lack of such a connection brings no stigma to a physician in the mind of the general public. Let the medical advantages of hospitals and Dispensaries be more fully understood by the public, and let the growth of hospitals and Dispensaries call into service a considerable majority of the local profession, and then the lack of a staff connection will soon mean the lack of public confidence in a physician. If the facilities of a Dispensary are to be open ^'to all the patients who need them and to all the doctors who know how to use them," there must and can be medical standards of qualification which the medical profes- sion itself must lay down and enforce. The medical profession must in fact look largely to the Dispensary as the center wherein the continuous training of its members shall take place. Medicine is a rapidly progressing science. It is not well that a physician leave medical school, and his interneship in the hospital, at the age of twenty-seven to thirty, and pursue ^'practice" for many years thereafter, without keeping abreast of advances in medical knowledge and technique. The leaders of the profession and the public should and will demand that there be regular or periodical relationships between the practitioner and centers of organized medical instruction. These must be largely in local Dispensaries. Lack of willing- ness to take advantage of such opportunities, as these will be offered in the future through the extension of 396 DISPENSARIES hospital and dispensary facilities, will come to be a stigma upon a physician. It is not too much to expect that the public authorities controlling the licensing and practice of medicine will ultimately re- quire that such opportunities be provided and utilized. How shall this program for dispensary development be adapted to the city of moderate size or to the town? Communities of this size cannot and should not expect to maintain a Teaching Dispensary. They do need the general or District Dispensary and they need the Health Center in due ratio to their population and their health problems. In fact we may readily work out the dispensary organization of a middle-sized community by considering that it is a section of a large city. The problem in the two is not quite the same, but the difference is chiefly in details. In small towns the problem of securing efficient specialist service arises and in the country this becomes serious. In rural districts the Dispensary may be peripatetic. There would not be enough people to require a daily or even a tri- weekly clinic, nor would local funds be sufficient to support these. The finan- cial burden must in fact be distributed over a wider area, the county or the State. It may often be neces- sary that the Health Centers in a district be supported, at least in part, by state funds. In the present pro- gram of the British Local . Government Board for treatment of venereal diseases, three-quarters of the expense of the clinic services is to be borne by the central authorities and one-quarter by the locality. Whatever the ratio of distribution, there is little COMMUNITY ORGANIZATION 397 doubt that the provision of adequate equipment, for preventive work and for certain most needed forms of curative service, must largely come from other than local funds in the sparsely settled districts. Very likely the services of specialists holding clinics at regular intervals must be paid at least in part from funds se- cured by taxation from a wider area than the imme- diate vicinity. Dental specialists might be required weekly or bi-weekly in a town wherein an oculist or laryngologist might come once a week, and a neurolo- gist, psychiatrist or orthopedist fortnightly. The reorganization and expansion of Dispensaries, and such state-wide or community planning as we have suggested, obviously face many difficulties. Paramount among these are the highly individualistic character of the medical profession and the small public comprehension of the nature and possibilities of modern medical science. The medical profession is by tradition a body of individual practitioners, each working on his own hook. The doctor's chief train- ing in the past has been in dealing with individual patients. He has not been trained to think in terms of public or community problems. The growth of public health work and the training of a certain num- ber of medical men for public health service has as yet changed the situation but slightly. A greater effect has been produced in recent years through the prevalence of interneships in hospitals. A period of residence as an interne in a hospital is now a practical necessity for the recent graduate of a medical school, and this period gives to the young medical man a 398 DISPENSARIES training in organization, in working as part of a sys- tem. To some extent we may count on this new ele- ment in medical training to create greater readiness and ability on the part of physicians to extend co- operative practice. Military service will perhaps have a similar influence. Such changes in the point of view of a great profes- sion are necessarily slow. The medical profession must frankly face the changes which medical science is bringing upon medical practice. The leaders in the medical profession bear the responsibility of making the rank and file understand that there is now a scientific necessity for the co-operative provision of diagnostic equipment, and of facilities for reception and care of patients, and that there must consequently follow a large development of co-operative medical service through various forms of institutional organization. Individualism in medicine should continue, so far as it implies a sense of direct responsibility for the patient, but individualism must not be and cannot continue to be in antagonism to working as part of an organiza- tion, with graded responsibilities established therein. We may be confident that whatever is clearly demanded by the public interests as a whole, should and will over-ride the special interests of any vocation or group; and also that there lies ahead of the medical profession a future of enlarged dignity and of more secure economic remuneration, if there is a broad com- munity organization of the wonderful resources of medical science and of the skill of its representatives in the medical profession, — an organization such as COMMUNITY ORGANIZATION 399 will render the very best of these resources accessible to all the people on a democratic basis. The great War is calling to everyone's attention the power of medicine to prevent disease among great masses of individuals whose countries were swept by pestilence, and to heal wounds and illness among the victims of the battlefield as these have never been healed before. The public will not fail to remember, however, that these wonders have been accomplished by organized rather than by individualistic medicine. 400 DISPENSARIES CHAPTER XXIV CONCLUSION In the preceding chapters we have endeavored to help those who are concerned with the practical man- agement of Out-Patient Departments and Dispen- saries, and also to point the way towards their devel- opment as agents of larger service to the people. Dispensaries must now be conducted under the unusual conditions created by the War. The short- age in medical staffs, the high cost of supplies, and the financial uncertainty of the times, raise many difficult problems. Yet despite these conditions, Dispensaries should not stand still, much less retro- grade. They should advance. They can advance, given some vision and a little courage. The imme- diate responsibility of the trustees, physicians, and superintendents of Dispensaries and Out-Patient Departments is to adapt their work so as to meet more fully and more effectively the present needs of their communities. Certain needs are increased because of the War, or will be recognized more fully by the public because of the mental quickening of these stirring years. For example, the improvement of existing clinics treating syphilis and gonorrhea, and the establish- / ment of many more such clinics, is no longer the I endeavor of a few especially interested individuals, CONCLUSION 401 but has become a great national program. The conservation of infant Hfe and of motherhood looms larger in the public eye than ordinarily, and this should lead to the advancement of children's and women's clinics, and to numbers of new public health clinics for mothers and babies. Again, since the production of food, fuel, munitions and War supplies must be maintained at a maximum, and expedited to the utmost, in addition to the necessary manufactures for the civilian population, the care of the health of the workers is a vital element in national efficiency. So far as Dispensaries are to render this care, — and in large industrial sections they must supply a great deal of it, — it is important that clinics should inter- fere as little as possible with the usual working hours. The loss in wages to the workers, and in output of product to the community, is of itself more than sufficient to pay the additional expense of clinics in the evenings or late afternoons. These are a neces- sary part of the War program for maximum national efficiency. In times of peace as well as war, such practical economic service of Dispensaries furnishes a sound basis of appeal to business men for financial support. The managers of Dispensaries and out-patient depart- ments will do well to bear in mind also, that a period when employment is general, is favorable for the development of fee systems in Dispensaries, from which a considerable proportion of the expenses can be met without interference with charitable service. A patient in a hospital is taken out of the com- 402 DISPENSARIES munity for the nonce. A patient of a Dispensary retains his normal social relationships and in many instances his earning power. When Dispensary treat- ment is practicable, it is a moral advantage and an economic gain. The War-time campaign for the '^reconstruction of soldiers'' should rest upon the Dispensary principle rather than the hospital principle, so far as medically possible. This campaign is in any case familiarizing the public with the idea of after-care and of vocational readjustment, following surgical operations, accidents, or acute medical dis- eases. As the humanity and economy of after-care becomes more apparent to hospital authorities, busi- ness men, and patients themselves, the lack of Dis- pensary facilities in any community, or for any hos- pital doing public work, will be regarded as a serious if not an incriminating deficiency. The development of Dispensaries, as prefigured in this book, must take place partly as a result of internal forces. The trustees, physicians and superintend- ents of existing institutions will strive to increase efficiency and improve technique. But with Dis- pensaries, as with other organizations, the impulses which set internal forces in operation are chiefly some stimulation from outside. The more that charitable and benevolent societies, fraternal orders, churches, and civic associations are interested in health; the more that the scope and powers of health departments are widened; the more that the general public thinks and understands about health problems; so much the more forcibly will CONCLUSION 403 stimuli to improvement penetrate the institutional shells of Dispensaries and hospitals, and so much the more readily will financial support be secured. The growing recognition by great managers of industry that the care of the health of the workers is a practical asset, is another powerful impelling force towards the development of existing Dispensaries and the establishment of new ones. The relation between the Dispensaries and the hospitals is of vital importance. The establishment of an out-patient department brings a hospital into a more extensive and varied contact with the commu- nity, and the rapid increase of out-patient departments in recent years may be taken as an encouraging indi- cation that our hospitals are becoming more responsive agents of pubHc service. The further advance of Dispensaries will continue to react beneficially upon the hospitals, for hospitals need improvement not only in technical standards of management, and in those relations with the medical staff in which the American College of Surgeons is especially interested, but also in the broader aspects of policy. An inquiry such as, ^^What shall a hospital do to increase its efficiency?'^ is largely an institutional question. The inquiry, ''What can the hospital do to increase its service to the community? '^ involves the former query as one element, but also much wider consid- erations of pubhc health and social policy. The Dispensary is part of the answer to the second ques- tion. More adequate facilities for medical care in the 404 DISPENSARIES small towns must be kept in the foreground of any general health program, and this means the estab- lishment of local clinics and of public health Dispen- saries. The War renders the conservation of life, the promotion of health, more important than ever before. The War is bringing the public to realize this as never before. The health of the productive workers of today, and of the mothers and the children, is the foremost element in the vital efficiency of the nation, and one of the chief items in its War-time productive efficiency. Health is now realized to be not only an individual but a national asset. The care of health is not only an individual, but a public responsibility. Provision for the care of health need not remove initiative or responsibility from the shoulders of the individual, but it can no longer be left solely to the individual's efforts. The care of sickness and the promotion of health must be organ- ized as conscious, co-operative undertakings, or as undertakings of the community itself through gov- ernmental agencies. Public understanding of the power of modern med- icine and of the nature of modern medical work grows but slowly. This is partly because doctors have not taken the public sufficiently into their confidence, and partly because of the very rapid growth of modern medicine itself, which has kept far ahead of its in- terpretation to the general public. The grown men of today received their first impressions of medicine largely at a time when modern medicine was just beginning to exist. It takes about a generation to CONCLUSION 405 make such a change understood by the public as a whole. It is more important that the public under- stand about medicine than about astronomy or engi- neering, because the health of the public is directly at stake. The people need to know what co-operative practice means, how great the need is for modern equipment in medicine, for adequate service of special- ists and for preventive work. For the education of the public we must rely partly on the writers and popularizers of scientific development, and partly upon the growth of health departments and medi- cal institutions themselves, as they extend their service through wider and wider sections of the com- munity. In proportion as they are democratic and efficient will their work be understood, appreciated and advanced. The tendencies of the War period are in favor of this development. But the nature and methods of modern medical service must be popularized. Volun- tary associations, health departments, journals, news- papers, writers, social workers and the leaders of the medical profession, must direct their efforts largely toward this fundamental pubHc education. The moral and financial foundation of all public and private health work, as well as of hospitals and Dispensaries, must be broad popular knowledge and democratic support. 406 DISPENSARIES ^ BIBLIOGRAPHY Citations in the text are indicated by small numbers, which refer to books or articles indicated by corresponding numbers below. An additional list of selected references, grouped by topics, is appended. The classification accord- ing to subject is rough, and for purposes of convenience only, since many articles treat of more than one topic. 1 TJie First London Dispensaries. By a Surgeon (probably H. N. Hardy). Fraser's Magazine, May, 1875, Vol. XI: pp. 598-607. 2 A History of The Boston Dispensary. Compiled by one of the Board of Managers (Wniiam R. Lawrence). Not Published. Printed by John Wilson & Son, 22 School Street, Boston, 1859. ' Page 140 of work just cited. * Osier, Dr. William, Remarks on the Functions of an Out-Patient Department. British Medical Journal, June 20, 1908, Vol. I for 1908, p. 1470. 6 Cabot, Dr. Richard C. Suggestions for the Reorganization of Out- Patient Departments, with Special Reference to the Improvement of Treat- ment. Maryland Medical Journal, March, 1907, Vol. L: p. 81. 6 Goldwater, Dr. S. S. Dispensary Ideals. American Journal of the Medical Sciences (1907), New Ser., Vol. 134: p. 313. ' Davis, Michael M., Jr. Efficiency Tests of Out-Patient Work. Boston Medical and Surgical Journal, June 20, 1912. 8 Associated Out-Patient CHnics of New York. First Annual Report, 1913. 17 West 43d Street, New York. Also later Reports. ^Report of Committee on Out-Patient Work. American Hospital Association, in Proceedings of the Association, 1914, p. 312. ^0 Quoted with modifications from Davis, Michael M,, Jr., The Func- tions of a Dispensary or Out-Patient Department. Boston Medical and Surgical Journal, August 27, 1914. 11 Report of Committee on Oui-Patient Work. American Hospital Association in Proceedings of Association, 1916, pp. 102 et seq. ^ Shrady, Dr. George F. A Propagator of Pauperism: The Dia- pmsary. The Forum (1907), Vol. 23: p. 420. BIBLIOGRAPHY 407 1' Thayer, Dr. W. S. Report on Dispensary Abuse, by Committee of the Medical and Chirugical Faculty of Maryland. Maryland Medical Journal (J907), Vol. L: p. 277. Also summary in Journal of the Amer- '"''ican Medical Association (1907), Vol. 49: p. 792. ^* Savage, Charles C. Dispensaries Historically and Locally Con- sidered. International Conference of Charities, Correction and Phil- anthropy (1893), p. 630. ' ^' Janeway, Dr. Theodore C. The Social Evolution of a Dispensary. ^^ Charities (1907), Vol. 17: p. 863. Kirkbride, Franklin B. Some Phases of the Dispensary Problem. Annals of the American Academy ^ (1904), Vol. 23: p. 424. Kleene, G. A. The Problem of Medical Char- ity, Vol. just cited, p. 409. 1^ Gay, Dr. George W. and Others. Symposium on Dispensary Abuse. Boston Medical and Surgical Journal (1905), Vol. 152: pp. 295-314. ^^ The Movement in Chicago for the Regulation and Improvement of Institutional Medical Charity. (Pamphlet.) Issued by the Committee on the Abuse of Medical Charity, Chicago Medical Society, November, 1910. 18 Report of the Committee on Dispensary Abu^e of the Medical Society of the County of New York. New York State Journal of Medicine (Jan- uary 1913), Vol. XIV: No. 1, p. 48. 1' Boston Dispensary, Annual Reports, 1911 et seq. Summary in: Davis, Michael M., Jr., A Medical Bugbear: Dispensary Abuse. The Medical Record, September 12, 1914 (contains a bibliography). 2° Veeder, Dr. Borden S. Standards for Determining the Suitability of Patients for Admission to a Free Dispensary. Journal of the American Medical Association (1916), Vol. 67: p. 95. ^1 Jobes and Hostetter. Social Survey of Dispensary Patients in Philadelphia. The Modem Hospital (1914), Vol. 5: p. 321. ^ Thornton, Janet. The Place of Medical Care in a Workingman'g Budget. Boston Dispensary, Annual Report, 1915, p. 43. 2' Report of the Social Insurance Commission of the State of California. January, 1917. P, 43. '* Report of the Social Insurance Commission of the Commonwealth of Massachusetts. January, 1918. Pp. 142-158. " Warner, Dr. A. R. Dispensary Abuse and its Eliminaiion by the Application of Sociologic Methods. Journal of the American Medical Association (1913), Vol. 60: p. 738. 27 ^ 408 DISPENSARIES 2« Davis, Michael M,, Jr. Present Status and Problems of Out-Patient Work. Proceedings of American Hospital Association (1913), p. 316. 2^ Valentine, Robert G. Application of the Principles of Organization to Hospital Service. The Modern Hospital, April, 1916, p. 262. 28 Thomson, Dr. Alec N. The Genito-Urinary Department of the Brooklyn Hospital Dispensary. Social Hygiene, January, 1916, p. 91. 29 Day, Dr. Hilbert F. Bridging a Gap in Out-Patient Service. Bos- ton Medical and Surgical Journal, March 2, 1916. 30 Davis, Michael M., Jr. The Efficiency of Out-Patient Work. Jour- nal of the American Medical Association, November 8, 1912. The reference made in the course of this citation is to an article by Drs. F. J. Cotton and R. J. O'Neil in Boston Medical and Surgical Journal (1903) Vol. 149: p. 538. '^ Report of the Committee of Inquiry into the Departments of Health, Charities, and Bellevue and Allied Hospitals in the City of New York, appointed by the Board of Estimate and Apportionment, 1913. Section VII, Care of Out-Patients, pp. 5-18. " Same reference as No. 26. ^ Presbyterian Hospital in the City of New York. Annual Report, 1915. ^ Portions of this Chapter are quoted with modifications from three articles by Davis, Michael M., Jr., (1) Dispensaries for the Smaller Hospitals: Why We Need Them? The Trained Nurse and Hospital Review, 54 (1915), p. 323. (2) How to Organize and Manage Them. Ibid. 55 (1915), p. 1. (3) Dispensaries vnthout Hospitals. Ibid. 55 (1915), p. 139. ^ Quoted with modification from: Davis, Michael M., Jr., The Bene- ficial Results of Prenatal Work. Boston Medical and Surgical Journal, January 4, 1917. ^ Wilhams, J. Whitridge. Journal of the American Medical Associa- tion, January 9, 1915. " Davis, Michael M., Jr. What the Campaign Against Venereal Disease Demands of Hospitals and Dispensaries. American Journal of Public Health, April, 1916, p. 346. '* Report of Committee on Social Insurance of the Council on Health and Public Instruction, American Medical Association. Journal of the American Medical Association, June 9, 1917, p. 1752. Also Davis, Michael M., Jr. A Report on Dispensaries in Massachusetts in the Re- port of the Massachusetts Social Insurance Commission, 1918, p. 142. " (a) Chapin, Robert Coit. The Standard of Living among Working- BIBLIOGRAPHY 409 merits Families in New York City. N. Y. Charities Publication Com- mittee, 1909. (b) New York Factory Investigating Commission. Fourth Report, 1915. Vol. IV. Appendix VII, pp. 1461-1844. The Cost of Living in New York Staie. *° State Charities Aid Association, New York. Sickness in Dutchess County, New York. Its Extent, Care and Prevention. September, 1915. Topical References Historical Vide Numbered References (1) and (2). U. S. Bureau of the Census. Special Report on Benevolent Institu- tions, 1904. Ihid. Report on Benevolent Institutions, 1910. American Hospital Association, Reports of Committee on Out-Patient Work. Proceedings of the Association, 1913 (p. 316); 1914 (p. 312); 1915 (p. 416); 1916 (p. 102). Anon. Medical Charity: Its Extent and Abuse. Westminster Review (1874), Vol. 101: pp. 174, 464. Anon. Self-Supporting Dispensaries. The Penny Magazine, June 21, 1834, Vol. 3: p. 238. Davis, Michael M., Jr. The Boom in Dispensary Work. Modern Hospital, August, 1914. Goldwater, Dr. S. S. Dispensaries: A Factor in Curative and Pre- ventive Medicine. Boston Medical and Surgical Journal, April 29, 1915. Lewinski-Corwin, E. H. The Associated Out-Patient Climes of New York: A Social Force. N. Y. Medical Record, February 15, 1913. Trevelyan, Sir Charles. On the Extension of Provident Dispensaries throughout London and its Environs. Pamphlet issued by Charity Organization Society of London, 1878. Winslow, C.-E. A. Public Health Administration in Russia in 1917 (Russian Dispensary System). In U. S. PubHc Health Reports, December 28, 1917, pp. 2191 et seq. Social and Economic Status of Dispensary Clientele Vide Numbered References 12 to 25 inclusive; also 39 and 40. For Special BibUography see in Numbered Reference 19. Committee on Dispensary Abu^se of the Academy of Medicine of Cleve- land, Ohio. Report, 1912. Cleveland Medical Journal, 11: p. 126. Cobb, Dr. Farrar. The Regulation of Medical Charity. Boston Medical and Surgical Journal, 152 (1905) : p. 307. 410 DISPENSARIES Foster, E. C. The Chanties Clearing House in its Relation to Dispen- sary and Hospital Abuse. Cleveland Medical Journal, 10 (1911) : p. 818. Warner, Dr. A. R. The Sources of Dispensary Abuse. Cleveland Medical Journal, 10 (1911): p. 833. Washburn, Dr. F. W. Medical Charity at the Massachusetts General Hospital. Boston Medical and Surgical Journal, 152 (1905) : p. 309. Williams, Dr. J. Whitridge. Dispensary Abuse and Certain Problems of Medical Practice. Journal of the American Medical Association, July 8, 1916. Social Service Annual Reports of existing Social Service Departments, particularly the Massachusetts General Hospital; Bellevue Hospital, N. Y.; Medical School of the University of Indiana; Boston City Hospital; Psychopathic Hospital, Boston; Boston Dispensary. Annual Reports of New York School of Philanthropy and of Boston School of Social Work. Briggs, Dr. L. Vernon. Three Months With and Three Months With- out a Social Worker in the Mental Clinic at the Boston Dispensary. Amer- ican Journal of Insanity, October, 1912. Cabot, Dr. Richard C. Social Service and the Art of Healing. N. Y. 1909. Cannon, Ida M. Social Work in Hospitals. Russell Sage Founda- tion, 1912. Davis, Michael M., Jr. Social Aspects of a Medical Institution. Proceedings, National Conference of Charities and Correction, 1912, p. 363. Ibid, Social Diagnosis. Medical Review of Reviews, June, 1912. Richards, Ehzabeth V. H. Social Service in an Out-Patient Depart- ment. Proceedings of the American Hospital Association, 1913, p. 412. Wilson, Mabel R. and Davis, Michael M., Jr. A New Minister to Minds Diseased. The Survey, April 5, 1913. Williams, Dr. Linsley R. The Value of the Social Worker and Visiting Nurse to the Dispensary Patient. N. Y. Medical Journal, 87 (1908): p. 143. Buildings, Equipment, Organization Vide Numbered References 5 to 11 inclusive. "The Function of the Dispensary." Report of Committee of Associa- tion of American Medical Colleges, Dr. George Blumer, chairman. Journal of the American Medical Association, 66 (1916): 1156. BIBLIOGRAPHY 411 Cabot, Dr. Richard C. Why Should Hospitals Neglect the Care of Chronic Curable Disease in Out-Patients? St. Paul Medical Journal, March, 1908. Camac, Dr. C. N. B. The Out-Patient Clinic: Its Aims and Possi- bilities. Canadian Journal of Medicine and Surgery. Vol. 32 (1912): No. 1. Hornsby, Dr. John A. and Schmidt, Richard E. The Modern Hos- pital. (Saunders) 1913. Klaer, Dr. Fred H. Methods and Efficiency in Medical Out-Patient Work. American Medicine, June, 1914. McLean, Dr. Stafford. Suggested Improvements for Medical Out- Patient Work with Children. Archives of Pediatrics, March, 1917. Massachusetts General Hospital. Anniuil Report, 1915, Sec. B, pp. 32-38. Peter Bent Brigham Hospital. Annual Report, 1916, pp. 134 et seq. Smith, Dr. James H. The Free Dispensary as a Municipal Health Agency. Bulletin of the Medical College of Virginia, 12 (1915): No. 3, p. 3. Reports of Committee on Out-Patient Work, American Hospital Asso- ciation. Vide supra. Follow-Up Systems and Efficiency Tests Vide Numbered References 7, 29, 30 and 31. Barringer, Dr. B. S. A Survey of Venereal Clinics in New York City, and Piatt, Philip S., A Statistical Efficiency Test. National Conference of Charities and Corrections, 1915, p. 281. Barron, Dr. Elmer W. and Davis, Michael M., Jr. A Follow-Up System for Promoting Efficiency in an Out-Patient Clinic. Boston Med- ical and Surgical Journal, December 4, 1913. Codman, Dr. E. A. A Study in Hospital Efficiency. Boston, 1917. Committee on Hospital Efficiency of the Philadelphia County Medical Society. Reports Submitted June 17, 1913; November 26, 1913; and October 21, 1914. (Pamphlets.) Corscaden, Dr. James A. The Follow- Up System of the Presbyterian Hospital in the City of New York. Journal of the American Medical Association, March 11, 1916. Hartshorn, Dr. Edward and Davis, Michael M., Jr. Follow-Up Work as an Element of Effective Treatment in an Out-Patient Clinic for Eye Diseases. Boston Medical and Surgical Journal, April 11, 1913. Langstroth, Dr. Lovell. A Critical Analysis of Out-Patient Work 412 DISPENSARIES from the Point of View of Efficiency. Journal of the American Medical Association, July 8, 1916. Sanford, Dr. Henry L. An Efficiency Test of Dispensary Treatment of One Hundred Cases of Gonorrhea. Cleveland Medical Journal, 12 (1913): p. 813. Public Health Dispensaries and Health Centers Association of Tuberculosis Clinics, New York. Annual Reports, especially the 6th Annual Report (1913). ''Dispensary Control of Tuberculosis." Crowell, F. EHzabeth. The Tuberculosis Dispensary: Method and Procedure. Published by the National Association for the Study and Prevention of Tuberculosis, N. Y., 1916. Davis, Michael M., Jr. The Health Center Idea. Public Health Nurse Quarterly, January, 1916. Efficient Dispensary Clinics^ a Requisite for Adequately Coping with Venereal Disease. Journal of the American Medical Associa- tion, December 4, 1915. Evening Clinics for Syphilis and Gonorrhea. Social Hygiene, June, 1915. What the Campaign against Venereal Disease Demands of Hospi- tals and Dispensaries. American Journal of PubUc Health, September, 1915. How Efficient Dispensary Clinics can Help Solve the Medical Social Problems of Venereal Disease. National Conference of Charitiea and Correction, 1912, p. 272. Eckstein, Dr. W. G, The Genito-Urinary Clinic: Its Relation to Sanitary and Moral Prophylaxis. The Postgraduate, September, 1907. Guhck, Dr. Luther S. and Ayres, Leonard W. Medical Inspection of Schools. Russell Sage Foundation, N. Y., 1910. The Modern Hospital, August, 1916. (Industrial Medicine) and sec- tions devoted to "Industrial Department" in various succeeding issues. Local Government Board (Great Britain), Regulations regarding Venereal Disease. July 12, 1916. (T. Fisher Unwin.) National Committee for Mental Hygiene. 50 Union Sq., N. Y. Re- ports and Publications, and Mental Hygiene (Quarterly). Piatt, PhiHp S. The Efficiency of Venereal Clinics: Suggested Reme- dies for Present Defects. American Journal of Public Health, 6 ( 1916): p. 953. Smith, Dr. C. Morton. The Relation of the Physician and Social BIBLIOGRAPHY 413 Worker in the Effort to Save Damaged Ooode. National Conference of Charities and Corrections, 1912, p. 369. Stokes, Dr. John H. Hospital Problems of Gonorrhea and Syphilis. Journal of the American Medical Association, December 23, 1916. Symposium on the Hospital and Dispensary Treatment of Venereal Disease (N. Y. Academy of Medicine). N. Y. Medical Journal, May 17, 1913. '^ Social Hygiene" (Quarterly), 1915 et seq. Thomson, Dr. Alec N. Attacking the Venereal Peril. (Pamphlet.) Read before Medical Society of the County of Kings, N. Y., February 14, 1916. United States Children's Bureau. PubKcations Nos. 3, 4, 6, 9, 11, 15, 16, 19, 20. (Infant Welfare Clinics, Prenatal Care, Maternal Mortality.) Pay Clinics Davis, Michael M., Jr. Pay Clinics for Persons of Moderate Means. National Conference of Charities and Corrections, 1915, p. 228. Pay Clinics for Tuberculosis. Transactions of the Twelfth Annual Meeting of the National Association for the Study and Prevention of Tuberculosis, 1914. Hartshorn, Dr. Edward and Davis, Michael M., Jr. A Self-Suppori- ing Eye Clinic for Working People. Archives of Opthalmologj'', 43 (1914): No. 6. Howell, Dr. Thomas and Buckley, Katherine. Hospitals and Work- men's Compensation. (Compensation CHnics.) The Modern Hospital, 9 (1917): p. 234. Public Problems Vide Numbered References 22-24, 38-40. Committee on Social Insurance, Council on Health and PubHc In- struction, American Medical Association. Statistics regarding the Medi- cal Profession. Social Insurance Series, Pamphlet No. 7. Davis, Michael M., Jr. The Medical Organization of Health Insur- ance. The Medical Record, January 8, 1916. Organization of Medical Service. American Labor Legislation Review, March, 1916, p. 16. Emmons, Dr. Arthur B., 2d. The Profession of Medicine: A Col- lection of Letters from Graduates of the Harvard Medical School. Harv- ard University Press, 1915. 414 DISPENSARIES Frankel, Lee K. and Dublin, Louis I, Sickness Surveys (Metropolitan Life Insurance Co.) as follows: (Rochester) U. S. Public Health Reports, February 25, 1916, p. 434. (North Carolina) Ibid., October 13, 1916, p. 2840. (Boston) A Sickness Survey of Boston, 1916 (Pamphlet). Hay hurst, Dr. E. R. Compulsory State Health Insurance and Its Relation to Medical Service. The Modern Hospital (1915), 6: p. 420. Lambert, Dr. Alexander. Medical Organization under Health Insur- ance. (Reprint by Author of Address at Annual Meeting of American Association for Labor Legislation, Columbus, Ohio, December 28, 1916.) Lyons, E. P. The Social Status of Medical Practice. Journal of the American Medical Association, December 19, 1914 (63: 271). Rubinow, Dr. I. M. Health Insurance in Relation to the Public Dis- pensary. Council on Health and Public Instruction, American Medi- cal Association. Social Insurance Series, Pamphlet No. 3. Health Insurance in Relation to Public Health. Ibid. Pam- phlet No. 4. Schneider, Franz. A Survey of the Activities of Municipal Health Departments in the United States. Russell Sage Foundation, 1916. Smith, Dr. Winford H. Presidential Address. American Hospital Association. Proceedings of the Association, 1916, p. 19. Warbasse, Dr. James P. The Sodalizaiion of Medicine. Journal of the American Medical Association, July 18, 1916, 63: 264. What is the Matter vyith the Medical Profession? Long Island Medical Journal, July, 1912. Are There Too Many Doctors? Ibid, April, 1912. BY-LAWS AND RULES 416 SUGGESTIONS FOR BY-LAWS AND ADMINISTRATIVE RULES OF A DISPENSARY* Article I. Governing Board Section L The management of this Dispensary shall be vested in a Board of Trustees, of members (nine to fifteen). The Board shall be chosen at the Annual Meeting of the Corporation, and its members are to serve for three years each, the terms to be so adjusted that one- third shall expire each year. Section 2. At the Annual Meeting, all contributors to the funds of the Dispensary, as well as all members of the Corporation, are entitled to a vote, in person or by proxy. Section 3. At each Annual Meeting shall be elected a nominating committee of seven, to present nomina- tions at the next Annual Meeting to fill vacancies in the Board of Trustees and in the officers of the Dispensary as hereinafter provided. Nominations shall also be received from the floor. Election shall be by ballot. Section 4. The officers of the Board shall include a President, a Vice-President, a Treasurer and a Secretary, elected at the Annual Meeting and serving for one year, or until their successors are appointed. Section 5. The duties of the officers shall be such as *For an out-patient department of a hospital, the by-laws on pages 425-426 may be substituted for portions of Articles I-V of these By- laws for a Dispensary, 416 DISPENSARIES usually appertain to their respective offices (or may be specially defined according to local conditions). Section 6. Meetings of the Board of Trustees shall be held monthly on , except during the month of August. Special meetings may be called by the President or the Secretary, and shall be called at the request of any three members. Section 7. members of the Board shall constitute a quorum. Section 8. The Board of Trustees shall have power to fill vacancies arising during the year in its offices or mem- bership. Section 9. The Board of Trustees shall have full power to conduct all affairs of the Dispensary, to appoint its medical staff, officers and employees, and to establish all needful committees, by-laws, rules and regulations for the management of the Dispensary, and to alter the same at its discretion. Section 10. All appointees to any position in the Dis- pensary shall hold office at the pleasure of the Board. Section 11. These By-laws of the Dispensary may be amended by a vote of not less than members of the Board, at any meeting, provided that a statement of their substance has been sent to all members of the Board, at least one week in advance of such meeting. Article II. Executive Committee Section 1. There shall be an Executive Committee of the Board of Trustees, of five members, chosen by the Board to serve for one year, or until their successors are appointed. Section 2. The Executive Committee shall meet on the day of each month, and at such other times as it BY-LAWS AND RULES 417 shall determine. The Executive Committee shall have the powers of the Board of Trustees in the interim of Board meetings, except as hereinafter provided, and shall have the full powers of the Board in cases of emergency, arising from fire, accident or other calamity. The Executive Committee shall have power to transfer funds appropriated to one department, or account of the Dispensary, to another de- partment or account; but may not vote new appropria- tions except in emergency, or for a period not longer than the end of the month during which the next Board of Trustees meeting is held. Section 3. The Executive Committee shall keep accu- rate minutes of its meetings and transactions, and shall make a report to the Board at each stated meeting thereof. Section 4. No payment of money, except for salaries or other items authorized in a budget approved by the Board, shall be made except on the written order of the Executive Committee, or of an agent thereof, duly author- ized by the Committee to take action in the matter. Section 5. The Executive Committee shall have power to form sub-committees, which may include members of the Board, as well as its own membership. Article III. Medical Staff Section 1. The medical work of the Dispensary shall be carried on by a body of physicians who shall be appointed as hereinafter provided, and who shall be di\dded into such Departments, representing the various branches of medicine, as may be authorized by the Board. Section 2. The following grades of appointment are recognized : — 1. Consulting Physicians or Consulting Surgeons. 2. Physicians or Surgeons. 418 DISPENSARIES 3. Assistant Physicians or Assistant Surgeons. 4. Assistants to the Physicians or Assistants to the Surgeons. 5. Resident Physicians (or House Officers). 6. Unofficial Assistants. Section 3. Appointments to grades (1) and (2) shall be made by the Board of Trustees on the nomination of the Executive Committee; grades (3), (4) and (5) by the Executive Committee, on the nomination of the Chief or Chiefs of the Department concerned. Preceding action by the Trustees or the Executive Committee, nominations shall be submitted to the Medical Advisory Board. Section 4. Such items concerning a nominee shall be submitted as may be required by the Board or the Execu- tive Committee. No nominations for appointment upon the Staff shall be considered, unless the nominee has served as Resident House Officer in an acceptable hospital; except in cases of appointment to the grade of Assistant to the Physicians or Assistant to the Surgeons when an excep- tion is recommended by special vote of the Medical Advi- sory Board. Section 5. All appointments to the Staff shall be for a period ending on December 31st of the calendar year in which they are made, except appointments as Unofficial Assistants or appointments made by special vote of the Board of Trustees for a period less than one year. Section 6. There shall be a Medical Advisory Board, consisting of five physicians, who shall not be members of the active Staff of the Dispensary, and shall be appointed by the Board of Trustees at the Annual Meeting, to serve for one year or until their successors are appointed. It shall be the duty of the Medical Advisory Board to assist BY-LAWS AND RULES 419 the Board of Trustees by advice and counsel as to questions of policy and appointments. Section 7. There shall be a meeting annually, at a time fixed by the Trustees, of the Board of Trustees (or the Executive Committee thereof), with the Medical Advisory Board, the heads of all the Departments in the Dispensary, and the Superintendent. Section 8. The Staff of each Department shall annually arrange the period and order of service of its members, subject to such rules as may be prescribed by the Board of Trustees. Services in each department must be so arranged that there shall always be on duty at least one member of the Staff holding the rank of Physician or Surgeon. Section 9. Unofficial Assistants include those who, without holding official appointment, assist a member of the official Staff in any department of the Dispensary. No physician not a member of the Official Staff is allowed to work in the Dispensary without receiving an appoint- ment as Unofficial Assistant. Such appointments are made by the Superintendent on the nomination of the Physician or Surgeon who is in charge of the department for the service during which the assistant is to work. The form of appointment for Unofficial Assistants shall state the condition and the length of service, to which the ap- pointee must be understood to agree. Section 10. No Unofficial Assistant shall hold such an appointment for more than one year. Section 11. No examination, treatment or operation shall be undertaken by an Unofficial Assistant, except under the direction of an official appointee who shall be responsible for the work of the Unofficial Assistant. Section 12. No clinic shall be conducted except when an official member of the Staff of the department is in personal attendance. 420 DISPENSARIES Article IV. Superintendent and Administrative Staff Section 1. The chief administrative officer of the Dis- pensary shall be the Superintendent, who shall be appointed by the Board. Section 2. The Superintendent shall be responsible to the Board of Trustees for the proper and efficient adminis- tration of the Dispensary in all its branches, and he shall have control of all subordinate officers and employees and charge of the building and appurtenances. He shall be responsible for seeing that proper records, accounts, and statistics are kept of the medical and social work of the Dispensary, and of its financial transactions, other than as recorded by the Treasurer; for the proper recording of the attendance of the members of the Medical Staff, and for the purchase and care of supplies. Section 3. As the stated meeting of the Board in Jan- uary, the Superintendent shall present to the Board an annual report, reviewing the work of the Dispensary during the preceding fiscal year, and he shall present such recom- mendations as he deems desirable. He shall also present an annual Budget of expenses which, previous to considera- tion by the Board, shall have been passed upon by the Executive Committee; and when necessary at other times he shall present supplementary or revised Budgets, the consideration of which shall follow the same procedure. Section 4. No annual Budget shall be voted upon by the Board unless a copy shall have been in the hands of the members at least one week before the meeting at which action is expected. Section 5. All subordinate administrative officers and assistants in the service of the Dispensary shall be appointed on the nomination of the Superintendent. BY-LAWS AND RULES 421 Section 6. Subject to such rules or policies as may be prescribed by the Board, the Superintendent shall have power to define administrative regulations for the admission, registration, transfer of patients; for the administration of the medical and social records; for the collection of fees from patients and for the remission of the same ; for the care and accounting for all monies taken in at the Dispensary; and for such other administrative matters necessary for the proper conduct of the work. Section 7. Except by special permission of the Super- intendent, the purchase of supphes must be made by an administrative official designated by him. Section 8. The signature of the Treasurer shall be required on all checks paying out any funds of the Dis- pensary. On all checks in payment for salaries or for sup- plies of any kind, the written approval or signature of the Superintendent shall be required. Article V. The Joint Council Section 1. There shall be a Joint Council of nine mem- bers, including three members of the Board, three of the Medical Staff, and three of the executive officials, including the Superintendent. (In small institutions, only seven, with only one executive official, the Superintendent.) Section 2. The Trustees shall designate annually, as members of the Joint Council, three of their own members, including the Chairman of the Executive Committee; and three of the executive officials, including the Superintendent. The Heads of all the clinical and laboratory departments of the Dispensary, in convocation, shall nominate the three staff members of the Joint Council. Section 3. The Joint Council shall meet six times a year at dates which it shall fix. The Chairman of the Executive 422 DISPENSARIES Committee shall be Chairman, and the Superintendent shall be Secretary. Section 4. The Council shall have power to receive suggestions, recommendations, or statements of facts or of problems from any person or department within the Dispensary, and may make recommendations on any mat- ter referred to it, or of its own motion. Such recommenda- tions may be made to the Board of Trustees, the Medical Staff, or to the administrative officers. Akticle VI. Administrative Rules Section 1. The Executive Committee shall fix the hours during which the various clinics and the Pharmacy are to be open; the hours during which the attendance of physi- cians is required; and the fees to be charged for admission, treatment, medicines, operations, or other services. But any fee may be remitted in whole or part by the Superin- tendent, or with his authority, in order that no patient shall be denied a needed service because of inability to pay for it. Section 2. All members of the official staff, and also unofficial assistants, shall register daily the time of their arrival and departure in a registration book provided for that purpose. Section 3. The Trustees, after consultation with the Medical Advisory Board, shall determine the diseases or groups of diseases which are to be treated in the several cUnical departments. The physician or surgeon in charge of each department is responsible for transferring to the proper department any patient who, from the nature of his disease, appears to have been improperly assigned. Section 4. In case a physician or a surgeon in charge of a department, or of any service, is unable to be present at BY-LAWS AND RULES 423 a clinic, he shall promptly notify the Superintendent, who shall assign a substitute. An assistant is to notify his chief in case of absence, or if his chief cannot be reached, the Superintendent. Section 5. Full and careful medical records shall be kept of the treatment of all patients, and also records of the patients assisted by the Social Service Department. Section 6. The medical records are the property of the Dispensary. The information contained on any record is regarded as privileged and shall be divulged only as re- quired by law, or when in the opinion of the Superintendent the furnishing of such information would be for the bene- fit of the patient or the community. Section 7. The purpose of the Dispensary is to place the best medical treatment within the reach of persons who would otherwise be unable to procure it. It is not the policy of the Dispensary to treat patients who are able to pay the usual private rates for the medical care which they require. Section 8. It is the responsibihty of the Admission Desk of the Dispensary, under the Superintendent, to ascertain the circumstances of each new patient, and after consideration of the patient's income, family responsibili- ties, and the probable cost of the medical treatment which he would require, to decide whether or not he should be admitted to the Dispensary. Section 9. Patients who in the clinics appear to a physi- cian to be able to pay for the medical care which they re- ceive are to be referred back to the Admission Desk, or to the office of the Superintendent. An investigation is to be made of every such case and if it is believed that the patient can pay a private physician, the patient is not to be treated in the chnic, except in cases of emergency. 28 424 DISPENSARIES Section 10. All patients who are refused treatment because of ability to pay private fees are to be referred to the office of a physician. If the patient himself has not a physician in mind, he will be given the name and address of a member of the Staff of the Dispensary. The selection of the member of the Staff, or of the members, to be given a patient, is to be made in the case of each Department after consultation between the Superintendent or his representa- tive, and the Chief or Chiefs of the Department. Section 11. All compensation to members of the medical, or of the administrative staff, shall be paid directly by the Dispensary, and no member of the medical or of the admin- istrative staff shall solicit private practice from Dispensary patients, nor receive any fee or reward from any patient for treatment given in the Dispensary. Section 12. Supplies shall be furnished to clinics, or to departments or to individuals within the Dispensary, only for Dispensary purposes, and only upon written requisition. Section 13. Records shall be made of all supphes or equipment purchased or donated and a current hst shall be kept of all articles lost or missing. Section 14. A written report shall be made of any acci- dent incidental to the treatment of a patient in the Dis- pensary, and forwarded promptly to the Superintendent. Section 15. Physicians are to give practical, plain directions for the use of medicines, and the pharmacist must see that written directions accompany the prescrip- tions, when dispensed. The term "as directed" must not be used. Except in unusual circumstances, not more than one week's supply of medicine is to be ordered in one pre- scription. Section 16. Students may be admitted to any depart- ment to receive instruction, from any medical school the BY-LAWS AND RULES 425 standing of which is satisfactory to the Board of Trustees, and with which arrangements are made satisfactory to the Staff of the department concerned and to the Board. Section 17. Medical students shall not undertake any examination or treatment of patients, except under the direction of their instructor, and he shall be responsible for their conduct while in the Dispensary. BY-LAWS FOR THE OUT-PATIENT DEPARTMENT OF A HOSPITAL (Assuming general Hospital By-laws providing for the usual Board of Trustees, Executive Committee, etc.) Article — . Out-Patient Department Section 1. There shall be an Out-Patient Committee to consist of three members of the Board of Trustees; two members of the House Staff (or of the medical board of the hospital) ; three members chosen by the Out-Patient Council; and the Superintendent of the Hospital. Section 2. The Out-Patient Committee, subject to rules established by the Board of Trustees, or the Executive Committee of the Hospital, shall have general charge of the administration of the Out-Patient Department, within the appropriations made therefor by the Board. Section 3. Out-Patient Council. The Heads of the Clinics of the Out-Patient Department, including the Laboratory, shall constitute the Out-Patient Council. There shall be quarterly meetings of the Council. The Superintendent of the Hospital and the Supervisor of the Out-Patient Department shall meet with the Council except during sessions for the election of officers, or other executive business. 426 DISPENSARIES Section 4. There shall be a Supervisor of the Out-Patient Department, appointed by the Board of Trustees, on the nomination of the Superintendent of the Hospital. He shall have the rank of an Assistant Superintendent of the Hospi- tal, and shall hold office during good behavior, or at the pleasure of the Board of Trustees. Section 5. The Supervisor of the Out-Patient Depart- ment shall have administrative charge of the Out-Patient Department, and all persons who are engaged in any way in the Out-Patient Department shall be responsible to him so far as concerns their duties therein. All directions con- cerning work in the Out-Patient Department shall be issued through the Supervisor thereof. THE MASSACHUSETTS DISPENSARY LAW (Chapter 131, General Acts of 1918) An Act to require that dispensaries shall be licensed by the state department of health. Be it enacted, etc., as follows: Section 1. For the purposes of this act a dispensary is defined to be any place or establishment, not conducted for profit, where medical or surgical advice or treatment, medicine or medical apparatus, is fur- nished to persons non-resident therein; or any place or establishment, whether conducted for charitable purposes or for profit, advertised, announced, conducted or maintained under the name "dispensary" or "clinic," or other designation of like import. Section 2. It shall be unlawful for any person, firm, association or corporation, other than the regularly constituted authorities of the United States, or of the commonwealth, to establish, conduct, manage or maintain any dispensary, as above defined, within the commonwealth, without first obtaining a license as hereinafter provided. Section 3. Any person, firm, association or corporation, desiring to conduct a dispensary shall apply in writing for a license to the state de- partment of health. The application shall be in a form prescribed by the said department, and shall be uniform for all schools of medicine. There shall be attached to the application a statement, verified by the oath of the applicant, containing such information as may be required by the said department. If, in the judgment of the said department, the statement filed and other evidence submitted in relation to the ap- plication indicate that the operation of the proposed dispensary will be for the pubUc benefit, a license, in such form as the said department shall prescribe, shall be issued to the appHcant. Licenses shall expire at the end of the calendar year in which they are issued, but may be renewed annually on appHcation as above provided for their initial issue. No license shall be transferable except with the approval of the said de- partment. For the issue or renewal of each Hcense a fee of five dollars shall be charged, except to incorporated charitable organizations which conduct dispensaries without charge and which report as required by law to the state board of charity. The fees shall be paid into the treas- ury of the commonwealth. Section 4. The public health council of the said department shall make rules and regulations, and may revise or change the same, in ac- cordance with which dispensaries shall be hcensed and conducted, but no such rule or regulation shall specify any particular school of medicine in accordance with which a dispensary shall be conducted. Section 5. The commissioner of health, and his authorized agent, shall have authority to visit and inspect any dispensary at any time in 428 DISPENSARIES order to ascertain whether it is licensed and conducted in compHance with this act and with the rules and regulations established hereunder. After thirty days' notice to a licensed dispensary and opportunity to be heard, the said department may, if in its judgment the public interest so demands, revoke the license of any dispensary. Section 6. Dispensaries legally incorporated or in operation in this commonwealth at the date of the passage of this act, shall, on applica- tion, be permitted to continue in operation for the remainder of the calendar year without fee. The said department is hereby directed to cause an inspection to be made of all such dispensaries prior to the thirty-first day of December in the current year. Section 7. Any person, firm, association, or corporation advertising, conducting, managing, or maintaining a dispensary as defined in this act, unless the same is duly licensed under this act, and any person, firm, association or corporation wilfully violating any rule or regulation made and published under the authority of this act, shall be guilty of a mis- demeanor, and, on conviction thereof, shall be punished by a fine of not less than ten dollars nor more than one hundred dollars. A separate and distinct offence shall be deemed to have been committed on every day during which the violation of any provision of this act continues after due notice of the violation is given in writing by the said depart- ment to the authorities of the dispensary concerned. It shall be the duty of the commissioner of health to report to the attorney-general any violation of this act. [Approved April 2, 1918.] INDEX "Abuse," by patients able to pay, 42-48, 55, 56 Anti-tuberculosis movement, ef- fect on growth of dispensaries, 11, 12, See Tuberculosis. Admission of patients, policy of, 60, 64, 67 Admission System, in Small Out- Patient Department, 292 Admission System, forms for use in, 196-202; functions of, 193, 194; identifying data concern- ing patients, 201; problems of, 192; procedure in, 194, 195, 205; re-admissions, 206; staff re- quired, 207, 208; transfers, 206 Admitting officers, 203, 204 Alphabetical Index to Patients, 197, 201 American College of Surgeons, 403 American Hospital Association, Committee on Dispensary Work, ix, 23, 36, 38, 40, 55, 263 Anaesthesia, 150, 170 Annual Reports, frequent defects in, 278, 279; value of if well prepared, 280, 281 Apparatus, Orthopedic, provi- sion of, 172 Apparatus provided, statistics of, 232 Appointment Cards, for patients, 240, 241 Appointments, to Medical Staff, how made, 88 Associated Out-Patient Chnics of New York, 22 "Baby Chnics," see Clinics, "Baby" Baltimore, 46, 309 BibUography, 406-414 Binet-Simon Tests, 149 Board of Trustees, functions of, 81, 82, 88, 97, 100 Boston, 4, 6, 7, 16, 39, 306, 309, 354, 357 Boston Dispensary, ix, 4, 6, 7, 33, 48, 49, 50, 110, 242, 270, 331, 336, 340, 341 British Royal Commission on Venereal Diseases, 16, 313 Brooklyn, 16 Brooklyn Hospital, 331 Budgets, family, 373; margin for care of health, 374 Buffalo, 15, 16, 323 Buildings, cleaning of, 131, 132; construction, 129; floors in, 130; general planning, 121, 127, 128; ground plans, 122-125, 138, 140; hghting of, 129, 130; vestibule or covered court needed, 127, 136; toilet facili- ties in, 132; use of elevator in, 132; walls, painting of, 130, 131; ventilation of, 133 Buildings, for small Dispensary, 136-139 Buildings, for Out-Patient De- partments, relation to hospital, 121, 125, 126 Burden of Sickness, too heavy un- less distributed, 374; how to be distributed, 375, 376, 380, 381 Burweli, Dr. Thomas, starting first London Dispensary, 2 By-law^s of Dispensary, sugges- tions for, 415-425 By-laws of Out-Patient Depart- ment, suggestions for, 425, 426 Cabot, Dr. Richard C, cited, 18; organized first Social Service Department, 101 429 430 INDEX California, 53 Cannon, Miss Ida M., book on Social Service, 102, 217 Cardiac Clinics, see Clinics, car- diac Centralized Medical Control, 154, 361 Charity, two meanings of term, 371; people not wishing to ac- cept, 329; "service" versus "charity," 371 Chicago, 15, 46 Chief of Chnic, duties of, 91, 92 Children's Medical Clinic, see Clinic, Pediatric Cincinnati, 323 Cleaning of Buildings, 131, 132 Clerical service in Dispensaries, 76, 94 Cleveland, 15, 16, 320, 322 Clinics, "Baby," equipment, 301; localization of, 301; manage- ment of, 302; dispensing milk, 300, 303 Clinics, cardiac, 145 Clinic, Children's Medical, see Clinic, Pediatric Clinics, cost of various, 273 Chnic, Dental, equipment of, 178; "dental hygienists" in, 178; public health motive in, 14 Clmic, Dermatological, 179 "Chnic," defined, 27 CUnics, equipment of, see under names of clinics Clinic, Eye, equipment of, 174; refraction work in, 173; pro- vision of eye-glasses in, 174; management of, 175; relation to optician, 175 Clinics, gastro-enterology, 145 Chnic, Genito-Urinary, 168-171; scope of, 168; management of, 168-170; equipment of, 170 Clinic, Gynaecological; relation to obstetrics, 166; management of, 167; equipment for, 167, 168 Clinic hours, often inconvenient for working people, 329 Clinic, Industrial, defined, 310; types of work, 311; equipment, 312; problems, 312, 313, 367, 368 Clinic Management, 77-79, 93 Clinic, Medical, arrangement of rooms, 133-135, 147; a clearing house for patients, 141; equip- ment of, 142; management of, 142, 143 Clinic, Medical, number of pa- tients in, 143 ; staff required for, 144 Chnic, Neurological, equipment of, 148, 149; relation to psy- chiatry, 149 Clinic, Nose, Throat and Ear, equipment of, 176, 177; ton- sillectomy in, 176; nursing serv- ice in, 177; management of, 176, 177 Chnics, number of different ones desu-able, 83-85 Clinics, "Nutrition," 145 Clinic, occupational diseases, 145 Clinic, Orthopedic, management of, 172; equipment of, 171, 172; relation to Massage and Zan- der, 172 Chnic, Orthopedic, provision of apparatus, 172 Clinics, Pay, see Pay Clinics Chnic, Pediatric, contagious dis- eases in, 146; management of, 146, 147; staff required for, 147 Chnics, peripatetic, in small towns and in country, 385, 396 Clinic, Prenatal, equipment of, 305; localization, 306; relation to maternity hospital, 306; to medical education, 306; to ob- stetrics, 304 Chnics, Prenatal, purpose and method, 304; development, 303, 304 Clinics, Psychiatric, relation to Mental Hygiene movement, 308; development of systems of clinics, 309; relations to court, prisons and schools, 309, 310 INDEX 431 Clinics, School Children's, equip- ment, 308; relation to medical school inspection, 14, 307 Clinic, Surgical, arrangement of rooms, 135; equipment of, 151, 152; management of, 151, 152; nursing in, 152; relation to Or- thopedics, Genito-Urinary work. Gynaecology and Proctology, 151; treatment of fractures in, anaesthesia in, 150 Clinic treating Syphilis, equip- ment of, 181; organization of, 180, 182; relation to other cUnics, 148, 173, 180; Wasser- mann tests in, 181 Clinics, tuberculosis, 145, 183; place of, in general Dispen- sary, 183 CHnics, Venereal, part of pub- he health program, 313; effect of War upon, 313; efficiency of, 314, 315; pay chnics, 315 Commercial Dispensaries, 22, 368 Community Organization of Dis- pensaries, 391 Consultations, between chnics, 214 Contagious Diseases, 146 Contagious Disease, exclusion of, 204 Co-operative medical practice, nature of, 352 ; pooling of equip- ment in, 352; must reach more doctors, 356 Corrective Gymnastics, 87 Cost accounting, 267, 270, 271, 272 Cost of Dispensarj^ work, small Out-Patient Department, 294 Cost of maintaining Dispensaries, 264^269 Cost of Medical Service, 63, 338 Cost per visit per patient, 264- 268, variations in, 264, 267 Cost Unit for Dispensary Work, 263 Cystoscopy, 168, 170, 348 Day, Mrs. Ehzabeth Richards, cited, 105 Dayton, Ohio, 323 Dental Clinic, see Clinic, Dental Dental Clinics, need of, as sub- stitute for "Dental Parlors," 177 "Dental Hygienists," 178 "Department" of a Dispensary, defined, 28 Department of Hygiene, in a Dis- pensary, 163-165 Dermatological Chnic, see Chnic, Dermatological Diagnosis Index, 230, 231 Diagnostic Clinic, at Mass. Gen- eral Hospital, 332, 333 Dietitian, place of, in Dispen- saries, 145 Dignity and Comfort for Patients, 362 Dispensary, a center of organized medical practice, 350 Dispensaries, admitting patients to, 60, 64, 67. See Admission system Dispensary, definition of, 26, 27, 34 Dispensary, efficient, requirements of, 364, 365 Dispensary, "general" and "spe- cial," defined, 32 Dispensary patients, economic classes from which drawn, 52, 53, 354 Dispensary, purpose of, 71 Dispensaries, administrative or- ganization of, 92-95 Dispensaries, advantages of, reach but few doctors, 357 Dispensaries, and pauperism, 42, 44 Dispensaries, broadening scope of 358 Dispensaries, chief present de- ficiencies in, 360 Dispensaries, classification of, 35 Dispensaries, cost of maintain- ing, 263-267; cost per visit, 264-268^ Dispensaries, districting, see Dis- trict Dispensary 432 INDEX Dispensaries, elements in, which attract medical staffs, 355 Dispensaries, "eligibility" for treatment in, 50, 53 Dispensaries, factors in organiza- tion of, 74, 80 Dispensaries, four motives in, 59 Dispensaries, function in medical education, 155, 158, 169 Dispensaries, future, 365 Dispensaries, general principles of organization, 82, 83, 99, 100 Dispensaries, location of, in a city, 139, 140; location of, in U. S., 38,39 Dispensaries, modes of improving, by pay cUnics, 387; by relations with industry, 388; by rela- tions wdth insurance groups, 388 Dispensaries, modes of improving, by financial aid, 389; by de- velopment of pubhc health cHnics, 390 Dispensaries, medical scope of, 28-31; medical staff of, 75 Dispensaries, number of patients in U. S., 39, 40 Dispensaries, number of, in U. S., 10, 36, 37 Dispensaries, Preventive Medi- cine in, 162-165 Dispensaries, providing special- ists for people of small means, 353 Dispensaries, raising funds for, 273, 277, 278, 281 Dispensaries, reimbursed for care of public dependents, 389 Dispensary "Abuse," 42-48, 55, ' 56 Dispensary, relation to hospital, 366, 367, 403 Dispensaries, relation to medical practice, 345, 353 Dispensaries, social groups reached by, 354 Dispensaries, Special, kinds of, 325; limitations of, 326; rela^ tion to i)ublic health Dispen- saries, 327 Dispensaries, Volunteer Workers in, 160-162 "District Dispensary," defined, 35; described, 366; place in community plan, 392 Districting Dispensaries, see Dis- trict Dispensarj^ Drinking Fountains, 132 Ear Clinic, see Clinic, Nose, Throat and Ear Education, comparison with med- ical service, 375, 383 Efl&ciency Conundrums, 261, 281 Efficiency Idea in Dispensaries, 18, 19, 20, 21 Efficiency, in Dispensaries, re- quirements of, 364 Efliciency tests, 20, 76; examples of, 249, 251, 252; forms for tabulating, 255, 258; modes of making, 255-259 Electro-Therapy, 87, 190 Elevators, see Buildings Equipment, medical, increase in amount required, 348; clinical, see under names of clinics Europe, Dispensaries on Con- tinent of, 4, footnote Evening CHnics, 343, 363, 401 Examining Rooms, 135 Eye CUnic, see CUnic, Eye Eye Diseases, facihties for treat- ment, 334; need of Pay CUnic illustrated by, 335 Eye-Glasses, provision of, 174, 175 Family Budgets, 373 Family physician, passing of, 345 Fees from patients, policy of charging, 65, 66, 70; how fixed, 68, 69; rates in vogue, 275, 276; how collected, 198, 199; remission of, 197, 202, 274; X-ray work, 186 Financing better medical service, 372 Floors in Dispensary Buildings, 130 INDEX 433 Follow-Up System, two senses of term, 234, 235; need of, 233- 235; effect on clinic efficiency, 246, 247 Follow-Up System, 75; principles of, 236, 237; procedure of op- eration, 239, 240; place in various clinics, 144, 147, 170, 175, 177, 179, 182, 184; cost of, 244 Follow-Up System, forms for use in, 237, 238, 241, 243; use of post-cards and letters in, 242- 245 Follow-Up System, doctor's part in, 239, 246; social worker's part, 245; clerk's duties in, 242, 245 Food problems of dispensary pa- tients, 144 Formulary, for prescriptions, 188 Four Motives behind Dispen- saries, 23 Funds for medical service, uses of, 377 Gastro-Enterology, sometimes branch of General Medical Clinic, 145 General practitioner, relation to specialists, 345 Genito-Urinary Clinic, see Clinic, Genito-Urinary Goldwater, Dr. S. S., viii, 22, 320; cited, 19 Gonorrhea, efficiency tests of treat- ment, 251; treatment of, 167, 169, 170 Gonorrhea, relation to syphihs from public health standpoint, 182 Ground plans, for Dispensaries, see Buildings Gynaecology, 151, 166 Gynaecological Clinic, see Clinic, Gynaecological Health Center, defined, 18, 318, 324; future of, 366, 392 Health Center, Buildings for, 137 Health Centers, in Buffalo, 323; in Cleveland, 320-322; in New York, 320, 323; in Philadel- phia, 323 Health Center, and Specialty Center, 328 Health Education, methods of, 164 Health Insurance, 368, 376, 379, 391, 404 Health Work in Industry, types of, 310-312 ''History-taking," in clinics, 157 "History corridor," uses of. 134 Holmes, Dr. Oliver Wendell, 7, 8 "Home Patient Department," de- fined, 34 Hospital, a center of organized medical practice, 350 Hospital, relation of buildings to Out-Patient Department, 121, 125, 126 Hospital, relation to Dispensary, 282, 283, 366, 403 Hospital reference forms, 220, 221 Hours of CUnics, should be con- venient for working people, 329, 342 Hydro-Therapy, 87, 191 Hygiene, Department of, in a Dispensary, 163-65 Income of Physicians, paucity of data on, 372; gross and net in- come, 339, 340 Immigrants, medical service avail- able to, 346 Industrial Chnics, 310-313. See Clinic, Industrial Identifying Data concerning pa- tients, 201 "Index Visible," of use in follow- up system, 239 Industrial Dispensary, future of, 367, 391; recent growth of, 16 Industrial Dispensaries, developn ment of, 391 Industrial Health Work, see Health Work in Industry 434 INDEX Inquiries concerning patients, dis- posal of, 194, 208 Installments, payment of fees by, how managed, 173, 276, 277 Johns Hopkins Hospital, 10 Laboratory, 87, 184, 185; in smaU hospital, Out-Patient Depart- ment, 287; in Medical Clinic, 142; in Pediatric Clinic, 146; in Surgical CUnic, 151; records for, 217, 220; statistics of, 232. See Wassermann tests Lakeside Hospital Dispensary, control of dispensary "abuse," 54, 55; pay clinic at, 331 Legal regulation of Dispensaries, 22, 330, 368; in New York 45, 369; in Massachusetts, 369, 427 Lighting, see Buildings "Line and Staff" organization, 94 Location of Dispensaries, 139, 140 London, first Dispensary in, 1 London, Dispensaries in, 3 Lumbar puncture, 181 Massachusetts General Hospital, 10, 101, 213 Massachusetts law licensing Dis- pensaries, 427, 428 Massage, 87, 172, 190 Mayo CUnic, 21, 330, 344, 368 Medical colleges, 394 Medical Education, function of Dispensary in, 155, 158, 159, 395; recent improvements in, 394 Medical Equipment, increase in quantity and expense, 348 Medical placement of patients, 203 Medical practice, individualistic, 347; specialist, 351; co-opera- tive, 352; Dispensary and hos- pital centers of co-operative practice, 350, 351 Medical profession, relation to Dispensaries, 345 Medical profession, individualistic trend of, 397; development of organized practice in, 350- 353, 399 Medical profession, need of bet- ter facilities for, 384, 394; pro- portion in Dispensaries, 357 Medical Records, see Records, Medical Medical School inspection, 14, 307 Medical service, insufiiciencies of, 383 Medical Staff, grades of appoint- ment 88-90; how appointed, 88; length of services, 90, 91; relation of hospital and Dis- pensary staffs, 88, 99, 100 Medical Staff, number of patients to be seen by, in given time, 143 Medical Staff, organization of, 96, 97, 99, 100 Medical Staff, salaries for, needed, 60, 355; effect on Dispensary costs, 269; how secure money for, 381, 390 Medical Staff, why attracted to Dispensaries, 355 Medicines, a chief feature of first Dispensaries, 2 Medicines, provision of, see Pharmacy Medical Students, 144, 156; his- tory-taking, 157; examining pa- tients, 157 Mental Hygiene, and Dispensaries 14, 15, 149, 150 "Milk Stations," see Baby Chnics Modern Hospital (magazine) cited, 282, 283, 312 Moore, Miss Anna, Study of 1000 Dispensary patients, 46-48 Mt. Sinai Hospital, N. Y., 19, 40, 87 Nationality of Patients, record- ing of, 228 Neurological Clinic, see Clinic, Neurological New York City, 4, 7, 15, 20, 39, 42, 43, 46, 60, 259, 266, 270, INDEX 435 302, 306, 308, 314, 320, 323, 354, 357 Nose, Throat and Ear Clinic, see Clinic, Nose, Throat and Ear Nursing, in Dispensaries, 76 Nurses, pupil, use of in Dispen- saries, 159, 160 Nurses, training of, in Dispen- saries, 159 "Nutrition" CHnics, 145 Occupational Disease CHnics, 145 Occupations of patients, record- ing of, 227, 228 One Hundred Per Cent Idea, 317 Operations, Statistics of, 231 Ophthalmological Clinic, see CHnic, Eye Optician, in Eye Chnic, 175 Organization in medicine, 349 Orthopedic Clinic, see Clinic, Orthopedic Orthopedics, growth of, 171, 290, 291; effect of War on, 171 Osier, Dr. William, quoted, 9 "Out-Patient Department," de- fined, 34 Out-Patient Departments, or- ganization of, 98-100 "Out-Patient Institution," de- fined, 34 Overcrowding in Dispensaries, 19, 269 Pay Clinics, definition of, 329, 330, relation to public, 334- 339; relation to doctors, 339- 341; relation to Dispensary, 341-343 Pay Clinics, co-operative enter- prises of physicians, 343, 344 Pay Clinics, fees in, 331; com- pensation of medical staff in, 332; equipment and manage- ment, 333 Pay Chnics, growth of, 331; future of, 344, 387 Pay Clinics, relation to free clinics, 333, 342, 343 Patent medicines, 329, 350 Patients and physicians, relations in cHnics, 153-155 Patients, should be under cen- trahzed medical control, 361 Pediatric CHnics, 145-147 Periodical Medical Examinations, 145, 164 Peripatetic CHnics, 385 Pharmacy, dispensing medicines, rules for, 188; equipment of, 188; fees for medicines, 189; use of formulary, 188 Philadelphia, 4, 45, 49, 323 Physical Gymnastics, 190 Physicians, income of, gross and net, 339, 340 Physicians, shortage of, in poor districts, 383 PoHcy in admitting patients, 60- 62, 64, 67 Population, proportion of doctors to, 382, 384 Population Unit for health service, 317 Posters and Exhibits, 131, 164 Post-graduate teaching in Dis- pensaries, 158 Pregnancy CHnics, see Clinics, Prenatal Prenatal Clinics, see CHnics, Pre- natal Prenatal Care, its value in saving Hfe, 306 Prenatal Work, 166 Presbyterian Hospital, N. Y., 270, 271, 272 Preventive Medicine in Dispen- saries, 162-165 Preventive Work, must be local- ized, 140 Proctology, 151 Psychiatric CHnics, 308-310. See CHnics, Psychiatric Psychiatry, relation to Neurologi- cal CHnic, 149 PubHc Dependents, reimburse- ment of Dispensaries for care of, 389 PubHc, does not understand trend of modem medicine, 353, 397, 436 INDEX 404; need of this understand- ing, 405 Public health Dispensaries, 12, 13; definition of, 34; militant purpose of, 315; localization of, 316; visiting nurse in, 316 Public health motive, establishing Dispensaries, 17, 297 Public health work, militant or- ganizations in, 11, 13 Quacks, 30, 336, 337 Raising funds for Dispensary work, 273, 277, 278, 281, 401 "Rand" visible iudex, of use in foUow-up system, 239 Records, administrative, for keep- ing track of expenses, 273 Records, four kinds of, 210 Records, Hospital and Dispen- sary, relation between, 220, 222, 223 Records, medical, 210-213; book records abandoned, 211; card record forms, 197, 200, 211; use of rubber stamps, 212; filing and distribution, 213; central record room, 213, 214 Record Room, central, 213, 214 Records, Social, 216, 217 Records, supervision of contents of, 223, 224 Record system, with central rec- ord room, 213, 214; without cen- tral record room, 215 Recovery Rooms, 150, 176, 178 "Refers," 214, 217 Registrar, importance in a Dis- pensary, 223 Relations between different Dis- pensaries in a community, 98. See District Dispensary Rochester, N. Y., 15 St. Louis, 49 Salaries, for Medical Staffs. See Medical Staff, salaries for Salvarsan, injection of, 182 Savage, Mr. Charles C., cited, 43 School children, promotion of health among, 14 School Children's Clinics, 307- 308. See CHnics, School ChU- dren School nurse, 177 SeK-Diagnosis and Self-Treat- ment, 30, 329, 336, 337 Sexes, separation of, how far needed in waiting rooms, 142, 145 Shrady, Dr. George F., cited, 42 Sickness, see Burden of Sickness Simultaneous operation of clinics, 86, 87 Small Dispensaries, 33 Small Dispensary, buildings for, 136-139 Small Dispensary, organization of, 95, 96 Small Hospital, Out-Patient De- partment, admissions and fees, 292; records, 292; nursing, 293; social service, 293; cost of, 294; financing of, 295; correlation with wards, 291 SmaU Hospital, Out-Patient De- partment, value of, 282, 285; clinics needed in, 84-86, 288, 290; organization of, 289, 296; Laboratory and X-ray in, 287; rooms and equipment, 289; medical staff and services, 290 Small Hospital, Out-Patient De- partment for private cases, 284 Social diagnosis, 105 Social Groups receiving poor medi- cal service, 338 Social needs of patients, 72 Social Service Advisory Com- mittee, functions of, 107, 108 Social Service, in Dispensary, 76, 98; defined, 101; kinds of cases dealt with, 102, 104; adminis- tration of, in Clinics, 147; functions performed, 103; mode of selecting cases, 109, 110; utihzes community resources, 104, 106 INDEX 437 Social Service, how much needed in Dispensary, 117-119 Social Service, in Small Hospital Out-Patient Department, 293, 294 Social Service, needed in various clinics, 144, 145, 147, 149, 152, 167, 172, 177, 182, 184 Social Service Departments, or- ganization of, 107, 113, 119, 120; records of, 216, 217 Social Surveys of Dispensary pa- tients, 113, 118, 120 Social Workers and nurses, 116 Social Workers, assigned to Clinics, 110, 111 Social Workers, relation to phy- sicians, 108, 109, 113; specializa- tion of. Ill, 112 Social Workers, specialization of, 111, 112 Social -Workers, training of, 114, 115, 160 Social Unit Organization, 323 Special Dispensaries, see Dispen- saries, special Specialist Medical practice, 351 Specialists, cost of treatment by, 328; much of treatment is am- bulatory, 328; increased use of, 353 Specialists, lack of, outside of cities, 385; in poorer districts of cities, 386 Specialization in medicine, rise of, 345, 347; continued develop- ment probable, 350; organiza- tion of, essential, 350 Specialization, in pubUc health services, 316, 317; need of co- ordination of, 317 Specialization, within a clinic, 86; within staff of Surgical Clinic, 151 Specialities, extent to which Dis- pensary should recognize, 84, 85 Statistics, in Dispensaries, 210; ambiguities in, 224; data de- sirable, 227, 228; forms for tabulation, 228, 229; principles for deciding what to record, 227, 230 Statistics, of Attendance, 193, 208; of apparatus provided, 232; of laboratory work, 232; of nationality, 228; of occupation, 228; of operations performed, 231;of X-ray work, 232 Stevens, Edward F,, viii; plans of buHdings, 122-125, 138 Superintendent of Dispensary or Out-Patient Department, 82, 94, 95, 100 Superintendent of Hospital, re- lation to Out-Patient Depart- ment, 81, 98, 99 Surgical Clinic, see CUnic, Surgical Syphilis, treatment of, 148, 168, 179-183. See Clinic treating Syphilis Taxation, for better health serv- ice, 379 "Teaching Dispensary," defined, 35, 56, 57, 61 Teaching Dispensary, rewards to staff, 355; future development, 370, 393 Teaching, medical, its value in Dispensaries, 9; a motive in de- veloping Dispensaries, 7, 8, 10. See Medical Education Throat Clinic, see CHnic, Nose, Throat and Ear Time and Continuity, requisites for efficient clinics, 153 Time required for patients, 143 Thayer, Dr. W. S., cited, 43, 46 Thornton, Miss Janet, studies of cost of medical service, 50-53 Toilet facilities, see Buildings Transfers, 215, 217, 218. See Admission System Treatment Departments, 87, 88, 187-191 Trustees, Board of, functions, see Board of Trustees Tuberculosis Chnics, 12, 183, 298- 299; a miUtant agent, 297. See Clinic, tuberculosis 438 INDEX Tuberculosis, sometimes branch of General Medical Clinic, 145 Unit of Dispensary Work, 225 Urine, examination of, routine, 141 Valentine, Mr. Robert G., cited, 72, 73 Veeder, Dr. Borden S., cited, 49, 50, 56, 57 Venereal disease clinics, 15, 16, 30, 31; co-ordination of, 183. ^ee Clinics, Venereal; Clinic treating Sj^philis ; Genito-Uri- nary Clinic; Gonorrhea; Syph- ilis Venereal Disease, program of con- trol, 15 Venereal Diseases, four types of treatment facilities, 30, 336; re- quire cUnics for adequate treat- ment, 313; a special province of Dispensarj'^, 314 Venereal Diseases, cost of treat- ment, 337 Ventilation, see Buildings Vestibule, see Buildings Virchow, Dr. Rudolph, 71, 73 Visiting Nursing, 145, 153, 166, 184, 305; in co-operation with various chnics, 299, 300, 305, 308, 309, 311, 316; a common factor in PubHc Health Dis- pensaries, 316 Visiting Nursing, co-ordination of special services in, 323, 324; in small towns, 324 Visits per patient, a useful test of work, 248; variations among clinics, 249 ; cautions in employ- ing as efficiency test, 253, 254 Volunteer Workers, uses of, 160- 162; training of, 161, 162 Wages, loss of, because of incon- venient clinic hours, 329, 363 Waiting rooms, separation of sexes in, 142, 145, 168, 289 War, effect upon Medical science and practice, v, vii, viii, 399, 401; effect on Dispensary staffs and on costs, 400; developing orthopedics, 171, 290, 291; developing venereal clinics, 313 Wassermann tests, 181, 314 Wilhams, Dr. J. Whitridge, cited, 306 Wright, Henry C, eflSciency test by, 257 X-ray Department, 87, 151, 186, 187; record forms for, 217, 219; statistics of, 232; in small Hos- pital Out-Patient Department, 287, 288 X-ray Department, work for pri- vate patients, 187, 288 Zander, 87, 172, 190 nPHE following pages contain advertisements of a few * of the Macmillan books on kindred subjects. 29 Reclaiming the Maimed A Handbook of Physical Therapy By R. TAIT McKENZIE, M. D. Major, Royal Army Medical Corps, Professor of Physical Therapy, University of Pennsylvania. Pocket Handbook Size; Waterproof Covers; profusely Illustrated with Photographs and Diagrams. Price, $2.00. 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